Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography.

BACKGROUND: To perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data. METHODS: Perigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery. RESULTS: Of the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively. CONCLUSIONS: Preoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Geospatial Assessments of DNA Adducts in the Human Stomach: A Model of Field Cancerization.

BACKGROUND: Field cancerization is a popular concept regarding where cancer cells arise in a plane, such as the opened-up gastrointestinal mucosa. The geospatial distribution of DNA adducts, some of which are believed to initiate mutation, may be a clue to understanding the landscape of the preferred occurrence of gastric cancer in the human stomach, such that the occurrence is much more frequent in the lesser curvature than in the greater curvature. METHODS: Seven DNA adducts, C5-methyl-2'-deoxycytidine, 2'-deoxyinosine, C5-hydroxymethyl-2'-deoxycytidine, N6-methyl-2'-deoxyadenosine, 1,N6-etheno-2'-deoxyadenosine, N6-hydroxymethyl-2'-deoxyadenosine, and C8-oxo-2'-deoxyguanosine, from different points and zones of the human stomach were semi quantitatively measured by liquid chromatography/tandem mass spectrometry. The differences in the quantity of these DNA adducts from the lesser and greater curvature, the upper, middle and lower third zones, the anterior and posterior wall of the stomach, and the mucosae distant from and near the tumor were compared to determine whether the location preference of cancer in the stomach could be explained by the distribution of these DNA adducts. Comparisons were conducted considering the tumor locations and operation methods. CONCLUSIONS: Regarding the DNA adducts investigated, significant differences in quantities and locations in the whole stomach were not noted; thus, these DNA adducts do not explain the preferential occurrence of cancer in particular locations of the human stomach.

Mass spectrometric profiling of DNA adducts in the human stomach associated with damage from environmental factors.

BACKGROUND: A comprehensive understanding of DNA adducts, one of the most plausible origins of cancer mutations, is still elusive, especially in human tissues in clinical settings. Recent technological developments have facilitated the identification of multiple DNA adducts in a single experiment. Only a few attempts toward this "DNA adductome approach" in human tissues have been reported. Geospatial information on DNA adducts in human organs has been scarce. AIM: Mass spectrometry of human gastric mucosal DNA was performed to identify DNA adducts associated with environmental factors. MATERIALS AND METHODS: From 59 subjects who had received gastrectomy for gastric cancer, 306 samples of nontumor tissues and 15 samples of tumors (14 cases) were taken for DNA adductome analysis. Gastric nontumor tissue from autopsies of 7 subjects without gastric cancer (urothelial cancer, hepatocellular carcinoma, lung cancer each; the other four cases were without any cancers) was also investigated. Briefly, DNA was extracted from each sample with antioxidants, digested into nucleosides, separated by liquid chromatography, and then electrospray-ionized. Specific DNA adducts were identified by mass/charge number and column retention time compared to standards. Information on lifestyle factors such as tobacco smoking and alcohol drinking was taken from the clinical records of each subject. RESULTS: Seven DNA adducts, including modified bases, C5-methyl-2'-deoxycytidine, 2'-deoxyinosine, C5-hydroxymethyl-2'-deoxycytidine, N6-methyl-2'-deoxyadenosine, 1,N6-etheno-2'-deoxyadenosine, N6-hydroxymethyl-2'-deoxyadenosine, and C8-oxo-2'-deoxyguanosine, were identified in the human stomach and characterized. Intraindividual differences according to the multiple sites of these adducts were noted but were less substantial than interindividual differences. N6-hydroxymethyl-2'-deoxyadenosine was identified in the human stomach for the first time. The amount of C5-hydroxymethyl-2'-deoxycytidine was higher in the stomachs of subjects without gastric cancer than in the nontumor and tumor portions of the stomach in gastric cancer patients. Higher levels of 1,N6-etheno-2'-deoxyadenosine were detected in the subjects who reported both smoking and drinking than in those without these habits. These DNA adducts showed considerable correlations with each other. CONCLUSIONS: We characterized 7 DNA adducts in the nontumor portion of the human stomach in both gastric cancer subjects and nongastric cancer subjects. A reduction in C5-hydroxymethyl-dC even in the nontumor mucosa of patients with gastric cancer was observed. Smoking and drinking habits significantly influenced the quantity of one of the lipid peroxidation-derived adducts, etheno-dA. A more expansive DNA adductome profile would provide a comprehensive understanding of the origin of human cancer in the future.

[Solid serous cystic neoplasm of the pancreas showing a gradual tumor enlargement for over five years:a case report].

