Pancreatic acinar cell carcinoma with pleomorphic and spindle cells: An autopsy-proven case.

Pancreatic acinar cell carcinomas are glandular and have amphophilic/eosinophilic cytoplasm, presenting acinar, solid, and trabecular structures. Unusual histological features of acinar cell carcinoma are known, such as oncocytic, pleomorphic, spindle, and clear cell variants, but their clinical significance has not been well described. A man in his 70s was referred to our hospital because of elevated serum pancreatic enzymes. Contrast-enhanced abdominal computed tomography revealed slight swelling of the pancreatic head and suspension of the main pancreatic duct in the pancreatic body. He died only 14 days after admission. Gross findings at autopsy showed an ill-defined tumor located in the pancreatic head, involving the gastric and duodenal walls. Peritoneal dissemination, liver metastases, and lymph node metastases were also observed. Microscopically, tumor cells had moderate-to-severe nuclear atypia and amphophilic cytoplasm showing pleomorphism, and diffusely proliferated in solid pattern without lumina, were admixed with spindle cells. Immunohistochemically, tumor cells including pleomorphic and spindle cells were positive for B-cell lymphoma/leukemia 10 and trypsin. Consequently, the diagnosis was pancreatic acinar cell carcinoma with pleomorphic and spindle cells. We encountered a rare variant of pancreatic acinar cell carcinoma with pleomorphic and spindle cells. Clinically, our case showed rapid progression.

Solid pseudopapillary neoplasm of the pancreas in a young male with main pancreatic duct dilatation: A case report.

BACKGROUND: Solid pseudopapillary neoplasms (SPNs) are rare tumors of the pancreas. Typically, they occur in young females, often have characteristic imaging features, such as cystic components and calcification, and have few effects on the pancreatic duct. CASE SUMMARY: A 31-year-old man was admitted to our hospital with the chief complaint of epigastric pain. There was only mild tenderness in his upper abdomen, and blood tests showed only a slight increase in alkaline phosphatase. Contrast-enhanced computed tomography showed a 40-mm-diameter, hypovascular mass in the head of the pancreas, and the main pancreatic duct upstream of the mass was severely dilated. Magnetic resonance imaging showed low intensity on T1-weighted images, with high intensity on T2-weighted image in some parts. Pancreatic ductal adenocarcinoma was the primary differential diagnosis. Portal vein infiltration could not be ruled out, so this case was a candidate for neoadjuvant chemotherapy. Subsequently, endoscopic ultrasound-guided fine needle aspiration was performed, and pathological evaluation and immunostaining suggested a diagnosis of SPN. Thus, pancreatoduodenectomy was performed. One year after the operation, the patient is alive with no recurrence. CONCLUSION: Main pancreatic duct dilatation is usually a finding of suspected pancreatic cancer. However, pancreatic duct dilatation can occur in SPN depending on the location and growth speed. Therefore, SPN should be considered in the differential diagnosis of tumors with pancreatic duct dilatation, and pathological evaluation by endoscopic ultrasound-guided fine needle aspiration should be actively performed.

Pancreatic ductal adenocarcinoma with mismatch repair deficiency resected after long-term observation.

Pancreatic ductal adenocarcinoma (PDAC) with mismatch repair (MMR) deficiency is a rare subtype, clinicopathological features of which have not been fully understood. A 70-year-old woman was admitted for the investigation of a 20-mm pancreatic tumor in the pancreatic head, detected during the cause scrutiny of exacerbation of diabetes mellitus and panhypopituitarism. The tumor decreased in size after administration of hydrocortisone for panhypopituitarism. Autoimmune pancreatitis, complicated with hypophysitis, was suspected, and prednisolone treatment was administered. The tumor did not show enlargement for 3 years during which a dose of prednisolone was maintained. However, 1.5 years after the cessation of prednisolone administration, the tumor size increased again. On endoscopic ultrasonography, the tumor was found to be a 25.2-mm mass lesion with almost uniformly low echogenicity and blood flow signal, and anisonucleosis on cytodiagnosis was revealed. Pancreatoduodenectomy was performed, and on histological analysis, moderately differentiated tubular adenocarcinoma with massive lymphocytic infiltration was observed. Immunohistochemistry revealed a concomitant loss of MSH2 and MSH6 in the tumor cells, which implicated mutant MSH2 gene. She has remained well with no recurrence for 2.9 years since her surgery. We herein report a case of PDAC with MMR deficiency, resected after long-term observation.

