Giant insulinoma: report of a case and review of published reports.

BACKGROUND: Larger insulinomas are reportedly more likely to be malignant; however, their biological behavior has not been clearly elucidated. We here report the characteristics and treatment of a giant insulinoma with local invasion and lymph node metastasis. We also review published reports concerning the clinical features of giant insulinomas and comparing their grading with that of pancreatic neuroendocrine tumors. CASE PRESENTATION: A 71-year-old man was referred to our hospital for investigation of persistent hypoglycemia. On the current presentation, laboratory tests showed serum glucose, immunoreactive insulin, and C peptide concentrations of 45 mg/dL, 17.2 µIU/mL and 4.1 ng/mL, respectively. Dynamic magnetic resonance imaging showed a hypervascular tumor measuring 13.5 cm in the head of the pancreas. Computed tomography scanning demonstrated local invasion and lymph node involvement. He thus had Whipple's triad, which is associated with malignant insulinoma. No distant metastases having been identified, pancreaticoduodenectomy was performed. Intraoperatively, three separate tumors were identified in the pancreatic head. Pathological examination showed all three tumors were pancreatic neuroendocrine tumors; the tumor cells in the largest mass were strongly immunoreactive for insulin. The Ki-67 index was 2-5% in most parts of the largest tumor and over 20% in the poorly differentiated areas. This tumor was classified as neuroendocrine carcinoma in accordance with the 2010 World Health Organization classification of pancreatic endocrine neoplasms. He remains free of evidence of recurrence 2 years postsurgery. A review of published reports indicated that giant insulinomas are more malignant than smaller ones, and metastatic disease is found on presentation in 56% of patients with giant insulinomas; however, we were unable to identify any correlation between grade of pancreatic neuroendocrine tumor and biological behavior of giant insulinomas. CONCLUSIONS: Giant insulinomas more frequently exhibit malignant behavior, such as local invasion, lymph node involvement, and liver metastasis, than smaller ones. However, there was no relationship between grade and rate of metastases or survival in this small case series. Identification of useful biological markers is necessary.

Primary gastrointestinal stromal tumor of the liver: a case report and review of the literature.

BACKGROUND: Recently, gastrointestinal stromal tumors that have developed outside of the digestive tract have been reported. These tumors are collectively termed extra-gastrointestinal stromal tumors. Extra-gastrointestinal stromal tumors can also develop in the liver. Only eight case reports involving primary GIST of the liver have been published. We report a case and review the literature regarding this disease. CASE PRESENTATION: A 70-year-old woman with a past history of gastric cancer visited our hospital for regular inspection. With extensive radiological imaging, a computed tomography scan revealed a mass with a size of 6.8 cm in the lateral segment of the liver. (18)F-Fluoro-2-deoxyglucose positron emission tomography revealed no other malignancies except for the liver tumor. Because the lesion was suspected of being a primary malignant hepatic tumor, lateral segmentectomy was performed. The immunohistochemical analysis supported the diagnosis of gastrointestinal stromal tumors in the liver. The patient has had no evidence of recurrence during the 10-month follow-up period; imatinib chemotherapy was not administered. CONCLUSIONS: Primary hepatic gastrointestinal stromal tumors had no characteristics that distinguished them from ordinary tumors in imaging examinations. Primary gastrointestinal stromal tumors might have developed from interstitial Cajal-like cells.

[Study of the Postoperative Adjuvant Chemotherapy with UFT/LV or Capecitabine for Stage III Colorectal Cancer].

OBJECTIVE: This study sought to compare UFT/LV with capecitabine as adjuvant chemotherapy for the treatment of stage III colorectal cancer. METHODS: We conducted a retrospective analysis of patients with Stage III colorectal cancer who underwent surgical resection, except low rectal resections (Rb), followed by adjuvant chemotherapy with UFT/LV or capecitabine between 2007 and 2009, and evaluated background factors, adverse event profiles, disease free survival (DFS), and overall survival (OS). RESULTS: The analysis included 39 patients treated with UFT/LV and 29 with capecitabine, with no significant differences observed between the groups in terms of gender, age, or disease Stage. The most common adverse events were gastrointestinal symptoms in the UFT/LV group, and hand-foot syndrome in the capecitabine group. The 3-year DFS was 69.2 and 64.7% in the UFT/LV and capecitabine groups respectively, and 3-year OS was 89.7 and 92.7% in the UFT/LV and capecitabine groups respectively, indicating no significant differences between the groups. CONCLUSION: There were no marked differences in treatment outcomes with UFT/LV or capecitabine when they were used as adjuvant chemotherapy for Stage III colorectal cancer, suggesting that a choice between these 2 agents can be made on the basis of avoiding adverse events.

