Teisuke Hirono

Multiple angiomyolipoma of the liver.

Angiomyolipoma (AML) of the liver is extremely rare; we believe only about 60 cases, all solitary, have been reported. We present here the first reported case, to our knowledge, of multiple AMLs in the liver. Two masses were found in the liver of a 43-year-old Japanese woman complaining of abdominal discomfort by ultrasonography and computed tomography. With a preoperative diagnosis of hepatocellular carcinoma, a tumor in the right lobe 4.0 cm in largest diameter and one in the left lobe measuring 2.4 cm were resected. Histologically, both tumors were composed of smooth-muscle cells, fat cells, and blood vessels, and contained foci of extramedullary hematopoiesis. Although the smooth-muscle cell component was predominant and both tumors exhibited some pleomorphism, no mitosis was found. These histologic findings are consistent with the diagnosis of AML.

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.

Malignant Mesenchymoma of the Retroperitoneum Involving Cecal Carcinoma. A Case Report.

患者は78歳の女性.後腹膜の黄色肉芽腫で左腎摘出術を施行された既往がある.主訴は左下腹部痛で, 同部に一致して径10cmの腫瘤を触知し, 血液検査ではCEA とCA19-9が高値を示した. CTでは左後腹膜に石灰化を有し周囲に脂肪成分を伴う腫瘤を認めた.注腸造影では下行結腸は内側に圧排され, また盲腸に腫瘤陰影を認めた.2型盲腸癌と黄色肉芽腫の再発との診断で手術を施行した.下行結腸周囲の後腹膜腔に複数の腫瘤を認め, 迅速病理にてmyxoid sarcomaと診断されたため結腸左半切除術を施行し, また盲腸癌にて回盲部切除術を併施した.切除標本では漿膜下から後腹膜に黄褐色または灰白色な弾性硬の腫瘤を認めた. 組織学的には分化型の軟骨肉腫や骨肉腫, 平滑筋肉腫および脂肪肉腫の成分を認め悪性間葉腫と診断された.盲腸癌は2型の高分化腺癌でss, ly2, v0, n1 (+) であった. 本疾患はまれであり組織発生を検討する上で興味ある症例と考えられたので報告する

CLINICAL RESULTS OF PRIMARY CLOSURE OF THE COMMON BILE DUCT FOR CHOLEDOCHOLITHIASIS

Twenty-nine patients undergoing primary closure (primary closure group) and seventy patients undergoing T tube drainage (T tube group) were compared clinically to elucidate the effectiveness and problems of the primary closure of the common bile duct for choledocholithiasis. The frequency of bile leakage after the operation was 24.1% in primary closure group. The frequency of localized peritonitis after removal of a T tube due to incomplete fistula formation was 8.6% in T tube group. Postoperative liver dysfunction was noted in 7.1% for primary closure group and in 14.3% for T tube group. The duration of hospital stay after the operation was 20.1 days in primary closure group, being significantly shorter than 38.8 days in T tube group. Recurrence of stones was observed in 1 patient for each group. Though the primary closure was predominantly performed for aged patients compared to T tube drainage group, primary closure group revealed less complications. In the primary closure group, shortening of duration of hospital stay after the operation and the same prognosis as that of T tube drainage group were obtained. We concluded that the primary closure of the common bile duct for choledocholithiasis is more effective than T tube drainage as long as the indications are kept.

A CASE OF RECURRENT GASTRIC CANCER WITHOUT JAUNDICE FOR 1 YEAR AND 6 MONTHS AFTER BILIARY ENDOPROSTHESIS USING AN EXPANDABLE METALLIC STENT

A 49-year-old man underwent a curative gastrectomy for a type 3 advanced gastric cancer. Liver dysfuntion was recognized 10 days after the operation. PTCD was carried out because of complete obstruction at the middle portion of the common bile duct. Under a diagnosis of biliary obstruction due to inflammation, second time operation was performed. A mass formation was recognized around the hepatoduodenal ligament. Adenocarcinoma cell invasion was found in the connective tissue in the induration at the biliary obstruction by intraoperative frozen section diagnosis. Only the biliary reconstruction was impossible. Expandable metallic stent was inserted using the route of PTCD after the operation. On the 30th day after the insertion, the PTCD tube was removed and complete biliary endoprosthesis was accomplished. From just before discharge, UFT-E 1.5g/day and PSK 3g/day were administered. Moreover CDDP 25 mg and MMC 2 mg were injected at the time of consultation. The injections were carried out 16 times until now. As of 1 year and 6 months after insertion of the stent, no evidence of exacerbation of gastric cancer has been recognized and the patient leads an ordinary life. During this period, no evidence of cholangitis and dilatation of intrahepatic bile duct on X-ray is recognized.

THE DIAGNOSTIC CAPACITY OF ABDOMINAL ULTRASONOGRAPHY AND PROBLEMS IN TREATMENT FOR ELEVATED LESIONS OF THE GALLBLADDER

Ninety-six cases with an elevated lesion of the gallbladder were analyzed to elucidate the diagnostic capacity of abdominal ultrasonography (US) and problems in the treatment for such elevated lesions of the gallbladder. Most of the nodular lesions on US were cancer, except adenomyomatosis. Moreover all eight cases with nodular type cancer more than 11mm in size invaded over the subserosal layer. These results indicate that the nodular lesions are necessary to be operated on as soon as possible once they are discovered and if a possibility of adenomyomatosis cannot be ruled out. In the papillary lesions less than 10mm in size, the frequency of cancer is 2%, versus 60% in the lesions more than 11mm in size. All papillary type cancers less than 20mm in size on US or macroscopic finding invaded the mucosal layer. These results suggest that the papillary lesions more than 11mm in size are necessary to be treated as cancer, but those less than 10mm in size can be followed until they grow to 10mm in size, even if the lesions are suspected of malignant potential. The lesions less than 10mm in size can remain in an early phase, if those are cancer.