Mutsuo Kitagawa

Treatment of Common Bile Duct Obstruction by Pancreatic Cancer Using Various Stents: Single-Center Experience

Purpose: To compare the effectiveness of various means of stenting in patients with biliary obstruction caused by pancreatic cancer in a retrospective analysis. Methods: Sixty-two patients with biliary obstruction due to unresectable pancreatic cancer underwent biliary stenting. On the basis of the findings obtained by percutaneous transhepatic cholangiography (10 patients) and endoscopic retrograde cholangiography (52 patients), the site of obstruction was distal to the hilar confluence, predominantly especially in the middle to lower third of the common bile duct. Polyurethane-covered Wallstents (9 mm in diameter) were inserted in 13 patients, while uncovered Wallstents (10 mm in diameter) were used in 10 patients and plastic stents (10 Fr and 12 Fr) were used in 39 patients. Results: Stenting was successful in 34 patients (87.2%) treated with plastic stents and in 22 patients (95.7%) treated with Wallstents. Effective biliary drainage was achieved in 32 out of 34 patients (94.1%) treated with plastic stents and in 21 out of 22 patients (95.5%) treated with Wallstents. The cumulative patency rate was significantly higher for the uncovered and covered Wallstents compared to plastic stents, but was not significantly higher for covered than for uncovered Wallstents. Stent occlusion occurred in 23 patients (70%; all by clogging) from the plastic stent group, in two patients (22%; by tumor ingrowth) from the uncovered Wallstent group, and in one patient (9%; by clogging) from the covered Wallstent group. The survival rate showed no significant difference among the three stent groups. Conclusion: The Wallstent is effective for long-term palliation in patients with obstruction caused by pancreatic cancer invading the middle to lower part of the common bile duct. The covered Wallstent can prevent tumor ingrowth, a problem with the uncovered Wallstent. However, it may be necessary to take measures to prevent the migration or clogging of covered Wallstents.

Polyurethane-covered wallstents to recanalize wallstents obstructed by tumor ingrowth from malignant common bile duct obstruction

Four patients with malignant obstruction of the common bile duct had been treated with uncovered Wallstents and suffered from a reobstruction after 2–13 months (mean 5.3 months). Repeat cholangiography revealed severe stenosis of the stent lumen caused by tumor ingrowth through the mesh. A Wallstent with a self-made polyurethane-cover was inserted through the uncovered stent in these patients. The four patients were followed for 3–13 months (mean 6.3 months) until death. There was good drainage with no evidence of recurrent obstruction in all patients. We conclude that a covered Wallstent may extend patency of stented bile ducts, preventing tumor ingrowth in patients with neoplastic obstruction. Further observations are needed.

CASE REPORT: Extrahepatic Biliary Schwannoma

Schwannoma (neurilemoma or neurinoma) rarely develops in the biliary tract. We report here a case of extrahepatic biliary schwannoma found in a 47-yr-old Japanese woman presenting with obstructive jaundice. The radiological imaging studies were suggestive of nonepithelial tumor involving the common bile duct. The patient underwent tumor resection. The tumor extended inward and outward from the wall of the common bile duct in the shape of a dumbbell. The extraductal tumor was solid with microcystic changes, while the intraductal lesion presented cystic changes. Microscopically, the tumor was predominantly composed of spindle-shaped cells with nuclear palisading, and it contained lymphoid aggregates. Immunohistochemically, the tumor cells were positive for S-100 protein. The final diagnosis was benign schwannoma of the common bile duct. The tumor differed from usual soft tissue schwannoma and closely resembled gastrointestinal schwannoma.

Palliation of Pyloric Stenosis Caused by Gastric Cancer Using an Endoscopically Placed Covered Ultraflex Stent: Covered Stent Inside an Occluded Uncovered Stent

A 71-year-old man developed pyloric stenosis caused by gastric cancer. Vomiting and nausea resolved after the insertion of an uncovered Ultraflex stent (length 10 cm, inner diameter 18û23 mm) through a 7-cm-long stenosis, and the patient was able to eat a soft diet. After 6 weeks, stent occlusion occurred due to tumor ingrowth and accumulation of food residue. Endoscopic observation showed a very narrow residual lumen. A covered Ultraflex stent (length 10 cm, inner diameter 18û23 mm) was inserted through the first stent and expanded to its maximum diameter over the next 2 days. The patients vomiting and nausea improved rapidly. He died 6 months after the second stenting procedure, from metastatic tumor spread, having remained free of nausea and vomiting. In this case, a covered metallic stent prevented tumor ingrowth and maintained gastrointestinal patency.

Case report: Hepatocellular carcinoma in type 1a glycogen storage disease with identification of a glucose-6-phosphatase gene mutation in one family.