Serous cystic neoplasms (SCNs) of the pancreas are slow-growing benign tumors. They are mostly monitored without surgical management. Solid SCN is rare and differentiating it from hypervascular tumors of the pancreas using preoperative imaging may be difficult. A 69-year-old woman was referred to our department for surgical treatment of an enlarged pancreatic tail tumor with a size of 22mm based on the abdominal computed tomography (CT). At the age of 60, she underwent thyroidectomy for papillary thyroid carcinoma and mastectomy for breast cancer. Initially, consecutive annual CT examinations did not show signs of recurrence. However, after 9 years, a hypervascular pancreatic tumor was detected and assumed to be either a neuroendocrine tumor or metastasis. The patient underwent distal pancreatectomy, and the resected specimen was histopathologically diagnosed as solid SCN of the pancreas. Before being referred for pancreatic resection, this patient had been followed up with serial annual CT examinations for over 9 years after a previous malignant disease. Retrospectively, the abdominal CT scans showed that the pancreatic tumor already existed 5 years ago and had gradually increased in size thereafter. In this case report, we focused on the characteristics of solid SCN to address the difficulty in diagnosing this rare malignancy.

Pancreatic schwannoma revealed contrast by contrast-enhanced ultrasonography: a case report.

An asymptomatic pancreatic tumor was discovered in a 77-year-old man during a medical check-up. An abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a cystic mass containing a septum-like solid portion in the head of the pancreas, measuring 3.5cm in diameter. Additionally, abdominal contrast-enhanced ultrasonography (US) revealed increased flow in the solid portion and a tumor capsule in its early phase. We preoperatively diagnosed the lesion as a cystic-degenerated pancreatic neuroendocrine tumor or solid-pseudopapillary tumor and performed a pancreatoduodenectomy. Histopathological examination revealed a cystic pancreatic mass consisting of spindle-shaped cells, with S-100-positive and SMA-negative immunohistochemical stainings. This lesion was diagnosed as a pancreatic schwannoma from these findings.

Macrophage density and macrophage colony-stimulating factor expression predict the postoperative prognosis in patients with intrahepatic cholangiocarcinoma.

PURPOSES: Macrophages are included in the stromal compartments in various neoplasms, and their behavior against tumors is diverse. The aim of this study was to examine the role of tumor-infiltrating macrophages and their main regulator, macrophage colony-stimulating factor (M-CSF), in intrahepatic cholangiocarcinoma (ICC). METHODS: Macrophage density and M-CSF expression in 39 resected ICC specimens were immunohistochemically evaluated in the central and peripheral areas of tumors, which were defined as fields more than and within 500 µm from the invasive front, respectively. The number of CD68-positive macrophages was counted using an image-analyzing software program. The relationship between these results and other clinicopathological factors and the postoperative prognosis were evaluated. RESULTS: Sporadic M-CSF expression in cancer cells around the peripheral area was observed in fourteen patients. M-CSF-positive ICCs showed a higher macrophage density in the tumor-peripheral area than did M-CSF-negative ICCs. M-CSF expression and higher macrophage density in the tumor-peripheral area were related to a better postoperative prognosis, whereas a higher macrophage density in the central area was one of the significant risk factors for a poor prognosis in a univariate analysis. CONCLUSION: Tumor-peripheral macrophage infiltration, presumably dependent on M-CSF, and M-CSF-independent tumor-central macrophage infiltration are predictive factors for better and worse postoperative prognosis in ICC patients, respectively. The tumor microenvironment, such as the presence of hypoxia, may affect the behavior of infiltrating macrophages in ICC.

A rare collision tumor composed of follicular lymphoma and adenocarcinoma in the ampulla of vater: a case report.

The duodenum is infrequently affected by malignant lymphoma, and follicular lymphomas of the duodenum are rare histological subtypes. There are no reported cases of collision of follicular lymphoma and other tumors in the ampulla of Vater. A 57-year-old Japanese man presented with jaundice, and abdominal computed tomography revealed a tumor of the ampulla of Vater invading the pancreatic head with biliary dilatation and a thickened duodenal wall. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histopathology of the resected specimen revealed lymphoid follicular formations with small-to-medium-sized centrocyte-like cells and some centroblast-like cells. The atypical lymphoid cells were immunohistochemically positive for CD10, CD20, and CD79a but negative for CD5 and cyclin D1. BCL2 protein was highly expressed in the follicle centers. The diagnosis was duodenal follicular lymphoma, Grade 1. The follicular lymphoma, 40 mm in diameter, involved duodenal submucosa and regional lymph nodes without distant metastasis. This duodenal follicular lymphoma was partially overlapped by adenocarcinoma of the ampulla of Vater, measuring 25 × 20 mm, which involved the lower common bile duct, pancreas, and duodenum. We report the first case of a surgically treated collision tumor composed of a rare mass-forming follicular lymphoma and adenocarcinoma of the ampulla of Vater.

