Search

症例は76歳女性で糖尿病，慢性膵炎の既往がある．第12胸椎の圧迫骨折のため脊椎短縮術，後方固定，後側方固定術を施行された．腹臥位で，手術時間6時間20分であった．麻酔覚醒後から腹痛が出現し，術後1日目も腹痛は強く，膵酵素，WBC，CRPの上昇を認め，予後因子スコア5点で重症急性膵炎と診断．造影CTでは膵頭部の腫大および膵頭部内の造影不良域を認め，右腎下極以遠までの滲出液貯留を認めたため，造影CT grade 2と診断．蛋白分解酵素阻害薬・抗菌薬膵局所動注療法などの治療を行った．術後16日目の造影CTでは膵頭部の造影不領域が増大し，右後腹膜膿瘍も増大した．十二指腸の壁構造は消失し，十二指腸壁の壊死と考えられた．術後18日目に膵頭十二指腸切除術（PD）を行った．手術では十二指腸は広範に壊死に陥り，後腹膜膿瘍を形成していた．術後は縫合不全など大きな合併症はなく，PD術後101日に退院した．

はじめに: センチネルリンパ節（sentinel node；以下，SNと略記）同定のトレーサーは，一般的に色素やradioisotope（以下，RIと略記）が用いられる．しかし，色素の粒子径は小さく，生体内で癌細胞の動態を反映するか疑問が残る．また，RIは特殊施設を要する欠点がある．癌細胞に近い粒子径で使用が簡便である蛍光ビーズを色素法（Indocyanine Green；以下，ICGと略記）と併用し，胃癌におけるSN同定の有用性を検討した．対象と方法: 蛍光ビーズ使用に同意を得たcN0の胃癌31例を対象とした．蛍光ビーズは，術前日内視鏡下に病変粘膜下に注入した．ICGは術中漿膜側から注入し，5～15分で緑色に染まったリンパ節および紫外線照射で蛍光発光したリンパ節をSNとした．SN摘出後は標準郭清を行い，摘出標本に紫外線照射し発光したリンパ節を検索した．結果: 早期癌に限ると同定率は蛍光ビーズ法のみで76%（19/25），併用法で92%（23/25），ICG法のみで60%（15/25）であった．平均SN個数はそれぞれ2.3個，3.1個，2.3個であった．同一リンパ節に両トレーサーを認めるリンパ節も7例あった．蛍光ビーズの分布は第1群リンパ節に限らず第2群にも認めた．結語: 早期胃癌症例で蛍光ビーズは色素と併用することでSN同定率を向上させることが可能であった．

A rare case of an epidermoid cyst originating in an intrapancreatic accessory spleen in a 50-year-old Japanese female is reported. A hypoechoic cystic tumor was detected incidentally by abdominal ultrasonography. It appeared to be a single cyst in the pancreatic tail with a contrasted mass lesion beside it. Laparoscopy-assisted spleen-preserving pancreatic tail resection was performed. Microscopic examination revealed that the cyst was surrounded by fibrous tissue and a thin layer of splenic tissue, adjacent to normal pancreatic parenchyma. The inner surface of the cyst was lined with non-keratinizing squamous epithelium. The diagnosis of an epidermoid cyst occurring in an intrapancreatic accessory spleen was confirmed. Laparoscopy-assisted spleen-preserving pancreatic resection is a safe and effective procedure for benign or low-grade malignant cystic diseases in the pancreas.

Background Rikkunshito, a traditional Japanese (Kampo) medicine, is widely prescribed as an oral preparation for the treatment of functional dyspepsia (FD). In our previous study, we reported that extracorporeal ultrasonography (US) is a useful technique for the assessment of the gastric accommodation reflex (AR) and duodenogastric motility. In this study, we examined the effects of Rikkunshito on the gastroduodenal function in patients with FD. Methods Sixteen FD patients (median age, 45 y) underwent US, before and after 14 days of treatment with Rikkunshito (7.5 g b.d.). For assessment of the AR, a cross-sectional area of the proximal stomach was measured after incremental ingestion of a liquid meal up to 400-mL. The expansion rate was used as the parameter to determine the AR. Then, the gastric emptying rate (GER), motility index (MI), and reflux index (RI) were evaluated using previously reported methods. Results Although no significant changes were observed in the total score of the Gastrointestinal Symptom Rating Scale (GSRS), the scores of 3 of the 15 symptoms of GSRS decreased significantly after treatment with Rikkunshito. The expansion rate of the proximal stomach was significantly greater after treatment with Rikkunshito than before the treatment. Although the GER and MI increased significantly, no significant differences in the RI were observed after treatment with Rikkunshito. Conclusion These observations suggested that Rikkunshito may be beneficial for the treatment of FD patients with impaired AR and gastric motility. These results also suggested that Rikkunshito has a therapeutic potential for FD and GERD.

