Pancreatic acinar cell carcinoma extending into the common bile and main pancreatic ducts.

Acinar cell carcinoma (ACC) of the pancreas is relatively rare, accounting for only approximately 1% of all exocrine pancreatic tumors. A 69-year-old man was found to have a mass lesion measuring approximately 4 cm in diameter in the pancreatic head on ultrasound, abdominal dynamic CT, and percutaneous transhepatic cholangiography. Magnetic resonance cholangiopancreatography showed defect of the lower common bile duct (CBD) due to obstruction by the tumor cast. Histopathologically, the pancreatic head tumor invaded the main pancreatic duct (MPD) and CBD with extension into the CBD in a form of tumor cast. The tumor cells consisted of a solid proliferation with abundant eosinophilic cytoplasm and round nuclei in an acinar and trabecular fashion. A 55-year-old man with upper abdominal pain and nausea, had a cystic lesion approximately 3 cm in size in the pancreatic tail on CT. Histopathologically, the tumor was encapsulated by fibrous capsule and had extensive central necrosis with solid areas in the tumor periphery, and invaded with extension into the MPD in a form of tumor cast. The tumor cells resembled acinar cells in solid growths. Two resected cases of ACC with unusual tumor extension into the CBD and the MPD, respectively, are reported.

A case of pulmonary embolism after abdominal angiography.

The patient was a 72-year-old woman who had been diagnosed with cholecystolithiasis and had undergone laparoscopic cholecystectomy. Since the postoperative pathologic diagnosis was a gallbladder cancer with a depth of wall penetration of subserosa, she was admitted to Kurume University Hospital for a second-look operation. After admission, abdominal angiography was performed with a right femoral arterial puncture. After the release of inguinal compression with a belt, chest pain and difficulty in breathing appeared. Despite her normal blood pressure, arterial blood gas analysis showed a PO2 of 74.7 mmHg and a PCO2 of 41.5 mmHg, representing a slight decrease in PO2. Chest X-rays showed an increased cardiothoracic ratio and decreased lucency in the left upper lung field. The electrocardiogram revealed atrial premature contraction. Cardiac ultrasound did not show expansion of the right heart and blood vessels or abnormal structures in the main pulmonary artery. Since lung perfusion scintigraphy revealed perfusion defects in the left upper to middle and right upper lung fields, acute pulmonary embolism was diagnosed, and oxygen inhalation, thrombolytic, and anticoagulant therapy were instituted immediately. The symptoms improved the following day, but 240,000 u/day of urokinase was administered for 5 days, and 1,500 u/day of heparin for 10 days. On lung perfusion scintigrams 6 days later, the defects had disappeared. Moreover, no definite abnormal shadows were noted on chest X-rays. Radical surgery for gallbladder cancer was performed 3 weeks later. Considering the possible development of pulmonary embolism, we felt the need for careful management if the patient is released from bed rest after abdominal angiography.

A case of benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma.

We report a patient with benign bile duct stricture causing difficulty in differential diagnosis from bile duct carcinoma. A 66-year-old woman consulted a local physician because of general fatigue. Blood biochemical tests showed increased levels of biliary tract enzymes. Abdominal ultrasonography (US) revealed tapering and blockage of the midportion of the bile duct and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography (MRCP) demonstrated obstruction of the midportion of the bile duct. Later, because a marked increase in biliary tract enzymes and jaundice appeared, percutaneous transhepatic biliary drainage (PTBD) was performed. Post-PTBD cytological examination of bile was negative for cancer. A third biopsy showed slight hyperplasia with no malignant findings. Recholangiography, performed through PTBD, suggested gradual improvement of bile duct stricture, but could not completely exclude the possibility of malignancy; thus, resection of the bile duct including the stricture site was performed, and the resected specimen was submitted for intraoperative frozen section examination. Histopathological diagnosis did not reveal malignant findings. After cholecystectomy and bile duct resection, hepaticojejunostomy (Roux-en-Y) was performed. Because only erosion and desquamation of the mucosal epithelium and mild submucosal inflammatory cell infiltration and fibrosis were observed, chronic cholangitis was diagnosed histopathologically. Surgical resection of the bile duct should be considered for potentially malignant stricture of the bile duct.

[Chemoradiation therapy for stage IV pancreatic cancer].

