Katsumi Kurihara

Sentinel lymph node biopsy in patients with breast cancer using superparamagnetic iron oxide and a magnetometer

BackgroundSome hospitals lack facilities for radioisotopes in sentinel node biopsy. A novel method is used with a superparamagnetic tracer and a magnetometer instead of a radioisotope.MethodsThirty patients were included in the study after obtaining IRB approval. Superparamagnetic iron oxide and patent blue dye were injected in the subareolar breast tissue. Following a few minutes of massage to promote migration of the iron tracer and blue dye throughout the lymphatic vessels, the axillary lymph nodes were detected transdermally using a handheld magnetometer and followed by standard axillary dissection in all patients.ResultsOf 30 patients evaluated, sentinel lymph nodes were identified in 90% (27/30) using both blue dye and magnetic tracer. Sentinel lymph nodes were identified using the magnetic method in 23/30 (77%) and blue dye in 24/30 (80%). There was one false-negative sentinel node, resulting in an overall sensitivity of 6/7 (86%).ConclusionsThis is the first study to use a magnetic tracer to identify sentinel lymph nodes in patients with breast cancer. This new technique may alter the role of radioisotopes with further refinement and experience.

Nuclear Localization of Immunoreactive β-Catenin Is Specific to Familial Adenomatous Polyposis in Papillary Thyroid Carcinoma

Thyroid carcinoma is the first symptom in some patients with familial adenomatous polyposis (FAP). We evaluated the cellular localization of β‐catenin in thyroid carcinomas associated (n=4) or not associated (n=173) with FAP, since loss of functional protein of the adenomatous polyposis coli (APC) gene leads to nuclear accumulation of β‐catenin in adenomas and carcinomas of the FAP colon. Immunoreactive β‐catenin was demonstrated at the cell membrane of glandular cells of the non‐neoplastic thyroid and non‐FAP carcinomas. On the other hand, cytoplasmic and nuclear accumulation of β‐catenin is specific to FAP‐associated papillary carcinomas. The abnormality in the APC/β‐catenin pathway is thus also important in FAP‐associated thyroid carcinoma, and β‐catenin immunohistochemistry is a feasible screening method to identify occult FAP in young patients with thyroid tumors.

Primary small-cell neuroendocrine carcinoma of the duodenum – a case report and review of literature

BackgroundSmall-cell neuroendocrine carcinoma in the duodenum is an extremely rare neoplasm with poor prognosis.Case presentationA 57-year-old man presented with sudden onset gastrointestinal bleeding and fainting attacks. Duodenoscopy and hypotonic duodenography revealed a 3 × 3 cm protruding tumor with ulcerations situated opposite the ampulla of Vater in the second part of the duodenum. Local excision of the tumor was performed, followed by adjuvant chemotherapy with 5-fluoro uracil and leucovorin. Examination of the tumor by immunohistochemistry and electron microscopy indicated it to be neuroendocrine in nature, expressing synaptophysin and AE1/AE3, and containing dense core granules. The patient showed no sign of recurrence and has been disease-free for more than 48 months after surgery.ConclusionsMost cases of small-cell neuroendocrine carcinoma in the duodenum show rapid progression of the disease, and even radical surgery with or without chemotherapy do not prevent death. We report a rare subtype of small-cell neuroendocrine carcinoma. This subtype appears to have a much better prognosis, and may be amenable to local excision, if the lesion is away from the ampulla of Vater.

