Purpose: Curative resection is the only chance for long-term survival for pancreatic carcinoma, however, the surgical results remain poor. Even after resection with a microscopically negative margin (R0), prognostic factors and predictors of recurrence are needed. Several reports revealed that sustained elevation of tumor markers (TM) after surgery is related to poor prognosis. A questionnaire survey to evaluate perioperative TM status as a prognostic factor for resected pancreatic carcinoma was conducted among Miyagi-HBPCOG institutions in the period from 2003 to 2007. Method: Of 333 cases collected, clinicopathological data including age, gender, operative procedure, TM, and adjuvant therapy from histologically confirmed 294 cohorts in which both pre- and post- operative TM measurements were analyzed by stratification of 3 groups depending on TM status (without increase, with normalization after surgery, with sustained elevation). Results: About 80% of all cohorts had elevated TM and half of them had sustained elevation of postoperative TM. Median survival of the group without elevation of preoperative TM, the group with normalization of postoperative TM, and the group with sustained elevation of postoperative TM were 36.4 months, 24.5 months, and 16.8 months, respectively (P<0.0001). Stage and sustained elevation of postoperative TM had a significant impact on overall survival. By subgroup analyses in the cases with R0 resection, patients with sustained elevation of postoperative TM had significantly poorer survival than those with normalized TM or without elevation of TM. Conclusion: These data showed that sustained elevation of serum tumor markers after resection is an important prognostic factor for pancreatic cancer.
The subject was a 52-year-old woman who underwent total gastrectomy for type 4 gastric cancer in October 2005 and received adjuvant S-1 chemotherapy for one year. In June 2007, a CT scan examination revealed a right hydronephrosis due to the retroperitoneal recurrence. After two courses of paclitaxel chemotherapy, the hydronephrosis disappeared. In October 2008, however, she suffered from pain and hardening of muscles in her lower limbs. In March 2009, a computed tomography (CT) scan examination revealed a low density area around the femoral arteries due to the progressing retroperitoneal recurrence. She underwent radiation therapy on each femoral area, however, the pain and hardening of her lower limbs became worse. An MRI examination revealed abnormal intensity of muscles in her back and lower limbs that suggested demyelinating disease or myositis. In November 2009, an incisional biopsy of the erector muscle was performed under local anesthesia. Pathological findings showed scattered atypical cells lying in the loose intestinal fibers replacing skeletal muscle fibers, and the final diagnosis was intramuscular metastasis from the primary gastric cancer. Intramuscular metastasis from gastric cancer is rare, moreover, there has been no report of a case of degenerating skeletal muscle.
A 76-year-old man with hematemesis was found to have a hemorrhagic gastric ulcer on endoscopic examination in 2000. Because recurrences of gastric bleeding were observed in spite of medication, further examinations were performed, and the patient was given a diagnosis of primary localized gastric amyloidosis, and was referred to our hospital in 2001. Repeated hematemesis was observed in spite of chemotherapy or endoscopic treatments and total gastrectomy was performed in 2010. Intraoperative findings revealed gastric submucosal hemorrhages and huge hematoma formation, suggesting bleeding diathesis. The postoperative course was uneventful and the patient remains alive without any symptoms. This is a rare case requiring gastrectomy for gastrointestinal bleeding due to amyloidosis, although several mechanisms have been reported in the literature by which amyloidosis can induce gastrointestinal hemorrhage.
We report a case of T-cell and natural killer (T/NK) cell malignant lymphoma of the duodenum, enteropathy type II with pneumobilia. A 69-year-old man was admitted to our hospital due to abdominal pain and duodenal ulcer with pneumobilia was diagnosed. Endoscopic study showed a giant ulcerated lesion of the 2nd portion of the duodenum including papilla of Vater, and biopsy study suggested enteral T cell malignant lymphoma. FDP-PET CT showed no other distant abnormal accumulation. Subtotal stomach preserving pancreato duodenectomy with lymph node dissection (D2) was carried out first. Postoperative histo-chemical study showed CD3+, CD20–, CD5–, CD7+, CD56+, CD4–, CD8+, CD30–, TIA-1+, GrazymeB+, EBER ISH–, and T/NK cell malignant lymphoma enteropathy type II was finally diagnosed. Here, we report a very rare case of primary duodenal T/NK cell malignant lymphoma, enteropathy type II with pneumobilia.