Impact of 5-fluorouracil metabolizing enzymes on chemotherapy in patients with resectable colorectal cancer.

Although 5-fluorouracil (5-FU) is an important drug for colorectal cancer (CRC) treatment, no useful biomarker is currently available to predict treatment response. Since 5-FU is converted into active or inactive forms by orotate phosphoribosyltransferase (OPRT) or dihydropyrimidine dehydrogenase (DPD), a correlation between these enzymes and response to 5-FU has been suggested. However, such a correlation has not been investigated prospectively. Therefore, in the present study, we aimed to prospectively evaluate whether OPRT and DPD were predictive factors of the response to 5-FU treatment in patients with resectable CRC. The present investigation was designed as a multicenter prospective cohort study. OPRT and DPD activities were assessed in biopsy samples, obtained surgically from patients with resectable CRC. The OPRT/DPD ratio was calculated and the cut-off values for this ratio were determined for 5-year disease-free survival (DFS) and overall survival (OS). Patients were treated with 5-FU/leucovorin (LV) regimens and oral 5-FU. The endpoint of this study was the correlation between the OPRT/DPD ratio and 5-year DFS and OS. The cut-off value for the OPRT/DPD ratio was determined by using the maximum χ2 statistic method against 5-year DFS and OS. Sixty-eight patients were enrolled from July 2003 to May 2005. The median follow-up period was 1925 days. The OPRT/DPD ratio cut-off values for 5-year DFS and OS were 0.015 and 0.013, respectively. During the 5-year DFS and OS periods, patients with higher cut-off values had a better prognosis than those with lower ratios (P=0.03 and 0.02, respectively). In conclusion, our results suggest that the OPRT/DPD ratio could be a predictive factor for response to 5-FU/LV adjuvant chemotherapy.

Adsorptive removal of cadmium by natural red earth: equilibrium and kinetic studies.

Natural red earth (NRE), an iron-coated sand found in the north western part of Sri Lanka, was used to examine the retention behaviour of cadmium, a heavy metal postulated as a factor of chronic kidney disease in Sri Lanka. Adsorption studies were conducted as a function of pH, ionic strength, initial Cd loading and time. The Cd adsorption increased from 6% to 99% with the pH increase from 4 to 8.5. The maximum adsorption was reached at pH > 7.5. Cadmium adsorption was not changed over 100-fold variations of NaNO3, providing evidence for the dominance of an inner-sphere bonding mechanism for both 10-fold variation of initial Cd concentrations. Surface complexation modelling suggests a monodentate bonding mechanism. Isotherm data were fairly fitted to a two-site Langmuir isotherm model and sorption maximums of 9.11 x 10(-6) and 3.89 x 10(-7) mol g(-1) were obtained for two surface sites. The kinetic study reveals that Cd uptake by NRE is so fast that the equilibrium was reached within 15 min and - 1 h for 4.44 and 44.4 microM initial Cd concentrations, respectively, and the chemisorption was the dominant mechanism over intra-particle diffusion. The study indicates the potential of NRE as a material for decontaminating environmental water polluted with Cd.

Successful utilization of coronary covered stents to treat a common hepatic artery pseudoaneurysm secondary to pancreatic fistula after Whipple's procedure: report of a case.

A 73-year-old man underwent a pylorus-preserving Whipple's procedure for distal cholangiocarcinoma. His postoperative course was complicated by the formation of a pancreatic fistula, which was initially managed conservatively. On postoperative day (POD) 86, he lost 100 ml of blood from the site of the pancreatic fistula. Contrast-enhanced computed tomography (CT) showed a pseudoaneurysm, 12 mm in diameter, in the common hepatic artery. The diameter of the pseudoaneurysm increased to 15 mm on POD 89, so we implanted coronary covered stents to prevent massive bleeding from rupture and to retain hepatic arterial flow. Six days after implantation, computed tomography findings confirmed a thrombosed pseudoaneurysm as well as patent hepatic arterial flow. Follow-up CT 18 months after surgery showed patent hepatic arterial flow. There have been no signs of rebleeding or abnormal liver function.

Increased epithelial cadherin expression among Japanese intestinal-type gastric cancers compared with specimens from American patients of European descent.