Pancreatic metastases of cerebellar hemangiopericytoma occurring 24 years after initial presentation: report of a case.

Hemangiopericytoma (HPC) preferentially developing in soft tissues and the meninges has been gradually recognized to be an aggressive, highly metastatic tumor. We herein report the case of a 65-year-old male with pancreatic metastases of cerebellar HPC that developed following two resections of intracranial local recurrent foci, 24 years after the initial craniotomy and 7 years after resection of metastases to the lungs and kidneys. Follow-up abdominal computed tomography scanning and magnetic resonance imaging revealed a solitary tumor in the pancreatic body. Since no other recurrent foci were detectable, distal pancreatectomy was performed. Another metastasis was incidentally found in the resected pancreas. Both foci were pathologically proven to be metastases of HPC. Among the 12 reported cases of pancreatic metastases of HPC, including ours, this case showed the longest duration between initial onset and the development of pancreatic metastases, suggesting that providing long-term follow-up is necessary for HPC patients.

Detection of intrahepatic veno-venous shunts by three-dimensional venography using multidetector-row computed tomography during angiography.

PURPOSE: The hepatic vein (HV) can be removed during hepatectomy if there is an effective intrahepatic veno-venous shunt (vv-shunt). We evaluated the efficacy of vv-shunt detection by three-dimensional (3D) venography reconstructed from multidetector-row computed tomography (MDCT) during angiography. METHODS: 3D venography was reconstructed using computer software in 88 patients with intrahepatic tumors. RESULTS: We found that 12 patients had one shunt [4 right hepatic vein (RHV)-middle hepatic vein (MHV) and 12 RHV- inferior right hepatic vein (IRHV)] and 1 patient had 2 shunts (RHV-MHV and -IRHV), confirming a clinically efficient vv-shunt in 14.8% of the patients. In one patient with an RHV-IRHV shunt, the preserved RHV-IRHV shunt worked well and prevented congestion of the postero-caudal subsegment after central bisegmentectomy with partial resection of the RHV ventral trunk for huge hepatocellular carcinoma (HCC). CONCLUSIONS: Although the vv-shunt detection rate by 3D venography is low, a visualized vv-shunt proved to be efficient. Thus, invasive occlusion venography is avoidable if a vv-shunt is seen on 3D venography.

Detection of hepatocellular carcinomas with near-infrared fluorescence imaging using indocyanine green: its usefulness and limitation.

BACKGROUND: Indocyanine green (ICG), an agent for measuring liver function, becomes fluorescent under near-infrared (NIR) light after binding to serum proteins. Hepatocellular carcinoma (HCC) with a deposit of preoperatively administered ICG becomes clearly detectable under ICG fluorography; however, it remains unclear whether this detection method is always reliable. This case series study was designed to clarify the reliability of this method. METHODS: ICG (0.5 mg/kg) was injected from the 3rd to 28th preoperative day to evaluate hepatic function in 58 patients with HCCs. Preoperative imaging modalities identified 76 HCC foci. The operative fields and resected specimens were observed with an NIR camera system. Preoperatively detected lesions and lesions newly detected by the ICG fluorography were histologically investigated. RESULTS: ICG fluorography identified 73 of 76 preoperatively diagnosed HCC lesions. Intraoperative ICG fluorography visualized 47 lesions in 40 patients. The other 26 lesions showing emission were found in the sectioned specimens under NIR observation. Other than preoperatively diagnosed foci, ICG fluorography visualized 35 new lesions, including 6 HCCs, 2 dysplastic nodules and 27 non-neoplastic lesions, such as bile plugs and cysts. The sensitivity of ICG fluorography for HCCs was 96% and its positive predictive value was 71.5%. CONCLUSIONS: Indocyanine green fluorography is useful to detect HCCs; however, attention should be paid to the fact that HCCs may be occasionally overlooked by this imaging method and that lesions detected by this method are not always neoplastic lesions.

Anomalous arterial ramification in the right liver.

