[A Case of Intraductal Pancreatic Mallignant Tumor with Difficulty in Differentiating between IPMN and ITPN].

The patient was a male in his early 60s. Diabetes had aggravated 6 months earlier, and the patient was referred to our hospital for close examination. On contrast CT, enhanced mass shadows filling the lumen of the main pancreatic duct, which was dilated throughout the pancreas, were observed, and the mass was diagnosed as an adenocarcinoma on EUS-FNA. Based on these findings, main-duct IPMN was suspected and total pancreatectomy was performed. On macroscopic observation of the resected specimen, outgrowth of a solid tumor was observed in the main pancreatic duct, whereas only low-level mucus retention was noted in the pancreatic duct. Histopathological examination revealed a papillary/tubular tumor growth, suggesting interstitial infiltration throughout the pancreas. On immunostaining, the tumor was partially positive for MUC5AC, based on which the patient was diagnosed with an intraductal pancreatic mallignant tumor, with difficulty in differentiating between IPMC and ITPC. Clinicopathologically, many aspects regarding ITPN remain unclear. Further accumulation of such cases and investigation of the tumor pathology are necessary.

Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT.

BACKGROUND: This retrospective study aimed to investigate the incidence of each type of accessory hepatic duct by drip infusion cholangiography with CT (DIC-CT). METHODS: Five hundred sixty nine patients who underwent preoperative DIC-CT and laparoscopic cholecystectomy were reviewed. Accessory hepatic ducts were classified as follows: type I (accessory hepatic ducts that merged with the common hepatic duct between the confluence of the right and left hepatic ducts and the cystic duct confluence), type II (those that merged with the common hepatic duct at the same site as the cystic duct), type III (those that merged with the common bile duct distal to the cystic duct confluence), type IV (the cystic duct merged with the accessory hepatic duct), and type V (accessory hepatic ducts that merged with the common hepatic or bile duct on the left side). RESULTS: Accessory hepatic ducts were observed in 50 patients. Type I, II, III, IV, and V accessory hepatic ducts were detected in 32, 3, 1, 11, and 3 patients, respectively. Based on their drainage areas, the accessory hepatic ducts were also classified as follows: a posterior branch in 22 patients, an anterior branch in 9 patients, a combination of posterior and anterior branches in 16 patients, a left-sided branch in 2 patients, and a caudate branch in 1 patient. None of the patients with accessory hepatic ducts suffered bile duct injuries. CONCLUSION: There are a number of variants of the accessory hepatic duct. DIC-CT is useful to detect the accessory hepatic duct.

[Metastatic Pancreatic Carcinoma from Renal Cell Carcinoma Indistinguishable from Primary Pancreatic Endocrine Tumor - A Case Report].

A hypervascularized tumor was detected in a 65-year-old man who had underwent a nephrectomy for a right renal cell carcinoma at the age of 55 years. We diagnosed the tumor as a non-functioning pancreatic neuroendocrine tumor or a metastatic tumor from the renal cell carcinoma. We performed distal pancreatectomy with splenectomy and lymph node dissection. The tumor was histopathologically diagnosed as metastatic renal cell carcinoma.

True left-sided gallbladder with variations of bile duct and cholecystic vein.

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

[A case of hepatocellular carcinoma with multiple lymph node metastases detected by FDG-PET].

We report a case of hepatocellular carcinoma (HCC) with multiple lymph node (LN) metastases. A 68-year-old man underwent hepatectomy at our hospital. Intrahepatic recurrence and swelling of multiple LNs were detected by enhanced CT 21 months later. FDG-PET was positive for multiple swollen LNs, but all were negative for the intrahepatic recurrences. Biopsy of para-aortic LNs was revealed LN metastases from HCC. Immunohistochemically, the LN metastases were composed of poorly differentiated HCC. The sensitivity of FDG-PET in patients with HCC varies in relation to degree of differentiation and decreased FDG uptake must be noted.

[A case of inflammatory myofibroblastic tumor of the lesser omentum with intratumoral hemorrhage].

A 24-year-old man presented complaining of epigastralgia and tenderness in the epigastric region. An abdominal computed tomography revealed a low density tumor, extending between the anterior wall of the stomach and the abdominal wall. Because the tumor was found to enlarge, an operation was performed to remove the tumor. During the operation, it was revealed that the tumor was connected with the lesser omentum, which suggested that it had originated from the lesser omentum. We diagnosed an inflammatory myofibroblastic tumor based on the pathological examination, which revealed infiltration of inflammatory cells, sparse proliferation of spindle cells and limited proliferation of collagen fibers, characterized by an irregular arrangement.

Shewanella infection in decompensated liver disease: a septic case.

Shewanella species are an unusual cause of disease in humans. However, reports of Shewanella infections have been increasing, and hepatobiliary disease has been proposed as a predisposing factor following a critical course. We report the first Japanese septic case of decompensated liver disease in which this bacterium acted as a definite pathogen. A 67-year-old Japanese man with primary sclerosing cholangitis was admitted to our hospital complaining of fever, general fatigue, pain, and a rash on the lower left extremity. He was tentatively diagnosed with necrotizing fasciitis caused by Vibrio vulnificus because of his decompensated cirrhotic liver and history of consuming raw fish. Thereafter, the diagnosis was altered to cellulitis and Shewanella septicemia on the basis of the characteristics of his skin lesion and an arterial blood culture. He died of multiple organ failure on the eleventh day in the hospital. Since several reports have demonstrated that Shewanella can cause lethal sepsis in patients with hepatobiliary disease, we should be aware of the pathogenicity of this bacterium.

[STI571 for gastrointestinal stromal tumors].

Since the effectiveness of STI571 for GIST was reported, therapy for GIST has changed markedly, and the disease has attracted attention. We have treated 19 patients with GIST since 2000 by 19 resections (local resection in 14 patients, total gastrectomy in 2 patients, distal gastrectomy in 2 patients, and hepatectomy in 1 patient), and administered STI571 to 5 patients with unresectable or recurrent GIST. Of these 5 patients, 2, 1, 1, and 1 had PR, SD, PD, and inevaluable disease, respectively, with a response rate of 50%. The disease was controllable in 80% of the patients. All patients had palpebral and crural edema as side effects, which were not severe, suggesting the safety of the drug. It is important to tailor therapy (STI571 or surgery) to the patient.