Toshimichi Nakayama

The prognostic significance of lymph node metastasis and intrapancreatic perineural invasion in pancreatic cancer after curative resection

To investigate the prognostic factors of pancreatic cancer, a retrospective analysis of 193 patients who underwent curative resection was conducted. Of the 193 patients, 38 (20%) survived for more than 5 years, the 5-year survival rates for stages I, II, III, and IV disease being 41%, 17% 11%, and 6%, respectively. According to a multivariate analysis, lymph node metastasis, intrapancreatic perineural invasion, and portal vein invasion were significant prognostic factors. Subsequently, a subgroup analysis concerning nodal metastasis and intrapancreatic perineural invasion was performed in 126 patients with records of these histological findings. In the group of patients without nodal metastasis, the 5-year survival rate for those without perineural invasion was 75%, whereas that for those with perineural invasion was 29%, the difference in survival of these subgroups being significant (P<0.02). In the group of patients with nodal metastasis, the 5-year survival rate for those without perineural invasion was 17%, while that for those with perineural invasion was 10%. The most favorable 5-year survival of 89% was observed in the subgroup of patients with stage I disease without perineural invasion. Thus, pancreatic adenocarcinoma categorized by the combination of these independent types of biological behavior showed 5-year survival rates ranging from very high to low, indicating that these two factors play an important role in the prognosis of this disease.

Angiographic demonstration of intrahepatic arterio-portal anastomoses in hepatocellular carcinoma.

Hepatic angiograms of 114 patients with hepatocellular carcinoma (HCC) were studied, particularly changes in the portal vein branches. Arterio-portal shunts of varying sizes, evidenced by opacification of intrahepatic portal branches, were seen in 72 cases (63.2%), with retrograde opacification of the portal vein trunk in 29 (25.4%). At least four types of shunts were found: (a) through a tumor thrombus in the portal branch, (b) in a retrograde direction via a peripheral tumor nodule, (c) through a small tumor invading or amputating an artery, and (d) through a tumor located near a major portal vein branch and supplied by a large, coiling artery. Postmortem angiography of the liver in 50 patients with HCC suggests that arterio-portal shunts are the result of the special vasculature in HCC and are highly diagnostic when accompanied by other angiographic changes.

Comparison of 5-fluorouracil, doxorubicin and mitomycin C with 5-fluorouracil alone in the treatment of pancreatic-biliary carcinomas

In this multicenter randomized trial, the efficacy of combination chemotherapy using 5-fluorouracil, doxorubicin and mitomycin C (arm A) was compared with that of 5-fluorouracil alone (arm B) in 81 patients with nonresectable carcinomas of the pancreas or biliary tract. There were no significant differences between treatment arms regarding the median time to progressive disease, median survival time, palliative effects or toxicities. It was concluded that combination chemotherapy is feasible but cannot be recommended.

Small mass lesions in cirrhosis: Transition from benign adenomatous hyperplasia to hepatocellular carcinoma?

Abstract Ten patients with cirrhosis, in whom small mass lesions were detected by imaging techniques and histological diagnosis of the resected specimens was difficult, are described. There were 17 grossly discrete lesions measuring 10 × 8 mm to 27 × 22 mm. Four were compatible with so‐called adenomatous hyperplasia showing no histological features of malignancy, and eight were equivocal as to whether they were benign or malignant. The other five lesions (in four patients) were hepatocellular carcinoma, co‐existing with apparently benign lesions. The eight equivocal lesions were eventually judged to be highly differentiated hepatocellular carcinomas. These benign‐appearing lesions, found by advanced imaging in patients with cirrhosis, create a serious problem in regions where primary liver cancer is endemic among cirrhotics, and hepatic resection is the preferred treatment.

Clinicopathologic comparison between resected hepatocellular carcinomas (HCC) and recurrent tumors A special reference to multicentric carcinogenesis of HCC

