Kazuhiro Yada

Optimal management of the branch duct type intraductal papillary mucinous neoplasms of the pancreas.

Goals To determine the optimal management of the intraductal papillary mucinous neoplasms (IPMNs) according to the morphologic type based on distinguishing between benign and malignant diseases. Backgrounds IPMNs are increasingly recognized clinicopathologic entity. Extended pancreatic resection with radical lymph node dissection has been recommended for treatment. Study A retrospective clinicopathologic study was carried out of the 57 cases with IPMNs who were treated between 1985 and 2001. Forty-three patients with IPMNs underwent resection, and 14 patients with small IPMNs were observed without resection. Results Among the 43 resected IPMNs, 25 were benign and 18 were malignant. Malignant tumors were significantly greater in diameter than benign tumors (52.9 vs. 30.2 mm, P < 0.05). All main duct type tumors with mural nodules were malignant. All branch duct type tumors less than 30 mm in diameter and without mural nodules were benign. Twelve branch duct type IPMNs size less than 30 mm were not resected and have not progressed. Conclusion These results suggest that the branch duct type IPMNs less than 30 mm and without mural nodules is benign and might be treatable with limited resection or careful observation.

Expression of CD10 in basal cell carcinoma.

We investigated the expression of CD10 by an immunohistochemical method in 51 basal cell carcinomas (BCCs), eight pilomatricomas, five trichoblastomas, two trichofolliculomas, three sebaceomas, five sebaceous carcinomas, ten syringomas, two spiradenomas, ten poromas, four porocarcinomas, one eccrine duct carcinoma (not otherwise specified, NOS), six mixed tumors of apocrine origin, and nine squamous cell carcinomas (SCCs). We detected strong expression of CD10 in tumor cells of BCC (86%), and found that the smaller the number of positive tumor cells, the larger the number of positive stromal cells, in particular in sclerosing BCCs. Spearmans rank correlation test revealed a significant negative correlation in BCCs between the expression of CD10 in tumor cells and that in stromal cells (P = 0.001). In all pilomatricomas (100%) and in four trichoblastomas (80%), strong expression was also detected in tumor cells. There was no detectable expression in trichofolliculomas. One sebaceoma (33%) and two sebaceous carcinomas (40%) expressed CD10 in a similar fashion to BCCs. All tumors of eccrine gland origin, including syringoma, spiradenoma, poroma, porocarcinoma, and eccrine duct carcinoma (NOS), did not express CD10. Five mixed tumors (83%) were immunopositive. In SCC, CD10 was overexpressed only in the stromal cells. These findings support the hypothesis that BCC is derived from the folliculo-sebaceous apocrine unit, especially having the same origin as trichoblastoma and pilomatricoma. CD10 might be an indicator of tumor invasiveness if it is expressed in stromal cells, while it might be a marker of follicular differentiation if it is expressed in the actual tumor cells of cutaneous epithelial neoplasms.

Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study.

Although laparoscopic distal pancreatectomy (LDP) is technically feasible, its benefits remain uncertain. The purpose of this study was to compare the clinical results of LDP and open distal pancreatectomy (ODP). The medical records of 14 consecutive patients who underwent LDP were reviewed and compared with those of 19 patients who underwent ODP. All patients were treated for benign or borderline malignant disease of the pancreas. Operation time was longer for LDP than for ODP (290.7 vs. 213.8 min, P=0.0022), and postoperative analgesics were administered less frequently for patients who underwent LDP. Patients treated by LDP had earlier recovery of bowel function, shorter time to oral intake, and shorter postoperative hospital stay than those treated by ODP. No difference in morbidity or inflammatory response was observed between the 2 groups. LDP for benign or borderline malignant disease of the pancreas provides benefits without increasing morbidity.

Factors predicting recurrence after resection of pancreatic ductal carcinoma.

Objective: Pancreatic ductal carcinoma frequently recurs postoperatively, and we analyzed clinicopathological features of patients treated by surgical resection to find predictors of postoperative recurrence. Methods: A retrospective cohort study was performed that included 69 patients between 1985 and 2003. Clinicopathologic factors were evaluated for tumor recurrences by univariate and multivariate analyses. Results: Mean survival time and actuarial 5-year disease-specific survival were significantly lower in cases of hepatic metastasis (13 months, 0%) and in cases of peritoneal carcinomatosis (15 months, 6.8%) than in cases of local retroperitoneal recurrence (30 months, 21%). Univariate and logistic regression analyses showed undifferentiated adenocarcinoma to be independently associated with hepatic metastasis (odds ratio, 7.4; 95% confidence interval, 1.5-37.0) and invasion of the portal vein to be independently associated with peritoneal carcinomatosis (odds ratio, 4.0; 95% confidence interval, 1.2-12.8). Multivariate analysis showed undifferentiated adenocarcinoma, invasion of the anterior capsule, and invasion of the portal vein to be independent prognostic factors. Conclusion: Undifferentiated adenocarcinoma and invasion of the portal vein are predictors of poor outcome and are related to hepatic metastasis and peritoneal carcinomatosis, respectively. Postoperative adjuvant chemotherapy, including intra-arterial chemotherapy, should be selected according to prediction of the patterns of recurrence.

