Localized 18F-fluorodeoxyglucose uptake at the pancreatic head during remission phase of autoimmune pancreatitis: A case report.

Autoimmune pancreatitis (AIP) is a unique form of pancreatitis, histopathologically characterized by dense lymphoplasmacytic infiltration and fibrosis of the pancreas with obliterative phlebitis. AIP is associated with a good response to steroid therapy. Differentiation between AIP and pancreatic cancer to determine a preoperative diagnosis is often challenging, despite the use of various diagnostic modalities, including computed tomography (CT), magnetic resonance imaging and endoscopic retrograde cholangiopancreatography. It has been reported that 18F-fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET)/CT may be a useful tool for distinguishing between the two diseases. In the present case report, a 71-year-old male patient presented with a well-circumscribed, solitary, nodular and homogenous 18F-FDG uptake at the pancreatic head, while receiving maintenance steroid therapy in the remission phase of AIP; preoperatively, the patient had been strongly suspected of having pancreatic cancer. Pathological examination revealed post-treatment relapse of AIP. The present case highlights the diagnostic and management difficulties with AIP in the remission phase. In certain cases, it remains challenging to differentiate the two diseases, even using the latest modalities.

Sarcoidosis manifesting as hepatic and splenic nodules mimicking ovarian cancer metastases: A case report.

The current study presents a case of sarcoidosis manifesting as hepatic and splenic nodules, which was difficult to differentiate from ovarian cancer metastases. A 24-year-old female, who was previously diagnosed with right ovarian cancer and underwent surgery at the age of 21, was found to have two nodules in the spleen revealed by contrast-enhanced computed tomography (CT). 18F-fluorodeoxyglucose positron emission tomography/CT revealed two abnormal high uptake lesions in the spleen and one abnormal high uptake lesion in the liver. Under a diagnosis of hepatic and splenic metastases from right ovarian cancer, a laparoscopic splenectomy and partial hepatectomy were performed. Histopathological examination showed that a large number of non-caseating epithelioid cell granulomas formed these nodules, which was compatible with sarcoidosis. This case indicates that it is difficult to distinguish sarcoidosis from metastatic disease even using the latest modalities, and that laparoscopic surgery is a minimally invasive and useful tool for forming a differential diagnosis.

Quantification of pancreatic stiffness on intraoperative ultrasound elastography and evaluation of its relationship with postoperative pancreatic fistula.

"Soft pancreas" has often been reported as a predictive factor for postoperative pancreatic fistula (POPF) after pancreatectomy. However, pancreatic stiffness is judged subjectively by surgeons, without objective criteria. In the present study, pancreatic stiffness was quantified using intraoperative ultrasound elastography, and its relevance to POPF and histopathology was investigated. Forty-one patients (pancreatoduodenectomy, 30; distal pancreatectomy, 11) who underwent intraoperative elastography during pancreatectomy were included. The elastic ratio was determined at the pancreatic resection site (just above the portal vein) and at the remnant pancreas (head or tail). Correlations between the incidence of POPF and patient characteristics, operative variables, and the elastic ratio were examined. In addition, the relationship between the elastic ratio and the percentage of the exocrine gland at the resection stump was investigated. For pancreatoduodenectomy patients, main pancreatic duct diameter < 3.2 mm and elastic ratio < 2.09 were significant risk factors for POPF. In addition, the elastic ratio, but not main pancreatic duct diameter, was significantly associated with the percentage of exocrine gland area at the pancreatic resection stump. Pancreatic stiffness can be quantified using intraoperative elastography. Elastography can be used to diagnose "soft pancreas" and may thus be useful in predicting the occurrence of POPF.

Protective effect of adeno-mediated human Bcl-xL gene transfer to the mouse liver in a partial ischemia/reperfusion model.

BACKGROUND: The protective effect of heat preconditioning has been ascribed to the induction of heat shock proteins (HSP) in the liver. We detected an increase in Bcl-xL expression prior to HSP 70 expression in the rat liver after heat preconditioning. The net effect of overexpression of human Bcl-xL with a recombinant adenovector was estimated in a partial ischemia/reperfusion model of the mouse liver. MATERIALS AND METHODS: The time courses of the expression of HSP, Bcl-xL, Bcl-2, Bax, and Bag-1 in the SD rat liver after heat preconditioning were studied by Western blotting. The localizations of Bcl-xL, Bcl-2, and Bax at 6 h after preconditioning were examined by immunostaining. The expression of Bcl-xL in the C57/BL mouse liver after intravenous injection of the recombinant adenovector was assessed by Western blotting and immunostaining. The protective effect of overexpression of Bcl-xL was estimated in a 60-min partial ischemia/reperfusion model of the mouse liver. RESULTS: The expression of Bcl-xL peaked 12 h after heat preconditioning. The overexpression of Bcl-xL decreased enzyme release, histological cell injury, and the number of TUNEL-positive cells. CONCLUSION: Transfer of the human Bcl-xL gene to the liver had a protective effect against ischemia/reperfusion injury in a mouse model.

