Nobuhiko Ueda

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.

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.

The spread and prognosis of carcinoma in the region of the pancreatic head

Tumor infiltration and prognosis were studied in 73 patients who underwent surgery for carcinoma in the region of the pancreatic head, in order to evaluate the grade of malignancy of pancreatic cancer. Twenty three patients had carcinoma of the head of the pancreas, 16 had carcinoma of the intrapancreatic bile duct and 34 had carcinoma of the papilla of Vater. It was found that the prognosis in carcinoma of the head of the pancreas was not related to tumor size, but to lymph node metastasis and the pancreatic capsular or perineural invasion of the tumor. The poorer prognosis seen in carcinoma of the head of the pancreas could be attributed to the fact that lymph node metastasis and invasion of the pancreatic capsule or nerve plexus occurred much more frequently in this carcinoma than in carcinoma of the other two areas. The 5-year survival rate of the patients with carcinoma of the head of the pancreas was 12.5 per cent, this being significantly lower than that of the patients with either carcinoma of the papilla of Vater (50.0 per cent) or carcinoma of the intrapancreatic bile duct (44.4 per cent). These findings suggest that lymph node metastasis and pancreatic capsular or perineural invasion closely correlate with the prognosis of patients with pancreatic carcinoma.

Clinical experience of biliary tract carcinoma associated with anomalous union of the pancreaticobiliary ductal system

Between 1978 and 1988, 15 patients with gallbladder cancer and 2 patients with bile duct cancer were seen among 49 patients with anomalous union of the pancreaticobiliary ductal system. Radiographic findings revealed two types of this anomalous condition: one in which the pancreatic duct entered the common bile duct(type 1) and one in which the common bile duct entered the pancreatic duct (type 2). In gallbladder cancer, the common bile duct presented no dilatation, or in some patients, mild dilatation, and type-1 anomalous union was frequently found among these patients. In contrast, the two patients with bile duct cancer had cystic dilatation of the common bile duct and type-2 anomalous union. The bile amylase level, which was determined in seven patients, was extremely high in all the patients. Histopathologically, the tumors in most patients showed papillary to papillo-tubular proliferation in the mucosal layer while atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that this congenital anomaly in both ducts results in a loss of the normal sphincteric mechanism of the doudenal papilla, and that chronic relapsing cholecystitis or cholangitis, caused by the reflux of pancreatic juice into the biliary tract, can induced progressive changes to atypical epithelial hyperplasia which may develop into carcinoma.

Intrasplenic pancreatic pseudocyst : a case report

SummaryAn intrasplenic psudocyst associated with the acute relapsing phase of chronic pancreatitis in a 51-year-old woman is reported, with a review of the Japanese literature. The patient was admitted with a complaint of left lateral and back pain. Abdominal US and CT revealed communicating cysts at the pancreatic tail and the subcapsule of the spleen. A repeat US and CT 1 month after admission demonstrated enlargement of the cyst at the pancreatic tail. ERCP revealed a dilated main pancreatic duct without any definite evidence of stenosis, and direct communication with the cyst at the pancreatic tail. Percutaneous cystography revealed that the subcapsular cyst of the spleen, the cyst of the pancreatic tail, and the main pancreatic duct communicated with each other. The cyst contained serous fluid with an amylase content of 57,500 IU/I. Distal pancreatectomy and splenectomy was performed. Histologically, there was a nonepithelial lining on the inner surface of the cysts at the pancreatic tail and the subcapsule of the spleen. Severe chronic inflammatory changes were present in the resected tail of the pancreas. Timely surgical treatment is advocated to reduce the mortality and morbidity associated with complications of intrasplenic pseudocysts.

Synchronous Cancer of the Biliary Tract and Pancreas Associated with Anomalous Arrangement of the Pancreaticobiliary Ductal System

A 58-year-old man on abdominal ultrasonography and CT had an irregularly elevated lesion at the neck of the gallbladder and a cyst of approximately 6.5 cm in diameter at the pancreatic tail. Percutaneous transhepatic cholangiography revealed a 2-cm shadow defect at the neck of the gallbladder and an irregular, translucent 30 x 12 mm lesion in the intrapancreatic bile duct. Total pancreatectomy and extended cholecystectomy with regional lymph node dissection was performed. An anomalous arrangement of the pancreaticobiliary ductal system (AAPBD) was demonstrated by postoperative contrast radiography of resected specimen. The lesions of the gallbladder and common bile duct were papillary adenocarcinoma. In addition, papillary adenocarcinoma was limited almost entirely to the mucosal layer of the main pancreatic duct and its branches, from the junction of the common bile duct and pancreatic duct to the pancreatic tail. The three tumors were not continuous. The cyst at the pancreatic tail was a pseudocyst. This case represents synchronous cancer of the gallbladder, common bile duct, and pancreas associated with AAPBD.