Duodenal gangliocytic paraganglioma treated with endoscopic hemostasis and resection

Gangliocytic paragangliomas are exceedingly rare tumors that arise in close proximity to the papilla of Vater. There are few reports of the endoscopic resection of duodenal gangliocytic paraganglioma. A 61-year-old woman was admitted with a complaint of melena. Endoscopic examination revealed a pedunculated submucosal tumor with erosion in the third portion of the duodenum. Hemostasis, using a gold probe, was performed. Nine days later, we successfully resected the tumor, using endoscopic polypectomy. To determine the depth of tumor invasion, endoscopic ultrasonography was used. The size of the tumor was 3.0 × 2.5 × 1.0 cm. A total of 25 cases of duodenal gangliocytic paraganglioma have been reported in Japan. Generally, this tumor is considered benign. However, resection was performed in many patients because preoperative diagnosis was impossible. In Japan, no previous studies have reported using endoscopic hemostasis, to our knowledge. Our patient is the fourth in Japan to be treated by endoscopic resection. We report on our patient, with a review of the literature.

Expression of matrix metalloproteinase-7 is an unfavorable prognostic factor in intrahepatic cholangiocarcinoma.

BackgroundIntrahepatic cholangiocarcinoma (IHCC) is a highly malignant neoplasm, but the prognostic factors of IHCC are not yet fully understood. The matrix metalloproteinases (MMPs) are known to be related to tumor viability. The aim of this study was to evaluate the prognostic significance of clinicopathological and immunohistochemical characteristics of resected IHCC.Patients and MethodsFrom 1996 to 2006, we surgically treated 35 patients with IHCC. Clinicopathological and immunohistochemical characteristics, including expression of MMPs, vascular endothelial growth factor, and epidermal growth factor receptor in the resected specimens, were investigated, and overall survival rates were evaluated with regard to the characteristics using univariate and multivariate analyses.ResultsUnivariate analysis revealed the significant prognostic factors to be preoperative serum CEA and CA19-9, intraoperative transfusion, tumor size, surgical margin, lymph node metastasis, invasion of portal and hepatic vein, intrahepatic metastasis, UICC stage, and expression of MMP-7. Subsequent multivariate analysis indicated that MMP-7 was an independent prognostic factor (hazard ratio (HR), 4.698; 95% confidence interval (CI), 0.057–0.866; P = 0.03) along with intrahepatic metastasis (HR, 5.694; 95% CI, 0.029–0.706; P = 0.017).ConclusionMMP-7 expression is associated with a poor prognosis in patients with resected IHCC.

Mammalian target of rapamycin signaling activation patterns in pancreatic neuroendocrine tumors

Phosphatidylinositol 3‐kinase/Akt/mammalian target of rapamycin (mTOR) pathway dysregulation has been implicated in the development of various human cancers. However, expression of mTOR cascade components in pancreatic neuroendocrine tumors (PNETs) has not been fully explored. The aim of this study was to assess the expression of mTOR pathway in PNETs using immunohistochemistry.

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute.

These authors suggest that the best timing of laparoscopic cholecystectomy for acute cholecystitis in Japan may be within 24 hours of the onset of the disease.

Biotin-rich intranuclear inclusions in morule-lacking adenocarcinoma of the gallbladder: a new category of “neoplastic/non-morular” lesions

Biotin-rich intranuclear inclusions, also called “optically clear nuclei,” are observed in various neoplastic and non-neoplastic lesions, including pregnancy-related endometrium and benign and malignant neoplasms with morular structures. A recent study reported that lesions with biotin-rich intranuclear inclusions can be classified as “(non-neoplastic) pregnancy-related endometrial” and as “(neoplastic) morular” category. In the present report, we describe two cases of well-differentiated adenocarcinoma of the gallbladder in which biotin-rich intranuclear inclusions were found without morular structures. Immunohistochemically, as reported previously, the intranuclear inclusions were positive for biotin and two biotin-binding enzymes (pyruvic acid carboxylase and propionyl CoA carboxylase). Intranuclear expression of β-catenin was also observed in neoplastic cells with and without intranuclear inclusion. We also detected a frame shift mutation of APC gene in one case but no mutation of β-catenin gene in both cases. Although intranuclear expression of β-catenin by mutation of APC gene might contribute to carcinogenesis in our cases, the relationships among intranuclear expressions of β-catenin, biotin, biotin-binding enzymes and intranuclear inclusions remain unclear. Our cases are the first neoplastic lesions with biotin-rich intranuclear inclusions that lacked morular structures. We propose a new “neoplastic/non-morular” category for lesions with biotin-rich intranuclear inclusions.

Benefit of laparoscopic liver resection in high body mass index patients

AIM To explore the impact of body mass index (BMI) on surgical outcomes in patients undergoing laparoscopic liver resection (LLR). METHODS From January 2010 to February 2015, sixty-eight patients who underwent primary partial liver resection in our institute were retrospectively reviewed. Surgical outcomes of LLR were compared with those of open liver resection (OLR). In addition, we analyzed associations with BMI and surgical outcomes. RESULTS Among 68 patients, thirty-nine patients underwent LLR and 29 were performed OLR. Significant difference in operation time, blood loss, and postoperative hospital stay was observed. There were no significant differences in mortality and morbidity in two groups. Twenty-two patients (32.4%) were classified as obese (BMI ≥ 25). A statistically significant correlation was observed between BMI and operation time, between BMI and blood loss in OLR, but not in LLR. The operation time and blood loss of OLR were significantly higher than that of LLR in obese patients. Open liver resection and BMI were independent predictors for prolonged operation time and increased blood loss in multivariate analysis. CONCLUSION The present study demonstrated that BMI had influenced to surgical outcomes of OLR. LLR was less influenced by BMI and had great benefit in obese patients.