A solid and cystic tumor (SCT) was located at the head of the pancreas in a 43-year-old Japanese male, and pancreatoduodenectomy was performed on the suspicion of papillary carcinoma or cystadenocarcinoma of the pancreas. The lesion, which measured 4.5 X 4.5 X 4.0 cm, was clearly demarcated by connective tissue. The cut surface showed solid grayish-white areas with central cystic degenerative changes. The solid areas consisted of small round cells proliferating in a small solid or a pseudopapillary pattern. The tumor cells partially invaded the surrounding normal pancreatic parenchyma. Immunohistochemical studies revealed positive staining for alpha-1-antitrypsin and neuron-specific enolase, but no staining for known pancreatic hormones. Moreover, ultrastructural studies showed the absence of zymogen granules and the presence of anullate lamellae and neurosecretory granules. On the basis of these findings, a diagnosis of SCT of the pancreas was established. In order to clarify the histogenesis and biological behavior of the tumor, it is necessary to accumulate and analyze similar cases, an endeavor which in turn will contribute to the successful management of this disease. Acta Pathol Jpn 41: 763-770, 1991.

症例は55歳，女性．貧血の精査のため腹部超音波検査，腹部CT検査を行い，小腸腫瘍が指摘された．当院を紹介受診し，精査加療目的で入院した．小腸内視鏡で，空腸に管腔半分を占める弾性軟の隆起性病変を認めた．生検で低分化のcarcinoma cellが認められ小腸腺癌が疑われたため，空腸切除術を行った．摘出した空腸腫瘍は乳白色の隆起性病変で，腸間膜リンパ節転移，腹膜播種を伴っていた．病理組織学的に空腸カルチノイドと診断された．本邦で小腸カルチノイドは，小腸腫瘍のうち1.38％と非常に少なく，また全消化管カルチノイドにおける臓器別発生頻度でも3.8％と稀な疾患である．小腸内の発生部位は回腸に多く，空腸発生は稀である．本症例は空腸原発のカルチノイドでリンパ節転移，腹膜播種を伴っていたため，術後の厳重な経過観察が必要である．

Gastrointestinal stromal tumor(GIST)に対するimatinib mesylate(IM)の抗腫瘍効果は60%以上と優れているが,頻度的に少ない大腸GISTに対する効果,neoadjuvant(NA)の有効性など不明な点も多い.今回,大きさ,部位的に切除困難が予想された若年者直腸GISTに対してIMによるNAを行い,容易に切除可能となった症例を経験したので報告する.症例は32歳,男性で便通異常を主訴に近医を受診した.直腸巨大GISTと診断されたが,切除困難を理由に当院に紹介された.直腸,膀胱を圧排する長径10cm超の直腸GISTを認めた.IMによるNAを6カ月間行い,腫瘍は23.8%縮小した.手術は腹会陰式直腸切断術を施行したが,ひとまわり縮小したために切除は容易で下腹:神経,骨盤神経叢も確認・温存できた.本症例はIMのNAによりresectabilityの上昇,神経温存などの点でNAの利点を十分享受できたと考えられた.

A case of depressed early gastric cancer with nodular gastritis is described. A 47-year-old Japanese man was referred to our hospital and admitted for surgical treatment of gastric cancer. Barium upper gastrointestinal study and endoscopy examination showed a 4.5 × 3.0 cm depressed lesion with a deep central ulceration in the anterior wall of the lower corpus. An unusual miliary pattern resembling ‘goose flesh’ was observed endoscopically in the antrum. Biopsy specimens from the tumor showed poorly differentiated adenocarcinoma, and specimens from the antrum showed many lymphoid follicles with a germinal center. Immunoglobulin G antibody and histological tests (Giemsa stain) for Helicobacter pylori were both positive. Early gastric cancer with nodular gastritis was diagnosed and a subtotal gastrectomy was performed. Histological examination of the resected specimen showed a stage I tumor infiltrating a poorly differentiated adenocarcinoma with a depressed lesion in the corpus (type 0 IIc + III) and nodular gastritis in the antrum. The patient is doing well 1 year after surgery.

Dihydropyrimidine dehydrogenase (DPD) is the initial, rate-limiting enzyme in the catabolism of 5-fluorouracil (5-FU). DPD expression levels are believed to correlate with the 5-FU sensitivity of malignant tumors. In colorectal cancer (CRC), a few previous studies demonstrated that females could benefit more from adjuvant chemotherapy. However, it is still unknown why the effectiveness of postoperative chemotherapy is affected by gender. The objective of this study was to clarify the beneficial differences in 5-FU chemotherapy between genders in patients with the CRC based on DPD expression. Ninety-seven tumor specimens and 92 adjacent normal tissue specimens from 97 patients with the CRC and no prior therapy were obtained. The DPD expression in the tissues was quantified and analyzed based on clinicopathological factors. In the tumor tissue, the DPD expression in females was significantly lower than that in males. In the normal tissues, however, there were no significant differences in DPD expression between genders. In the treatment of CRC, cases who will benefit most because of 5-FU sensitivity; i.e. cases with lower DPD expression, must be given priority. Based on DPD expression, female gender seems to be a predictive factor for a better response to chemotherapy with 5-FU.

