Guide to diagnosing primary pancreatic lymphoma, B-cell type: immunocytochemistry improves the diagnostic accuracy of endoscopic ultrasonography-guided fine needle aspiration cytology.

Primary pancreatic lymphoma (PPL) is a rare disease with <1%of extranodal non-Hodgkin's lymphoma arising in the pancreas. This report provides immunocytochemical information on PPL that would be valuable for making differential diagnoses between PPL, pancreatic neuroendocine tumor, acinar cell carcinoma, and pancreatic ductal cancer. A 68-year-old woman had a chief complaint of abdominal pain. Fine needle aspiration cytology (FNAC)was performed. The FNAC smear showed moderate cellularity,with a small to moderate number of irregular cells and lymphocytes.No epithelial tumor clusters or abundant mucoid background were seen. The cells were scattered with pleomorphism and showed irregular nuclear shapes with finely granular chromatin,an increased nuclei­cytoplasm ratio, and prominent nucleoli.Cytologically, PPL was suspected with Papanicolaou staining but definite diagnosis was not made. Therefore, the specimen was destained, immunocytochemically examined for leukocyte common antigen (LCA), and PPL was suspected again. Numerous tumor cells were found in the surgical sample and tumor cells were positive for CD20 and negative for CD45RO. Based on these findings,the tumor was diagnosed as PPL, B-cell type. The preoperative FNAC smear that was examined for LCA was then reexamined for CD20, CEA, and Synaptophysin. As a result, the tumor cells were positive for LCA and CD20, whereas they were negative for CEA and Synaptophysin. Taking these findings together with the cytopathologic findings, this specimen was reconfirmed as PPL. Immunocytochemical examination for LCA and CD20 is useful in the identification of malignant pancreatic lymphoma, B-cell type.

A case of IgG4-related sclerosing mesenteritis.

IgG4-related disease has been recognized as a systemic syndrome characterized by mass-forming lesions with lymphoplasmacytic infiltration and sclerosis. This disease has been identified in various sites, including the pancreas, retroperitoneum, lung, head, and neck. Herein we report a case of IgG4-related sclerosing mesenteritis. An 82-year-old woman was admitted to our hospital due to persistent abdominal pain. Abdominal computed tomography demonstrated a solitary mass with a maximal diameter of 11.7cm in mesentrium of the small intestine. On her laboratory examination, only C-reactive protein level was elevated. Although the pre-operative diagnosis was indefinite, she underwent ileocecectomy. Grossly, an elastic soft mass with foci of hemorrhage was seen in the mesentrium. Microscopically, the lesion was composed of fibroblastic or myofibroblastic spindle cells with abundant stromal fibrosis and inflammatory infiltrate, such as lymphocytes and plasma cells accompanied by lymphoid follicles with a germinal center. Obstructive phlebitis was observed. Immunohistochemically, numerous IgG4-positive plasma cells were observed, and the IgG4/IgG ratio was 75.9%. The serum level of IgG4 examined at post-operation was high. These findings suggested that this lesion was consistent with IgG4-related sclerosing mesenteritis.

Multi-centric pancreatic cancer without PanIN lesion.

The patient was a 67-year-old man under follow-up after gastric cancer surgery. An abdominal CT scan performed 1 year earlier had shown an approximately 14-mm hypovascular mass in the pancreatic body; however, he did not consent to treatment and was followed up for 1 year. A blood workup showed that the fasting blood glucose level, which had been within normal limits, was elevated to 174 mg/dl (normal, 70-109 mg/dl), and the HbA1c level was 12.0% (normal, 4.3-5.8%). Abdominal CT revealed an approximately 20-mm mass in the pancreatic body and an approximately 12-mm mass in the pancreatic tail, and magnetic resonance imaging cholangiopancreatography (MRCP) showed discontinuity of the main pancreatic duct (MPD). Since these findings led to the suspicion of invasive ductal carcinoma (IDC) of the pancreas developing in the pancreatic body and tail, we performed distal pancreatectomy with splenectomy. Histologically, IDCs were observed in the pancreatic body and tail. However, PanIN was not observed in the MPD between the two carcinomas. They were diagnosed as independent invasive ductal carcinomas of the pancreas.

[Phase I/II study of combination chemotherapy with gemcitabine and UFT for advanced pancreatic cancer in a multi-center trial].

The aim of this phase I/II study was to evaluate the tolerability and efficacy of combination chemotherapy with gemcitabine (GEM) and UFT for advanced pancreatic cancer. In phase I study UFT was given orally every day for 14 days and GEM was infused on day 1 and 8 at three dose levels (800, 900, 1,000 mg/m(2)/week) every 21 days. GEM 1,000 mg/m(2) and UFT 400 mg/m(2) did not reach the maximum tolerated dose. We decided that the recommended dose (RD) was GEM 1,000 mg/m(2)and UFT 400 mg/m(2). In phase II study 27 patients were enrolled and received GEM and UFT at RD. The tumor response rate was 17.6%, and the median survival was 221 days, which was very similar to that of GEM monotherapy. Due to adverse events, especially liver dysfunction, protocol therapy was discontinued in 12 patients. This study could not revealed the superiority of the GEM monotherapy.

Video-assisted thoracic surgery lobectomy for extralobar pulmonary sequestration in a child: report of a case.

