Hajime Amano

Current Treatment Strategies for Pancreatic Cancer in the Elderly

Pancreatic cancer, which is responsible for >90% of exocrine pancreatic tumours, is typically a disease of the elderly (≥70 years of age). However, older patients are less likely to be staged than younger patients despite having a worse overall 5-year survival rate than their younger counterparts. Various radiological, ultrasonographic and endoscopic investigations are used not only as diagnostic tools but also to accurately stage the cancer for possible surgery. Many patients with pancreatic cancer have mutations of the K-ras oncogene, and various tumour suppressor genes are also inactivated. Pancreas resection can be performed in elderly resectable patients without excess mortality, even in those >80 years of age. However, treatment for locally advanced, unresectable and metastatic pancreatic cancer is palliative. Fluorouracil-based chemoradiation for locally advanced or unresectable cancer, and gemcitabine for patients with metastatic disease, can result in clinical benefits. Placement of a stent in the biliary tract has been shown to improve symptoms of obstructive jaundice or ascites, as well as quality of life. As molecular targets are identified, interventions with targeted specific agents may improve tumour control. However, further studies will be needed to demonstrate whether or not various agents targeting signal transduction pathways or nuclear transcription factors are useful for elderly patients with advanced pancreatic cancer.

MANAGEMENT STRATEGIES FOR BRANCH DUCT INTRADUCTAL PAPILLARY‐MUCINOUS NEOPLASMS

Management strategies for branch duct intraductal papillary‐mucinous neoplasms (IPMN) have been discussed. The authors’ clinical criteria with special attention to the size of cystic lesion, the diameter of main pancreatic duct, and the size of mural nodule established in 2001 is useful for managing branch duct IPMN. A total of 55 of 60 cases with branch duct IPMN had no radiologic progression during an average follow up of 701 days. In addition, no case out of 27 cases with branch duct IPMN followed up for 3 years changed to positive in cytological examination using pancreatic juice. There were four cases of branch type IPMN with some changes in their image findings. There were two cases of branch type IPMN with pancreatic symptoms. A total of three out of these five cases were surgically resected. The ordinary‐type ductal carcinoma was detected in two cases with branch duct IPMN at 3 or 4 years later. These results suggest that a long‐term careful follow‐up study by computed tomography or ultrasonography at every 6 months would be needed in the management of branch duct IPMN. Further studies will be needed to dissolve this problem in the future.

Percutaneous transhepatic sclerotherapy for recurrent bleeding ileal varices diagnosed by capsule endoscopy and computed tomography during percutaneous transhepatic venography

We report a case of acute uncontrolled gastrointestinal bleeding in a patient with liver cirrhosis. A 64‐year‐old man was admitted to our hospital for further investigation of blood in stools. Preliminary examination by computed tomography (CT) as well as upper and lower endoscopy could not detect the bleeding source. Exploratory laparotomy was considered difficult due to potential easy bleeding and adhesions caused by past abdominal surgery. The hemoglobin level was normalized by blood transfusion. Capsule endoscopy (CE) identified ileal varices. The top of these ileal varices was red, prompting their identification as the source of bleeding. Percutaneous transhepatic venography (PTV) confirmed the presence of many varices in the branch of the superior mesenteric vein, although the bleeding source could not be identified. CT during PTV identified varices protruding into the ileal lumen, which were managed subsequently by percutaneous transhepatic sclerotherapy (PTS). The procedure stopped the bleeding completely. CE proved less invasive and effective in detecting obscure gastrointestinal bleeding. CT during PTV followed by PTS is suitable for diagnosis and treatment of bleeding varices in patients with portal hypertension.

A Trial of the Use of Patency Capsules in Combination with Overnight Capsule Endoscopy

Background: The PillCam® patency capsule (PPC) was developed to minimize the risk of capsule retention during capsule endoscopy (CE). Typically, the use of patency capsules prior to CE requires patients to be monitored over a period of time. To reduce the need for frequent outpatient visits during PPC examination and CE, we developed the overnight CE (ON-CE) procedure. Methods: Between October 2012 and January 2014, a total of 19 patients (15 males and 4 females, mean age 48.4 years) were administered PPC to assess the patency of the small intestine prior to ON-CE at JA Onomichi General Hospital in Hiroshima, Japan. Results: PPC confirmed patency of the small intestine in 15 of the 19 patients. Of these 15 patients, 14 proceeded to ON-CE. The CE was cancelled in 1 patient and the cecal intubation time exceeded 8 h in another patient. For the remaining 12 patients, the mean small intestine observation coverage was 92.3% and the mean cecal intubation time was 325 min. There were no adverse events and the discharge of the capsule was confirmed in all cases. Conclusion: When patency of the gastrointestinal tract was confirmed with the PPC, ON-CE was performed safely and effectively.

