Tetsufumi Kojima

Alpha-fetoprotein-producing acinar cell carcinoma of the pancreas

A pancreatic carcinoma and liver metastases associated with marked elevation of the serum alpha-fetoprotein (AFP) level were resected from a 57-year-old man. On microscopic examination, the tumor cells showed a predominantly acinar arrangement, with tubular and trabecular structures; in some foci it had features of a medullary pattern. Alpha-fetoprotein, lipase, trypsin, chymotrypsin, and alpha 1-antitrypsin were strongly demonstrated in tumor tissue by immunohistochemical techniques. A biochemical analysis of AFP on affinity sepharose columns revealed that the AFP derived from the tumor tissues was similar to that of hepatocellular carcinoma. Ultrastructural study showed that most of the tumor cells had abundant rough endoplastic reticulum and numerous zymogen granules. No squamoid corpuscles, neuroendocrine granules, bile production, or bile canaliculi were recognized. These findings suggest that this unique tumor originated from acinar cells.

Successful laparoscopic right gastroepiploic aneurysmectomy: report of a case.

A 75-year-old woman presented with a pulsatile, movable mass, about 5 cm in diameter, in her lower abdomen. Abdominal ultrasonography revealed a circular mass with a variable hypo- and isoechoic border and a hypoechoic center. Color Doppler echography showed blood flow in the hypoechoic center, which was strongly enhanced on contrast-enhanced computed tomography. Based on these findings, we diagnosed a splanchnic artery aneurysm; however, celiac arteriography, performed twice, could not definitively identify it. An operation was performed under the tentative diagnosis of an aneurysm of the superior mesenteric artery or the gastroepiploic artery. On laparoscopic exploration, a globe-shaped mass, about 5 cm in diameter, was found in the right side of the greater omentum, which was diagnosed as an aneurysm of the right gastroepiploic artery. We resected the aneurysm laparoscopically and the patient had an uneventful postoperative course. Thus, laparoscopic surgery was effective for this patient who required no vascular reconstruction.

Cystic endocrine tumor of the pancreas

SummaryA large cystic tumor in the pancreatic body was found incidentally in an 85-yr-old male. A distal pancreatectomy was performed after a diagnosis of cystadenocarcinoma. Microscopic examination of the resected specimen revealed a pancreatic cystic endocrine tumor; however, this tumor produced no symptoms. Immunohistochemical studies of the tumor cells showed positivity for gastrin, neuron-specific enolase, chromogranin A, and synaptophysin, and two cell types of neurosecretory granules were recognized in electron-microscopic studies. Although endocrine tumors of the pancreas are usually solid and cystic change occurs only rarely, such tumors should be considered in the differential diagnosis of patients who have a cystic lesion in the pancreas.

Inflammatory malignant fibrous histiocytoma of the gallbladder: Report of a case

Abstract We describe herein a case of inflammatory malignant fibrous histiocytoma (IMFH) of the gallbladder that subsequently metastasized to the ascending colon and later to the stomach. A 70-year-old Japanese man with a palpable mass in the right upper quadrant of the abdomen was referred to our hospital for investigation and treatment. Laboratory data showed severe leukocytosis and elevated serum granulocyte colony-stimulating factor (G-CSF) concentrations. A laparotomy was performed, and the tumor was excised en bloc with the gallbladder and part of the liver bed. Histopathologically, the tumor was composed of ordinary malignant fibrous histiocytoma (MFH) components characterized by pleomorphic tumor cells, bizarre giant cells, and conventional spindle cells in a storiform growth pattern, as well as a xanthogranulomatous component, including inflammatory cells, foamy histiocytes, and plasma cells. Immunohistochemical study revealed that the pleomorphic tumor cells and bizarre giant cells were positive for antibodies against α1-antitrypsin and α1-antichymotrypsin. The final pathologic diagnosis was IMFH. The tumor cells were diffusely positive for anti-G-CSF monoclonal antibody, and the inflammatory reaction subsided immediately after tumor resection, strongly suggesting that the primary tumor cells produced G-CSF. This patient is still alive with no signs of recurrence more than 3 years after his primary operation, which to our knowledge is the longest survival period ever reported. Therefore, visceral IMFH is manageable in some cases by resecting the primary and isolated metastatic lesions.

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.