Abstract Postoperative metachronous multicentric carcinogenesis of hepatocellular carcinoma (HCC) was studied by comparison of the histologic grade of resected and recurrent tumors in 31 cases which underwent ultrasound-guided fine-needle biopsies for the initial recurrent tumors with diameter of less than 20 mm. The criteria that the cases in which recurrent tumors show well-differentiated HCC without regard to the differentiation of resected tumors should be multicentric carcinogenesis, and that the cases in which recurrent tumors show moderate or poorly differentiated HCC with the same or lower degree of differentiation compared with the differentiation of resected tumor was consistent with metastasis, were applied. In 16 (51.6%) out of the 31 cases, multicentric carcinogenesis was thought to occur (multicentric group). In 14 cases, recurrence was thought to be metastasis (metastatic group). The multicentric group tended to have smaller diameters in resected tumors and a high incidence of the association of liver cirrhosis and adenomatous hyperplasia. In gross classification of resected tumors, six cases of all single nodular with perinodular tumor growth type and infiltrative type had metastatic recurrences, and multicentric carcinogenesis was often seen in cases of single nodular type, multinodular type and confluent multinodular type. In the multicentric group, recurrence occurred at every postoperative period as long as 65 months including four cases of early recurrence within 6 months and six cases of late recurrence later than 24 months. On the contrary, in 12 cases in the metastatic group the recurrent interval ranged from 6 to 19 months.

ILEO-ABDOMINAL WALL FISTULA CAUSED BY DIVERTICULUM OF THE ILEUM

Abstract: We report a very rare case of ileo-abdominal fistula caused by penetration of the ileal diverticulum. Small bowel diverticulosis is generally considered to be an innocuous condition. In this report, we describe a case of ileal diverticulitis associated with an abdominal wall abscess.

A new technique of hepatectomy using an occlusion balloon catheter for the hepatic vein

To minimize intraoperative bleeding and allow more accurate resection, we have devised a new technique for hepatectomy. In addition to occlusion of the afferent vessels, we occlude the hepatic vein at the hepatocaval junction using a balloon catheter inserted transhepatically under intraoperative ultrasonic guidance. We have performed eight hepatectomies using this method. A sequence of 15 minutes of vascular occlusion followed by 5 minutes reperfusion was repeated throughout the operation, and the total ischemic time ranged from 45 to 90 minutes. This method greatly decreased intraoperative bleeding without causing significant elevation of the postoperative transaminase or lactic dehydrogenase levels when compared with occlusion of only the afferent vessels or nonischemic resection using a microwave tissue coagulator in patients undergoing equivalent resections. Also, the postoperative prothrombin time recovered to a significantly higher level, and there were no fatal postoperative complications using this method. Our method is useful for systematic hepatic resection along the hepatic vein or for resection of tumor sited at the confluence of the hepatic vein.

SMALL MULTIPLE CARCINOID TUMORS OCCURRING IN THE ILEUM WITH A PSEUDOCYSTIC LIVER METASTASIS

A 49‐year‐old woman was admitted to the hospital with a palpable mass in the right hypochondrium. A laparotomy was performed under the clinical diagnosis of a solitary cyst of the liver. The cystic lesion of the liver was removed. Although the histological finding of the cyst wall showed a similarity to hepatocellular carcinoma of trabecular pattern, the tumor cells with uniform nuclei and little mitotic figure were positive for both argyrophil and argentaffin reaction. The pathological diagnosis was metastatic carcinoid tumor of the liver. There was no carcinoid syndrome nor the other clinical symptoms after the operation and various postoperative examinations could not reveal a primary site of the carcinoid tumor. The cystic lesion of the liver recurred ten months after the first operation and a second laparotomy was performed to reveal the primary site in the ileum: three submucosal tumors, 0.8, 0.7, and 0.3 cm. in diameter, two of them, however, extended into the muscle wall or subserosa and conclusively, the small lesion of the ileum metastasized into the liver as a large pseudocystic lesion.

Hilar bile duct resection for bile duct carcinoma at the hilus of the liver

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuths type I or II.

Surgical Results of Pancreatoduodenectomy for Disease in the Pancreatic Head Region

Between January 1965 and September 1995, 330 patients underwent pancreatoduodenectomy in our institution. In 249 cases, we performed the Child method of reconstruction after pancreatoduodenectomy. Of these patients, 299 underwent pancreatoduodenectomy because of malignant disease and 19 died in the hospital after the operation; the mortality rate was 5.8%. We must be aware of certain complications after pancreatoduodenectomy, especially anastomotic leakage of the pancreatiocojejunostomy. It 16 cases of pancreatic fistula, 7 patients died of this complication. Five-year survival rates of patients with carcinoma of the pancreas, bile duct, and papilla of Vater were 17.3%, 19.7%, and 56.2%, respectively. In cases of carcinoma of the papilla of Vater with no lymph node involvement, the 5-year survival rate was 64.9%; for cases with lymph node involvement, it was 40.0%. Many more strategies must be developed to obtain a better outcome in cases of carcinoma of the pancreas and bile duct. The most important need is to prevent metastasis of carcinoma to the liver in these patients.