Background/Purpose Matrix metalloproteinases (MMPs) have been implicated as playing an important role in cancer invasion and metastasis. MMPs have been identified in various malignancies, including pancreatic duct adenocarcinomas. Methods We investigated the circulating level of MMP-2 and MMP-9 in sera from Syrian golden hamsters into which hamster pancreatic duct adenocarcinoma tissues had been transplanted subcutaneously (HPDt hamsters). Northern blot analysis and gelatin zymographic analysis were performed to detect the expression of MMPs and that of tissue inhibitors of metalloproteinases (TIMPs) in HPDt hamsters. Results Northern analysis revealed overexpression of MMP-2, MMP-9, and TIMP-2 mRNAs in subcutaneous tumors of HPDt hamsters as compared with normal pancreatic tissue. Sera from HPDt hamsters possessed significantly higher levels of serum MMP-2 and MMP-9 than control sera, as determined by gelatin zymographic analysis, and there was a significant correlation between tumor growth and serum MMP levels. Conclusions These results indicate that overexpression of MMP mRNAs is involved in the progression of pancreatic duct adenocarcinomas, and that MMP protein expression in hamster sera is associated with the presence of pancreatic duct adenocarcinoma cells. The findings also suggest that serum MMPs could be useful markers for monitoring patients with pancreatic duct adenocarcinomas.

The carcinogenic potential of 9-(4’-aminophenyl)-9H-pyrido[3,4-b]indole (aminophenylnorharman: APNH), a newly identified heterocyclic amine, was evaluated in a rapid production model for pancreatic duct adenocarcinoma in hamsters. In experiment 1, the initiation potential of APNH was examined. Hamsters received corn oil, 30 mg/kg body weight N-nitrosobis(2-oxopropyl)amine (BOP) or APNH (totally 50 and 100 mg/kg) as initiators followed by two cycles of augmentation pressure for pancreatic duct carcinogenesis and were sacrificed 75 to 78 days after the beginning of the experiment. Ductal hyperplasia and atypical hyperplasias developed in hamsters receiving APNH but their numbers and incidences did not differ from the corn oil case. In experiment 2, promoting potential of APNH for pancreatic duct carcinogenesis was examined. Hamsters received 30 mg/kg body weight BOP as an initiator followed by augmentation pressures and thereafter diet containing 0, 25 or 50 ppm APNH for 50 days. All hamsters were sacrificed 100 days after the beginning of the experiment. The numbers and incidences of ductal lesions, including adenocarcinomas, did not differ among the experimental groups. The results suggest, APNH may not have initiation or promotion potential for pancreatic duct carcinogenesis in hamsters.

A 57 year-old man presented with abdominal discomfort and melena. Abdominal ultrasonography clearly revealed a duodenal tumor as a hypoechoic mass in the transverse segment of the duodenum. The lesion was a 4 x 4-cm oval mass with partial concavity, an irregular surface, high-level central echoes, and a hypoechoic periphery. After confirmation of the diagnosis of duodenal carcinoma, a pylorus-preserving pancreatoduodenectomy was performed curatively. Pathological examination revealed moderately differentiated tubular adenocarcinoma partially invading the pancreatic parenchyma. Ultrasonography can be used to detect lesions of the transverse segment of the duodenum as the first imaging procedure.

Inflammatory bowel disease (IBD), the precise etiology of which remains unknown, is comprised of two forms of chronic intestinal inflammation; ulcerative colitis (UC) and Crohn's disease (CD). Recent evidence increasingly suggests that IBD is the result of dysfunctional immunoregulation manifested by inappropriate production of mucosal cytokines. An abnormal microcirculatory system has also been implicated in its pathogenesis. To elucidate the mechanism of ischemic change in IBD, we assesse serum concentration levels of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF), and plasma level of endothelin-1 (ET-1). We also investigated the expression of VEGF, b-FGF, and transforming growth factor-beta1,2,3 (TGF-beta1,2,3) in tissue by immunostaining.Blood samples were obtained from 11 patients with UC, 11 patients with CD, and 10 patients as controls. Paraffin-embedded samples were used for an immunohistochemical study.The concentration levels (in picograms per milliliter) were as follows: for ET-1, UC: 127+/-47.0, CD: 167.3+/-35.1, and controls (asthma: 38.5+/-23.8, p0.01; diverticulitis: 40.5+/-25.6, p0.01), for b-FGF, UC: 9.2+/-1.9, CD: 9.1+/-1.5, and controls (asthma: 5.0+/-0, p0.01; diverticulitis: 5.0+/-0, p0.01), for VEGF, UC: 659.8+/-181.0, CD: 740.0+/-182.3, and controls (asthma: 193.7+/-58.7, p0.01; diverticulitis: 199.6+/-59.7, p0.01). The levels of VEGF and b-FGF were significantly higher in active IBD than those in the controls. There was a significant positive correlation among the serum levels of VEGF and b-FGF and the plasma level of ET-1; that is, elevated VEGF, b-FGF, and ET-1 levels correlated well with each other. Immunohistochemical studies showed increased venula in the submucosa and lamina propria. Overexpression of VEGF and b-FGF in endothelial cells was revealed and TGF-beta2 and TGF-beta3 were found in inflammatory cells of active IBD, but no change was observed around the vessels in the controls.It is suggested that the reciprocal reaction of these cytokines may contribute to angiogenesis in IBD b inducing intestinal ischemia through vasoconstriction.