A 70-year-old man complaining of epigastralgia visited our hospital for the treatment of a hepatic mass. The serology for viral hepatitis was negative, but his serum CA19-9 level was elevated. Contrast-enhanced computed tomography demonstrated a heterogeneously enhanced tumor, 6 cm in diameter, in the medial segment of the liver, the tumor thrombus extending to the left portal vein and the intrahepatic bile ducts dilatation of the left liver. Under a diagnosis of mass-forming type intrahepatic cholangiocarcinoma, extended left hepatectomy was performed. Pathologically, the tumor consisted of a moderately differentiated adenocarcinoma component, a solid proliferative component and a spindle-shaped sarcomatous component, and there was gradual transition among the different components. The portal vein tumor thrombus was composed of the spindle-shaped sarcomatous component. Eight months after surgery, CT showed multiple liver and mediastinal lymph node metastases. He then underwent systemic chemotherapy, and remains alive for 27 months after the initial surgery. Case reports of intrahepatic cholangiocarcinoma with portal vein tumor thrombus are rare, and this case is, to the best of our knowledge, the first report of intrahepatic cholangiocarcinoma with portal vein tumor thrombus containing a sarcomatous component. We present here the clinicopathological characteristics of this disease and review the previous reports.
We encountered four cases of resectable metastatic pancreatic cancer from colorectal cancers. The metastases arose from sigmoid colon cancer in two cases, and from rectal cancer in the other two. All of the colorectal cancer cases also showed Stage IIIa. One of the pancreatic metastases was a primary recurrence, while in the other three cases, the metastases developed after resection for other organ metastases. Pancreatectomy with lymph node dissection was performed in all the cases. Three cases had lymph node metastasis. Two cases died of pulmonary metastasis 11 months and 57 months after the pancreatectomy. The other two remain alive 12 months and 46 months after the pancreatectomy. We reviewed the date of 42 cases, including our own, of resected metastatic pancreatic cancer from colorectal cancer in Japan. The primary cancer was frequently rectal cancer, and many cases had lymph node metastases. Of all the cases, 27 metastatic pancreatic cancers were in the pancreatic body or tail, and 17 cases had lymph node metastases. A total of 15 cases lived for more than one year after the pancreatectomy, whereas 21 cases developed cancer recurrence and 8 cases died within only one year. Therefore, we suggest that patients with metastatic pancreatic cancer require adequate systemic investigation, and in selected cases, complete surgical resection and adjuvant chemotherapy can be administered safely.
A 33-year-old woman was given a diagnosis of Peutz-Jeghers syndrome at the age of 2 years, and had undergone laparotomy 4 times due to abdominal pain and/or intussusception. She had abdominal distention and visited the department of gynecology of our hospital. Computed tomography showed massive ascites and a right ovarian tumor, and cytology of the ascites indicated adenocarcinoma. Ovarian cancer with peritoneal dissemination was diagnosed. Gynecologists performed a right salpingo-oophorectomy, however, an intestinal tumor 100 cm distal to the Treitz ligament was found. Partial resection of the small intestine was performed by gastrointestinal surgeons. The intestinal tumor was a papillary semipedunculated mass 6 cm in diameter and exposed to the serous membrane. Pathological examination revealed moderately differentiated adenocarcinoma concomitant with adenoma and hamartoma components. The ovarian tumor was histologically diagnosed to be metastasis from the carcinoma of the small intestine. Twelve cases of Peutz-Jeghers syndrome associated with small intestinal carcinoma have been reported in Japanese literature, and most of their carcinomata are thought to have originated from polyps of the small intestine. Patients with Peutz-Jeghers syndrome should be closely followed up, taking care of malignancy of the gastrointestinal tract and other organs.