Abstract A 40‐year‐old man with glycogen storage disease type 1a (von Gierke disease, GSD1a) developed hepatocellular carcinoma (HCC). Cold single‐strand conformation polymorphism (SSCP) with 12% glycerol identified the G727T mutation in the glucose‐6‐phosphatase (G6Pase) gene, which has been reported to be the most common mutation in Japanese GSD1a patients. This case report is the first documentation of HCC in a case with G727T mutation. Given the prevalence of HCC in GSD1a with various germline mutations, analysis is needed to confirm that the germline mutation in this case is really related to hepatocarcinogenesis. DNA analysis of the family pedigree of this case, revealed three individuals with GSD1a and seven heterozygous carriers of the G727T mutation. As the diagnosis of GSD1a in this family was made only after these three patients reached adulthood, DNA diagnosis may help early identification of GSD1a patients and prevention of the progression of the disease. This DNA‐based diagnosis permits prenatal diagnosis in at‐risk patients and may facilitate screening and counselling of patients clinically suspected of having this disease.

Ovarian mucinous cystadenocarcinoma as a cause of Zollinger-Ellison syndrome: report of a case and review of the literature.

Gastrin producing ovarian tumor is a rare cause of the Zollinger-Ellison syndrome. We report the case of an ovarian carcinoma showing increased plasma gastrin concentration. A 60-yr-old woman presented with epigastric pain and diarrhea. Physical examination showed a large mass in the lower abdomen. Computed tomography revealed a large multilocular ovarian cyst. Upper gastrointestinal endoscopy examination showed multiple ulcerations of the stomach and duodenum. The plasma gastrin level was 1500 pg/ml. No tumors were found in the pancreas and duodenum, and salpingo-oophorectomy was performed. Histologic examination revealed a mucinous tumor of borderline malignant potential. Immunoperoxidase studies for gastrin showed many gastrin-producing cells within the epithelium of the tumor. There have been 11 cases (including our patient) of gastrin-producing ovarian tumor reported in the literature. We review here the relevant literature. Although ovarian gastrinoma is extremely rare, it should be considered as a possible cause of the Zollinger-Ellison syndrome in women.

Ovarian mucinous cystadenocarcinoma as a cause of zollinger-ellison syndrome:

Gastrin producing ovarian tumor is a rare cause of the Zollinger-Ellison syndrome. We report the case of an ovarian carcinoma showing increased plasma gastrin concentration. A 60-yr-old woman presented with epigastric pain and diarrhea. Physical examination showed a large mass in the lower abdomen. Computed tomography revealed a large multilocular ovarian cyst. Upper gastrointestinal endoscopy examination showed multiple ulcerations of the stomach and duodenum. The plasma gastrin level was 1500 pg/ml. No tumors were found in the pancreas and duodenum, and salpingo-oophorectomy was performed. Histologic examination revealed a mucinous tumor of borderline malignant potential. Immunoperoxidase studies for gastrin showed many gastrin-producing cells within the epithelium of the tumor. There have been 11 cases (including our patient) of gastrin-producing ovarian tumor reported in the literature. We review here the relevant literature. Although ovarian gastrinoma is extremely rare, it should be considered as a possible cause of the Zollinger-Ellison syndrome in women.

A case of type Ia glycogen storage disease associated with cholangiocellular carcinoma.

症例は38歳, 男性. 10歳時, 他院にて糖原病と診断された. 平成6年5月12日, 尿路結石発作のため入院. 保存的治療により症状は消失したが, 腹部超音波検査にて肝腫大と両葉の多発性腫瘍を認めた. 血液検査では高乳酸, 高尿酸, 高ピルビン酸, 高脂血症を認め, 腫瘍マーカーはCA19-9が軽度上昇していた. 画像上, 腫瘍はいずれも低エコーで, 造影CTの早期に辺縁造影効果あり. 逆行性膵胆管造影では, 胆嚢, 肝内胆管第一分枝～総胆管および膵管に異常なし. 他臓器に腫瘍を認めず, 原発性肝腫瘍と考えられた. 腫瘍生検を施行し, 胆管細胞癌と診断した. 非腫瘍部肝組織のGlucose-6-phosphatase活性は低下しており糖原病Ia型であった. 化学療法を施行したが, 癌性腹膜炎を併発し, 当院受診後1年10カ月で死亡した. 糖原病I型は, ときに腺腫の合併を認めることは知られているが, 胆管細胞癌が合併した報告は本症例が最初である.

A Case of Early Gastric Reticulum Cell Sarcoma Detected by Lavage Cytology

This paper has reported a case of the so-called early gastric reticulum-cell sarcoma a case in which no malignant tumor was proved by X-ray and endoscope inspections but atypical cells were found by proteolytic lavage cytology and diagnoses were subsequently repeated for two years until finally typical malignant cells were found.The paper has also emphasized the importance of studying the cell morphology of malignant lymphoma and of the follow-up by cytodiagnoses.

Two Cases with Minutes Early Gastric Cancer Detected by Lavage Cytology

Two cases of gastric carcinoma which were as small as not more than 2mm and 1mm in maximum diameter and which were confined to the gastric mucosa, respectively, were found by protease lavage cytologic diagnosis. These cases have been presented, with special reference to the courses of their diagnoses. Clinico-pathologic problems in the diagnosis of minor gastric carcinomas difficult to grossly distinguish have been discussed.