Chronic calcifying pancreatitis associated with primary hyperparathyroidism —Report of a case and review of the literature—

A 34 year old male was hospitalized because of severe abdominal pain and diarrhea. An abdominal X-ray revealed multiple calculi in the head of pancreas and blood tests showed his serum calcium level to be high. He underwent surgery of the parathyroid gland and a parathyroid tumor was removed. Two months later, resection of the head of the pancreas was also performed. Eighteen months after his operation there has been no recurrence of abdominal pain or diarrhea and his serum calcium level is within the normal range. We report this case herein and also discuss the possible cause and effect relationship between primary hyperparathyroidism and pancreatitis, and the appropriate management, in relation to a review of the literature.

A Case Report of Zollinger Ellison Syndrome and Review of the Literature

There is much controversy concerning the mode of therapy for patients in whom Zollinger-Ellison syndrome is strongly suspected but a tumor can not be located. We recently experienced a patient with Zollinger-Ellison syndrome presenting with melena in whom an attempt to stop the bleeding by H-2 antagonists failed and an emergency operation had to be carried out. At laparotomy, no tumor was found in the pancreas, duodenum or stomach wall and there was no specific swelling in any of the lymph nodes. A total gastrectomy was thus done with lymphadenectomy and a histopathological examination revealed two gastrinomas in the lymph nodes of the gastrinoma triangle. Postoperative secretin tests with 2 u/kg of secretin have been negative even 6.5 years later, and the patient is now well and working as a full time teacher. In this case, an emergency total gastrectomy was performed for uncontrolled bleeding, but we want to stress the importance of lymphadenectomy based on the findings of the frozen section and changes in gastrin levels.

Laparoscopy-Guided Transthoracic Transdiaphragmatic Radiofrequency Ablation for Hepatic Tumors Located Beneath the Diaphragm

BACKGROUND It is often difficult to perform percutaneous radiofrequency ablation (RFA) for hepatic tumors beneath the diaphragm. Diaphragmatic thermal damage is one of the fatal late complications of percutaneous transdiaphragmatic RFA. Our experience with laparoscopic transthoracic transdiaphragmatic intraoperative RFA (LTTI-RFA) for hepatic tumors beneath the diaphragm is reported. METHODS Ten patients who underwent LTTI-RFA from 2009 to 2012 were evaluated. Two cases had concomitant partial hepatectomy, and one underwent RFA for two tumors at the same time. The diagnosis was hepatocellular carcinoma in eight cases and metastatic hepatic tumors in two cases. Nine of eleven tumors were located at segments 7 and 8. Nine tumors were less than 20 mm in diameter. The patients were placed in the half left lateral decubitus position with single-lumen tube intubation. After placement of four abdominal ports, a 12-mm port was inserted in the fourth or fifth intercostal space into the diaphragm. The tumor was ablated by an RFA needle through the port. The routine follow-up consisted of laboratory tests and abdominal imaging every 3-6 months. RESULTS The median operation time for only one tumor was 137 minutes (range, 105-187 minutes). The median number of times for ablation was three. Severe postoperative complications (>Clavien-Dindo IIIa) were observed in one case (right upper limb paralysis). The median follow-up period was 35 months (range, 11-43 months). There was no local tumor progression. Recurrent hepatic tumor appearance occurred in other parts of the liver in 6 of the 11 patients. CONCLUSIONS Laparoscopic transthoracic transdiaphragmatic RFA is an acceptable procedure with a low rate of local recurrence.

A Case of Perforation of Diverticulum of the Third Duodenal Part due to Ileus Tube

3回の開腹歴がある79歳の女性が, イレウスの診断で当院内科に入院となった. 同日イレウス管の挿入が行われたが, 十二指腸水平脚近位にとどまり, より遠位に進めることが困難であった. 翌々日, 症状の改善なく, イレウス管造影検査で腸管外への造影剤の漏出と, 腹部CTで十二指腸周囲のfree airを認めたため, イレウス管による十二指腸穿孔の診断で緊急開腹術を施行した. 手術所見では十二指腸水平脚に憩室が存在し, 同部よりイレウス管の脱出を認めた.憩室切除, ドレナージ術, 結腸右半切除術を施行した. 十二指腸憩室が穿孔を来すことはまれであり, 穿孔例の多くは下行脚の憩室である. 医原性穿孔は3例のみ報告されているが, イレウス管による穿孔例は, 本邦では他に報告は見当たらない. イレウス管挿入時に十二指腸にて先進しない場合は, 憩室の存在も念頭におき, 慎重な操作を心がける必要があると考えられた.