Alpha-Fetoprotein-Producing carcinoma of the colon: Report of a case

We report herein the rare case of a 67-year-old man in whom alpha-feto-protein (AFP)-producing carcinoma originated in the transverse colon, describing the clinical course of the patient and the histological features of the tumor. At the age of 63, the patient had been diagnosed as having sigmoid colon carcinoma, and surgery was carried out. However, 4 years later, his fecal occult blood test was positive, and further investigation revealed a transverse colon carcinoma with liver metastasis. The serum AFP measured preoperatively was 10978 ng/ml. Resection of the transverse colon and a liver biopsy were performed, following which his serum AFP level decreased to 4804 ng/ml. Histology of the ulcerated lesion in the transverse colon showed a poorly differentiated adenocarcinoma with a medullary growth pattern. Using an immunohistochemical staining method, AFP-producing cells were detected in the transverse colon carcinoma and the liver metastasis. Based on our experience of this patient and a review of the literature on the few cases previously reported, we conclude that AFP-producing coloretal carcinoma has a tendency to produce blood-borne metastasis and to be associated with a poor prognosis.

Gastric neuroendocrine carcinoma associated with chronic atrophic gastritis type A

We report a case of gastric neuroendocrine (NE) carcinoma associated with chronic atrophic gastritis type A (CAG/A) or reversed atrophic type gastritis. A 9 × 6 cm tumor was resected from the stomach to control pain in a 55-year-old Japanese woman with peritoneal dissemination and metastatic tumors of the liver and ovary. Histologically, the tumor was NE carcinoma which showed an organoid structure, but consisted of NE Cells with overt cytological atypia and frequent mitotic activity. Multiple microcarcinoids and NE cell micronests (NECMs) were also observed in the atrophic non-neoplastic mucosa of the gastric body. CEA immunoreactivity and a high Ki-67 labeling index were characteristic features of the neoplastic NE cells of the carcinoma. Although most NE tumors arising from CAG/A are typical carcinoid tumors, the present case illustrates that a high-grade NE carcinoma can develop from diverse NE cell proliferation in association with CAG/A.

CT virtual pancreatoscopy : a new method for diagnosing intraductal papillary mucinous neoplasm (IPMN) of the pancreas

BackgroundWe sought to validate computed tomographic virtual pancreatoscopy (CT-VP) created by multidetector row CT (MD-CT) in the clinical diagnosis of intraductal papillary mucinous neoplasm (IPMN) of the pancreas.MethodsFive cases of pancreatic IPMNs were included in this study. A nasopancreatic drainage tube was inserted and the pancreatic duct was filled with contrast medium, after which an upper abdominal scan was performed by MD-CT. CT-VP and three-dimensional (3D) CT pancreatographic images were created using a workstation and compared with images by conventional diagnostic techniques. All cases were evaluated by endoscopic retrograde pancreatography (ERP) and three cases of main duct type were assessed by intraoperative real pancreatoscopy (RP).ResultsIn the main duct cases, papillary projections in the main pancreatic duct and branch orifices were clearly detected by CT-VP. These lesions and structures were confirmed by intraoperative RP, and the CT-VP images were clearer than RP images. In branch cases, a surface-rendering method allowed protruding lesions to be clearly detected in the dilated branches.ConclusionCompared with conventional ERP or RP, CT-VP and 3D-CT pancreatographic images were finer in quality, and the procedures were less invasive, faster, and less expensive. The potential shown by CT-VP with 3D-CT pancreatography in the clinical diagnosis of pancreatic IPMNs suggests that this approach may replace ERP in the near future.

Pleomorphic carcinoma of the pancreas with massive lymphocytic stromal infiltration and long-term survival after resection

SummaryBackground. Pleomorphic carcinoma of the pancreas is a rare tumor with an extremely poor prognosis. The mean survival time is reported to be approx 3 mo.Clinical and Histological Findings. A 56-yr-old Japanese man presenting with general fatigue, loss of weight, and high fever was found to have a large hypervascular mass in the body of the pancreas with regional lymph node metastases. Laboratory investigation revealed leukocytosis, elevated erythrocyte sedimentation rate (ESR), and high serum C-reactive protein (CRP). In addition to distal pancreatectomy, splenectomy and lymph node dissection were performed. Histology showed the presence of pleomorphic large cells with bizarre mono- or multinuclei, growing in sarcomatoid pattern without mutual cohesiveness. Another noticeable finding was massive lymphocytic infiltration of the stroma of the neoplasm. Immunohistochemically, the infiltrating lymphocytes consisted of cytotoxic type of T cells. In addition, in situ hybridization for Epstein-Barr virus-encoded RNA (EBAR-1) was not seen in the tumor cells or in lymphocytes. After surgery the patient did not undergo chemotherapy or radiotherapy. He has been well without recurrence for 8 yr.Conclusion. We report a case of pleomorphic carcinoma, possibly lymphoepithelioma-like carcinoma, of the pancreas with massive lymphocytic stromal infiltration and long-term survival after resection. Cytokine responses and cellular immunoreactivity may have contributed to a long-term survival, which is unusual in the common type of pleomorphic carcinoma of the pancreas.