Pulmonary sequestration in infants and children is conventionally treated by resecting the sequestered lung parenchyma (sequestrectomy) or by performing lobectomy through a standard thoracotomy. We performed lobectomy by video-assisted thoracic surgery, using an original tracheal tube that we designed, in a 6-year-old boy with extralobar pulmonary sequestration and bronchiectasis in the left lower lobe.

[Multi-center trial of gemcitabine for 49 patients with advanced pancreatic cancer].

Forty-nine patients with unresectable pancreatic cancer (stage IV disease) received gemcitabine in a multi-center trial in the Fukuoka pancreatic cancer chemotherapy group, Japan. No complete remissions, 5 partial remissions (10%) and 25 no changes (51%) were obtained. Gemcitabine could maintain QOL. Main toxicities were hematologic, especially neutropenia. Neutropenia tended to appear in early administration. Non-hematologic toxicities were anorexia, nausea/vomiting, and skin rash. The mean overall survival period was 7.5 months. Carcinomatous ascites and/or pleural effusion resulted in a poor prognosis (average survival 3.1 months). Gemcitabine could be given without severe toxicities in outpatient clinics. These results suggested that gemcitabine is currently a first-line therapeutic agent for advanced pancreatic cancer.

Signet-ring cell carcinoma of the ampulla of Vater: report of a case.

An 83-year-old man was admitted to our hospital complaining of general fatigue, fever, and obstructive jaundice. Percutaneous transhepatic bile duct drainage was performed. Gastroduodenal fiberscopy revealed carcinoma of the ampulla of Vater, and early gastric cancer was suspected. A pancreatoduodenectomy with lymph node dissection was performed. Although a biopsy specimen from the gastric lesion was suspected to be well-differentiated adenocarcinoma, no cancerous lesion was found in a specimen resected from the stomach. The histopathologic findings of the ampullary lesion were compatible with a diagnosis of signet-ring cell carcinoma. This is a rare lesion, and a review of the literature revealed only three previous similar cases.

Modified Dumon stent for the treatment of a bronchopleural fistula after pneumonectomy.

We describe the case of a 72-year-old man in whom a bronchopleural fistula developed after induction chemotherapy followed by right pneumonectomy for lung cancer. Resuturing of the right main bronchial stump, endoscopic treatment, and repair using a latissimus dorsi muscle flap were not effective. Consequently we placed a modified Dumon stent in the carina, which effectively closed the stump.

Xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis: report of a case.

There have been no reported cases of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis in the literature. There has been only one other case of xanthogranulomatous cholecystitis associated with a liver abscess in Japan prior to the present report. A 53-year-old man was admitted to a local hospital complaining of high fever. Abdominal ultrasonography and computed tomography showed a liver abscess. After percutaneous transhepatic abscess drainage, he complained of an abnormal sensation in his left eyeball and was diagnosed to have endophthalmitis. After being treated for the endophthalmitis, he was referred to our hospital to have the liver abscess evaluated. Endoscopic retrograde cholangiopancreatography showed a normal biliary system without any communication with the liver abscess. Two weeks after endoscopic retrograde cholangiopancreatography he complained of right hypochondralgia. Ultrasonography revealed the presence of sludge in the swollen gallbladder. Under a diagnosis of cholecystitis with a liver abscess, a cholecystectomy was performed. A histological examination indicated xanthogranulomatous cholecystitis based on the findings of a granulomatous lesion consisting of foamy cells in the gallbladder wall. We herein present the first known case of xanthogranulomatous cholecystitis with a liver abscess and metastatic endophthalmitis, while also making a review of the literature.

Surgical resection combined with chemotherapy for advanced hepatocellular carcinoma with tumor thrombus: report of 19 cases.

BACKGROUND: Prognosis of hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein (MPV), inferior vena cava (IVC), or extrahepatic bile duct (EBD) treated by conventional therapies has been considered poor. This study aimed to evaluate the efficacy of hepatic arterial infusion chemotherapy after surgical resection as an adjuvant therapy or as a treatment for intrahepatic recurrence of HCC with tumor thrombus in MPV, IVC, or EBD. METHODS: Nineteen patients with HCC and tumor thrombus in the MPV, IVC, or EBD who underwent hepatectomy with thrombectomy were reviewed retrospectively. RESULTS: The overall 3-year survival rate was 48.5%. Two patients with postoperative residual tumor thrombus died within 6 months owing to rapid progression of the residual tumor thrombus. Five patients survived more than 5 years after their operations. Tumors disappeared completely in 3 patients after hepatic arterial infusion chemotherapy with a combination of cisplatinum and 5-fluorouracil, and the longest survival period was 17 years and 11 months in a patient with EBD thrombus. CONCLUSIONS: If hepatic reserve is satisfactory, an aggressive surgical approach combined with chemotherapy seems to be of benefit for patients having HCC with tumor thrombus in the MPV, IVC, or EBD.

Appendicitis caused by caecal carcinoma: report of a case.

Appendicitis can rarely occur in association with carcinoma of the caecum, particularly in elderly patients. We report a case of acute appendicitis provoked by an adenocarcinoma of the caecum which obstructs the lumen of the appendix in a 58-year-old man. The patient underwent an ileocaecal resection with lymph node dissection. The difficulties of identifying a small tumor at laparotomy and the implication for optimal treatment are emphasized.