高齢人口の増加とともに大腸癌手術症例のうち高齢者の占める割合は増加の一途をたどり,当科では高齢者 (75歳以上)は20%を越えた.そこで高齢群(75歳以上)(240例) と非高齢群(41～50歳)(155例)を臨床病理学的に比較し高齢者の特徴を検討した.他病死を含めた累積生存率は高齢群で不良であった.術後早期死亡例の検討では高齢群といえども非高齢群と変わらず安全に手術が行われていた.両群間の腹膜播種,肝転移,リンパ節転移,壁深達度には有意差はみられず高齢者に進行例が多いとはいえなかった.組織学的分化度の検討では高齢群は高分化型が多いという傾向はみられず,一般的に高齢者癌は悪性度が低いという印象があるが,大腸癌にっいては非高齢者と変わらなかった.腫瘍占居部位は高齢群女性で右側結腸に発生する頻度が高かった.死因では他病死の占める割合が多く,併存疾患,余命を考慮した手術が行われるべきである.

脾原発inflammatory pseudotumorの2 例を経験したので報告する. 症例1は53歳の男性で, 胃癌にて遠位側胃切除術を施行後, 腹部超音波検査にて脾腫瘤を指摘され入院した. 腹部CT検査で脾内に被膜を有する低吸収値の腫瘤を認め被膜のみに造影効果を認めた. 胃癌の孤立性脾転移, 脾過誤腫などを疑い摘脾術を施行した. 症例2は40歳の女性で, 6 年前に子宮全摘の既往があり, 胃粘膜下腫瘍の経過観察中に腹部超音波検査にて脾腫瘤を摘摘され入院した. 腹部CT検査で等吸収値の腫瘤を認め, MRI検査ではT1, T2強調像とも低信号で, ガドリニウム負荷にて内部が淡く造影された. 症例1の経験からinflammatory pseudotumorも疑い摘脾術を施行した. いずれも病理組織学的に脾原発in-flammatory pseudotumorと診断した. 本例は2例とも開腹手術の既往があり, 開腹操作が本症の発生に関与している可能性が示唆された.

We describe herein the case of a 68-year-old man with malignant mesothelioma of the tunica vaginalis testis. The pathological diagnosis was based upon the clinical findings, gross and microscopic morphology, and special stains. Malignant mesothelioma is a rare tumor associated with asbestos exposure that can be effectively treated with orchidectomy via an inguinal approach.

A case of solid-pseudopapillary carcinoma (SPC) of the pancreas in a 34-year-old Japanese woman is presented. An abdominal ultrasonography revealed a mass, which measured 10 cm in diameter, in the body and tail of the pancreas. The tumor was resected and it was originally diagnosed as a non-functioning islet cell tumor. One year and five months later, the patient was re-admitted to hospital, and liver metastasis was confirmed by ultrasonography. The patient died 6 days after the second transcatheter arterial embolization (TAE) required for the metastasis. The autopsy showed small foci of liver metastasis. A retrospective examination of the tumor suggested the diagnosis of SPC because of its characteristic solid and pseudopapillary structures, immunohistochemical findings, and liver metastasis. This case suggests that capsular invasion, specifically found at the surgical margin of the peritoneal side, may be an important pathological finding that is suggestive of malignant potential in solid-pseudopapillary tumor. If there is such a finding in a surgical specimen, an intensive follow up should be advised to the clinician.

A primary hepatic carcinoid tumor arising in a 49-year-old woman is reported. The patient was admitted with multiple hepatic tumors and treated by a left lobectomy and cholecystectomy. Cut sections of the specimen revealed a solid and necrotic mass, measuring 10 x 12 x 13 cm, with multiple small satellite nodules. Histologically, the tumor cells had small oval-shaped nuclei and presented with a trabecular arrangement and rosette-like formation. Both Grimelius and Fontana-Mason stainings were positive. The tumor cells were positive for chromogranin A and negative for other antigens. Ultrastructural studies of the tumor cells revealed duct-like formation with microvilli and a cluster of dense small immature neurosecretory granules in the cytoplasm. These findings were consistent with those of carcinoid tumors. Postoperatively, the patient was treated with repeated transcatheter arterial chemoembolization for any remnant tumors. However, she died of the disease 5 years after the initial surgery. The autopsy findings suggested the primary site to be the liver.