Simultaneous macroamylasemia and macrolipasemia in a patient with mucosa-associated lymphoid tissue lymphoma.

We report a case of simultaneous macroamylasemia and macrolipasemia complicated with mucosa-associated lymphoid tissue (MALT) lymphoma. A 78-year-old man presented with hyperamylasemia and hyperlipasemia for 2 years and was misdiagnosed with chronic pancreatitis at another hospital. However, his other pancreatic enzymes were normal, his amylase-creatinine clearance ratio was low, and no definite findings of pancreatic disease were evident. Immunological analyses revealed that both amylase and lipase were bound to immunoglobulin (Ig) A-κ, and that serum IgA was high (827.1 mg/dL). He was diagnosed with simultaneous macroamylasemia and macrolipasemia. Since these diseases are associated with malignancy, an additional investigation was performed which revealed the complication of MALT lymphoma, and polymerase chain reaction analysis showed monoclonal immunoglobulin light chain gene rearrangement (κ >> λ). In this case, macroamylasemia and macrolipasemia may have developed due to the formation of macroenzymes resulting from excess IgA-κ secreted by the MALT lymphoma. Simultaneous macroamylasemia and macrolipasemia are very rare and difficult to diagnose and can lead to diagnostic and therapeutic errors. When encountering atypical clinical features associated with hyperamylasemia and hyperlipasemia, the possibility of macroenzymes and underlying diseases such as lymphoproliferative disorders should be considered.

Effects of rumen-protected methionine on milk production in early lactation dairy cattle fed with a diet containing 14.5% crude protein.

We evaluated the influence on milk production of feeding early lactation cows a diet that included 14.5% crude protein (CP) and that did not meet methionine (Met) requirements or that met them by supplying rumen-protected Met (RPMet). Thirty-nine multiparous Holstein cows were allocated into two groups. For 15 weeks after calving, each group was fed one of the two total mixed rations, Control (n = 20) or Treatment (n = 19). The Treatment group received added RPMet at 0.034% (8 g/day) of the Control diet on dry matter basis. The adequacies of Met for the Control and Treatment groups were 96% and 106%, respectively, and for other amino acids, >110%. The CP level (14.5%) was 1 percentage point lower than that recommended by the Japanese Feeding Standard (2006). No between-group differences were found in milk yield (40 kg/day), milk composition, plasma profile, rumen fermentation, nitrogen balance, or cow health. Met intake and the amount of rumen-undegradable feed Met were higher in the Treatment group (p < 0.05). Microbial Met and total metabolizable Met did not differ between groups. Supplying RPMet in a 14.5% CP diet during early lactation did not dramatically affect milk production, because the amount of total metabolizable Met was unchanged.

Treatment of biliary tract stones after gastrectomy in the era of laparoscopic cholecystectomy.

BACKGROUND: The incidence of biliary tract stones has widely been reported to be high after gastrectomy. Treatment of biliary tract stones in post-gastrectomy patients was examined retrospectively, particularly minimally invasive therapy with laparoscopic cholecystectomy for gallbladder stones and endoscopic bile duct lithotomy for common bile duct stones. METHODS: Treatment of 122 post-gastrectomy patients with biliary tract stones was examined retrospectively from 1995 to April 2015. RESULTS: Symptomatic biliary tract stones were found in 3.7% of post-gastrectomy patients. The frequency of bile duct stones was higher in post-gastrectomy patients with gallbladder stones (44%) than in the nongastrectomy patients (11%). Laparoscopic cholecystectomy was carried out in 84% of the patients with gallbladder stones. Endoscopic bile duct lithotomy was feasible in 89% of patients with common bile duct stones. CONCLUSIONS: Laparoscopic cholecystectomy was feasible for removing gallbladder stones after gastrectomy. Endoscopic bile duct lithotomy followed by laparoscopic cholecystectomy was a good option for patients in whom endoscopic intervention could be performed. On the other hand, choledochoenterostomy could be a good option for patients in whom endoscopic bile duct lithotomy cannot be performed, particularly considering the risk of recurrent bile duct stones.

Adrenal Metastasis and Hemorrhage Secondary to Hepatocellular Carcinoma.