An 83-year-old man was admitted to our hospital because of intermittent abdominal pain. Abdominal CT revealed small intestinal dilatation and niveau formation. The patient had a history of appendectomy, and we diagnosed adhesive intestinal obstruction. The patient was treated non-surgicaly. On the 9th day in hospital, sudden abdominal pain and vomiting developed. We performed an operation under a diagnosis of recurrence of intestinal obstruction. Laparotomy revealed a circumferential stenosis of the jejunum, 60 cm proximal from the ileocecal junction. We performed a partial resection of the small intestine. Histopathologically, the diagnosis was peripheral unspecified type T cell lymphoma. After surgery, the patient underwent half-dose CHOP therapy. His postoperative course was uneventful. Only 58 cases of primary T-cell lymphoma of the small intestine have been reported in Japan. Furthermore, unspecified type peripheral T-cell lymphoma of the small intestine is very rare, and only 4 cases, including the present case, have been reported.
A 59-year-old man who had visited our hospital regularly for hemodialysis, complained of abdominal pain. Ultrasonography revealed multiple diverticula in the appendix. Based on this result, the patient was diagnosed with appendiceal diverticulitis. Appendectomy was performed. His postoperative course was uneventful, and he was discharged the hospital on the fifth day after the operation. The pathological diagnosis was also appendiceal diverticulitis. It has been said that appendiceal diverticulitis is relatively rare, and that distinguishing the disease from acute appendicitis preoperatively is difficult. We think, however, that the possibility of preoperative diagnosis would increase, if ultrasonography is performed with greater awareness of appendiceal diverticulitis.
We report a case of mixed adenoneuroendocrine carcinoma of the appendix. A 48-year-old man with right lower abdominal pain was admitted to our hospital. He underwent appendectomy under a diagnosis of acute appendicitis. Histopathological examination revealed adenocarcinoma, in which a portion indicated endocrine cell carcinoma. Then we conducted ileocecal resection with paracolic lymph node resection and no residual tumor cells were shown histologically. Ultrasound examination 3 years and 6 months later, showed a small amount of ascites, and the value of tumor marker such as CEA and CA19-9 increased suddenly, therefore we performed abdominocentesis. Cytologic specimen of ascites showed the almost same morphology of the tumor cells of appendix. Immunohistochemically, both types of tumor cells were positive for CD56 and synaptophysin, yielding a diagnosis of peritoneal metastasis with mixed adenoneuroendocrine carcinoma of the appendix. Only 7 cases, including the present case, have been reported in Japan.
An 18-year-old man was referred to our hospital because of abdominal pain. Abdominal X-ray revealed multiple gaseous lesions in the right-sided colon. Moreover, enhanced computed tomography (CT) showed a multiple concentric ring sign in the transverse colon, leading to the diagnosis of intussusception. We then performed an emergency operation for reduction and searched for the cause of intussusception. The intussusception of ileo-colic type was observed at the transverse colon and was caused by a multiple mass in the right colon and mobile cecum. Therefore ileocecal resection was performed. The masses consisted essentially of cystic gas-filled components. Histopathological findings showed the pneumatosis in the submucosal layer. Although many cases with pneumatosis cystoides intestinalis (PCI) have been reported worldwide, PCI cases with intussusception are relatively rare. In this report, we reviewed previous reports and characterized PCI cases with intussusception.
Clostridium difficile colitis has become an increasingly common cause of hospital-acquired infection. However, we have not clearly recognized fulminant C. difficile colitis, a condition that causes significant systemic toxic effects and shock, requiring intensive therapy. Subject 1: A 69-year-old woman was admitted for abdominal pain and high fever, and underwent emergency laparotomy on suspition of intussusception. The patient died on the 1st post-operative day. Autopsy showed that she had developed toxic megacolon due to C. difficile colitis. Subject 2: A 63-year-old man complained of abdominal pain with distention and high fever, and underwent emergency laparotomy for acute obstruction caused by descending colon carcinoma. He was admitted to the intensive care unit for hypovolemic shock due to C. difficile colitis. Subject 3: A 61-year-old man underwent transverse colostomy for sigmoid colon carcinoma that had invaded the bladder. On the 4th post-operative day, he complained of abdominal pain with high fever, and on the 7th post-operative day, he developed septic shock due to C. difficile colitis. The nonspecific symptoms of abdominal pain and high fever are the signs of onset of toxic megacolon, and these symptoms together with diarrhea indicate acute exacerbation leading to fulminant C. difficile colitis. Based on our observations of these patients, we consider that early diagnosis and intracolonic vancomycin therapy are of great importance for survival in such cases.
