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OBJECTIVE The aim of the study was to develop a formula for predicting the probability of malignancy of mucinous cystic neoplasm (MCN) of the pancreas with ovarian-type stroma. METHODS A total of 364 patients were enrolled. A total score was calculated as the sum of the approximate integers of the odds ratios of the predictive factors identified by multivariate analysis. The relationship between the total score and pathological results was assessed. RESULTS A total of 321 patients had benign MCN and 43 had malignant MCN. Five possible predictive factors were analyzed: 56 years or older, high serum carcinoembryonic antigen level, high carbohydrate antigen 19-9 level, tumor size of 51 mm or greater, and the presence of mural nodules. The total score was significantly higher in patients with malignant MCN (median, 24; range, 0-37) compared with benign MCN (median, 5; range, 0-33; P < 0.001). Receiver operating characteristic curve analysis demonstrated that the area under the curve was 0.86, and the sensitivity and specificity of the total score for discriminating malignant MCNs were 72% and 83%, respectively, using a cut-off value of 22. CONCLUSIONS The current simple formula can predict the malignancy of MCN and may thus contribute to the adequate management of patients with MCN.

Objective We previously published a nomogram for prediction of carcinoma in patients with intraductal papillary mucinous neoplasm (IPMN). The objective of the current study was to validate this nomogram in an external cohort of patients at multiple institutions. Methods The clinical details of 180 patients with IPMN who underwent a pancreatic resection at 3 hospitals were collected. Four significant predictive factors (sex, lesion type, nodule height, and pancreatic juice cytology) were analyzed. Results Of the 180 patients, 66 (36.7%) had a main pancreatic duct-type IPMN and 114 (63.3%) had a branch pancreatic duct-type IPMN. The final pathological diagnosis was benign IPMN in 95 (52.8%) patients and malignant IPMN in 85 (47.2%) patients. The area under the receiver operating characteristic curve for the model was 0.760. The area under the receiver operating characteristic curve of the IPMN nomogram for prediction of malignancy was 0.747 in main pancreatic duct-type IPMN and 0.752 in branch pancreatic duct-type IPMN. The sensitivity and specificity of the model were 80.0% and 57.9%, respectively, when the predictive probability of more than 10% was used to indicate the presence of carcinoma. Conclusions This nomogram for predicting the probability of carcinoma in patients with IPMN was accurate in an external validation patient cohort.

Objectives This study investigated whether a risk assessment nomogram can predict the malignant potential of intraductal papillary mucinous neoplasms (IPMNs) and provide valuable information for the follow-up and counseling strategies of such patients. Methods We studied 126 of 589 patients with IPMN who were followed up for at least 36 months with annual endoscopic ultrasonography. We analyzed scores derived from our nomogram, incorporating the parameters of sex, lesion type, mural nodule height, and pancreatic juice cytology determined at the initial IPMN evaluation. Results The rate of malignant IPMNs was 5.5% (7/126). The initial average nomogram score was 19.8 (range, 0-55), and the final follow-up average was 23.8 (range, 0-109). When a cutoff score was set at 35 points, the sensitivity, specificity, and accuracy of the nomogram to assess malignancy risk were 87.5%, 96.6%, and 96%, respectively. The area under the receiver operating characteristic curve of malignant IPMN prediction during follow-up was 0.865. Conclusions The ability of the nomogram to predict malignancy in patients with IPMN was validated. Our findings can suggest that a follow-up for patients at high and low risk for cancer progression could be scheduled every 3 to 6 and 12 months, respectively.

Adenosquamous carcinoma of the pancreas (ASC) is a variant of pancreatic ductal adenocarcinoma (PDAC), but the prognosis remains unclear. The purpose of this study was to clarify the prognosis of ASC using a matched case-control design.We evaluated clinical characteristics of ASC treated between 2001 and 2011 in our institution. As controls, PDAC cases matched with ASC cases for sex, age, pretreatment Eastern Cooperative Oncology Group performance status, location, initial therapy and American Joint Committee on Cancer TNM staging for pancreatic cancer were also evaluated.Of the 914 cases of pancreatic neoplasm, 28 cases (3.06%) of ASC were identified, and 56 cases of PDAC were matched as controls. Median overall survival (OS) was significantly worse for ASC (8.38 months) than for PDAC (15.75 months; hazard ratio [HR], 1.94; 95% confidence interval, 1.07-3.51; P = 0.026). Of the 22 unresected cases, median OS was again significantly worse for ASC (4.67 months) than for PDAC (12.36 months; HR, 2.39; 95% confidence interval, 1.27-4.51; P = 0.007).These results demonstrate that ASC is more aggressive than PDAC.

