Keizo Ogasahara

Primary coexistent neuroendocrine carcinoma, hepatoid adenocarcinoma, and tubular adenocarcinoma of the stomach with focal trophoblastic differentiation in metastatic lymph nodes.

ated small solitary polygonal cells were growing (Fig. 2c). Those two areas were separated from each other and intermingled with the adenocarcinoma area, but the transition phenomenon was unclear. The metastasized lymph nodes were structured with small polygonal cells, but several foci of lymph nodes had syncytiotrophoblastic giant cells, which showed choriocarcinoma-like features (Fig. 2d) Those histological patterns could not be detected in the primary cancer site. In immunohistochemical examination, all histological foci were stained by the keratin markers cytokeratin 8 and AE1/AE3. The hepatoid adenocarcinoma focus was stained by AFP (Fig. 2b, lower right), and an undifferentiated cellular focus was stained by neuroendocrine markers such as cromogranin A, which revealed neuroendocrine carcinomatous features (Fig. 2c, lower right). Human chorionic gonadotropin -subunit (hCG) was positive in the syncytiotrophoblastic giant cells of metastatic lymph nodes. The preoperative serum hCGlevel was about 226.4 mIU/ml. Pathological classification concluded that this was miscellaneous carcinoma, pT3 (SE), med, INF-α, v2, ly2, pN2 (#3, 5, 6, 8). Five months after the operation, a recurrent mass lesion in the liver was revealed, although the patient had been without symptoms. She died of liver metastasis and carcinomatosis on May 12, 2002. The serum AFP level had reached a maximum level of 4286ng/ml. Motoyama et al. described a case of coexistent choriocarcinoma and hepatoid adenocarcinoma of the stomach, and concluded that their case had derived from trophoblastic metaplasia of intestinal-type adenocarcinoma and liver cell metaplasia of poorly differentiated solid-type adenocarcinoma, respectively.2 In our case, neuroendocrine carcinoma and hepatoid adenocarcinoma areas were associated with an adenocarcinoma area and were stained by keratin markers; this would have resulted from the dedifferentiation of preexisting adenocarcinoma or independent development from normal gastric epithelial cells. Trophoblastic Primary gastric carcinoma is usually composed of adenocarcinoma. However, a few rare histological variants have been reported, including neuroendocrine carcinoma, hepatoid adenocarcinoma, and choriocarcinoma.1 Its origins are controversial. We experienced the first case of coexistence of neuroendocrine carcinoma and hepatoid adenocarcinoma in the stomach with focal trophoblastic differentiation in metastatic lymph nodes, which suggests those variants are derived from the usual type of adenocarcinoma. A 78-year-old woman was admitted to our hospital because of abdominal discomfort on November 11, 1997. Serum level of alpha fetoprotein (AFP) was 168ng/ml. Gastrointestinal endoscopy revealed a protuberant lesion at the pyloric antrum. A biopsy specimen disclosed poorly differentiated adenocarcinoma. A subtotal gastrectomy with lymphadenectomy was performed on November 18, 1997. There were no tumor lesions in the liver, ovaries, uterus, and retroperitoneal area. The Japanese classification of gastric cancer was 9 6 3cm in size, L, Post-Less-Ant, type 5, T3 (SE), H0, P0, N2 (#3, 4, 5, 6, 8), stage IIIB, surgically. A macroscopic specimen is shown in Fig. 1a. A grayish-white protuberant mass surrounded by an ulcerated lesion was found in the pyloric antrum of the stomach. By hematoxylin and eosin staining, the gastric tumor showed three histological patterns (Fig. 1b). Tubular adenocarcinoma composed of cuboidal tumor cells was found in the mucous layer around the ulcerated lesion (Fig. 2a). Incomplete intestinal metaplasia was also observed. In the ulcerated lesion, tumor cells with abundant eosinophilic cytoplasm arranged in a trabecular pattern had invaded the submucosal layers, which showed hepatoid adenocarcinomatous features (Fig. 2b). In the protuberant mass lesion, undifferenti-

Immunohistochemical expression of nm23 gene product, nucleotide diphosphate kinase, in pancreatic neoplasms

SummaryConclusionOur findings suggest that contrary to the proposed role for the nm23 protein as a tumor metastasis suppressor, in pancreatic tumors, the nm23 protein does not play an important role as a suppressor against tumor metastasis.BackgroundThe nm23 gene product, nucleotide diphosphate kinase, is believed to suppress tumor metastasis. Although a number of studies on many kinds of tumors have examined the relationship between nm23 expression and metastatic potential, the antimetastatic activity of nm23 remains controversial. The expression of the nm23 protein has not been examined in pancreatic tumors, except for a few reports on pancreatic duct cell carcinomas.MethodsWe have investigated nm23 expression in pancreatic duct cell carcinomas, islet cell tumors, and ampullary carcinomas by immunohistochemical methods.ResultsIn 73 cases of pancreatic duct cell carcinomas, the nm23 expression was increased when compared with the adjacent normal pancreatic ducts; diffuse immunostaining was detected in 21 (29%) cases, focally positive immunostaining in 47 (64%) cases, and negative immunostaining in 5 cases (7%). All five negative samples were obtained from distant metastatic regions. However, there was no significant difference in the nm23 expression between primary tumors and regional lymph node metastases. Furthermore, there was no significant correlation between nm23 expression and the prognosis of the 55 resected cases. In the 15 cases of ampullary carcinomas, all 15 tumors were positive for nm23 protein (6 diffuse and 9 focal), and the staining intensity was stronger than in normal pancreatic ducts. There was no significant difference in the nm23 expression in the primary regions between patients with and without lymph node metastasis (2 diffuse and 5 focal out of 7 patients with lymph node metastasis, and 4 diffuse and 4 focal out of 8 patients without lymph node metastasis). All 12 islet cell tumors showed strong and diffuse staining for the nm23 protein.