Carcinoma Arising from Brunner's Gland in the Duodenum after 17 Years of Observation - A Case Report and Literature Review

A 60-year-old man presented with melena and hematemesis in 1984. Esophagogastroduodenoscopy (EGD) detected a small protruding lesion in the duodenal bulb, which was diagnosed as Brunner’s adenoma. No significant change was detected in subsequent annual EGD and biopsies for 10 years, after which the patient was not observed for 7 years. The patient presented with melena again in 2001. The lesion had changed shape to become a 10 mm sessile tumor with a central depression, and following a biopsy was diagnosed as an adenocarcinoma. The patient underwent partial resection of the duodenum. Histopathological assessment showed acidophilic cells with swollen nuclei, and clear cells forming a tubular or papillary tubule in the mucosal lamina propria and submucosal layer. The tumor cells stained positive for lysozyme, indicating that they arose from Brunner’s gland. The patient showed no sign of recurrence and was disease-free for more than 34 months after surgery. The patient died of pneumonia. This is an extremely rare case of primary duodenal carcinoma arising from Brunner’s gland in a patient observed for 17 years.

Retroperitoneal hand-assisted laparoscopic surgery for endoscopic adrenalectomy.

Although hand-assisted laparoscopic surgery (HALS) is very common in various laparoscopic procedures, it is rarely used for retroperitoneal endoscopic adrenalectomy because of the small working area. The authors evaluate HALS in endoscopic adrenalectomy with respect to its use as a rescue procedure in complicated cases. In their department, 47 patients underwent endoscopic adrenalectomies between 1998 and 2004. Mainly because of complicated anatomy, three primary aldosteronism cases were converted to retroperitoneal HALS. This involved making an additional 6 cm skin incision, into which the surgeon’s left hand was inserted, with the palm used to create a sufficient visual field and working area. The fingers were used for tactile sensation and blunt resection. For these three cases, successful retroperitoneal HALS in endoscopic adrenalectomy resulted in no mortality or morbidity. These findings indicate that this procedure is a feasible technique for complicated benign adrenal tumor cases.

Quality of Life of Recurrence-Free Patients After Pancreatoduodenectomy for Periampullary Cancer: A Statistical Comparison with Healthy People Without Surgery and Patients After Subtotal and Total Gastrectomy for Early Gastric Cancer

Quality of life (QOL) of recurrence-free patients after pancreatoduodenectomy (PD) for periampullary cancer was investigated employing nutritional parameters and QOL instruments to evaluate health- and non-health-related aspects of patients’The study focused on comparison of post-PD patients with a control group without surgery and with patients after subtotal and total gastrectomy performed for early gastric cancer, matching pairs according to age, gender, and date of surgery. The results suggested that the long-term, health-related QOL of patients after PD for advanced periampullary cancer would be the same as that of healthy people without surgery, somewhat better than that after subtotal gastrectomy for early gastric cancer, and much superior to that after total gastrectomy for early gastric cancer. Assessment of total life did not reveal any difference among the individual groups. The present study failed to advocate the advantage of the pylorus-preserving PD over the conventional PD (Whipple) in postoperative QOL of five closely matched pairs. A prospective randomized study with a larger sample is needed to clarify the rationale of pylorus preservation.