BACKGROUND: Pancreatic cancer is a malignant tumor with a poor prognosis. It frequently presents with locally advanced and distant metastasis at the time of diagnosis. Favorable results were obtained by performing intraoperative radiation therapy (IORT) and chemotherapy (administration of GEM) for the treatment of inoperable pancreatic cancer. A study was conducted on its efficacy as an adjuvant therapy for inoperable and advanced pancreatic cancer. SUBJECTS AND METHODS: Between May 1998 and December 2002, 40 patients with stage IV pancreatic cancer were treated at our institution. The study comprised background factors, adjuvant therapy and survival rate. RESULTS: According to the treatment modality, the study population was classified into four groups: group A, consisting of 3 patients with localized unresectable tumors who had been treated with IORT: group B, 5 patients who underwent curative resection of primary tumor combined with IORT: group C, 6 patients who were administered GEM combined with IORT: group D, 26 patients not falling into groups A, B or C. The mean survival for group A, B, C and D was 10.3 months, 6.7 months, 16.8 months and 9.4 months, respectively. The 1-year survival rates were 0%, 0%, 80.0% and 19.3%, respectively. The mean survival and the 1-year survival rate were significantly better in group C than in the other groups. In group C, the tumor decreased in size, invasion of large vessels and pancreatic posterior evolution was suppressed, and 4 patients survived for 17 months or more. CONCLUSIONS: Prolongation of the survival period was shown by concomitant IORT and administration of GEM for inoperable advanced pancreatic cancer. Thus, attempting to combine chemotherapy with IORT and giving additional consideration to the administration method was shown to provide adjuvant therapy that can be expected to be effective against stage IV inoperable pancreatic cancer.

Evaluation of resection of the papilla of Vater for the treatment of cancer in the papilla of Vater.

We evaluated the resection of the papilla of Vater performed in patients with cancer in the papilla of Vater. The subjects were 6 patients who underwent resection of the papilla of Vater between January 1969 and December 2001. The patients aged 57-87 years consisted of 3 males and 3 females. The maximal diameter of the tumors was 0.5 cm in 1 patient, 1.5 cm in 3 patients, and 2.0 cm in 2 patients. Macroscopically, the tumors were of the protruded type (exposed) in 3 patients, of the mixed type (predominant protruded type) in 2 patients, and of the ulcerative type in 1 patient. The histological depth of the tumors was up to the mucosa in 1 patient, up to the oddi in 1 patient, up to the panc0, du1 in 1 patient, up to the panc1, du2 in 1 patient, and unknown in 2 patients. Histologically, the tumors were papillotubular adenocarcinoma (pap-tub) in 4 patients and tubular adenocarcinoma of the well-differentiated type (tub1) in 2 patients. Resection of the papilla of Vater was chosen because of high risk factors such as advanced age in 2 patients, complicated severe cirrhosis and confinement to bed due to poor systemic conditions after intracerebral hemorrhage in 3 patients, and hepatic metastasis observed during surgery in 1 patient. Residual cancer cells around the excised region were positive in 4 patients and unknown in the remaining 2 patients. Of the 6 patients, 5 died within 2 years after surgery, but 1 is alive without symptoms of recurrence 7 years after surgery. The death causes were the primary disease in 3 of the 5 patients. From the viewpoint of radical treatment, resection of the papilla of Vater cannot be chosen as a reduced surgery for cancer in the papilla of Vater. However, resection of the papilla of Vater can be applied to very elderly patients and patients under poor systemic conditions, for whom pancreatoduodenectomy (PD) is considered excessively invasive due to a small diameter of tumor.

Effective extracorporeal shock wave lithotripsy for pancreatic duct stone.

A 55-year-old man with alcoholic chronic pancreatitis was hospitalized for further treatment of intractable repeated upper abdominal pain. A laboratory data showed normal hepatobiliary enzymes and glucose tolerance test, but abnormal pancreatic enzymes including amylase, lipase, trypsin and elastase I. Pancreatic function diagnostant test was 71%. Abdominal ultrasound examination and computed tomography showed an approximately 4 mm main pancreatic duct stone and multiple small stones in the surrounding parenchyma, and the findings being compatible with chronic pancreatitis. Endoscopic retrograde cholangiopancreatrography revealed that there was a main pancreatic duct stone in the pancreas head, and that the caudal pancreatic duct could not be visualized due to the impacted stone. In addition, intrapancreatic bile duct showed no malignant irregularity, but pancreatitis-induced smooth narrowing. The patient underwent extracorporeal shock wave lithotripsy (ESWL) alone, because endoscopic manipulation for pancreatic stone removal was impossible due to tightly impacted stone with stenosis. Successful ESWL was achieved with the stone disappearance and without any complication.

Two cases of acute cholecystitis in which percutaneous transhepatic gallbladder aspiration (PTGBA) was useful.

We report 2 patients with acute cholecystitis for which percutaneous transhepatic gallbladder aspiration (PTGBA) was useful. In Case 1, the patient was a 75-year-old woman who experienced a sudden onset of back pain and upper abdominal pain at night. Abdominal ultrasound (US) showed enlargement of the gallbladder with thickening of the wall, a sonolucent layer, and a stone in the neck of the gallbladder, which led to a diagnosis of acute cholecystitis. Magnetic resonance imaging (MRI) demonstrated thickening of the gallbladder wall and 2 areas of low-intensity signal. The pain and fever persisted, for which we performed PTGBA, aspirating about 113 ml of infected bile. Subsequently, the pain and fever subsided, and abdominal US revealed a reduction in the enlargement of the gallbladder with the persistence of thickening of the wall. On the eighth day after PTGBA, open abdominal cholecystectomy was performed. In Case 2, the patient was a 56-year-old woman who had right hypochondriac pain after supper. The pain gradually increased in severity. Abdominal US showed enlargement of the gallbladder with a thickened wall, a sonolucent layer, and a gallstone in the neck of the gallbladder, which led to a diagnosis of acute cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) showed enlargement of the gallbladder with no abnormalities in the common bile duct. After admission to hospital, the pain and fever persisted, for which we performed PTGBA, aspirating about 50 ml of infected bile. Subsequently, the pain and fever vanished. Abdominal US revealed a reduction in the enlargement of the gallbladder with the persistence of thickening of the wall. On the seventh day after PTGBA, laparoscopic cholecystectomy was performed. PTGBA seems useful for early alleviation of the symptoms of acute cholecystitis because of low invasiveness and ease of performance.