Combined hepatic resection and radiofrequency ablation for multiple hepatic adenomas.

We describe the novel use of radiofrequency ablation (RFA) in combination with surgical resection for treatment of multifocal hepatic adenoma. We show three cases without recurrent lesions detected in follow-up examination. Two of the patients have subsequently gone on to carry pregnancies successfully to term.

[Two cases of advanced pancreas cancer treated with GTX: combined use of gemcitabine, docetaxel and capecitabine].

Two cases of advanced pancreas cancer were treated with GTX. One cycle was 3 weeks, capecitabine (1,000 mg/m(2)/day) was administered from day 1 to 14, and GEM 750 mg/m(2) and DOC 30 mg/m(2) were drip-infused on day 4 and 11. A 62-year-old man with pancreas head cancer and 2 liver metastases was treated with GEM 1,000 mg/m(2)/week at weeks 1, 2, and 3, and drug-free week 4 for 3 cycles, but was PD. After 3 cycles of GTX, the liver metastases decreased in size, and thereafter tumor markers became lowest after 7 cycles. The patient was shifted to another regimen after 14 cycles for 9 months of GTX. A 75-year-old man with pancreas head cancer and vascular invasion has been treated with GTX. As leukopenia was seen after the first cycle, the administration doses were reduced and GTX has been continued for a total 13 cycles. The tumor reduced in size and tumor markers decreased. GTX is suitable for outpatient chemotherapy with mild adverse effects.

The usefulness of early laparoscopic surgery for determining a medical treatment plan in severe acute pancreatitis.

A 41-year-old woman presented with sudden onset severe epigastric pain. She was diagnosed as having severe acute pancreatitis (SAP) with an APACHE II score of 10, and initially, general supportive therapy was performed. Because the patient's condition kept worsening, early laparoscopic surgery was performed. It revealed swelling, hemorrhagic necrosis of the pancreas, and massive fluid collection in the abdominal cavity. Kocherization and bursectomy were performed for these lesions, and drainage tubes were indwelled. The white blood cell count (WBC) and serum interleukin-6 value prominently improved shortly after the operation, and the WBC count remained at a low level. The patient gradually recovered and was finally discharged 39 days after her initial presentation. To summarize, we performed a successful exploration for SAP, and we found that postoperative continuous lavage effectively eliminated toxic enzymatic exudates in the abdominal cavity and prevent them from circulating. Regarding SAP with peritonitis, early laparoscopic surgery is very useful for determining the pathological extent of the disease and for selecting appropriate treatment options.

Downregulation of cytokine release by heat preconditioning of livers used for transplantation in rats.

We evaluated the changes in the levels of released cytokines following heat preconditioning of the livers used in rat liver transplantation. The donor rats in the heat preconditioning (HP) group were subjected to heat preconditioning 48 h before graft harvesting. The liver isografts were preserved in Euro-Collins solution for 8 h, and then transplanted orthotopically. The one-week survival rate of the HP group was significantly better than that of the control (C) group. The serum levels of interleukin-6 and interleukin-10 were significantly lower in the HP group than in the C group. Histological staining revealed that the stagnation of red blood cells and infiltration of neutrocytes were reduced in the HP group. The expression of intercellular adhesion molecule-1 was decreased around the central vein in the HP group, as revealed by immunohistochemistry. These results indicate that heat preconditioning downregulates cytokine release and reduces the frequency of microcirculation disorders.

Phylogenetic investigation of Dogiel's pericellular nests and Cajal's initial glomeruli in the dorsal root ganglion.

