Para-Aortic Lymph Node Micrometastasis in Patients with Node-Negative Biliary Cancer

Background/Aims: The presence of para-aortic lymph node metastasis in biliary cancer negatively impacts prognosis. The present study aims to immunohistochemically identify and evaluate the clinical significance of para-aortic lymph node micrometastases in 66 patients who had undergone curative resection of biliary cancer. Methods: We used an antibody against cytokeratins 7 and 8 (CAM5.2) to immunostain 529 para-aortic lymph nodes that were negative according to conventional analysis from 66 patients with biliary cancer. Results: We detected CAM5.2-positive occult carcinoma cells in para-aortic lymph nodes from 3 (5%) of the 66 patients and in 3 (0.6%) of the 529 para-aortic lymph nodes. One of the three patients also had micrometastasis in the regional lymph nodes. All three patients with para-aortic lymph node micrometastasis are alive at 45, 48 and 90 months after surgery despite having locally advanced cancer. Conclusions: Occult cancer cells were identified in para-aortic lymph nodes from 5% of patients with node-negative biliary cancer, yet these patients have survived over the long term. The presence of para-aortic nodal micrometastasis might not have influence on survival. However, further studies including a greater number of patients are required to support this notion

Spindle cell carcinoma of the common bile duct

Spindle cell-type undifferentiated carcinoma arising from the extrahepatic bile duct is extremely rare. We report herein a case of this type of carcinoma in the common bile duct of the hepatic hilus. A 59-year-old man was admitted to our hospital complaining of jaundice. Laboratory data revealed elevation of serum CA 19-9. Cholangiography revealed complete obliteration of the left hepatic bile duct and stenosis of the bile duct from the superior to the right hepatic bile duct. Computed tomography showed the tumor, measuring 15×12 mm, in the hepatic hilus, obliteration of the right to main trunk of the portal vein and a lymph node in the hepato-duodenum ligament swelling. Arteriography revealed a kink of the right hepatic artery, so encasement of the right hepatic artery was suspected. We preoperatively diagnosed hilus bile duct carcinoma and scheduled right trisection hepatectomy. Intraoperative frozen sections taken from the tumor and tissues around hepatic arteries showed spindle cells and inflammatory cells, so inflammatory pseudotumor was diagnosed intraoperatively. Because the right hepatic bile duct was occluded, right lobe hepatectomy was performed. However, permanent section revealed both spindle cells and poorly differentiated tubular adenocarcinoma cells positive for CAM5.2, AE1/AE3 and vimentin. Based on these findings, the tumor was finally diagnosed as spindle cell-type undifferentiated carcinoma. The patient died of pulmonary infarction 11 days after the operation

Pancreatic metastasis from renal cell carcinoma with intraportal tumor thrombus.

A 68-year-old woman with a history of renal cell carcinoma (RCC) resected curatively 12 years previously was admitted to our department for scrutiny of pancreatic tumors. Various imaging studies demonstrated heterogeneously well-enhanced masses in the head and tail of the pancreas. The well-enhanced mass in the head of the pancreas was connected with the tumor thrombus in the portal vein. To differentially diagnose the multiple pancreatic lesions, we performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB). Histopathologic findings of the EUS-FNAB specimens were similar to those of the renal clear cell carcinoma previously resected. The patient underwent a surgical operation with segmental resection of the portal vein with the preoperative diagnosis of RCC metastasis to the pancreas with intraportal growth. Histopathological examination of the resected specimen revealed that the masses in the pancreas were multiple pancreatic metastases with intraportal tumor thrombus of RCC. The pancreas is a rare target for metastasis. This is a rare case of pancreatic metastasis from RCC with intraportal extension, and is the first preoperatively definitely diagnosed case using EUS-FNAB

Impact of residual in situ carcinoma on postoperative survival in 125 patients with extrahepatic bile duct carcinoma

Purpose: The aim of this study was to determine the impact of the presence of carcinoma in situ at the bile duct stump on postoperative survival in patients who underwent resection of extrahepatic bile duct carcinoma. Methods: The patients with resected extrahepatic bile duct carcinoma were divided into three groups according to resected margin status: no evidence of residual carcinoma (Negative group, n=96); carcinoma in situ at the bile duct stump (CIS group, n=10); and invasive carcinoma at any surgical margin (Invasive group, n=19). Cause-specific survival for these groups was compared statistically. Results: Surgical margin status was identified as a prognostic factor on univariate analysis (p=0.005) and was an independent prognostic factor on multivariate analysis (p=0.018). The CIS group displayed significantly better survival than the Invasive group (p=0.006), and the survival was comparable to that for the Negative group (p=0.533). Two of three patients in the CIS group with local recurrence died >5 years after surgical resection. Conclusions: Patients with positive ductal margins of carcinoma in situ of the extrahepatic bile duct do not appear to show different survival after resection compared to patients with negative margins, but remnant carcinoma in situ is likely to develop late local recurrence

Autoimmune pancreatitis associated with hemorrhagic pseudocysts: a case report and literature review.

Autoimmune pancreatitis (AIP) is a new category of pancreatic diseases. AIP associated with pseudocysts is rare; only 8 cases have been reported in the literature. A 63-year-old man was admitted to our department because of upper left abdominal pain and back pain. Various imaging studies demonstrated swelling of the tail of the pancreas with hemorrhagic pseudocysts. The patient underwent a surgical operation. A pancreatogram of the specimen revealed total occlusion of the main pancreatic duct in the tail of the pancreas. Histopathological examination revealed that it was AIP with hemorrhagic pseudocysts

Gastrointestinal Obstruction due to Solitary Lymph Node Recurrence of Alpha-Fetoprotein-Producing Gastric Carcinoma with Enteroblastic Differentiation

We report an unusual case of alpha-fetoprotein (AFP)-producing gastric carcinoma with enteroblastic differentiation. A 75-year-old woman was admitted to our hospital with occasional upper abdominal discomfort. We performed gastroscopy and observed a type 2 tumor, primarily in the pyloric region. Histological examination of biopsies confirmed gastric adenocarcinoma. Based on these findings, we diagnosed gastric adenocarcinoma and performed laparoscopic distal gastrectomy with lymph node dissection. Histological examination revealed an invasive lesion composed of adenocarcinoma with a tubulopapillary growth pattern. Tumor cells were cuboidal in shape with characteristically clear cytoplasm rich in glycogen. Two regional lymph node metastases were seen microscopically. Immunohistochemically these cells were positive for AFP, carcinoembryonic antigen, caudal-type homeobox transcription factor 2 and common acute lymphoblastic leukemia antigen. The final diagnosis was AFP-producing gastric carcinoma with enteroblastic differentiation. 26 months after initial surgery, the patient was readmitted to our hospital for gastrointestinal obstruction due to lymph node recurrence