To investigate the prognostic factors of pancreatic cancer, a retrospective analysis of 193 patients who underwent curative resection was conducted. Of the 193 patients, 38 (20%) survived for more than 5 years, the 5-year survival rates for stages I, II, III, and IV disease being 41%, 17% 11%, and 6%, respectively. According to a multivariate analysis, lymph node metastasis, intrapancreatic perineural invasion, and portal vein invasion were significant prognostic factors. Subsequently, a subgroup analysis concerning nodal metastasis and intrapancreatic perineural invasion was performed in 126 patients with records of these histological findings. In the group of patients without nodal metastasis, the 5-year survival rate for those without perineural invasion was 75%, whereas that for those with perineural invasion was 29%, the difference in survival of these subgroups being significant (P

Two cases of anorectal malignant melanoma are reported. Malignant melanoma of the digestive tract is rare and the prognosis is dismal. Both a 70-year-old woman (case 1) having a left inguinal lymphadenopathy and an 80-year-old woman (case 2) having multiple metastatic shadows on a chest x-ray film were admitted to the hospital with a year's history of blood stools. A digital examination easily revealed a bleeding ulcerating tumor in the anterior wall of the anal canal in case 1, and in the left posterior wall of the rectum close to the anal verge in case 2. The biopsy specimens of both cases were diagnosed as malignant melanoma histologically and immunohistologically. An abdominoperineal resection (APR) was performed, followed by adjuvant immunochemotherapy with DAV and interferon-β in case 1. Case 2 did not receive chemotherapy because no enlargement of metastatic lesions in the lung occurred during her hospitalization. In this paper some problems in the diagnosis and treatment of the disease are discussed based on our cases together with previous cases in the literature. We would emphasize the importance of our surgeons careful attention to the possible presence of the disease and early detection based on macroscopic findings to improve the prognosis.

Two cases of retroperitoneal leiomyosarcoma are reported. Patient 1, a 68-year-old man, was admitted to the hospital because of a left upper abdominal mass.Abdominal echo and CT scan showed giant masshaving necrotic change. The tumor 16×15×19cm in size and developing in the retroperitoneum was removed with the body and tail of pancreas, and spleen tran-speritoneally.Patient 2, a 65-year-old man, was admitted to the hospital because of tarry stool and fatigability.Abdominal echo and CT scan showed a well demarcated large abdominal mass accompanying with colonic gas. Intraoperative findings showed that the tumor invaded the second portion of duodenum and pancreas head. The tumor 13×7×6cm in size, was removed by partial resection of the duodenum and pancreas tran-speritoneally.The pathological diagnoses of case 1 and 2 were retroperitoneal leiomyosarcoma.Postoperative courses of both patients were uneventful.Histological grading is the Determinant prognostic factor for retroperitoneal sarcomas.We would emphasize the importance of early detection and if necessary, radical resection as much as possible which is the most effective and available treatment.

A 59-year-old male with an established diagnosis of malignant melanoma of the nasal cavity plus multiple pulmonary metastases was referred to our hospital because of abdominal pain and vomiting. Double-contrast study of the small intestine revealed a filling defect in the middle of the ileum. lntraoperative enteroscopy revealed that the ileal tumor was ulcerated, and that it was covered by ileal mucosa of normal appearance. Because no other lesions were identified within the intestine, the ileal segment with the tumor was surgically removed. The tumor was diagnosed as malignant melanoma with a histology similar to that of nasal mass. The patient has survived for the subsequent 13 months, during which no gastrointestinal symptoms recurred. Our case suggests that metastasis should be included in the differential diagnosis of a single small intestinal tumor. (Dig Endose 1999; 11: 47–51)

Background Intraductal papillary-mucinous carcinoma of the pancreas is a new diagnostic term proposed by the 1996 World Health Organization classification of the exocrine pancreas. So far, there have been only a few reports concerning its cytologic findings, especially in noninvasive cases. Cases The clinical and cytohistologic findings in two cases of noninvasive intraductal papillary-mucinous carcinoma of the pancreas were reviewed. Cytologic specimens were obtained from pure pancreatic juice in the dilated main pancreatic duct during the operation (case 1) and during endoscopic retrograde pancreatography (ERP) (case 2). Both cases showed three-dimensionally or individually scattered tumor cells with an increased nuclear/cytoplasmic ratio and prominent nucleoli. Conclusion Our cases suggest that pancreatic juice cytology during ERP or surgery is useful in diagnosing pancreatic cancers and that it may detect noninvasive intraductal papillary-mucinous carcinoma of the pancreas.

Pyogenic granuloma, a polypoid form of capillary hemangioma, commonly occurs on the skin and mucosal surfaces but only rarely in portions of the gastrointestinal (GI) tract other than the oral cavity. We report the case of a 75-year-old woman who suffered from recurring fatigue and had anemia. Double-contrast radiography revealed a sessile tumor of the ileum, and endoscopy during surgery revealed a polypoid lesion in the ileum, 150 cm from Bauhin's valve. The histological features were consistent with those of pyogenic granuloma.

Telomerase activities in intrahepatic cholangiocarcinomas induced by N-nitrosobis(2-oxopropyl)amine (BOP) in female hamsters were determined using a telomeric repeat amplification protocol (TRAP) assay followed by densitometric quantification. Each determination was repeated to confirm the results and telomerase activity was also detected by gel electrophoresis. An increase was evident in all of 10 cholangiocarcinomas examined, with levels ranging from 2.48 to 4.40 times the normal liver value by densitometric quantification. This finding of a consistent increase suggests that telomerase activation is involved in the development of intrahepatic cholangiocarcinomas and immortalization of cancer cells.