Cajal's initial glomeruli (IG) and Dogiel's pericellular nests (PCNs) were first described from methylene blue preparations of healthy animal tissues around the beginning of the last century. Since that time, although many reports have been published concerning these structures, few have focused on their development and phylogeny in healthy animals. The aim of this study was to examine the phylogenetic development of the sensory neurons in Cajal's IG (also called axonal glomeruli) and Dogiel's PCNs in the dorsal root ganglion (DRG) of the healthy adult frog, chick, rat, and rabbit. The three-dimensional architecture of the neurons was observed in ganglia by scanning electron microscopy after removal of the connective tissue. The neurons in the DRG of fish are known to be bipolar, but DRG neurons in the species examined here were found to be pseudounipolar, with single stem processes. The proportion of neurons having IG or PCNs increased with increasing phylogenetic complexity in the species examined here. Cajal's initial glomeruli, the convolution of the stem process near the parent cell body: In frogs, the ganglia were small and the neuronal stem processes were very short and straight. In chicks, the stem processes were longer; sometimes very long, tortuous processes were observed. However, no neurons with typical IG were observed in either species. Typical IG were observed in rats and rabbits; their occurrence was much more frequent in rabbits. Pseudounipolarization, i.e., the transition from bipolar to pseudounipolar neurons, is thought to save space, limit the length of neuronal processes, and reduce conduction time. However, an explanation of the evolutionary advantage of the IG, which is formed by the excessive prolongation of the stem process, remains elusive. The cytological and electrophysiological importance of IG has been discussed. Dogiel's pericellular nests (PCNs), which resemble balls of yarn made of thin unmyelinated nerve fibers around DRG neurons, have been observed in the DRG of rats and rabbits, but not in frogs or chicks. This interesting structure shows not only ontogenetic development in healthy animals but also phylogenetic development among species. The nerve fibers in the PCNs were less than 1.2 mum in diameter and had some varicosities. An immunohistochemical study using anti-tyrosine hydroxylase (TH) antibody revealed that some PCNs contain TH-positive nerve fibers and varicosities. Such TH-positive PCNs disappear after sympathectomy. These results suggest that the PCNs are made up of autonomic nerve fibers.

Adenovirus-mediated p53 gene transfer to the bile duct by direct administration into the bile in a rat cholangitis model.

BACKGROUND: Hepatolithiasis is a common disease in East Asia and its aggravating factor is bile duct stenosis because of refractory cholangitis. This study investigated the feasibility of gene therapy for bile duct stenosis by administration of p53 adenoviral vectors into the bile. MATERIALS AND METHODS: Adenoviral vectors (AxCALacZ or AxCAhp53) were injected transpapillarily into the bile in the bile duct in a rat model of cholangitis. The extent and duration of the gene expression was evaluated with X-gal staining and p53 immunostaining. The bile duct tissue was examined to evaluate the inhibitory effect on the proliferative changes at 3 and 7 days after administration, and Ki-67 labeling index was determined. RESULTS: beta-galactosidase was expressed in the bile duct epithelia, the bile duct wall and the surrounding connective tissue. The expression of beta-galactosidase was detected at 4 weeks after the administration. Mean thickness of the bile duct wall at 7 days was 343.2 +/- 14.0 microm for the AxCAhp53 group, 446.5 +/- 25.3 microm for the AxCALacZ group and 447.1 +/- 53.4 microm for the control group. The proliferation of the bile duct wall was significantly suppressed in the AxCAhp53 group (P < 0.05). Maximum thickness was 408.0 +/- 23.9 microm for the AxCAhp53 group (P < 0.05), 650.0 +/- 49.3 microm for the AxCALacZ group, and 590.0 +/- 64.3 microm for the control group. Mean Ki-67 labeling index for the three groups was 20.7% (P < 0.05), 34.4% and 37.4%, respectively. CONCLUSIONS: P53 gene transfer by administration of the adenoviral vector into the bile suppressed the proliferative changes in the bile duct in a rat cholangitis model.

Human leukocyte antigen antibodies and human complement activation: role of IgG subclass, specificity, and cytotoxic potential.

BACKGROUND: Human leukocyte antigen (HLA) antibodies are defined as complement (C) fixing and clinically relevant based upon the complement-dependent cytotoxicity (CDC) test. However, the sub-lytic activation of individual C components is of critical biologic significance. The requirements of HLA antibodies to activate human C are not known. METHODS: IgG, IgM, IgG subclasses, and human C3b deposition upon T cells were evaluated by flow cytometry with sera from HLA-sensitized patients and human monoclonal HLA antibodies. RESULTS: Comparative studies showed that there was poor correlation between the amount of IgG on target cells and their ability to produce CDC. Human C3b deposition was influenced more by the particular serum/cell combination under study than by the amount of IgG, with some combinations showing high IgG and low C3b and others showing low IgG and high C3b. IgG1 was the predominant IgG subclass in all patients. The other subclasses were low or undetectable and did not correlate with C3b deposition. Human monoclonal HLA antibodies, mostly IgG1, did not activate human C efficiently despite high IgG binding. However, combinations of two monoclonal antibodies to different epitopes of the same antigen did produce significant C3b deposition. CONCLUSIONS: Contrary to common assumptions, CDC, IgG binding, and IgG subclass are poor predictors of human C activation by HLA antibodies. The mix of specificities in a given serum and the antigens of a particular target cell appear to determine the efficiency of C activation. Measuring both antibody and C3b deposition (or other C component) may improve the assessment of donor-recipient compatibility.

Prognostic significance of Bcl-xL in human hepatocellular carcinoma.

