Kikuo Miyagawa

Selective infiltration of CCR5(+)CXCR3(+) T lymphocytes in human colorectal carcinoma.

T cell infiltration in colorectal cancer is associated with a favorable prognosis, suggesting an occurrence of a certain degree of anti‐tumor immunity. T helper type 1 (Th1) and Th2 cells are now known to selectively express CC‐chemokine receptor 5 (CCR5)/CXC‐chemokine receptor 3 (CXCR3) and CCR4, respectively. To clarify the mechanism of T cell infiltration, we examined in situ expression of these chemokine receptors and their respective chemokine ligands in 40 cases of human colorectal cancer. Immunohistochemistry showed a predominant accumulation of T cells expressing CCR5 and CXCR3 mainly along the invasive margin, whereas those expressing CCR4 were rare. Flow cytometric analysis showed that more than half of CD8+ T cells and a fraction of CD4+ cells isolated from fresh tumor tissues co‐expressed CCR5 and CXCR3, and CD8+ T cells and CD4+ cells predominantly produced interferon‐γ (IFN‐γ) over interleukin‐4 (IL‐4) after in vitro stimulation. RANTES/CCL5, a ligand of CCR5, was localized within infiltrating CD8+ T cells in a granular pattern, whereas IP‐10/CXCL10, a ligand of CXCR3, was localized in cancer cells and macrophages along the invasive margin. These data were consistent with an active recruitment of T cells expressing CCR5 or CXCR3 into the invasive margin of colorectal cancer. With the previous clinicopathological studies showing a favorable prognostic impact of T cell infiltration in colorectal cancer, our study supports the occurrence of a certain level of Th1‐shifted cellular immune responses in human colorectal cancer.

Pancreatic function and rehabilitation after pancreaticoduodenectomy

Postoperative pancreatic function and rehabilitation were monitored in 149 patients who had had reconstruction of the digestive tract by Childs method, out of a total 151 patients who had undergone pancreaticoduodenectomy. The occurrence of peptic ulcer following Childs method may be prevented by the resection of a wider area of the stomach. Because the source of gut hormone secretion is removed by the pancreaticoduodenectomy, the secretion of this hormone is subsequently reduced and thus metabolic abnormalities also occur. If careful attention however, is paid to the maintenance of residual pancreatic function most patients who undergo pancreaticoduodenectomy can be expected to lead reasonably normal lives.

Malignant insulinoma with metastasis to gallbladder and bone, accompanied by past history of peptic ulcer and hyperthyroidism

SummaryA case of a malignant insulinoma in a 53-year-old female is presented. In 1973, the patient underwent caudal pancreatectomy for a malignant insulinoma. Ten years later, it was discovered that the insulinoma had spread to the bones. On admission for cholecystectomy because of a gallbladder polyp and gallstones, she often experienced hypoglycemic attacks, and both calcium and glucagon provocation tests elicited marked release of insulin. Selective angiography of the common hepatic artery showed a tumor blush near the hilum of the liver. Immunohistochemical staining of the gallbladder polyp and the bone tumors proved positive for insulin. Plasma levels of insulin and prolactin were abnormally high. The patient had also been treated for a perforated duodenal ulcer and hyperthyroidism. It is concluded that this may have been a case of a multiple endocrine neoplasia.

Surgical management of insulinoma: Diagnosis of tumor location and high incidence of malignancy

The findings in twenty-two patients with insulinoma were reviewed, as continuous efforts should be made to establish preoperative localization of the tumor. Superselective arteriography and percutaneous, transhepatic portal vein and pancreatic venous catheterization are highly recommended approaches. At the time of surgical intervention, a cautious exploration of the pancreas after thorough mobilization is most important. Recent use of intraoperative ultrasonography increases the likelihood of finding these occult tumors which locate deeply in the head of the pancreas. Apart from the diagnostic problems, we wish to emphasize the high incidence of malignancy (7/22, 31.8 per cent) in our series. Althout patients with malignant isulinoma had a much better prognosis compared to those with a pancreatic ductal malignancy, pancreatic resection with regional lymphnode dissection seems to be a rational procedure. Enucleation can be done when intraoperative findings of the tumor and regional lymphonode indicate no malignant features and no multiple lesions. However, at the first operation, enucleation is still a procedure of choice, even for the malignant insulinoma in the head with a well-defined capsule and no metastatic lesions, the objective being to avoid a duodenopancreatectomy or total pancreatectomy.

Predicton and countermeasure of sepsis with acute pancreatitis.

急性膵炎に併発する敗血症の病態を明らかにする目的で, 23例の出血壊死型膵炎症例を敗血症併発群 (n=11), 敗血症を併発しなかった群 (n=12) の2群に分け, 生化学的パラメーター, 細菌学的検索を中心に検討した.敗血症併発群は入院後10～15日目以降, 多臓器障害が顕著となり, 敗血症を併発しなかった群にくらべ死亡率も有意に高かった.敗血症の併発を予測する因子としては, 入院時の重症度が高いこと, また, α2-MG, α2/α1 ratioの著明な低下などの指標が有用である可能性が示唆された.敗血症の感染巣は膵および膵周囲の壊死組織であり, これらの徹底的な除去が重要であると考えられた.