We report a case of rectosigmoid cancer that developed after a living-donor liver transplantation. A 54-year-old woman underwent a living-donor liver transplantation for hepatic failure caused by primary biliary cirhhosis. The liver graft had been donated by her son. The immunosuppressive agents (tacrolimus hydrate and mycophenolate mofetil) were administered after a living-donor liver transplantation. Computed tomography (CT) and colonoscopy were performed because of bloody stool 7 years after transplantation. CT showed thickening of the rectosigmoid wall and no hepatic tumor. Colonoscopy showed a Borrmann 3 type tumor in the rectosigmoid region and the histological findings of the biopsy specimen showed Class V (tub2). We performed rectosigmoidectomy with lymph node dissection. Pathological diagnosis suggested moderately differentiated adenocarcinoma (pSS, pN1, Cy1, INFb, ly1, v1, pPM0, pDM0, pRM0, Stage IIIa). The postoperative course was uneventful without anastomotic insufficiency, and she was discharged on postoperative day 10. We administered adjuvant mFOLFOX6 and UFT, together with immunosuppressive agents. The patient died of hepatorenal failure caused by trauma. Because the number of malignancies in patients following liver transplantation is expected to increase, close surveillance in transplant recipients reated with immunosuppressive agents is important, in order to make a timely diagnosis.
We report an extremely rare case of protein C deficiency presenting as intestinal ischemia caused by superior mesenteric artery (SMA) and portal vein (PV) thrombosis while receiving medication. A 64-year-old man with a history of deep venous thrombosis and pulmonary infarction, and who had been taking warfarin potassium for protein C deficiency, complained of abdominal pain. Abdominal computed tomography showed the thrombosis of both the SMA and PV and ischemic change of the upper jejunum. An emergency operation was therefore performed. Macroscopic findings revealed congestion in the jejunum 20–80 cm distal to the ligament of Treitz’s and thrombi in the SMA and PV. We then conducted resection of the jejunum and jejunostomy. Serous protein C activity was decreased at 34%. The urokinase and heparin had been administered postoperatively as an anticoagulant therapy. When enteral nutrition was started, warfarin potassium was taken orally, instead of heparin. He underwent stoma closure at 74 days after the operation. At 34 months after surgery, the patient remains well without any evidence of recurrence.
Abdominal CT in a 40-year-old man admitted for severe abdominal pain was found to have his small intestine compressed by multiple intra-abdominal tumors, leading to small intestinal ileus with ascites. Emergency surgery was performed because the presence of a strangulated ileus could not be ruled out. At surgery, a tumor 4.5 cm in diameter at the edge of the greater omentum was found under the umbilicus, partially covered by sloughing of pus and compressing the small intestine. The tumor was resected to resolve the small intestinal ileus. Moreover, another tumor 5.0 cm in diameter, detected around the lesser curvature of the stomach, was resected simultaneously. Numerous small white nodules were found on the surface of the greater omentum, lesser omentum and mesenterium. The resected specimens from the greater and lesser omentum were 5.0×3.5 and 5.0×4.6 cm in size, respectively. Both of them showed multinodular tumors on their surface. Consequently, according to the histopathological findings, the definitive diagnosis of those tumors was inflammatory myofibroblastic tumor derived from the greater and lesser omentum, and the numerous small white nodules were tumors due to inflammatory reactions. In Japan, reports of multiple inflammatory myofibroblastic tumors arising from the greater and lesser omentum are extremely rare, and a case of those tumors leading to small intestinal ileus is unprecedented in the literature.