BACKGROUND: Proliferation and apoptosis of liver cancer cells are closely related phenomena. We investigated the correlation between overexpression of Bcl-xL, an anti-apoptosis-related protein of the Bcl-2 family, and the clinical course of hepatocellular carcinoma (HCC). METHODS: Specimens from 7 HCC patients were used for Western blotting and immunoelectron microscopy tests. Samples from 33 HCC patients who had undergone hepatectomies were used for immunohistochemical staining. The degrees of expression of Bcl-xL and Ki-67, as an index of HCC mitosis severity, were each classified into 2 groups. RESULTS: With the use of Western blot analysis, enhanced immunoreactivity of Bcl-xL was found in cancerous specimens. Bcl-xL overexpression was found in cancer specimens in 21 of 33 patients (63.6%). The overall survival (P=.019) and disease-free survival (P=.030) rates of the group overexpressing Bcl-xL were definitely poorer. The Ki-67 higher labeling index LI > 10) group had a poorer survival rate (P=.016). There were significant correlations between Bcl-xL and overall survival and disease-free survival. Multivariate analyses revealed that Bcl-xL, tumor size, histologic portal invasion, and histologic metastatic foci were independent prognostic factors for overall survival and disease-free survival. CONCLUSIONS: These results showed Bcl-xL in HCC specimens, suggesting that Bcl-xL was a significant prognostic factor for disease progression in human HCC.

Advanced cholangiocarcinoma in a patient with stage I primary sclerosing cholangitis.

A 29-year-old woman presented with jaundice and fever in May 2001. Cholangiography showed multiple strictures and beading of the biliary tree, with a large stricture in the common bile duct and marked dilatation of the hilar bile ducts. Typical cholangiography findings and elevated hepatobiliary enzymes suggested primary sclerosing cholangitis (PSC). At the same time, computed tomography detected a 2-cm tumor in the common bile duct, and angiography showed an encasement in the portal vein. Tumor markers, cytology, and biopsy were all negative for cancer. Although laparotomy showed a healthy liver and no lymph node metastasis was found, suggesting early-stage PSC and a low likelihood of accompanying cholangiocarcinoma (CCA) reported so far, the tumor in the resected common bile duct was subsequently diagnosed as CCA. Therefore, pancreatoduodenectomy was performed combined with partial resection of the portal trunk. Histology also revealed invasion of the wall of the portal vein by cancer cells. The patient had a recurrence 5 months later and died 12 months after her operation. This is a rare case in which stage I PSC was complicated by advanced CCA.

Bcl-xL overexpression in human hepatocellular carcinoma.

It is known that proliferation and apoptosis are closely related phenomena in liver cancer cells. In this study, using surgical specimens from 42 patients with hepatocellular carcinoma (HCC), we investigated the expression and localization of Bcl-xL, an antiapoptosis-related protein of the Bcl-2 family. Using Western blotting, Bcl-xL expression was detected in both cancerous and non-cancerous specimens from all of the HCC patients, and elevated Bcl-xL levels were found in cancerous specimens from two thirds of the patients. In normal human liver specimens, Bcl-xL was found mainly in the cytoplasm of hepatocytes, although it was also found in the cytoplasm of bile duct cells in Glisson's capsule by immunohistochemical staining. To the best of our knowledge, this is the first report of Bcl-xL overexpression and localization in HCC specimens. Bcl-xL was found not only in the cytoplasm of HCC cells, but also in the nuclei of some HCC cells, suggesting that Bcl-xL is involved in the progression of HCC cells in vivo.

Significance of serum type IV collagen level of hepatectomized patients with chronic liver damage.

Type IV collagen, one of the serum markers for hepatic fibrosis, was measured perioperatively in patients with and without chronic liver damage to investigate whether this parameter changes in response to acute stress to the liver and can predict the surgical risk of hepatic resection. The serum type IV collagen level was significantly elevated in patients with liver cirrhosis. There were significant correlations between serum type IV collagen levels and the indocyanine green clearance test and cholinesterase activity, although the correlation coefficients were not high. The size of the resected hepatic mass was not the primary factor to influence the postoperative serum type IV collagen level. In patients with liver cirrhosis, the postoperative serum type IV collagen level increased significantly compared to that in patients with normal liver or chronic hepatitis. Postoperative liver failure occurred in 0%, 11.6%, and 44.4% of patients with preoperative serum type IV collagen levels of <150, < or = 150 to 300, and > or = 300 ng/ml, respectively. In those with postoperative liver failure, the serum type IV collagen levels were significantly higher both pre- and postoperatively compared to those in patients with uneventful courses. Several preoperative liver function tests indicated that type IV collagen is an independent risk factor for postoperative liver failure. Thus perioperative measurement of the serum type IV collagen levels seemed to be useful for predicting the risk of hepatic resection in patients with chronic liver damage.