The different patterns of gastric cancer in the Far East and West have evolved to the extent that it has been suggested that the disease in Japan is biologically less aggressive than in the West. We studied paraffin-embedded, formalin-fixed tissue blocks from Japanese patients and American patients of European descent who had undergone gastrectomy for gastric cancer not involving the gastroesophageal junction. Specimens were staged (T stage), graded (Lauren classification), and biomarker expression (epithelial cadherin [E-cadherin], c-erbB2, Ki67, and p53) was quantified using immunohistochemistry without knowledge of the country of origin. E-cadherin was expressed in 49 per cent of malignant cells from Japanese specimens compared with 27 per cent of malignant cells from American specimens (P = 0.04). The expression of E-cadherin on diffuse cancers from the two countries was similar (34.4 in Japanese vs 41.5 in American, P = 0.92). E-cadherin expression, however, was significantly higher among intestinal cancers from the two countries: 56.3 per cent of cells from intestinal or mixed cancers from Japan (n = 32) expressed E-cadherin compared with 22.2 per cent of American specimens (n = 12; P = 0.008).-c-erbB2 was expressed on a higher proportion of malignant cells from American specimens (30% vs 22%; P = 0.20). E-cadherin expression, a favorable prognostic factor, is more common in Japanese intestinal-type gastric cancer not involving the gastroesophageal junction. If the biology of gastric cancer in the Far East is less aggressive than that in the United States, it is likely that treatments need to be individualized.

Concentrations of arsenic in brackish lake water: application of tristimulus colorimetric determination.

The evaluation of a simple and rapid tristimulus colorimetric method for the determination of arsenic in brackish waters and its application to brackish water samples taken from brackish Lake Nakaumi are described. The determinations of arsenic in brackish water samples were made satisfactorily independent of sample salinity. By applying this method to lake water samples, the distributions and behaviors of arsenic in the lake and their controlling factors were clarified, such as seasonal variations of arsenic and the effect of a typhoon.

A simple and rapid in situ preconcentration method for trace ammonia nitrogen in environmental water samples using a solid-phase extraction followed by spectrophotometric determination.

A simple and rapid in situ preconcentration method for the spectrophotometric determination of trace ammonia nitrogen in environmental water samples has been developed based on solid-phase extraction using a small column packed with octadecyl group-bonded silica gel (Sep-Pak C18 cartridge). A water sample was taken into a graduated syringe for easy and simple operation and prevention of contamination immediately after sample collection. Ammonia in the sample was reacted with hypochlorite and thymol to be converted into indothymol blue; then the formed indothymol blue was collected as an ion pair between indothymol blue and tetrabutylammonium ion on a Sep-Pak C18 cartridge. The indothymol blue on the cartridge was stable for 4 days. The retained indothymol blue was easily eluted with a mixture of methanol and 0.01 mol/l sodium hydroxide solution. The color intensity due to the indothymol blue was spectrophotometrically measured at 725 nm. The proposed method was successfully applied to environmental water samples such as river water.

The liquid-liquid extraction using hydrophilic solvents occluded to an oil-adsorbent as an organic phase: extraction of 8-quinolinolato complexes of alkaline earth metals into tetrahydrofuran.

In order to use a hydrophilic solvent as an organic phase in liquid-liquid extraction by retaining it to a solid support, the occlusion and desorption of nine hydrophilic solvents, such as methanol, to three kinds of commercially available oil-adsorbent were examined. The combination of tetrahydrofuran and WOSEP made by fibrous polypropylene was finally selected, and was subjected to the extraction of alkaline Earth metals with 8-quinolinol. It was proved that Mg2+, Ca2+, and Sr2+ ions could be successfully extracted into the tetrahydrofuran phase in the form of 8-quinolinolato complexes, which could not be extracted into CHCl3.

A simple and sensitive method for the determination of hydroxylamine in fresh-water samples using hypochlorite followed by gas chromatography.

A new and simple method for the determination of hydroxylamine in environmental water, such as fresh rivers and lakes using hypochlorite, followed by its gas choromatographic detection, has been developed. A glass vial filled with sample water was sealed by a butyl-rubber stopper and aluminum cap without head-space, and then sodium hypochlorite solution was injected into the vial through a syringe to convert hydroxylamine to nitrous oxide. The head-space in the glass vial was prepared with 99.9% grade N2 using a gas-tight syringe. After the glass vial was shaken for a few minutes, nitrous oxide in the gas-phase was measured by a gas chromatograph with an electron-capture detector. The dissolved nitrous oxide in the liquid-phase was calculated according to the solubility formula. The proposed method was applied to the analysis of fresh-water samples taken from Iu river and Hii river, flowing into brackish Lakes Nakaumi and Shinji, respectively.