The effects of alpha-carotene, beta-carotene, palm carotene, and green tea polyphenols (GTP) on the progression stage of pancreatic carcinogenesis after rapid production of ductal lesions were studied in Syrian hamsters. Dose threshold inhibitory effects were noted for beta-carotene, 25 ppm, and palm carotene, 40 ppm, which includes 24 ppm beta-carotene reducing the numbers of putative preneoplastic lesions of duct epithelial hyperplasia and atypical hyperplasia, as well as carcinoma in situ and invasive carcinomas. GTP at doses of 500 and 5000 ppm, but not 100 ppm, also significantly decreased the numbers of hyperplasia and total duct lesions. Combined administration of 40 ppm palm carotene, and 50 ppm GTP similarly inhibited the lesion development. Alpha-carotene, however, did not affect pancreatic carcinogenesis. The results suggest that chemopreventive effects are exerted by beta-carotene and GTP above critical doses and that combined administration of palm carotene and GTP might be a candidate chemoprevention strategy for pancreatic cancer in humans.

An experimental model for the induction of extrahepatic biliary duct carcinomas in hamsters given cholecystoduodenostomy with dissection of the extrahepatic duct at the distal end of the common duct (CDDB) followed by N-nitrosobis(2-oxopropyl)amine (BOP) has been reported [Tajima et al. (1994) Jpn. J. Cancer Res., 85, 780-788]. The CDDB procedure greatly accelerates cell turnover in the biliary epithelium. In the present experiment, mutations of K-ras and p53 genes in the induced lesions were investigated by the reverse transcriptase-polymerase chain reaction-single strand conformation polymorphism (RT-PCR-SSCP) method followed by direct sequencing. Mutations of K-ras, involving a G to A transition in second position of codon 12 of K-ras exon 1, were detected in six out of eight (75%) extrahepatic bile duct carcinomas and six out of eleven (54.5%) pancreatic duct carcinomas. However, no mutations of p53 were observed in either tumor type. The results indicate an association between anomalous pancreaticobiliary junction and development of biliary carcinomas that may be pertinent to the human situation, and indicate that conditions of the model predispose to mutations occurring in K-ras but not p53.

We experienced a rare case of malignant melanoma metastasized to the small intestine. A 59-year-old man, who had been diagnosed as having a malignant melanoma of the nasal cavity two years earlier, had been admitted to the Department of Otorhinolaryngology in our hospital several times for anticancer drug treatment. On November 6, 1994, he was seen at the Department of Surgey in the hospital because of upper abdominal pain. He had a protuberant tense abdomen with slight tenderness and bilateral nasal bleeding with anemia. Plain abdominal roentgenograms showed multiple, small fluid levels of the small bowel. These findings were suggestive of obstruction of the small intestine. Nasogastric long tube suction was continued and intravenous hyperalimentation was given. After relief of the intestinal obstruction, an abdominal firm mass was palpated and a barium meal study demonstrated a filling defect in the ileum. The preoperative diagnosis was made as metastatic malignant melanoma to the ileum. At operation, endoscopic examination of the small intestine showed a 3.0×3.0 cm nodular mass in the ileum with no other lesions. Partial resection of the ileum with the tumor was performed. Macroscopic examination of the resected specimen revealed a brown nodular mass with an ulcer, 2.5×2.5 cm in size, which occupied most of the intestinal wall area. In immunohistological stainig, S-100 antibody was positive. The histological diagnosis was thus established as metastatic malignant melanoma to the ileum. The patient was discharged on the 14th day after the surgery following an uneventful postoperative course. However, he died of metastatic lung cancer with no abdominal complaints one year after the operation.

We report a case of adenosquamous carcinoma of the stomach which involved only the mucosa and submucosa, but was found to have already metastasized to a regional lymph node and the liver at surgery. Adenosquamous carcinomas of the stomach are rare and usually invade deeply into the muscular layer. Those limited to the mucosa and submucosa are extremely rare, and only seven cases have been reported to date. It was interesting that in our case, 80% of the tumor in the stomach and lymph node was composed of squamous cell carcinoma and 20% consisted of adenocarcinoma, whereas the metastases in the liver consisted entirely of adenocarcinoma. The literature on this type of gastric carcinoma is reviewed and the possible histogenesis of this tumor is discussed.

The aim of this study was to examine whether the type of bilioenterostomy enhances biliary carcinogenesis in the hamster model. Syrian hamsters were divided into the following groups ; simple laparotomy (control group), cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CDDB group) and cholecystoileostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CIDB group). Following these procedures, all hamsters received N-nitrosobis(2-oxopropyl)amine. The diameter of the extrahepatic bile duct and plasma levels of cholecystokinin (CCK) were measured and the number of neoplastic lesions was counted microscopically. Proliferative effect of the procedures on the biliary epithelium was examined by proliferative cell nuclear antigen. In the CDDB group the extrahepatic bile duct was significantly dilated and carcinogenesis of the gall-bladder and extrahepatic bile ducts was enhanced. In the CIDB group the CCK bioactivity was stimulated and intrahepatic biliary duct, but not gall bladder and extrahepatic bile duct, carcinogenesis was promoted more than that observed in the CDDB group. Proliferation of the biliary duct epithelium was enhanced in both the CDDB and CIDB groups. Cholecystoduodenostomy enhanced intra- and extrahepatic bile duct carcinoma, whereas cholecystoileostomy promoted only intrahepatic bile duct carcinoma. Some factors in the intestinal juice seem to play a role in the promotion of biliary tract carcinoma.