Morphological study of cholesterol hepatolithiasis. Report of three cases.

Three cases of pure cholesterol intrahepatic stones are compared morphologically to those of calcium bilirubinate stones. Cholesterol stones were found in the intrahepatic bile duct of the left lateral lobe in two cases and in both the left lateral and the right posterior lobe in one. Although the chronic inflammatory reaction and fibrous thickening of bile duct wall were similar in both types of hepatolithiasis, the proliferation of intrahepatic periductal glands and the production of mucin were rather mild, compared to that is the liner containing calcium bilirubinate stones. Multiple intramural cholesterol calculi and cholesterin granulomas (cholesterin crystals surrounded by foreign-body giant cells) were found within the cystically dilated small bile duct branches and/or conduits of periductal glands. The calculi and granulomas were characteristic for cholesterol hepatolithiasis. These findings suggest that the formation of the cholesterol stones differs from that of calcium bilirubinate stones; the perturbation of factors influencing cholesterol nucleation in the hepatic bile may be related to the changed microenvironment of the intrahepatic bile ducts, which is followed by the formation of cholesterol stones.

Pathogenesis of hepatic atrophy in canine model of hepatolithiasis

SummaryThe pathogenesis of the hepatic atrophy that accompanies hepatolithiasis was investigated pathomorphologically using a canine model. Two groups were evaluated: infected and noninfected. In the infected group, inflammation in Glisson’s capsule caused by cholangitis involved the portal vein at the region of the large bile duct. At this region, the periportal fibrosis ratio was significantly greater in the infected group than in the noninfected group both at 1 and 3 months. At the regions of the septal and interlobular bile ducts, the caliber ratio of the portal vein in the two experimental groups was less than in the normal liver both at 1 and 3 months. At both regions, the caliber ratio of the portal vein in the infected group was less than in the noninfected group at 3 months. The rate of atrophy was significantly greater in the infected group than in the noninfected group at 3 months. These results suggest that disturbance of the portal venous blood flow attributed to cholangitis of the large bile ducts is one of the most important factors leading to hepatic atrophy in hepatolithiasis.

Clinicopathological studies on solid and cystic tumors of the pancreas

SummaryThree cases of pancreatic tumor in two females (case 1, case 3) and one male (case 2) were reported. Macroscopically cases 1 and 3, which were surrounded by a thick fibrous capsule, developed toward the outside of the pancreas and the cut surface showed mainly cystic degenerative areas filled with necrotic and hemorrhagic materials. In contrast with these two cases, case 2 was buried in the pancreatic tissue and the cut surface showed cystic degenerative areas in its center with a thick fibrous capsule and tumor cell nests invading beyond the capsule to the parenchyma of the pancreas. Microscopically each tumor was identical. The solid areas on the periphery were composed of sheets of polygonal uniform cells subdivided by delicate fibrovascular stalks. Near the degenerative areas, tumor cells lay on a delicate fibrovascular core in one or two layers, with pseudopapillary patterns. Mitotic figures were very rare. All three cases demonstrated immunoreactivity for alpha-1-antitrypsis, but not for islet hormones, tumor markers nor neuron-specific enolase. Although electronmicroscopically, zymogen granules were detected in cases 2 and 3, and annulate lamellae in cases 1 and 3, ductal cell character features were not so developed. From the above, these tumors were diagnosed as solid and cystic tumors of the pancreas. Furthermore, it was suggested that they differentiated in the direction of acinar cells.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis.

A case of intraductal papillary adenocarcinoma of the pancreas associated with mass forming chronic pancreatitis without calcifications is described. Pancreatolithiasis, or calcified pancreas, is recognized as a high risk factor for pancreatic cancer. However, epidemiologic studies have found that carcinoma of the pancreas associated with chronic pancreatits was rare. The question is whether chronic pancreatitis without calcifications is actually a precancerous background lesion or not. This case suggests that hyperplasia of the pancreatic ductal epithelium may be a precancerous lesion for pancreatic cancer in some patients with chronic pancreatitis.