A simple in situ visual and tristimulus colorimetric method for the determination of trace arsenic in environmental water after its collection on a mercury(II)-impregnated paper.

A simple in situ visual and tristimulus colorimetric method for the determination of trace arsenic in environmental water after collecting arsenic on a test paper impregnated with mercury(II) bromide and rosaniline chloride by its reduction aeration has been developed. The color development on the test paper is based on the formations of AsH(HgBr)2 (yellow) and/or As(HgBr)3 (brownish yellow) by a reaction between mercury(II) bromide and arsine (AsH3), which is produced through the reduction of As(III) (arsenite ion) and/or As(V) (arsenate ion) in a sample solution. To a sample solution, potassium iodide, tin(II) chloride, zinc sand and 4 ml of 6 M hydrochloric acid solution were added successively. The liberated arsine was collected on the test paper. The yellow or brownish-yellow color intensity on the test paper was measured by a tristimulus colorimeter and also by a visual method. The established method is applicable to the determination of arsenic in environmental water sample such as river, brackish, and seawater types.

Early gastric cancer with Krukenberg tumor and review of cases of intramucosal gastric cancers with Krukenberg tumor.

A 47-year-old woman was admitted because of hypermenorrhea. Transvaginal ultrasonography revealed an ovarian tumor and myoma uteri, and total hysterectomy with bilateral salpingo-oophorectomy was performed. Histology revealed signet-ring cell carcinoma in the right ovary. In order to find out the primary site of this tumor, gastroendoscopy was performed after the operation, and showed a IIc lesion in the lower body of the stomach; biopsy specimens showed signet-ring cell carcinoma similar to that in the right ovary. Total gastrectomy revealed that the lesion was an early gastric cancer confined to the mucosa, but there was lymphatic invasion slightly beneath the muscularis mucosa, with regional lymph node metastasis. In the light of a review of the seven cases of early gastric cancer with Krukenberg tumor previously reported, lymphatic metastasis seemed to be the most likely pathway of ovarian metastasis in early gastric cancers.

A simple and rapid in situ preconcentration method using solid-phase extraction for the determination of dissolved manganese in brackish lake water samples.

A simple and rapid in situ preconcentration method for the determination of dissolved manganese in environmental waters has been developed based on solid-phase extraction using a Sep-Pak C18 cartridge. Manganese in water samples, which was taken into a graduated syringe to easily perform the operation for collecting manganese at sampling sites, was converted into a stable complex with 4-(2-pyridylazo)resorcinol (PAR) at pH 10 immediately after sample collection. The formed Mn-PAR complex was collected by a Sep-Pak C18 cartridge, which was packed with C18-bonded silica. The complex was stable in the Sep-Pak C18 cartridge for at least one month. The retained complex was quantitatively eluted with 0.5 M hydrochloric acid. The manganese was determined by graphite-furnace AAS. The proposed method was successfully applicable to brackish lake water samples to investigate the behavior of dissolved manganese in brackish lakes.

Retroperitoneal lymphangioma with a duodenal lesion in an adult.

A multilocular-cystic and cavernous, retroperitoneal tumor was found in a 40-year-old man whose past medical history was unremarkable. On admission, he complained of a large and still growing intra-abdominal mass associated with dull pain and a low-grade fever. Laboratory findings revealed leukocytosis and C-reactive protein elevation, compatible with inflammation of the tumor. Percutaneous aspiration of the tumor was performed under transabdominal ultrasonographic guidance, and continuous drainage of fluid from within the tumor ameliorated his symptoms. From preoperative examinations, including radiological imaging, fluid aspiration, and endoscopy with biopsy, a diagnosis of retroperitoneal lymphangioma was made. Laparotomy revealed extensive adhesions between the tumor and both the duodenum and the pancreatic head. A pancreaticoduodenectomy was therefore performed. At 3-year follow-up, there was no sign of recurrence. Retroperitoneal lymphangioma is an uncommon disorder, and the cavernous type is extremely rare. The duodenal lesion was an important feature of the present case, and endoscopic biopsy of this lesion facilitated precise preoperative diagnosis of retroperitoneal lymphangioma.