Sadao Amano

Evaluation of follow-up strategies for corticosteroid therapy of idiopathic granulomatous mastitis

PurposeIdiopathic granulomatous mastitis (IGM) is a rare inflammatory pseudotumor. No therapeutic modality has been established because of the rareness of this disease. The aim of this study was to investigate the clinical course of IGM treated with corticosteroid, and to evaluate the optimal methods of observation during corticosteroid therapy of IGM.MethodsThe retrospective study included eight women who met the required histological criteria of IGM. The clinical data of the presentation, histopathology, and management were analyzed by reviewing the medical records.ResultsThe mean age of the patients was 44.8 years (range, 28–75 years) and all patients complained of a breast mass. Seven of them had pain. All of them underwent a core needle biopsy and were diagnosed as having IGM. Five took prednisolone orally and three received prednisolone plus antibiotics; one patient of the latter group underwent a resection due to severe pain. Seven patients healed without surgery and it took from 4 to 10 months to achieve a cure. The period until confirmation of the disappearance of a mass was the shortest by palpation, followed by contrast magnetic resonance imaging and ultrasonography in that order.ConclusionSteroid therapy was effective for the treatment of IGM, which was cured without surgery in seven of eight cases. Ultrasonography was considered an excellent method for evaluating the treatment outcomes.

Application of liquid-based preparation to fine needle aspiration cytology in breast cancer.

OBJECTIVE To examine the performance of liquid-based cytology (LBC) in breast cytology to confirm the diagnosis of carcinoma. STUDY DESIGN Using cell clusters directly scratched from surgically removed tumor masses, we examined the immunocytochemistry, molecular biology and cytomorphology of the specimens. RESULTS LBC was very useful for gene analysis and evaluating the immunocytochemistry. The cytologic features of LBC were slightly different from those ofa conventional aspiration cytology smear. CONCLUSION LBC is a promising method for improving the standardization ofpreparations in breast cytology, although care should be taken to account for its characteristic cytologic features. The quantitative analysis of HER-2 mRNA correlated with the results of immunohistochemistry.

Increased Serum Concentrations of Soluble Tumor Necrosis Factor Receptor I in Noncachectic and Cachectic Patients with Advanced Gastric and Colorectal Cancer

The serum levels of soluble tumor necrosis factor receptor I (sTNF-RI) were measured in 74 noncachectic patients including 42 with gastric cancer and 32 with colorectal cancer, as well as in 39 patients with severe cachexia and 15 healthy volunteers. The sTNF-RI levels increased with the advance of disease, being highest in the cachectic patients. The levels were inversely correlated with the serum concentrations of nutritional parameters such as prealbumin, transferrin, retinol binding protein, and the percentages of CD3(+) cells in the peripheral blood lymphocytes, and positively correlated with the serum concentration of immunosuppressive acidic protein (IAP) and soluble interleukin-2 receptors. These findings suggest that sTNF-RI could be an important prognostic factor to predict the advance of gastric and colorectal cancers and deterioration of the patient’s nutritional and immune activity.

Aryl hydrocarbon receptor ligand 2,3,7,8-tetrachlorodibenzo-p-dioxin enhances liver damage in bile duct-ligated mice