The role played by extrinsic nerves in colonic motor activity and motor coordination between the small intestine and the colon in the fasting state was investigated in a canine model. To evaluate motor activity before and after celiac and superior mesenteric ganglionectomy (CSMG), seven strain gauge force transducers were implanted in the small and large bowels of five dogs. No significant differences were observed in the frequency, duration, cycle, or migration time of bursts of contractions from the colon (BCC), or in the duration of the quiescent state before and after CSMG. When small intestinal phase III activity reached the ileocecal junction before and after CSMG, a characteristic contractile pattern, namely, small intestinal phase III activity followed by BCC, was observed at the ileocecal junction. Before and after CSMG, 84% and 83% of the small intestinal phase III activity, respectively, was transmitted to the colon as BCC after reaching the ileocecal junction. However, only 19% and 18% of BCC before and after CSMG, respectively, followed small intestinal phase III activity. These results led us to conclude that the extrinsic nerves exert little effect on fasting colonic motor activity and motor transmission from the small intestine to the colon.

A nonfunctioning islet cell tumor of the pancreas in a 68-yr-old female is reported. All of the laboratory data, including serum hormones, glucose, and tumor markers, were within normal limits. A pancreatoduodenectomy was performed. Cut sections of the specimen revealed a cystic mass measuring 6.0 x 4.5 x 3.5 cm. Histologically, the tumor consisted of large acidophilic cells with bizarre giant nuclei. The tumor cells were positive for chromogranin-A, synaptophysin, neuron-specific enolase, and S-100 protein. Multifocal proliferation of endocrine cells, centroacinar cells and changes in acinar cells were found in the adjacent uninvolved pancreatic tissue. Ultrastructural studies of the tumor revealed clear nuclei with no zymogen, but immature neurosecretory granules in the cytoplasm of the tumor cells. These findings were consistent with those of nonfunctioning islet cell tumors, especially of the pleomorphic type. To the best of our knowledge, this is the first report on pleomorphic nonfunctioning pancreatic islet cell tumors.

An unusual case of a toothpick perforating the stomach, then penetrating the liver, and thereafter forming a liver abscess is reported. A 48-year-old woman who had ingested a toothpick 1 month earlier was admitted to our hospital because of severe epigastralgia which had progressively worsened. A laparotomy was performed because a granulomatous abscess in the liver due to this ingested foreign body was suspected. We found a granulomatous abscess in the liver due to the penetration of the toothpick through the stomach. The toothpick had become completely embedded about 2 cm deep in the left lobe of the liver. When dissecting the tumor, a 5.5-cm toothpick was removed, and a partial lateral resection of the liver was performed. The histological diagnosis was a hepatic abscess with granulomatous change. This was a rare case of a migration of an ingested toothpick into the liver through the stomach.

A carcinoma of the gallbladder was transplantable in Syrian golden hamsters. The tumor was induced by subcutaneous injection of N-nitrosobis (2-oxopropyl) amine (BOP) following dissection of the common duct and preparation of a cholecysto-duodenostomy. The histology revealed a poorly differentiated adenocarcinoma. The tumor was inoculated into the cavity of the gallbladder and subcutaneous tissue of the hamster and was transplantable (uptake rate was 100%). This tumor expressed blood group-related antigens, including A, H, and P-glycoproteins. To our knowledge, this is the first report of carcinoma of the gallbladder transplantable in a laboratory animal.

The pancreatic lesions in 6- to 36-week-old spontaneously hypertensive rats (SHR), stroke prone SHR (SHRSP) and Wistar-Kyoto rats (WKY) were examined histopathologically. Inflammatory cell infiltration with hemorrhage and stromal fibrosis became evident in 12-week-old SHR and SHRSP together with acinar atrophy and/or degeneration and ductular proliferation. These changes in SHR and SHRSP were even more prominent at the age of 24 weeks and extremely severe at 36 weeks. In addition, in SHR and SHRSP over 12 weeks of age, small necrosis of acinar cells was found occasionally together with fibrosis and arteriosclerosis. Pancreatic arteriosclerosis was marked in SHR and SHRSP over 24 weeks of age at the level of arterioles < 200 microns in diameter. Adrenergic nerve fibers stained by fluorescence histochemistry were present around the pancreatic arteries and ducts and within the parenchyma, and they were denser in SHR and SHRSP than in WKY, indicating hyperinnervation of the sympathetic nervous system in SHR and SHRSP. It is suggested that the pancreatic ischemia caused by arteriosclerosis due to facilitation of the sympathetic nervous system is an important factor in the pathogenesis of the spontaneous pancreatitis of SHR and SHRSP.

