Keiichi Ueno

An evaluation of radical resection for pancreatic cancer based on the mode of recurrence as determined by autopsy and diagnostic imaging.

Background. To determine the extent of dissection in curative resection for cancer of the pancreatic head, the mode of recurrence was determined at autopsy and by radiographic examinations.

Results of extensive surgery for pancreatic carcinoma

Since 1973, 210 patients with pancreatic carcinoma have undergone surgery in our clinic, including 144 with carcinoma of the head of the pancreas. Of these 144 patients, macroscopic curative resections were performed on 53 (36.8%). Five patients (9.4%) died within 30 postoperative days, and an additional 3 (5.7%) died within 60 days. The overall median survival was 13 months. Eight of the patients who underwent macroscopic curative resection survived 5 years, giving a 5‐year survival rate of 27.4% using the Kaplan–Meier method. The 5‐year survival rate was 39.7% after a microscopically curative resection and 0% after a microscopically noncurative resection.

Surgical strategy for carcinoma of the pancreas head area based on clinicopathologic analysis of nodal involvement and plexus invasion.

BACKGROUND The pattern of tumor spread, vis-à-vis nodal involvement and invasion of the extrapancreatic plexus (Plx), has not been thoroughly described for carcinoma of the pancreatic head area. METHODS From 1973 to 1991, 110 patients (49 with carcinoma of the pancreatic head [Ph], 29 with distal bile duct cancer [Bi], and 32 with carcinoma of the papilla of Vater [Pv]) underwent pancreatectomy at Kanazawa University Hospital. Nodal involvement and Plx invasion were precisely evaluated by histopathologic examination. RESULTS Thirty-seven (76%) of the 49 patients with Ph, 20 (69%) of the 29 with Bi, and 14 (44%) of the 32 with Pv had nodal involvement. The lymph nodes most commonly involved for Ph were the posterior pancreaticoduodenal lymph nodes (numbers 13a [superior] and 13b [inferior]), the superior mesenteric lymph nodes (number 14), the paraaortic lymph nodes (number 16), and the anterior pancreaticoduodenal lymph nodes (number 17) (13a, 51%; 13b, 47%; 14, 36.7%; 16, 18.4%; 17a, 33%; 17b, 22%). In patients with Bi, lymph nodes around the hepatoduodenal ligament (number 12) and lymph nodes numbers 13a and 14 were most commonly involved (12, 27.6%; 13a, 51.7%; 14, 34.5%). In patients with Pv, lymph node numbers 13b and 14 were most frequently involved (13b, 34.4%; 14, 15.6%). No significant correlation was noted between the tumor size and nodal involvement in these three lesions. Nodal involvement was an important prognostic factor for carcinoma of the pancreatic head area. Plx invasion in these three carcinomas was observed in 61% of patients with Ph, 29% of patients with Bi, and 3% of patients with Pv. CONCLUSIONS Nodal involvement and Plx invasion differed significantly among carcinomas of the pancreatic head area. We believe that nodal dissection of at least group number 14 is needed for Ph, Bi, and Pv cancers. In addition, dissection of lymph nodes of number 16 and the Plx around the superior mesenteric artery and celiac axis are needed in Ph cancer. Plx dissection of the first portion of plexus pancreaticus capitalis is needed in Bi cancer.

A clinicopathologic study on neural invasion in cancer of the pancreatic head

Thirty‐four patients who had resection of cancer of the pancreatic head were examined clinicopathologically to elucidate neural invasion of cancer of the pancreatic head to the extrapancreatic nerve plexus. Invasion of cancer to the retropancreatic tissue (rp+) was observed in 29 (85%) of the 34 patients, and neural invasion to the extrapancreatic nerve plexus was observed in 21 (72%) of the 29 patients with rp+. The incidence of invasion to the second region of the nerve plexus of the pancreatic head was high (14 patients; 67%). The degree of the neural invasion tended to increase as the intrapancreatic neural invasion became more severe and lymph vessel invasion more marked. Based on these findings, en bloc resection of the retropancreatic tissue involving the nerve plexus and fat tissue is necessary in the surgical treatment of cancer of the pancreatic head. Cancer 1992; 69:930–935.

Clinicopathological study of pancreatic carcinoma with particular reference to the invasion of the extrapancreatic neural plexus.

SummaryA clinicopathological study of 44 ductal carcinomas of the head of the pancreas revealed 39 with retroperitoneal invasion, of which 27 showed extrapancreatic plexus involvements. The second portion of the plexus pancreaticus capitalis was the most frequent site of invasion. A statistically significant correlation was found between neural invasion in the pancreatic tissue and plexus invasion, but no clear correlation was found between plexus invasion and lymphatic invasion or tumor size. Even small-sized tumors (t1) showed plexus invasion. The cases with plexus invasion had a statistically higher incidence of lymph-node involvement around the superior mesenteric artery than those without plexus invasion.These results indicate that complete dissection of extrapancreatic plexus around the superior mesenteric artery, including lymph nodes and soft tissue, could prolong the survival of patients with ductal carcinoma of the pancreas, even in cases of small-sized carcinomas.

Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatholithiasis

Four cases are reported of the intraductal variant of peripheral cholangiocarcinoma among surgical specimens from 32 cases of hepatolithiasis. The cancers arose from the periphery of the stone‐containing bile duct and spread chiefly along the luminal surface. Microscopically, these tumors showed papillary proliferation and therefore were diagnosed as the intraductal spreading type of peripheral cholangiocarcinoma. Mucosal dysplasia also was noticed in the vicinity of the tumors. In six other cases, mucosal dysplasia was observed in the periphery of the stone. Immunohistochemically, anti‐CA 19‐9 staining was observed diffusely in the cytoplasm of dysplastic lesions and carcinomas. Anticarcinoembryonic antigen staining was restricted to the luminal surface and/or the supranuclear region of the cytoplasm in carcinomas. It was not identified in dysplastic cells. These results suggest that the mucosal dysplasia occasionally observed near stones is a precursor of the intraductal spreading type of peripheral cholangiocarcinoma in the presence of hepatolithiasis. The authors hypothesize that the lining epithelium of the large bile duct, when persistently exposed to biochemically altered bile, may undergo a carcinomatous transformation through a stage of mucosal dysplasia. Cancer 68:2217–2223, 1991.

Patterns of neural and plexus invasion of human pancreatic cancer and experimental cancer

SummarySpecimens from four patients who underwent resection of cancer of the pancreatic head were examined histologically by serial sections to study the patterns of extrapancreatic nerve plexus invasion of cancer. To understand the mode of neural invasion and its specificity for pancreatic cancer, we also examined retropancreatically transplanted virus-induced rabbit papilloma (VX2) cells in six rabbits. Histological evaluation of the specimens from patients revealed neural invasion near the primary lesion, where cancer cells broke the perineurium and showed communication of cancer cells between the inside and outside of the perineurium. Tumor cells found distant from the primary cancer were confined to the perineurium, grew in a continuous pattern, and followed the branches of nerves. When the rabbit’s VX2 cells were implanted into the retropancreatic region of recipient rabbits we also observed neural invasion. This study shows that neural invasion is a common, but not a specific, feature of pancreatic cancer, and it suggests thaten bloc excision of the retropancreatic tissue, including fat tissue and the extrapancreatic nerve plexus, should be the basic procedure of radical surgery in the treatment of pancreatic cancer.

Analysis of paraaortic lymph node involvement in pancreatic carcinoma

Lymph node status is a key prognostic factor for pancreatic carcinoma. The paraaortic lymph nodes are the highest level of lymph nodes that can be resected safely in the abdomen for pancreatic and other gastrointestinal tumors. The pattern of paraaortic lymph node involvement and its relation with other lymph node groups were analyzed and the significance of this information relative to surgical therapy examined.

A spontaneously ruptured gastric stromal tumor presenting as generalized peritonitis: report of a case.

Abstract Among the diverse clinical presentations of gastrointestinal stromal tumor (GIST), spontaneous rupture with peritonitis is extremely rare. We report herein the unusual case of a 75-year-old man found to have a spontaneously ruptured gastric stromal tumor after presenting with generalized peritonitis. The patient was brought to the emergency department of our hospital by ambulance, with generalized severe abdominal pain. On examination, his abdomen was extensively distended with generalized severe rebound tenderness. Abdominal computed tomography scan showed a giant mass arising from the anterior gastric wall with an irregular internal low-density area and a small amount of ascites. An emergency laparotomy revealed a ruptured gastric tumor with dissemination of its necrotic tissue throughout the peritoneal cavity. The tumor was excised together with normal gastric tissue around its base. The tumor, which was 15 × 11 × 4.4 cm in size, had a coarse laceration over its well-capsulated smooth serosal surface with massive necrosis and clotted blood inside. Immunohistochemical examination revealed positive reactivity to C-kit protein, which was consistent with the newly introduced diagnostic criteria of GIST. The patient had an uneventful postoperative course and remains well.

The results and problems of extensive radical surgery for carcinoma of the head of the pancreas.

Since 1973, 152 patients with pancreatic carcinoma have undergone surgery in our clinic, including 110 with carcinoma of the head of the pancreas. Of these 110 patients, resections were performed on 43 (39.1 per cent), 33 (30 per cent) of whom underwent a curative resection based on macroscopic evidence. Six of the patients who underwent macroscopic curative resection survived for five years, giving a five-year survival rate of 36.5 per cent by the Kaplan-Meier method after excepting 6 operative deaths. We compared the extent of pancreatic cancer by constructing survival curves according to the General Rules published by the Japan Pancreas Society. There was no statistical difference in survival based on tumor size or stage, however, there was a significant difference in the survival curves of so and se, being the absence or presence of the anterior capsule of the pancreas, rpo and rpe, being the absence or presence of invasion of the retroperitoneal tissue; ew(−) and ew(+) being the absence or presence of invasion at the surgical margin of resection, or n0 and n1 being the extent of lymph node metastasis. The results of this comparison suggest that extended radical pancreatectomy may be indicated for the treatment of pancreatic cancer as the standard radical operation for pancreatic cancer may miss tumors which have spread to the retroperitoneum and extrapancreatic nerve plexus.