Nuclear DNA content as a prognostic predictor in carcinoma of the pancreas

SummaryEighty-six patients with carcinoma of the pancreas were studied retrospectively. Paraffin-embedded specimens and flow cytometry were used to evaluate the accuracy of the measurement of nuclear DNA as a predictor of the postoperative prognosis. From the series of 86 patients, 72 with a diagnosis of tubular adenocarcinoma (Japanese classification) were selected, and their DNA ploidy pattern and clinical and pathological features were correlated; 52.3% of the 86 patients and 52.8% of the 72 tubular adenocarcinoma patients showed DNA aneuploidy. Histological examinations of the tubular adenocarcinomas showed 42.9% DNA aneuploidy in well differentiated, 56.8% in moderately differentiated, and 71.4% in poorly differentiated types. The DNA ploidy showed a statistically significant positive correlation with the T category. The presence or absence of retroperitoneal invasion was thought to be the most important prognostic factor. Cumulative survival rates showed that the prognosis for patients with retroperitoneal invasion and DNA aneuploidy was significantly worse than for those with DNA diploidy or those without retroperitoneal invasion.

Two-stage hepatectomy and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) in treating liver metastases of rectal cancer: a case report.

IntroductionAn innovative approach, called associated liver partition and portal vein ligation for staged hepatectomy(ALPPS), has made possible a marked increase in future liver remnant (FLR) volume over a short period of time, thus permitting extended hepatectomy.Case descriptionThis report describes ALPPS in a 63-year-old male patient with rectal cancer and synchronous multiple liver metastases. The primary lesion was resected, followed by chemotherapy. We had planned to completely resect the metastases in both liver lobes, but CT volumetry revealed a very small FLR (364 ml, 29% of the total liver volume, 0.61% of total body weight). His indocyanine green retention rate at 15 minutes was 12.7%. Because of the risk of tumor progression in the interim, we performed ALPPS. During the first stage, the tumor in segment 3 was resected, the right lobe was mobilized, the liver was partitioned, and the right portal vein was ligated. The right hepatic artery, duct and vein were secured with vessel loops. CT on postoperative day 6 showed sufficient FLR increase (from 364 ml to 573 ml, or from 0.61% to 0.96% of total body weight) and ICGR15 improvement to 3.4%. The second stage of ALPPS was on postoperative day 7, completing resection of the metastases. The patient recovered well and was discharged 21 days after the second step.Discussion and evaluationThe ALPPS approach has many advantages, but it lacks evidence of long-term results. Considering the high mortality and morbidity rates of ALPPS, it is essential to evaluate its risks and benefits in individual patients and determine the strict criteria for this surgical method.ConclusionsALPPS procedure rapidly increases FLR, permitting extended hepatectomy for patients with initially insufficient FLR.

Inflammatory polyp in the common bile duct with pancreaticobiliary maljunction.

A 63-year-old woman was admitted because of epigastric pain and obstructive jaundice. Endoscopic retrograde cholangiopancreatography and intraductal ultrasonography revealed a 25-mm papillary nodule in the middle to inferior portion of the common bile duct (CBD). Pancreaticobiliary maljunction (PBM) was also identified. Contrast-enhanced computed tomography also showed an enhanced nodule in the CBD, and we suspected intraductal papillary neoplasm of the bile duct. We performed pylorus-preserving pancreatoduodenectomy. Postoperative pathological examination revealed an inflammatory polyp in the middle CBD. Inflammatory polyp in the bile duct is rare and there are no previous reports accompanied by PBM. PBM is a major risk factor for biliary tract cancer. Preoperative diagnosis of a benign disorder was difficult in this case.

MAGNETIC RESONANCE IMAGING IN PREOPERATIVE DIAGNOSIS OF OMENTAL CYSTS IN CHILDREN -A CASE REPORT-

患児は4歳の男児.間欠的な腹部自発痛と腹部膨満,発熱を主訴に当院受診.受診時超音波検査およびCT検査にて腹腔内巨大嚢胞性疾患と診断.血液,生化学検査にて炎症所見を認めるもその他に目立った所見なく,腹部症状も軽度であることから,入院後保存的に経過観察し,炎症の消退を得た後, MRI検査にてさらに精査した.胃体下部大彎側に連続し,横行結腸を背側に圧排し,骨盤腔まで拡がる内部信号均一な巨大嚢胞性病変を認め,大網嚢腫と術前診断し,開腹手術施行.開腹時,胃壁から連続性に大網内に拡がるリンパ液の貯留した1,300gの嚢胞を認め,胃大彎側漿筋層を含めてこれを切除した.病理組織学的所見は嚢胞性リンパ管腫であった.本症の診断には超音波またはCTが有用であるとされるが,正確な嚢胞の発生部位および嚢胞内容物の性状の診断につき, MRIもまた有用な検査であると考えられた.