症例は84歳の女性.主訴は右季肋部痛.Computed tomographyにて膵頭部に腫瘤を認め, 血管造影にて同部に淡いtumor stainあり.十二指腸粘膜下腫瘍の診断で膵頭十二指腸切除術施行.摘出腫瘤は径8cm大, 十二指腸壁より壁外性に発育し, 内部に出血壊死を認めた.組織学的にはH.E.染色でリンパ球浸潤が多く, 紡錘型の腫瘍細胞が束状に配列し, 核のpalisadingを示すAntoniA型の組織型を部分的に認めた.銀染色では, 繊細な好銀線維が, 線維末端まで不規則に分枝していた.免疫染色ではS-100蛋白, desmin, neuron specific enolase, actinすべて陰性であった.Mitosisは少なく, 良性もしくは低悪性度の神経鞘腫と診断された.しかし, 35か月後, 肝転移再発により死亡した.十二指腸神経鞘腫の本邦報告は20例のみで, なかでも悪性は3例であった.本例は免疫染色を用いても, 平滑筋腫瘍との鑑別が困難で, H.E.および銀染色所見より神経鞘腫と診断し, 臨床経過より悪性と判断した.

To assess the postoperative outcome of jaundiced patients and to select the optimal timing for surgical intervention, indocyanin green (ICG) concentrations in the bile were measured after biliary decompression in patients with obstructive jaundice. The maximal excretion rate of ICG in the bile was calculated as a function of time (ICG Bmax). Among 59 patients with positive ICG Bmax values, morbidity was 15.2% and postoperative hospital mortality was 3.3%. However, the morbidity and mortality in nine patients with values between -0.5 and 0 were 88.8 and 44.4%, respectively. The 13 patients with in ICG Bmax below -0.5 had a 76.9% morbidity and a 61.5% mortality. The patients with ICG Bmax values below 0 showed a significantly higher morbidity and mortality than positive ICG Bmax patients. In patients showing ICG Bmax values below -0.5, surgery is contraindicated despite intensive postoperative care. The ICG Bmax value improved according to the increasing effect of biliary decompression. The index is useful not only as a prognostic index in the early phase of biliary decompression but also as an index of bile secretory capacity at a given time. By means of time course measurement of this index, the suitable time for operation can be determined. The ICG Bmax is a useful and reliable indicator in the assessment of hepatobiliary functional reserve in jaundiced patients after biliary decompression and prior to further surgical intervention.

A solid and cystic tumor (SCT) of the pancreas occurring in a 35-yr-old male is reported. Cut sections of the specimen revealed a solid, ill-defined mass measuring 2.5 x 2.3 x 2.0 cm, without cystic or necrotic changes. Histologically, the solid tumor consisted of small, round acidophilic cells invading the surrounding pancreatic parenchyma. The tumor cells were positive for alpha-1-antitrypsin and neuron-specific-enolase. Ultrastructural studies revealed clear nuclei with no zymogen, but immature secretory granules in the cytoplasm of the tumor cells, which had a junctional complex-like structure. These findings were consistent with the so-called solid and cystic tumor of the pancreas. There was neither a capsule surrounding the tumor nor a papillary structure, known to be characteristic findings of the SCT tumor. The small tumor reported in the present article might represent an early-stage SCT of the pancreas.

A total of 143 patients who underwent hepatic resection for hepatocellular carcinoma in our department were reviewed. The review was conducted for two periods: 1970-1982 (early period) and 1983-1990 (late period), that is, the periods before and after introduction of the hepatic surgical technique involving the use of a microwave tissue coagulator and ultrasonic dissector. One patient underwent extended lobectomy, 12 lobectomy, 9 segmentectomy, and 26 partial hepatectomy during the early period. Two patients underwent extended lobectomy, 7 lobectomy, 9 segmentectomy, 36 subsegmentectomy, and 41 partial hepatectomy during the late period. Operative mortality and hospital mortality were 16.7% and 22.9% during the early period and 1.1% and 8.4% during the late period, respectively. The overall mortality rate was significantly lower during the late period than during the early period. Postoperative complications developed in 62.5% of the patients with hepatic resection during the early period and in 48.4% of the patients during the late period. The size of tumors during the early period was significantly greater than that during the late period. Intraoperative blood loss during the late period was significantly lower than that during the early period. The survival curve was better among patients who underwent hepatic resection during the late period than among those during the early period. The satisfactory results during the late period are due to the introduction of intraoperative ultrasonography, microwave tissue coagulation, and ultrasonic dissection for hepatic surgery.

Five patients with peripancreatic abscesses associated with severe acute pancreatitis were treated by hyperbaric oxygen therapy (HBO). In 3 patients, the course after surgical mobilization of the pancreas and drainage of the pancreas bed was complicated by peripancreatic abscesses. HBO was conducted under a pressure of 2.8 atmospheres for two hours daily. Four of the 5 patients showed a progressive improvement in their condition. In one patient who failed to respond despite seven sessions of HBO, Pseudomonas aeruginosa was isolated from the discharge, and resection of necrotic tissue and drainage were performed. The main effects of HBO were the alleviation of high spiking fever, the improvement of white blood cell count and serum amylase levels, and the reduction of the abscess size. We recognized HBO to be a successful treatment for peripancreatic abscess associated with severe acute pancreatitis and better results were obtained than in cases that did not receive HBO.