PURPOSE: The aim of this study was to investigate whether individual arterial and portal venous division during hepatectomy is always safe by examining the presence of the anomalous arterial ramification in the right liver. METHODS: The ramifications of the right hepatic artery (RHA) were investigated by three-dimensional (3D) reconstruction imaging using a computer software program in 87 patients undergoing computed tomography during angiography as a preoperative assessment of intrahepatic tumors. RESULTS: The anterior view showed that the RHA bifurcated into the anterior and posterior sector arteries at the hilum in 76 patients. Sector-intersecting arteries from the posterior to the anterior sector and vice versa were found in 7 and 4 of those patients, respectively. The RHA in the other 11 patients was divided in a complex manner into more than 2 arteries: e.g., the first branch to the cranial part of the posterior sector, the second to the anterior sector, and the third to the caudal part of the posterior sector. A total of 22 patients showed anomalous ramification of RHA. CONCLUSION: Preoperative observation of the hepatic artery by 3D imaging is very useful to detect anomalous ramification. Arterial dissection during the intrafascial approach should be cautiously performed based on the 3D images.

Impact of cell cycle disruption on impaired hepatic regeneration in aged livers with ischemic insult.

BACKGROUND: The number of elderly patients with hepatobiliary malignancies has increased with the steady growth of elderly population. However, the safety of major hepatectomy for elderly patients remains controversial. This study investigated the effect of aging on the hepatic regenerative response after partial resection of livers subjected to ischemic insult. METHODS: Two-thirds hepatectomy following 1-h hepatic ischemia was performed in young (12-wk-old) and old (18-mo-old) rats under portosystemic shunt establishment by subcutaneous transposition of the spleen. RESULTS: The survival rate 48 h after hepatectomy of the old rats was significantly lower (20%) than that of the young rats (53%), whereas all animals without hepatic ischemia were alive at 48 h. Hepatic necrosis and hepatocyte apoptosis during the early post-hepatectomy phase were more severe in the aged livers, which also showed delayed Akt activation. Liver mass restoration was significantly retarded in the old rats, despite higher plasma IL-6 levels, rapid and prolonged activation of hepatic STAT3, and increased hepatocyte nuclear cyclin D1 levels. In the young livers, cyclin E, which is essential for G1/S transition, and cyclin A, a marker of S phase, were observed in the nucleus from 24 h, reaching peaks 48 h after hepatectomy. In contrast, the old livers showed greatly delayed and decreased nuclear cyclin E and cyclin A levels. CONCLUSION: Age-related reductions in the regenerative ability of ischemically damaged livers may be caused by cell cycle disruption at either the late G1 phase or the G1/S transition, despite increased cyclin D1 levels and compensatory IL-6/STAT3 activation.

Peripancreatic arterial anatomy analyzed by 3-dimensional multidetector-row computed tomography.

BACKGROUND/AIMS: Since the anatomy of the peripancreatic vessel system is complex, it is important to preoperatively clarify the running aspects of such vessels, especially when pancreatoduodenectomy is performed. METHODOLOGY: In 166 patients undergoing multidetector-row computed tomography, peripancreatic vessels were three-dimensionally reconstructed using computer software. RESULTS: The dorsal pancreatic artery branched from the splenic artery (45.4%), common hepatic artery (24.8%), superior mesenteric artery (SMA, 15.6%), celiac axis (9.9%) and other arteries such as the middle colic artery (4.3%). Branching of the inferior pancreatoduodenal artery (IPDA) was categorized into two types: a single main IPDA branching from one artery, such as the first jejunal artery (J1a, 55.2%) and SMA (25.1%) and two IPDAs branching from one artery (J1a, 7.0% or SMA, 2.8%) or separately from two arteries (3.5%). Most IPDAs (129 of identified 168 IPDAs) ran behind the SMA at the right edge of the SMA. In 52 patients, superior mesenteric vein tributaries ran above the SMA and mask the IPDA's ramification. CONCLUSIONS: Peripancreatic vessel anatomy is very complex. The preoperative 3D arteriography and portography enables us to obtain precise information about peripancreatic vessels.

[Primary hepatic actinomycosis concomitant with elevation of protein induced by vitamin K absence or antagonist II - report of a case].

We report a case of primary hepatic actinomycosis showing elevation of serum protein induced by vitamin K absence or antagonist II (PIVKA-II). A 68-year-old man visited an affiliated hospital with a complaint of high fever and body weight loss. Hematological examination revealed severe inflammatory reactions and liver dysfunction. Abdominal CT showed a heterogeneous low density area composed of cystic and solid part. We suspected the cystic part with band-like enhancement to be a hepatic abscess and performed percutaneous transhepatic abscess drainage. Although inflammatory reactions decreased after the drainage, the solid part did not shrink and blood chemistry revealed elevation of PIVKA-II. Since we could not rule out the possibility of hepatoma, right hepatectomy was performed. Histological examination revealed actinomycetes. Although primary hepatic actinomycosis is a rare disease, it must be kept in mind in the differential diagnosis of the liver tumor.

