Tokio Yamaguchi

Rupture of liver metastasis of malignant melanoma —A case of hepatic resection—

A case is reported in which resection of the left lateral segment of the liver was performed for rupture of a metastatic malignant melanoma in an attempt to control hemorrhaging. The primary lesion was located in the skin of the head, and there were multiple metastases to the lung, liver and distant nodes. The patient, a 47-year-old woman, had been undergoing systemic chemotherapy for the disseminated disease, but she presented with intraabdominal bleeding from a metastatic nodule in the left lateral segment of the liver. An emergency operation was performed, and the immediate postoperative course was uneventful. She was discharged 10 days after the operation. The patient died, however, of hemorrhagic shock due to renewed intraabdominal bleeding on the 39th postoperative day. It is concluded from the above case that hepatic resection for a bleeding metastasis of malignant melanoma is a viable option even in patients with disseminated disease.

Radical resection of primary malignant melanoma of the gallbladder with multiple metastases : report of a case

We present herein an usual case of primary malignant melanoma of the gallbladder in a 51-year-old man in whom an exploratory laparotomy for melena revealed six malignant melanoma lesions located in the gallbladder, main pancreatic duct, stomach, duodenum, jejunum, and a mesenteric lymph node. Total pancreatectomy was performed and histologically, junctional activity was seen only in the gall-bladder, suggesting that this was the primary site. No melanotic lesions were found on the skin or eyes. The metastases to the main pancreatic duct and gastrointestinal tract appeared likely to have occurred as a consequence of the mucosal dissemination of the tumor cells shed into the bile. The post-operative course was uneventful and combined chemotherapy was administered for 16 months. No new metastatic lesions were found until 21 months postoperatively, when metastases were detected in the brain and thoracic spinal cord. These metastatic tumors were removed surgically, but the patient died from cerebral disturbance 26 months after the initial operation. Thus, we consider that aggressive surgical therapy was effective for extending the survival time and improving the quality of life of this patient.

Primary malignant lymphoma of the spleen

We treated two patients with primary splenic malignant lymphoma. One was a 63-year-old man with diffuse histiocytic non-Hodgkins lymphoma accompanied by multiple liver metastases which were composed of necrotic tissue probably due to preoperative transarterial chemoembolization (TAE). He eventually died of liver failure two years and six months after splenectomy. The autopsy revealed that a large part of the cirrhotic liver had been occupied by a diffuse-type hepatocellular carcinoma, but no recurrence of the malignant lymphoma was found in the liver or other organs. The second patient was a 40-year-old woman with a massive invasion of the stomach, colon, pancreas, and diaphragm by a splenic tumor. The splenic tumor and the adjacent involved organs were resected. Pathologically, well-differentiated diffuse lymphocytic non-Hodgkins malignant lymphoma was evident. No recurrence has been found for six years and two months. Based on an evaluation of the 71 patients with primary splenic malignant lymphoma reported to data in Japan, the patients treated by a curative resection in an early clinical stage have a more favorable prognosis.

Histometric analysis of the distal pancreas in pancreatic head cancer

To clarify the histological status of the pancreas tail after pancreatoduodenectomy (PD), fibrosis, islets of Langerhans, and A, B, and D cells were examined histometrically in surgical cases of pancreatic cancer. The same investigations were also performed during an autopsy examination of the pancreas tail of survivors of surgery who had received either PD or total pancreatectomy with segmental autotransplantation (SAT). In the surgical cases, fibrosis and the islet percentage compared with nonpancreatic cancer cases were significantly higher while the B cell ratio was significantly lower. In addition, in pancreatic cancer patients, the fibrosis and islet ratio in the group with a blocked pancreatic duct were higher while the B cell ratio was lower than in the group with an open pancreatic duct. A direct relationship between the islet ratio and the degree of fibrosis, and an inverse relationship between the B cell ratio and the degree of fibrosis, were thus found. From the autopsy cases, the fibrosis progressed and the islet ratio increased following PD, but after SAT only the islet ratio increased compared to the time of surgery. The progression of fibrosis after PD thus suggests the presence of some problems in both the surgical method and postoperative management.

Recurrent valvular pneumoperitoneum caused by a minute gastric ulcer —A case report—

A rare case of valvular pneumoperitoneum is reported. A 49-year-old Japanese man underwent an emergency laparotomy under a tentative diagnosis of perforating panperitonitis on the 19th post-open heart surgery day. A large volume of free intraperitoneal gas was revealed, but no identification of gastrointestinal perforation. On the 17th postlaparotomy day, pneumoperitoneum recurred. On the 41st postalaparotomy day, a tiny gastric perforation was detected with an oral contrast medium. The patient died of liver failure due to serum hepatitis. The autopsy revealed a minute gastric ulcer scar 2 mm in diameter in the mucosa of the fornix, which was thought to have caused the valvular pneumoperitoneum. A literature review was made of 8 reports on 11 cases. In two cases of valvular pneumoperitoneum, the perforating site could not be found even during laparotomy. It is suggested that either gastrointestinal series or endoscopy must be carefully repeated in order to identify the perforating site.

Recurrence of cancer in the heterotopically auto-transplanted caudal pancreas

We performed segmental auto-transplantation of the caudal pancreas to the groin after total pancreatectomy and sufficiently preserved the endocrine functions of the pancreas in 20 patients with advanced pancreatic head cancer. Nineteen patients have died, and autopsies were permitted for 18 of these 19 patients. The autopsies were performed 49–922 (mean 404) days after surgery. Cancer cells were microscopically noted in the transplanted pancreas in 2 of 2 patients in whom cancer cells had been noted on the transected plane of the pancreas in the postoperative examination. Cancer cells were also noted in the transplanted pancreas in 10 of 16 patients whose transected plane had been free of cancer cells in the postoperative examination. In the surviving patient, the transplanted pancreas was removed 39 months after surgery, due to recurrence. Thus, the recurrence rate was 11/17 (64.7%). The site of recurrence was the proximal portion of the graft in 10 of these 11 patients. It is suggested that there were some precursor cells left in the transected portion of the transplanted pancreas which subsequently developed into cancer cells.

Papillary cystic neoplasm (PCN) of the pancreas with lymph node metastasis: Case report of a 77-year-ood woman and a review of 198 reported cases

A case of papillary cystic neoplasm (PCN) of the pancreas in a 77-year-old woman, the oldest patient in the English literature, is reported. Distal pancreatectomy with regional lymphadenectomy was performed for the tumor in the pancreatic tail. Postoperative pathology examination revealed a metastatic lesion in one of the regional lymph nodes. This patient is well doing without recurrence 5 years after surgery.

Radical Resection for Synchronous Primary Cancers of the Pancreas and Stomach

We present the reports of 2 patients who underwent radical operation for synchronous primary cancers of the pancreas and stomach. The 1 st case underwent a total pancreatectomy and a distal gastrectom