Motomichi Sato

Sequential Percutaneous Microwave Coagulation Therapy for Liver Tumor

BACKGROUND Percutaneous microwave coagulation therapy (PMCT) is effective for small liver tumors. To enhance the radicality of PMCT, we developed a sequential coagulation technique. METHODS After inserting the first guide-needle under sonography, multiple needles were placed through a disk-type introducer that was devised to guide needle puncture at regular intervals, and microwaves were irradiated. Six patients, including 4 with hepatocellular carcinoma and 2 with liver metastasis, underwent this technique for tumors of 15 to 80 mm in diameter. RESULTS This technique can coagulate an area up to 60 mm in diameter in one session. Insertion of multiple needles, ranging from 2 to 11, was successful without complications. Three patients undergoing curative PMCT developed no tumor recurrence. The other 3 received incomplete PMCT due to the large size and location of the tumor. CONCLUSIONS This preliminary study indicates the efficacy of this technique to facilitate and secure PMCT in selected patients with liver tumors.

CT-guided treatment of ultrasonically invisible hepatocellular carcinoma

New techniques of CT-guided management were introduced to ablate ultrasonically invisible hepatocellular carcinomas. In six patients with HCC, a total of six nodules (8–30 mm in diameter) were treated under the guidance of CT. These lesions were not visualized by sonography but were visualized as Lipiodol spots on CT after chemoembolization. Tumor localization was successful in all patients without difficulty, using a thin needle or hookwire under the guidance of CT. Two patients underwent subsequent hepatic resection and/or microwave coagulation therapy (MCT) through a small incision after hookwire placement. Four patients received percutaneous MCT (n = 2) or ethanol injection (PEI) (n = 2) at the time of localization. The postoperative CT with contrast enhancement indicated that tumor ablation was complete in four of the five nodules treated with MCT or PEI. However, in one nodule (30 mm in diameter) treated with PEI, tumor ablation was not complete. There were no complications. There has been no local tumor recurrence 6–46 months after treatment in any of the patients. In conclusion, these CT-guided procedures were effective in treating ultrasonically invisible hepatocellular carcinomas that otherwise would have remained untreated.

Incidence of p53 and Ha‐ras gene mutations in chemically induced rat mammary carcinomas

To determine whether p53 alterations, which are frequent in human breast cancers, are also common in rat mammary tumors, we examined 40 tumors from 24 rats treated with 7,12‐dimethylbenz[a]anthracene (DMBA) and 34 tumors from 14 rats treated with N‐nitroso‐N‐methylurea (NMU) (an N‐nitroso compound). DMBA and NMU are known genotoxic mutagens. The entire coding regions of the p53 and Ha‐ras genes were examined for mutations by polymerase chain reaction single‐strand conformational polymorphism analysis and by direct sequencing. One of the 40 DMBA‐induced mammary tumors had a p53 mutation, a single‐base substitution (???AGC→???GGC) at codon 307, resulting in an amino‐acid change from Ser to Gly. No mutations were found in NMU‐induced tumors. The incidence of Ha‐ras gene mutation was 79% (27 of 34) at codon 12 in the NMU group and 23% (nine of 40) at codon 61 in the DMBA group. Thus, p53 mutation, in contrast to Ha‐ras mutation, did not seem to be a prerequisite for carcinogenesis in chemically induced rat mammary tumors.

Enteric absorption of FK 506 : Estimation by a block liver perfusion technique in rats

This perfusion model enables a pharmacokinetic study of enteral absorption and hepatic metabolic rate simultaneously. FK 506 is absorbed mainly via the proximal small intestine and metabolized rapidly by the liver during single passage. These results may lead to further analyses of absorption and metabolism of FK 506 under various conditions.

Carcinoma of the cystic duct associated with pancreaticobiliary maljunction.

We report a rare case of carcinoma of the cystic duct (CCD) associated with pancreaticobiliary maljunction (PBM). A 63-year-old man had presented with relapsing cholecystitis of 4 months, duration. Computed tomography showed a distended gallbladder: however, small mass in the cystic duct was overlooked. Endoscopic retrograde cholangiopancreatography demonstrated a long common channel (20-mm-long) and fusiform dilatation of the common bile duct, findings, which were consistent with PBM. At laparotomy, we found a papillary tumor, 20 mm in diameter, that obstructed the cystic duct. The patient underwent resection of the gallbladder and the common bile duct, lymph node dissection in the hepatoduodenal ligament, and hepaticojejunostomy. Histologic study revealed a papillary adenocarcinoma confined within the subserosal space. There was no lymphatic or perineural invasion of cancer cells. The surrounding cystic ductal mucosa showed dysplasia and hyperplasia, and the gallbladder and common bile duct showed severe inflammation. The patient has been doing well for 16 months after surgery, without tumor recurrence. This case suggests a relationship between CCD and chronic biliary inflammation caused by PBM, as in cases of gallbladder carcinoma.