Hepatectomy for metastatic liver tumors complicated with right umbilical portion.

We report the case of a 76-year-old man, presenting with a right umbilical portion (RUP), with two liver metastases of rectal cancer, 2cm and 1 cm tumors in the caudate lobe and anterior segment, respectively. The portal first branch ran to the right posterior segment and the remaining formed a left trunk, thereafter forming RUP. The tumor in the caudate was close to the right posterior segment's Glissonean pedicle. On 3-dimensional CT analysis under tubography via an endoscopic naso-biliary tube, the anatomical patterns of the arteries and bile ducts were complicated. On laparotomy, the gallbladder was located to the left of the round ligament. Right posterior segmentectomy plus partial caudate resection and partial hepatectomy of the anterior segment was performed after skeletonization of the biliovascular structures at the hepatic hilum. Precise examination of the biliovascular structures is needed to safely perform hepatectomy in patients complicated with RUP.

[A case of hilar bile duct cancer which recurred at abdominal and cervical lymph nodes 8 years after curative resection].

A 40-year-old man underwent right hemihepatectomy with biliary reconstruction for hilar bile duct cancer, and the surgical margin being negative. The tumor, showing atypical intraductal growth, was solid adenocarcinoma with rich mucinous component, although it was negative for MUC1, MUC2 and MUC5AC, suggesting that the tumor was not an intraductal papillary neoplasm of the bile duct (IPN-B). Eight years after operation, abdominal and cervical lymph node metastases were found on computed tomography and (18)F-deoxyglucose positron emission tomography examination. Late remote recurrence after curative resection of the extrahepatic bile duct cancer is relatively rare. The recurrence in the present case maybe explained by the tumor dormancy theory.

Postoperative bile leakage managed by interventional intrabiliary ethanol ablation.

We report a case of postoperative bile leakage that was successfully managed by intrabiliary ethanol ablation. A 68-year-old man with peritoneal and liver metastases from a jejunal gastrointestinal stromal tumor (GIST), which were refractory to molecular-targeted agents, underwent extended left lobectomy and peritoneal tumor resection. Bile leakage from the drainage tube persisted at a constant volume of 100 ml per day. On the 20th postoperative day, fistulography through a drainage tube and endoscopic cholangiography revealed biliary leakage from the bile ducts of segments 5 and 1. Since these bile ducts did not communicate with the proximal hilar bile ducts, two 5F balloon catheters were separately advanced into the leaking bile ducts via the drainage tube on day 30, and 1 ml absolute ethanol was injected into both of these catheters for 10 minutes. After three sessions of ethanol ablation, the bile leakage stopped. Although the bile leakage from segment 1 relapsed five days later, it gradually decreased and then stopped again until day 70. Intrabiliary ethanol ablation using the interventional technique is useful for managing bile leakage after hepatectomy when the leaking distal bile duct is isolated from the proximal biliary tree.

Pancreatic neuroendocrine cell tumor secreting parathyroid hormone-related protein and gastrin: Report of a case.

This report presents a case of pancreatic neuroendocrine cell carcinoma with multiple liver metastases secreting gastrin and parathyroid hormone-related protein (PTHrP) related to lumbar bone fracture and hypercalcemia. A 58-year-old woman visited an affiliated hospital with a chief complaint of lumbago without any evidence of trauma. She was diagnosed with hepatic dysfunction and hypercalcemia as well as multiple lumbar compression fractures without osteolytic lesions. Abdominal computed tomography (CT) showed a hypervascular mass in the pancreatic tail and multiple liver tumors. Duodenal ulcers were found with gastrointestinal endoscopy. There was a marked increase in the serum gastrin level. She was diagnosed as gastrinoma with multiple liver metastases and was admitted to the hospital. She had an increase in serum PTHrP level without the elevation of intact parathyroid hormone at the time of admission. She underwent an extended right hepatectomy in addition to a distal pancreatectomy with a regional lymphadenectomy and splenectomy. The postoperative course was uneventful, and serum gastrin and PTHrP activities reduced to normal levels. She remained symptom-free, and serum calcium, gastrin, and PTHrP levels remain within the normal ranges 19 months after surgery without adjuvant therapy.

Bile leak test by indocyanine green fluorescence images after hepatectomy.

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.