Hisao Matsunou

Papillary‐cystic neoplasm of the pancreas. A clinicopathologic study concerning the tumor aging and malignancy of nine cases

Nine female patients with papillary‐cystic neoplasms (PCN) of the pancreas were studied clinicopatho‐logically. The ages of seven of these patients ranged from 8 to 24 years. The remaining two patients, who were 47 and 60 years of age, were considered to have had the onset in their youth. There were few subjective symptoms, and the lesion was most often detected as a palpation of a mass by the patients themselves. Although the prognosis was generally favorable, the two older patients died of metastases. This suggested low‐grade malignancy of PCN. The tumors were large (6.9 cm in mean diameter) and encapsulated, and their cross‐sections showed an intermingling of solid tumoral areas and cystic necrotic areas. The histologic features of the solid tumoral portion were relatively uniform, with the tumor cells showing solid and pseudopapillary or pseudoglandular proliferation but few mitoses or atypism. Histo‐chemical, immunohistochemical, and electron microscopic examinations showed polymorphic differentiation, which means that part of the tumor cells differentiated into duct epithelium, acinus, and endocrine cells (primary constituents of the pancreas). These findings suggest that the origin of PCN is totipotential primordial cells found in the development of the embryonic pancreas.

Solid, infiltrating variety of papillary cystic neoplasm of the pancreas

Four tumors with histologic, histochemical, and ultrastructural characteristics of papillary cystic neoplasm of the pancreas but lacking the capsule commonly observed in papillary cystic neoplasm and infiltrating interiorly into the pancreatic parenchyma were seen in two men and two women who were 39 to 51 years old. These tumors contrasted with typical encapsulated papillary cystic neoplasms that show extrapancreatic growth and that are detected as a palpable abdominal mass in young women. These four tumors, although unpalpable, were all detected by nodular images of calcification in abdominal plain radiography. The tumors had a mean diameter of 3.1 cm (range, 1.7 to 4.5 cm), were confined within the pancreatic parenchyma, and showed central fibrosis accompanied by dystrophic changes such as calcification and ossification. A small necrotic cyst contiguous to the fibrous focus also was observed in the tumor in three patients. Tumor cells similar to those of a papillary cystic neoplasm had infiltrated among the pancreatic parenchyma in solid and pseudopapillary patterns. and pleomorphic atypism was observed in some parts of the tumor in three patients. These tumors were tentatively designated solid, infiltrating variety of papillary cystic neoplasms to differentiate them from ordinary encapsulated papillary cystic neoplasms. Although no signs of recurrence have been noticed after surgical treatment in these patients, the infiltrating growth pattern and the presence of pleomorphic atypism suggest higher malignancy than the ordinary papillary cystic neoplasm. The contrasting growth pattern and possible malignancy may warrant establishment of these tumors as a papillary cystic neoplasm subclass.

Hypertension and unilateral renal ischemia (page kidney) due to compression of a retroperitoneal paraganglioma

We describe a 17-year-old hypertensive man with a left abdominal mass on the computed tomographic scan. Radiologic studies revealed a large tumor near the left renal hilus, resulting in renal compression and displacement toward the posterolateral abdominal cavity. Aortography excluded stenosis of the renal arterial vessels. Plasma and urinary catecholamines were normal and plasma renin activity (PRA) was high. The left renal vein renin was 2.1-fold higher than the right one. After resecting the tumor including the left kidney and adrenal, high blood pressure and elevated PRA returned to normal. Histologically, the tumor was a paraganglioma, and the affected kidney showed hyperplasia of the juxtaglomerular apparatus. Thus, the hypertension in our patient was probably due to renal ischemia extrinsically compressed by a non-functioning retroperitoneal paraganglioma (Page kidney).

Lymphoepithelioma-like esophageal carcinoma: Report of a case

We herein report the rare case of a patient suffering from lymphoepithelioma-like poorly differentiated squamous cell carcinoma of the esophagus. The patient was a 74-year-old woman in whom an esophageal tumor was found during an operation for thyroid cancer. After performing a subtotal thyroidectomy and cervical esophagectomy, esophageal reconstruction was performed using a free jejunal graft. Based on the results of the pathological examination, the esophageal tumor was diagnosed to be primary lymphoepithelioma-like esophageal cancer, not metastasis of either unknown nasopharyngeal cancer or thyroid cancer. Since surgery, she has survived postoperatively for more than 4 years with no evidence of recurrent disease.