MALIGNANT FIBROUS HISTIOCYTOMA SHOWING CYTOPLASMIC HYALINE GLOBULES AND STROMAL OSTEOIDS: A Case Report with Light and Electron Microscopic, Histochemical, and Immunohistochemical Study

A 56‐year‐old man died of widespread metastases of malignant fibrous histiocytoma (MFH) primarily developed in the left lower gingiva after a rapid clinical course is reported. Primary and metastatic tumors showed light and electron microscopic, histochemical and immunohistochemical characteristics of MFH together with cytoplasmic hyaline globules and stromal osteoids. Hyaline globules revealed periodic acid‐Schiff positive and diastase resistant reactions but not positive with any histochemical and immunohistochemical reactions. Osteoids were partially calcified and rimmed by osteoblastic tumor cells. The present case of MFH may provide difficulties in the differential diagnosis from some osteoid‐forming sarcomas in soft tissues with relation to the histogenesis.

Hand-assisted laparoscopic total colorectal resection for familial adenomatous polyposis with coexisting rectal cancer

When familial adenomatous polyposis (FAP) is diagnosed in a patient, prophylactic surgery must be performed whether colorectal cancer is present or not. Operations for FAP have been performed through a large median abdominal incision or an additional perineal incision, depending on the coexistence of rectal cancer. Recently, we reported a technique of laparoscopic rectal amputation without abdominal skin incision for patients with rectal cancer to minimize postoperative cardiac and respiratory complications [6]. In this article, we report a case of laparoscopically assisted proctocolectomy with ileostomy through a minimal abdominal and perineal skin incision performed by a handassisted procedure. The purpose of combining the perineal and laparoscopic approaches is to minimize the skin incision, while retaining a rate of cure and safety equivalent to those of conventional rectal amputation, by using the advantages of laparoscopic procedures, and to facilitate postoperative recovery and improve the quality of life for relatively young patients with FAP.

The effect of combination splenectomy and low-dose FK506 therapy on graft survival after liver allograft transplantation in rats

The effect of splenectomy on allograft survival was investigated using orthotopic liver transplantation in a rat experimental model (ACI rat liver grafted to LEW rat). Control rats without any immunosuppressive treatment died, on average, 10.4 +/- 1.4 days after operation. Splenectomy alone somewhat prolonged the survival (13.4 +/- 2.0 days), and low-dose FK506 therapy moderately prolonged it (22.7 +/- 7 days). The graft survival period was significantly prolonged (39.7 +/- 6.3 days) when them two treatments were combined. The elevation of cytotoxic antiallograft antibodies was suppressed by splenectomy but not by low-dose FK506 therapy. The development of jaundice was moderately suppressed by FK506 but not by splenectomy. There was no difference between the pattern of body weight decline in either of them two groups and that in control rats. When these two treatments were combined at the same time, the elevation of cytotoxic antibodies, development of jaundice and decline of body weight were suppressed. These data indicate that B cells play an important role in the acute rejection of the rat liver allograft at least partially via production of cytotoxic antiallograft antibody. Splenectomy or other immunosuppressive methods affecting B cells can be a supplement for immunosuppression when using reduced-dose FK506.

Multiendoscope-assisted treatment for blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome is characterized by gastrointestinal and cutaneous hemangiomas and gastrointestinal bleeding causing anemia. We report a unique case of this syndrome in an adult woman. It was associated with congenital heart disease, for which the patient underwent surgery at 12 months of age, and cutaneous hemangiomas, for which surgery was performed later in childhood. Gastrointestinal bleeding was diagnosed and treated when she was 21 years of age after a workup for iron deficiency anemia. Successful total resection of all gastrointestinal hemangiomas was performed by minimally invasive surgery with gastric, small intestinal, and colonic fiberscopy and laparoscopy. The postoperative course was uneventful. The patient could walk the day after surgery, and she was discharged from the hospital 14 days after surgery. Our experience and findings given in other reports suggest that total resection of hemangiomas should be the final goal and that minimal skin incision is preferable for this benign disease, with multiendoscope-assisted treatment to ensure that any hemangiomas remaining in the gastrointestinal tract are not overlooked.

Painless Lithotripsy by Flashlamp-Excited Dye Laser for Impacted Biliary Stones: An Experimental and Clinical Study

OBJECTIVE To find out the appropriate dye laser output and frequency for each kind of stone experimentally, and to use flashlamp-excited dye laser for impacted biliary stones. DESIGN Prospective study. SETTING University hospital, Japan. SUBJECTS 12 patients undergoing lithotripsy for both intrahepatic and extrahepatic impacted biliary stones. MAIN OUTCOME MEASURES Appropriate dye laser output and frequency, histological changes in the bile duct wall, and outcome. RESULTS Stones were pulverised, and required a median 155 pulses (range 80-205) at 40 mJ for bilirubin stones and 355 pulses (range 205-405) at 50 mJ for cholesterol stones. At the standard energies used, the laser caused only superficial damage to the serosa of the common bile duct. It was successful in fragmenting 133/135 stones (99%), and in addition pulverised 125/135 stones (93%). No patients complained of pain during laser lithotripsy even under local anaesthesia. All patients were discharged from the hospital after an uneventful recovery, and no recurrent stones have been found at outpatient follow-up ranging between 2 and 85 months. CONCLUSION Flashlamp-excited dye laser with a small choledochoscope seems to be safe and painless way of treating biliary stones, even if they are impacted in the peripheral biliary tree and patients are at high risk.