Surgical treatment for chronic pancreatitis: results of pancreatic duct drainage operation and pancreatic resection.

Between 1978 and 1999, 86 patients with chronic pancreatitis were surgically treated at the Surgical Department of Kurume University Hospital. Of these patients, 30 were treated by pancreatic duct drainage operation (drainage operation), while 40 were treated by pancreatic resection, and the results were compared between the two groups. In patients who underwent drainage operation, pain disappeared in 85.7%, slightly relieved in 10.7%, and not relieved in 3.6%. In patients who underwent pancreatic resection, pain disappeared in 73.4%, slightly relieved in 13.3%, and not relieved in 13.3%. Therefore, there was no significant difference in the pain-relieving effect between the two groups. However, the pain-relieving effect was poorer in patients who underwent pancreatic resection than in those who underwent drainage operation. In addition, all patients who showed poor results for pain relief had alcoholic pancreatitis. Endocrine and exocrine functions of the pancreas were improved in 6, maintained in 2, and exacerbated in 4 patients who underwent drainage operation. In patients who underwent pancreatic resection, endocrine and exocrine function of the pancreas were improved in 3, maintained in 3, and exacerbated in 13. Therefore, endocrine and exocrine function of the pancreas were poorer in patients who underwent pancreatic resection than in those who underwent drainage operation. Distant results in patients who underwent drainage operation were good in 75.0%, fair in 15.0%, and poor in 10.0%. In patients who underwent pancreatic resection, distant results were good in 80.0%, fair in 13.3%, and poor in 6.7%. Therefore, favorable distant results were obtained in both groups. These findings suggest that surgical techniques that preserve functions of the pancreas should be selected during surgical treatment for chronic pancreatitis. We consider that the presence or absence of main pancreatic duct dilation and the site of pancreatic lesions are important indices for selecting surgical techniques. Therefore, drainage operation consisting of pancreaticojejunostomy should be indicated for patients with main pancreatic duct dilation, while pancreatic resection should be indicated for those without main pancreatic duct dilation, those with localized pancreatic lesions, and those with suspected pancreatic cancer.

A case of gallbladder cancer associated with pancreaticobiliary maljunction.

We report a case of gallbladder cancer associated with pancreaticobiliary maljunction. The patient was a 60-year-old woman who consulted a local doctor because of discomfort in the right hypochondriac region. Abdominal ultrasonography (US) showed a gallbladder abnormality, and she was referred to Kurume University Hospital, where she was hospitalized for further study and surgery. Abdominal US revealed a sessile tumor with an irregular surface in the fundus of the gallbladder. The internal echo of the tumor was nonhomogeneous, and the structure of the gallbladder wall was partly torn. The common bile duct and the left intrahepatic bile duct were dilated. Abdominal computed tomography (CT) showed an elevated lesion with the same degree of imaging effect as that of the liver on the peritoneal side of the fundus of the gallbladder. The structure of the gallbladder was preserved, and the gallbladder was well demarcated from the surrounding tissue. No hepatic or lymph node metastases were noted. Endoscopic retrograde cholangiopancreatography (ERCP) visualized the pancreaticobiliary maljunction where the pancreatic duct joined the bile duct, entering an approximately 2-cm-long common channel. Dilatation of the common bile duct and intrahepatic bile ducts was observed and diagnosed as the IV-A type according to the Toya classification. Abdominal angiography in the arterial phase showed dilatation of the cystic artery and hyperplasia of vessels but no apparent encasement. In the venous phase, a deep-staining tumor was observed. From the above findings, we made a diagnosis of gallbladder cancer complicating pancreaticobiliary maljunction, and performed an operation. Since intraoperative US showed that the outermost layer of the gallbladder was in part ill-demarcated, we diagnosed the depth of penetration as ss, and performed cholecystectomy and bile duct resection and hepatic resection (S4a and S5), and lymphnode dissection (D2; dissection of groups 1 and 2 lymphnodes). The resected specimen grossly showed a papillomatous lesion with a cauliflower-like surface. The histopathologic diagnosis was papillary adenocarcinoma, depth ss, stage II. Tumor cells proliferated in a papillomatous pattern and were mostly confined to the muscular coat but partly infiltrated into the subserosal coat. In the diagnosis of pancreaticobiliary maljunction, it is crucial to consider complicating gallbladder cancer.