Multifocal intraductal papillary adenocarcinoma of the pancreas: Report of a case

This paper descibes a case of a mucin-producing tumor of the pancreas, histologically diagnosed as multifocal intraductal papillary adenocarcinoma. The patient had a markedly dilated main pancreatic duct, detected by ultrasound (US) and computed tomography (CT), and endoscopy showed a papillary tumor projecting from the patulous orifice of the enlarged papilla of Vater. Several biopsies taken from the tumor indicated a diagnosis of papillary adenocarcinoma. Total pancreatectomy was thus performed, revealing a multifocal papillary tumor growing along the main duct in the head, body, and tail of the pancreas. Microscopically, these multiple tumors were found to be mucin-producing papillary adenocarcinoma of the main and subsidiary pancreatic ducts with nodular and microfocal periductal invasion. The surgical treatment of multifocal tumors, may therefore necessitate total pancreatectomy to achieve curative resection, in some cases.

Gallbladder cancer associated with cholesterosis

We report herein two cases of carcinoma in situ of the gallbladder associated with cholesterosis. The patient in case 1 was an 81-year-old man who underwent a cholecystectomy for cholelithiasis. The resected specimens revealed gallbladder cancer in the fundus which was diagnosed histologically as mucinous carcinoma. Other findings included 13-mm, 12-mm, and 5-mm poly-poid lesions in the neck of the gallbladder which macroscopically appeared to be cholesterol polyps, but histologically demonstrated carcinoma in situ with cholesterosis. The patient in case 2 was a 76-year-old man in whom ultrasonography revealed a highly echogenic, elevated lesion in the gallbladder. Cholecystectomy was performed, and a 33×28-mm papillary, elevated lesion with cholesterosis was resected from the neck of the gallbladder. Histologically, this was demonstrated to be papillary adenocarcinoma in situ with cholesterosis surrounded by glandular dysplasia. The distribution of the carcinomas and cholesterosis in both of these patients suggests that the adenoma or carcinoma of the gallbladder had occurred first. Then, the tumor epithelium absorbed cholesterol from the bile, and foamy cells were produced. Thus, when treating cholesterol polyps, it should be remembered that it is often difficult to distinguish between cholesterol polyp and gallbladder cancer with cholesterosis.

A case of gallbladder cancer associated with a common bile duct neuroma, and a cystic lesion of the liver with histologic findings similar to those of an inflammatory pseudotumor

We report a rare case of gallbladder cancer associated with a common bile duct neuroma, and a cystic liver lesion with histologic findings similar to an inflammatory pseudotumor, in a patient who had had no previous abdominal surgery. The patient was a 62-year-old man whose major complaint was fever. Ultrasonography and a computed tomography scan revealed gallstones, an elevated lesion in the gallbladder, and a cystic liver lesion. Endoscopic retrograde cholangiopancreatography demonstrated stenosis of the common bile duct. Cultures of the cystic fluid and gallbladder bile were positive forStaphylococcus aureus. The patient underwent hepatectomy (inferior S4, S5, and S6), cholecystectomy, resection of the common bile duct, and right hemicolectomy. The resected specimens revealed gallbladder cancer with the microscopic appearance of a papillary adenocarcinoma, and a 12×4.5×3.5 cm cystic liver lesion with a wall 7 mm thick. Histologic studies of the wall of the cystic liver lesion revealed infiltration by histiocytes and plasma cells, and the presence of fibrous connective tissue, which findings are characteristic of inflammatory pseudotumors. A 9×6 mm elevated lesion, with the microscopic appearance of a neuroma, was resected from the common bile duct.

Abstracts of selected papers presented at the 30th Annual meeting of the Japanese Society of Gastroenterology

S OF SELECTED PAPERS PRESENTED AT THE 30TH ANNUAL MEETING OF THE JAPANESE SOCIETY OF GASTROENTEROLOGY October 20-22, 1988 -Kagoshima, Japan Chairman: Shuji HASHIMOTO, M.D.