Yoshihiro Kondo

Carcinoma of duodenum arising from Brunner's gland

Primary carcinoma of the duodenum is a rare lesion. In conjunction with the widespread use of panendoscopy, reported cases of carcinoma of the duodenum have recently increased. Although benign hyperplasia of Brunners gland is well documented, duodenal carcinoma originating in Brunners gland is extremely rare, and, consequently, there is little data on the morphological or histochemical characteristics. We report here a case of early duodenal carcinoma arising from Brunners gland, whose origin was proven by mucin immunohistochemistry.

Hepatic infarction with portal thrombosis

A case of hepatic infarction with portal thrombosis is reported. A 63-year-old woman with liver cirrhosis and esophageal varices was admitted for treatment of the esophagel varices. Endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) were performed. Two months later, she experienced right hypochondralgia and right flank pain. Serum transaminase levels were suddenly elevated, and computed tomography scans of the liver showed multiple small nodular lesions. Her condition worsened, and she died of hepatic failure. Autopsy revealed splenic and portal vein thrombosis, multiple hepatic infarction, and evidence of chronic pancreatitis. We believe that liver cirrhosis and chronic pancreatitis were the main risk factors for the portal thrombosis, and the treatment for esophageal varices appeared to have triggered the thrombosis. The hepatic infarction was caused by the portal thrombosis.

Rare type of pancreatitis as the first presentation of anti-neutrophil cytoplasmic antibody-related vasculitis

A pancreatic tumor was suspected on the abdominal ultrasound of a 72-year-old man. Abdominal computed tomography showed pancreatic enlargement as well as a diffuse, poorly enhanced area in the pancreas; endoscopic ultrasound-guided fine needle aspiration biopsy and endoscopic retrograde cholangiopancreatography failed to provide a definitive diagnosis. Based on the trend of improvement of the pancreatic enlargement, the treatment plan involved follow-up examinations. Later, he was hospitalized with an alveolar hemorrhage and rapidly progressive glomerulonephritis; he tested positive for myeloperoxidase-anti-neutrophil cytoplasmic antibody (ANCA) and was diagnosed with ANCA-related vasculitis, specifically microscopic polyangiitis. It appears that factors such as thrombus formation caused by the vasculitis in the early stages of ANCA-related vasculitis cause abnormal distribution of the pancreatic blood flow, resulting in non-uniform pancreatitis. Pancreatic lesions in ANCA-related vasculitis are very rare. Only a few cases have been reported previously. Therefore, we report our case and a review of the literature.

Measurement of circulating biliary glycoprotein (CD66a) in liver diseases.

Purpose. Biliary glycoprotein (BGP), a member of the carcinoembryonic antigen (CEA) gene family, is produced by hepatocytes, and is suggested to function as a cell adhesion molecule, mouse hepatitis virus receptor, and tumor suppressor. Our aim was to establish an enzyme immunoassay for circulating BGP and to study its significance in liver diseases. Methods. For enzyme immunoassay, a monoclonal antibody (mAb), TS135, which recognizes BGP was used as a catcher, and biotin-labeled polyclonal anti-CEA antibodies were used as a tracer. Seventy-six serum specimens obtained from patients with various liver diseases were submitted to the assay. Results. The incidence of positivity for antigen TS135 in the serum samples of the 76 patients was 57.9%. The most significant correlation among conventional liver function tests was found between antigen TS135 and γ-glutamyl transpeptidase (γ-GTP). However, among the 56 patients whose serum antigen TS135 and γ-GTP levels could be measured simultaneously, 5 were antigen TS135-positive and γ-GTP-negative (8.9%) and 6 were antigen TS135-negative and γ-GTP-positive (10.7%). The increased serum level of antigen TS135 in 6 cholangiocellular carcinoma (CCC) patients led us to the immunohistochemical study of CCC, in which 8 of the 8 tissue specimens tested were positive for mAb TS135, indicating the production of the antigen from CCCs. Conclusions. This preliminary study suggests that the circulating antigen TS135 level correlates with γ-GTP in liver diseases, but that TS135 may also have a unique significance, different from that of γ-GTP, as a liver function test.

Loss of HER2 Positivity after Trastuzumab in HER2-Positive Gastric Cancer: Is Change in HER2 Status Significantly Frequent?