A 66-year-old man was admitted to undergo treatment for the sudden onset of hypogastric pain radiating to the left flank. Based on the clinical presentation and radiological findings, left adrenal hemorrhage secondary to hepatocellular carcinoma was diagnosed. Although the patient was hemodynamically stable, anemia progressed over the first four days after admission and a blood transfusion was subsequently initiated, which was effective. According to the results of interval imaging with computed tomography, elective transcatheter embolization (TAE) was performed nine days after admission to treat the bleeding from the adrenal tumor. After TAE, the patient's abdominal pain resolved, with no further progression of anemia.

Ewing sarcoma of the liver with multilocular cystic mass formation: a case report.

BACKGROUND: Ewing sarcoma is a rare tumor that occurs commonly in the long bones of children or adolescents that can also arise in soft tissues including the extremities, retroperitoneum, chest wall, and rarely in the liver as primary sites. We report a case of Ewing sarcoma arising primarily in the liver and, to our knowledge, this is the fourth reported case of Ewing sarcoma occurring in the liver. CASE PRESENTATION: A 27-year-old Japanese woman was admitted with sudden onset right upper abdominal pain. Clinical examination revealed a multilocular cystic mass consisting of thickened, irregular septa and nodal walls in the right hepatic lobe. Ultrasound-guided aspiration biopsy of the liver mass showed clusters of small atypical round cells and the clinical preoperative diagnosis was mucinous cystadenoma of the liver. The patient underwent an extended right hepatectomy and histopathological findings revealed sheet-like proliferation of small- to medium-sized round cells. Tumor cells were positive for periodic acid-Schiff reaction and immunoreactive for glycoprotein C99 and gene NKX2.2, as well as the neuroendocrine markers, CD56 and synaptophysin. EWS-FLI-1 fusion transcript type 1 was detected by reverse transcriptase polymerase chain reaction. Pathological and molecular analysis confirmed the diagnosis of Ewing sarcoma arising primarily in the liver and the patient received adjuvant systemic chemotherapy with vincristine, doxorubicin, and cyclophosphamide, alternating with ifosfamide and etoposide. We found no evidence of recurrence 15 months after completing chemotherapy. CONCLUSION: We present an extremely rare case of Ewing sarcoma arising primarily in the liver. To our knowledge, this is the fourth reported case of Ewing sarcoma occurring in the liver, and the first case with a multilocular cystic liver mass. Imaging examinations of the other three reported cases showed solid tumors and a diffuse enlarged liver without mass lesion. Clinicians should consider the possibility of Ewing sarcoma in young patients with a multilocular cystic mass with thick and/or irregular cyst walls in the liver.

Recurrent common bile duct stones composed of ursodeoxycholic acid: a report of four cases.

Ursodeoxycholic acid (UDCA) is often used to treat cholesterol gallstones. UDCA makes cholesterol stones soluble, thereby improving biliary emptying. Conversely, however, UDCA can also form stones via an unknown mechanism, as shown in a few previous reports of cholangitis caused by the formation of UDCA stones in the common bile duct (CBD). We herein report four cases of recurrent cholangitis resulting from UDCA stones. The withdrawal of UDCA administration was highly effective in these patients. The details of these four cases suggest that clinicians must rethink the indications for UDCA treatment in cases in which cholangitis caused by CBD stones frequently recurs over a short period of time.

A modified catheterization procedure to reduce bladder damage when collecting urine samples from Holstein cows.

This study proposed a modified procedure, using a small balloon catheter (SB catheter, 45 ml), for reducing bladder damage in cows. Holstein cows and the following catheters were prepared: smaller balloon catheter (XSB catheter; 30 ml), SB catheter and standard balloon catheter (NB catheter; 70 ml, as the commonly used, standard size). In experiment 1, each cow was catheterized. The occurrence of catheter-associated hematuria (greater than 50 RBC/HPF) was lower in the SB catheter group (0.0%, n=7) than in the NB catheter group (71.4%, n=7; P<0.05). In experiment 2, general veterinary parameters, urine pH, body temperature and blood values in cows were not affected before or after insertion of SB catheters (n=6). The incidence of urinary tract infection (UTI) was 3.0% per catheterized day (n=22). In experiment 3, feeding profiles, daily excretion of urinary nitrogen (P<0.05) and rate from nitrogen intake in urine (P<0.01), were higher with use of the SB catheter (n=13) than with the use of the vulva urine cup (n=18), indicating that using the SB catheter can provide accurate nutritional data. From this study, we concluded that when using an SB catheter, the following results occur; reduction in bladder damage without any veterinary risks and accuracy in regard to feeding parameters, suggesting this modified procedure using an SB catheter is a useful means of daily urine collection.

