A case of metastatic hemangiopericytoma occurring 16 years after initial presentation: with special reference to the clinical behavior and treatment of metastatic hemangiopericytoma.

A 40-year-old woman was referred to our Department of Surgery because of an abdominal wall mass. Sixteen years earlier, she had undergone surgical resection of an inguinal tumor that had been diagnosed as a hemangiosarcoma. Fourteen months after the initial resection, the tumor recurred locally, and complete resection was performed. Twenty-nine months later, computed tomography showed multiple metastatic tumors in the lung. All these tumors were resected during thoracoscopic surgery. Thirteen years after the patient's 3rd operation, a firm mass was detected in the left lower quadrant of the abdominal wall. Magnetic resonance image showed a well-defined mass with heterogeneous contrast enhancement within the rectus abdominis muscle. Positron emission tomography-computed tomography demonstrated no recurrent tumors other than this mass. Complete resection was performed. Microscopic examination showed that this tumor was composed of hypercellular spindle cells and staghorn-shaped blood vessels. The average number of mitotic figures was 28 per 10 high-power fields. Immunohistochemical examination of the tumor showed focal positivity for CD34. Therefore, the tumor was diagnosed as a metastatic hemangiopericytoma with malignant potential. Careful long-term follow-up is required because metastases can develop after an extended disease-free interval. Aggressive surgical treatment is recommended for distant metastases.

Efficacy of a Blake drainR on pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND/AIMS: The aim of this study was to evaluate the efficacy of the Blake drain for the management of pancreatic fistula (PF) in comparison with the Duple drain. METHODOLOGY: Our study consisted of two parts: a retrospective review of 33 patients with PF after pancreaticoduodenectomy, and a basic experiment to investigate the effects of the Blake drain on the management of PF in an animal model. RESULTS: In the clinical study, 19 patients received Blake drains (B-group) and 14 received Duple drains (D-group). Grade C fistulas with abdominal bleeding developed in only 2 patients in the B-group. All the patients in the B-group healed with conservative treatment (P<0.01). and none of them required percutaneous drainage or reoperation (P<0.05). In the basic experiment, no collections of fluid were detected around the Blake drains. When leakage occurred, it did not lead to abdominal abscess, and a "drain canal" formation linking the anastomosis with the extracorporeal orifice was demonstrated all along the drainage route. CONCLUSIONS: Blake drains may be efficient therapeutic tools in patients with grade B fistulas. The basic experiment affirms that Blake drains provide excellent drainage and contribute to the formation of "drain canals" effective in localizing and controlling PF.

Multicentric pancreatic intraepithelial neoplasias (PanINs) presenting with the clinical features of chronic pancreatitis.

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.

Improvement of intraoperative frozen section diagnosis in patients with biliary strictures by Levovist injection into the bile duct on color Doppler ultrasonography.

BACKGROUND: This study evaluates the efficiency of color Doppler ultrasonography-guided intraoperative pancreatic biopsy (CDUS-IPB) using Levovist injected into the bile duct in conjunction with stimulated acoustic emission (SAE) in patients with biliary strictures. METHODS: The study was performed on 12 patients. After completing a conventional intraoperative pancreatic biopsy (c-IPB), each subject underwent CDUS with SAE imaging using Levovist. Upon identification of the biliary stricture, the IPB was taken from the area surrounding the stricture on the same imaging setting. Section diagnosis of the CDUS-IPB specimen was compared to that of the c-IPB specimen and resected tissue. RESULTS: Biliary strictures were identified as enhanced areas of color Doppler signal on CDUS. CDUS-IPB provided adequate specimens from the biliary strictures in all cases and corrected false-negative diagnoses by c-IPB in three cases. Section diagnosis by CDUS-IPB corresponded to the permanent section diagnosis. There were no complications. CONCLUSIONS: CDUS-IPB with Levovist is an accurate diagnostic tool. The method is especially useful for patients with a suspected malignant biliary stricture who show no tumor mass in preoperative images and no evidence of malignancy on cytologic examinations.

Clinicopathologic study on pancreatic groove carcinoma.

OBJECTIVES: Pancreatic groove carcinoma usually presents with duodenal stenosis. This report describes the clinicopathologic features of 5 cases. METHODS: All the clinical and radiological features were reviewed retrospectively and analyzed to identify correlations with the histological findings. RESULTS: Vomiting was an initial symptom in all cases, but obstructive jaundice was not inevitable until the disease progresses. Hypotonic duodenography demonstrated severe postbulbar stenosis. Pathological findings of biopsy specimens showed no evidence of malignancy at the early stage. Computed tomography revealed a hypovascular mass. Magnetic resonance imaging indicated a hypointense mass on T1-weighted images and an isointense to slightly hyperintense mass on T2 images. Macroscopically, the stenosis seemed to be the result of a hard yellowish-white tumor invading the duodenal wall. Histopathologically, an adenocarcinoma arising from the groove infiltrated the submucosal layer of the duodenum circumferentially. No cancer cells were found in the mucosa at the early stage. The intrapancreatic common bile duct was involved at the advanced stage. CONCLUSIONS: We believe that these features resulted from the anatomical characteristics of the groove involvement and that the string stricture of the duodenum resulted from invasion of the groove tumor into the submucosal layer around the wall.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases.

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis: a case report.

A 69-year-old man presented with obstructive jaundice and dark urine. Contrast-enhanced computed tomography revealed an enlarged pancreas with homogenous enhancement. Endoscopic retrograde pancreatography demonstrated short-segmental, irregular narrowing of the main pancreatic duct. The patient underwent exploratory laparotomy and needle biopsies of the pancreas, which showed marked fibrotic change with lymphocyte infiltration. These clinicopathologic findings suggested autoimmune pancreatitis. Four years later, computed tomography demonstrated marked periaortic soft tissue surrounding a calcified infrarenal abdominal aorta compatible with retroperitoneal fibrosis. We diagnosed retroperitoneal fibrosis with noncontiguous pancreatic fibrosis. This patient responded well to corticosteroid treatment. Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis seems to be extremely rare, and to our knowledge, only a few cases have been reported.

Pancreatic arteriovenous malformation involving adjacent duodenum with gastrointestinal bleeding: report of a case.

A 54-year-old man was admitted to our hospital with the symptoms of palpitation, dyspnea, and tarry stool. Upper gastroduodenal endoscopy revealed submucosal lesions with vascular ectasia in the second part of the duodenum. Dynamic computed tomography (CT) detected a hypervascular lesion in the pancreatic head and the duodenum. Selective angiography showed proliferation of a vascular network and early filling of the portal vein at the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation (AVM), we performed pylorus-preserving pancreaticoduodenectomy. At laparotomy, localized and meandering vessels were seen on the surface of the head of the pancreas. Histological examination showed dilated tortuous vessels accompanied by severed elastic fibers in the vessel media and blood clot formation. The incidence of pancreatic AVM remains extremely low, and recurrent gastrointestinal bleeding is a frequent complication. To prevent recurrent bleeding and progressive portal hypertension, surgery may be the definitive management of symptomatic AVM.