4650 Comparative studies of covered and non-covered expandable metallic stents in autopsy cases with inoperable malignant biliary duct strictures.

Background : Recently, there have been some reports about the usefulness of expandable metallic stents (EMS) covered with polyurethane membrane (PM) in cases with inoperable biliary malignant strictures (IBMS). These reports provoked us to evaluate histological findings of covered and noncovered EMS in 14 autopsy cases with IBMS. Materials and Methods : For these three years, we have studied 14 autopsy cases with IBMS treated by EMS histopathologically. There are 4 cases of bile duct carcinoma (BDCA), 8 cases of pancreatic carcinoma (PCA), one case of hepatocellular carcinoma (HCC), and one case of gastric carcinoma (GCA) with metastasis to hilar lymph node. Of these 14 cases, 5 were treated by EMS covered with PM. Combined radiation therapy was performed in three out of 8 cases with BDCA. Results : The average days of patency was 191 in the non-covered group (NCG), and 234 in the covered group (CG). Tumor ingrowth was detected in 7 out of 9 (78%) cases of NCG, and in 1 out of 5 (20%) cases of CG. This tumor ingrowth in CG was found in a case of PCA whose patency of EMS was 212 days. Overgrowth was detected in 1 out of 9 (11%) cases of NCG, and 1 out of 5 (20%) cases of CG. The debris in EMS was observed in all (100%) cases of NCG, and in 2 out of 5 (40%) cases of CG. The liver abscess was observed in 6 out of 9 (67%) cases of NCG, and in 1 out of 5 (20%) cases of CG. In the non-cancerous lesion of biliary duct, EMS invaded to the submembranous layer and expanded the muscular layer. Necrosis, fibrosis, and granulomatous changes were found in three cases with BDCA treated by radiation. No case with perforation of biliary duct was experienced. Conclusions . EMS covered with PM may play an important role in preventing from tumor ingrowth, debris and liver abscess in cases with IBMS. PM may contribute to keeping longer patency of EMS in cases with IBMS. The risk of tumor ingrowth should be considered in the case treated by EMS with PM.

Hepatic arterial infusion chemotherapy followed by sorafenib in patients with advanced hepatocellular carcinoma (HICS 55): an open label, non-comparative, phase II trial

BackgroundIn patients with advanced hepatocellular carcinoma (HCC), evidence is unclear as to whether hepatic arterial infusion chemotherapy (HAIC) or sorafenib is superior. We performed a prospective, open-label, non-comparative phase II study to assess survival with HAIC or HAIC converted to sorafenib.MethodsFifty-five patients were prospectively enrolled. Patients received HAIC as a second course if they had complete response, partial response, or stable disease (SD) with an alpha fetoprotein (AFP) ratio < 1 or a des-γ-carboxy prothrombin (DCP) ratio < 1. Patients were switched to sorafenib if they had SD with an AFP ratio > 1 and a DCP ratio > 1 or disease progression. The primary endpoint was the 1-year survival rate. Secondary endpoints were the 2-year survival rate, HAIC response, survival rate among HAIC responders, progression-free survival, and adverse events.ResultsOf the 55 patients in the intent-to-treat population, the 1-year and 2-year survival rates were 64.0 and 48.3%, respectively. After the first course of HAIC, one (1.8%) patient showed complete response, 13 (23.6%) showed partial response, 30 (54.5%) had SD, and 10 (18.1%) patients had progressive disease. Twenty-three patients (41.8%) had SD with AFP ratios < 1 or DCP ratios < 1, and 7 (12.7%) had SD with AFP ratios > 1 and DCP ratios > 1. Thirty-seven patients (68.5%) were responders and 17 (30.9%) were non-responders to HAIC. In responders, the 1-year and 2-year survival rates were 78 and 62%, respectively.ConclusionGiven the results of this study, this protocol deserves consideration for patients with advanced HCC. This trial was registered prospectively from December 12. 2012 to September 1. 2016.