Trastuzumab has recently been introduced as a treatment for HER2-positive metastatic and/or unresectable gastric cancer (MUGC); however, compared with breast cancer, some issues concerning HER2 and trastuzumab therapy for gastric cancer remain unclear. A 74-year-old woman received trastuzumab-containing chemotherapy for HER2-positive MUGC. She had a marked response to 8 months of chemotherapy, and gastrectomy and hepatic metastasectomy with curative intent were performed. The resected specimen showed complete loss of HER2 positivity in the residual tumor. For MUGC, a change in HER2 status during the course of the disease with or without chemotherapy has rarely been reported. However, in breast cancer, a significant frequency of change in HER2 status during the course of disease has been reported, and reevaluation of HER2 positivity in metastatic/recurrent sites is recommended. The choice of trastuzumab for MUGC is currently based on the HER2 status of the primary tumor at the time of initial diagnosis, without reassessment of HER2 status during the course of disease and/or in metastatic/recurrent sites, on the assumption that HER2 status is stable. However, our case casts doubt on the stability of HER2 in gastric cancer.

A Case of Xanthogranulomatous Cholecystitis with High CA19-9 Levels thatNormalized Post-Cholecystectomy

The patient was an 81-year-old male. His blood tests revealed a mild hepatic dysfunction and an abnormally high Carbohydrate antigen 19-9 (2,830 U/ml). Ultrasonography, contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography were carried out, and showed that the gallbladder was filled with microcalculi, that the gallbladder was enlarged, and that the gallbladder wall had thickened; however, no calculi were found in the common bile duct, and positron emission tomography was performed for the detection of malignancies but the findings were poor; therefore, the condition was diagnosed as calculous cholecystitis, and cholecystectomy was performed. The pathological findings indicated a xanthogranulomatous cholecystitis, and the levels of Carbohydrate antigen 19-9 returned to normal immediately after surgery. The immunostaining of Carbohydrate antigen 19-9 showed that epithelial mucosa of the gallbladder, cytoplasm of multinucleated foreign-body giant cells, and infiltrating macrophages were positive, and suggested that the abnormally high levels of Carbohydrate antigen 19-9 may have been due to xanthogranulomatous cholecystitis. In some cases, Carbohydrate antigen 19-9 levels can be high in benign diseases such as cholangitis and pancreatitis, but markedly high levels are rare. Only two cases of xanthogranulomatous cholecystitis have been reported to have shown abnormally high Carbohydrate antigen 19-9 that returned to normal after cholecystectomy. We report our experience along with a discussion based on the literature.

EDUCATION AND IMAGING. Gastrointestinal: Needle tract implantation after endoscopic ultrasound-guided fine-needle aspiration of a pancreatic adenocarcinoma.

Figure 2 (a) HE-stained (×150) pathological tissue resected by distal gastrectomy showed moderately differentiated tubular adenocarcinoma mainly in the gastric mucosa over the muscular layer. This was similar to findings in pancreatic cancer tissue resected in the previous surgery, suggesting dissemination of pancreatic cancer to the stomach through EUS-FNA. (b) HE-stained (×150) pathological tissue resected by distal pancreatectomy. Atypical cubical epithelium formed large and small gland ducts.Moderately differentiated tubular adenocarcinoma was mainly noted and was diagnosed as infiltrating pancreatic duct cancer. Figure 1 (a, b) Upper gastrointestinal endoscopy revealed an about 25-mm submucosal tumor-like protrusion with erosion of the apex in the lower posterior wall of the stomach body.

Needle tract implantation after endoscopic ultrasound‐guided fine‐needle aspiration of a pancreatic adenocarcinoma

Figure 2 (a) HE-stained (×150) pathological tissue resected by distal gastrectomy showed moderately differentiated tubular adenocarcinoma mainly in the gastric mucosa over the muscular layer. This was similar to findings in pancreatic cancer tissue resected in the previous surgery, suggesting dissemination of pancreatic cancer to the stomach through EUS-FNA. (b) HE-stained (×150) pathological tissue resected by distal pancreatectomy. Atypical cubical epithelium formed large and small gland ducts.Moderately differentiated tubular adenocarcinoma was mainly noted and was diagnosed as infiltrating pancreatic duct cancer. Figure 1 (a, b) Upper gastrointestinal endoscopy revealed an about 25-mm submucosal tumor-like protrusion with erosion of the apex in the lower posterior wall of the stomach body.