The environmental pollutant 2,3,7,8-tetracholorodibenzo-p-dioxin (TCDD) is known to cause a wide variety of toxic effects, including hepatotoxicity, by way of the aryl hydrocarbon receptor (AHR). Although inducible expression of cytochrome P450 (CYP) 1A1 and CYP1A2 is associated with liver injury caused by high-dose TCDD, the specific role of the AHR-CYP1 cascade in hepatotoxicity remains unclear. We investigated the effects of AHR activation under conditions of cholestasis. We administered oral TCDD to mice at a dose that can effectively induce Cyp1 gene expression without overt liver toxicity and then ligated their bile ducts. TCDD pretreatment enhanced bile duct ligation (BDL)-induced increases in liver and plasma bile acids, bilirubin, and aminotransferases. Histology of TCDD-pretreated BDL mice revealed massive hepatic necrosis without any increase in number of apoptotic cells. Whereas induction of AHR-target genes by TCDD was observed similarly in sham-operated as well as in BDL mice, TCDD pretreatment of BDL mice altered the expression of hepatic genes involved in bile acid synthesis and transport. Increased plasma proinflammatory cytokines, tumor necrosis factor and interleukin-1β, in BDL mice were further elevated by TCDD pretreatment. Liver injury by TCDD plus BDL, such as increased plasma bile acids, bilirubin and aminotransferases, liver necrosis, and increased tumor necrosis factor production, was exaggerated in Cyp1a1/1a2(-/-) double knockout mice. These findings indicate that TCDD aggravates cholestatic liver damage and that the presence of CYP1A1 and CYP1A2 plays a protective role in liver damage caused by TCDD and BDL.

Primary Hyperparathyroidism with Thyroid Hemiagenesis

Thyroid hemiagenesis is a very rare anomaly. We herein report a case with right thyroid lobe agenesis, which was incidentally found during the assessment of primary hyperparathyroidism. A 42-year-old male presenting with urinary lithiasis was suspected of having primary hyperparathyroidism, and had elevated levels of both serum calcium and intact parathyroid hormone. Both computed tomography and ultrasonography demonstrated the absence of right thyroid lobe and a mass of 1 cm in diameter at the left lower pole of the thyroid. The patient underwent lower left parathyroidectomy, which confirmed the right thyroid hemiagenesis, as well as the absence of both upper and lower right parathyroid glands. The resected left lower parathyroid gland was pathologically diagnosed as adenoma. The postoperative course was favourable and he was discharged on the 2nd day after surgery, without complications.

Preventing delayed gastric emptying in pancreaticogastrostomy by a modified subtotal-stomach-preserving pancreaticoduodenectomy: Oida modification.

BACKGROUND/AIMS Delayed gastric emptying (DGE) is one of the most troublesome complications of pylorus-preserving pancreaticoduodenectomy (PPPD). In Japan, since the 1990s, subtotalstomach- preserving pancreaticoduodenectomy (SSPPD) has been performed as an alternative to PPPD. Here, we evaluated the efficacy of our modification of the original SSPPD technique as compared to PPPD with an aim to decrease the incidence of DGE. METHODOLOGY We retrospectively analyzed 67 patients who underwent PD with pancreaticogastrostomy (PG). They were divided into 2 groups on their basis of the surgical treatment: the PPPD group and the modified SSPPPD (MSSPPD) group. The incidence of DGE was determined and compared between the 2 groups. RESULTS In the MSSPPD group, 98%, 2%, and 0% of the cases developed class A, class B, and class C DGE, respectively; the corresponding values in the PPPD group were 4%, 52%, and 44%, respectively. The incidence of DGE differed significantly between the 2 groups (p<0.0001). CONCLUSIONS We consider that our reconstruction procedure is useful for preventing DGE in patients who have undergone SSPPD with PG.

Long-term outcome of laparoscopic cystogastrostomy performed using a posterior approach with a stapling device.

Background: Internal drainage of an acute pancreatic pseudocyst is indicated 6 weeks after its first detection. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Pseudocysts located adjacent to the posterior gastric wall are best drained by pseudocyst gastrostomy. Although the anterior approach for drainage has frequently been reported, reports on the posterior approach are rare. Methods: Seven patients underwent laparoscopic cystogastrostomy for pancreatic pseudocysts. The posterior approach that enables the direct visualization of the posterior gastric wall and pseudocyst was used, and the cyst was drained with a needle. After creating a sufficient drainage orifice, the cyst was thoroughly debrided. Cystogastrostomy was performed using the posterior approach with a stapling device. The insertion site of the stapling device closed using a hernia stapler. Results: Cystogastrostomy was performed using the posterior approach with a stapling device in all patients, without requiring conversion to the anterior approach or open surgery. There were neither operative complications nor late recurrences during the follow-up period (median 65 months). Conclusion: Laparoscopic cystogastrostomy using the posterior approach, which facilitates adequate internal drainage, is a safe and feasible procedure for pancreatic pseudocyst, and it is not accompanied with a risk of recurrence in the long term.