Small cell gall bladder carcinoma complicated by syndrome of inappropriate secretion of antidiuretic hormone (SIADH) treated with mozavaptan.

Small cell gall bladder carcinoma (Scc-GB) is a very rare entity. Although some cases present with endocrine manifestations, paraneoplastic hyponatraemia has been reported in only one previous case. Recently, the antidiuretic hormone (ADH) receptor antagonist mozavaptan has become available. Herein we report a case with Scc-GB complicated with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) treated with mozavaptan. A 47-year-old woman was referred to our hospital for hyponatraemia. Physical examination revealed elevated serum ADH, a gall bladder mass. She was clinically diagnosed with Scc-GB with SIADH as a paraneoplastic syndrome. Mozavaptan was used for SIADH. Serum sodium was quickly normalised after mozavaptan treatment. Two months later, metastasis to the subcutis of the abdominal wall was observed. The metastatic nodule was resected, and small cell carcinoma (Scc) was identified pathologically. Mozavaptan was effective for improvement of hyponatraemia in this patient with Scc-GB complicated with SIADH.

Hepatocellular carcinoma metastasis to the brain mimicking primary pituitary tumor around the sella turcica.

We report on two cases of hepatocellular carcinoma (HCC) with metastasis to the cavernous sinus and sphenoid sinus. Both cases presented with diplopia and retro-orbital headache and both underwent surgery for a primary pituitary gland tumor. After surgery, both cases were diagnosed with metastases from HCC. Case 1 was a 67-year-old male with a history of HCC who was referred to our hospital for pituitary tumor surgery. The tumor appeared to be in the sella turcica and to invade the sphenoid sinus and right cavernous sinus. Transnasal transsphenoidal surgery (TSS) was performed. The tumor was postoperatively diagnosed by histology to be a metastatic pituitary tumor from HCC. Radiotherapy was administered to the metastatic site. Case 2 was a 58-year-old male with a history of TSS for a pituitary tumor 16 years previously. He was referred to our hospital for TSS for a recurrent pituitary adenoma. TSS was performed twice in 3 months. During a preoperative general examination, HCC and chronic hepatitis B were revealed. TSS was performed initially, followed by arterial infusion chemotherapy. After TSS, the pituitary tumor was diagnosed by histology to be a metastasis from HCC. As with Case 1, radiotherapy was administered to the metastasis. Most tumors in the sella turcica are pituitary adenomas, although some cases of metastatic pituitary tumors and skull base metastases have been reported. Distant metastases generally have a poor prognosis; however, surgery to the metastatic site can effectively control symptoms caused by the metastatic tumor.

Expression profiling of cytokines and related genes in regenerating skeletal muscle after cardiotoxin injection: a role for osteopontin.

To examine the roles of cytokines in muscle regeneration, we injected cardiotoxin into mouse tibialis anterior muscle and examined the expression profiles of cytokines and related genes in the regeneration process. Expression of 40, 64, and 7 genes among 522 genes spotted on a cytokine expression array were increased more than fivefold at 48 hours, 96 hours, and 7 days after toxin injection, respectively, when compared with those of the control muscle. Especially the levels of mRNA for chemokines and chemokine receptors, many of which are potent regulators of macrophages, were highly elevated 48 hours after injury. The expression of osteopontin (OPN), a versatile regulator of inflammation and tissue repair, was up-regulated more than 118-fold in regenerating muscle at 48 hours after injury. Northern blotting confirmed that the expression of OPN was highest at 48 hours after cardiotoxin injection and declined sharply thereafter. Immunohistochemistry showed that OPN was detected both in the cytoplasm of macrophages and in necrotic muscle infiltrated with macrophages. Our studies suggest OPN may serve as an adhesion molecule that promotes macrophage binding to necrotic fibers and may be an important mediator in the early phase of muscle regeneration.