Antecolic and retrocolic route on delayed gastric emptying after MSSPPD.

BACKGROUND/AIMS Previously, we developed a modified subtotal stomach-preserving pancreaticoduodenectomy for preventing delayed gastric emptying and achieved a decrease in the incidence of delayed gastric emptying. In this study, we compared the antecolic and retrocolic routes to determine which reconstruction route is better for decreasing the incidence of delayed gastric emptying in modified subtotal stomachpreserving pancreaticoduodenectomy. METHODOLOGY We retrospectively analyzed 42 patients who underwent modified subtotal stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy. The patients were divided into 2 groups based on type of reconstruction: the antecolic reconstruction group and the retrocolic reconstruction group. The incidence of delayed gastric emptying was determined and compared between the 2 groups. RESULTS The mean time during nasogastric suction and before initiation of a diet after surgery was shorter in the retrocolic reconstruction group (without significant difference); however, the mean time before oral ingestion of solid food could be safely resumed was significantly shorter in the retrocolic reconstruction group (9.7±1.2 days) than in the antecolic reconstruction group AC group (11.4±3.0 days; p<0.0112). CONCLUSIONS We consider retrocolic reconstruction preferable to antecolic reconstruction for preventing delayed gastric emptying in patients who have undergone modified subtotal-stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy.

Protection of major vessels and pancreaticogastrostomy using the falciform ligament and greater omentum for preventing pancreatic fistula in soft pancreatic texture after pancreaticoduodenectomy.

BACKGROUND/AIMS Pancreatic fistula is one of the major causes of morbidity in patients undergoing pancreaticoduodenectomy. Protection of the skeletonized vessels and the anastomotic site of pancreaticoenterostomy is one of the surgical options to prevent the development of a pancreatic fistula. The aim of this study was to describe an operative technique to protect the vessels and anastomotic site by wrapping them with the falciform ligament and the greater omentum. METHODOLOGY After a modified subtotal stomach-preserving pancreaticoduodenectomy reconstruction with pancreaticogastrostomy was performed, the falciform ligament and greater omentum was used on the skeletonized major vessels and wrapped around the anastomotic site of pancreaticogastrostomy. Twenty consecutive patients were enrolled in this prospective study. RESULTS The entire procedure did not result in any operative complications. Postoperative pancreatic fistula developed in 2 cases (10%). According to the international postoperative pancreatic fistula criteria, grade A and grade B was observed in 1 case each. No intra-abdominal hemorrhage and late intra-abdominal abscess were observed. CONCLUSIONS This procedure is a convenient and safe technique, and may be helpful in preventing major complications caused by pancreatic fistula.

Aggressive progression of granulocyte colony-stimulating factor producing squamous cell carcinoma of the esophagus: case report and literature review

We report a case of a 69-year-old man who was diagnosed to have granulocyte colony-stimulating factor (G-CSF)-producing esophageal squamous cell carcinoma, based on a histological examination of endoscopic biopsy specimens. A high serum level of leukocytes and G-CSF was noted. Moreover, immunohistochemical examination revealed that the tumor cells were positive for antibodies against G-CSF. Palliative radiation therapy was performed because of existing distant metastasis at the time of presentation, and the patient died of tumor progression 7 months after the initial diagnosis. To the best of our knowledge, only five cases with G-CSF-producing squamous cell carcinoma have been described in the English literature, including our present case. Because many cytokines induced by G-CSF-producing tumors contribute to tumor growth and aggressive inflammation, these patients might have a poor prognosis. G-CSF-producing tumor is extremely rare; however, we should consider a differential diagnosis for such disease when a patient shows a high leukocyte count with no evidence of systemic infection or hematological disease.