The present study was a retrospective investigation of predictors of malignancy in intraductal papillary mucinous neoplasm (IPMN) of the pancreas.The subjects were 310 patients who underwent pancreatic resection at 3 high-volume centers. Preoperative laboratory and imaging findings were analyzed in logistic regression analyses. Endoscopic ultrasonography measurements were essential for the size of mural nodules, and a central review was conducted for pathological diagnosis.Pathological diagnosis was benign IPMN in 150 cases and malignant in 160 (noninvasive carcinoma, n = 100; invasive, n = 60). In multivariate analysis, size of mural nodules, diameter of main pancreatic duct, and cyst size of branch pancreatic duct were independent predictors of malignancy, and areas under the receiver operating characteristic curve for these 3 factors were 0.798, 0.643, and 0.601, respectively. With 7 mm taken as the cutoff value for the size of mural nodules, the diagnosis of malignant IPMN had sensitivity of 74.3% and specificity of 72.7%. Carcinoma without nodules was present in 15 patients (15/160 [9.4%]).The size of mural nodules measured with endoscopic ultrasonography showed high predictive ability. However, about 10% of carcinoma patients did not have nodules, and the handling of the diagnosis in such cases is a problem for the future.

There have been only a few reports on follow-up results of serous cystic neoplasm (SCN) of the pancreas. The frequency of malignancy and surgical indication of SCN are not determined yet.In this multi-institutional study of the Japan Pancreas Society, a total of 172 patients with SCN were enrolled. The mean follow-up period was 4.5 years. Surgical resection was performed in 90 patients, whereas the remaining 82 were simply observed.Of all patients, 20% were symptomatic. The tumor was located in the pancreatic head (39%), body (35%), and tail (22%). The mean diameter of the tumor was 4.1 cm. None of the patients showed distant or lymph node metastasis except for liver metastasis found in 2 patients (1.2%). No patient died during the follow-up. The preoperative diagnosis did not correctly identify SCN in 57 (63%) of 90 resected cases. A honeycomb appearance, which is one of the most characteristic findings of SCN, could be diagnosed better by endoscopic ultrasonography than by other imaging diagnostic modalities.Surgical resection should be considered only when clear distinction from other surgical diseases is difficult, when symptoms or mass effects are present, and when the tumor size is large.

Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), a novel technology, visualizes parenchymal perfusion in the pancreas. This study prospectively evaluated how accurately CH-EUS characterizes pancreatic lesions and compared its diagnostic ability with that of contrast-enhanced multidetector-row computed tomography (MDCT) and endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA).A total of 277 consecutive patients with pancreatic solid lesions that were detected by conventional EUS underwent CH-EUS for evaluation of vascularity. After infusing an ultrasound contrast, CH-EUS was performed by using an echoendoscope and a specific mode for contrast harmonic imaging. On the basis of the intensity of enhancement, the lesions were categorized into four patterns: nonenhancement, hypoenhancement, isoenhancement, and hyperenhancement. For comparison, all patients underwent MDCT. The ability of CH-EUS to differentiate ductal carcinomas from the other solid tumors, particularly small lesions (≤2 cm in diameter) was assessed, and compared with the differentiating abilities of MDCT and EUS-FNA.In terms of reading the CH-EUS images, the κ-coefficient of the interobserver agreement test was 0.94 (P0.001). CH-EUS-depicted hypoenhancement diagnosed ductal carcinomas with a sensitivity and specificity of 95.1% (95% confidence interval (CI) 92.7-96.7%) and 89.0% (95% CI 83.0-93.1%), respectively. For diagnosing small carcinomas by CH-EUS, the sensitivity and specificity were 91.2 % (95% CI 82.5-95.1%) and 94.4% (95% CI 86.2-98.1%), respectively. CH-EUS-depicted hypervascular enhancement diagnosed neuroendocrine tumors with a sensitivity and specificity of 78.9% (95% CI 61.4-89.7%) and 98.7% (95% CI 96.7-98.8%), respectively. Although CH-EUS and MDCT did not differ significantly in diagnostic ability with regard to all lesions, CH-EUS was superior to MDCT in diagnosing small (≤2 cm) carcinomas (P0.05). In 12 neoplasms that MDCT failed to detect, 7 ductal carcinomas and 2 neuroendocrine tumors had hypoenhancement and hyperenhancement on CH-EUS, respectively. When CH-EUS was combined with EUS-FNA, the sensitivity of EUS-FNA increased from 92.2 to 100%.CH-EUS is useful for characterizing conventional EUS-detected solid pancreatic lesions. EUS equipped with contrast harmonic imaging may play an important role in the characterization of small tumors that other imaging methods fail to depict and may improve the diagnostic yield of EUS-FNA.

BACKGROUND AND AIMS Endoscopic mucosal resection (EMR) is the standard procedure for treatment of colorectal tumors. Endoscopic submucosal dissection (ESD) can be performed for resection of larger tumors, but has not been studied in the colorectum because of technical difficulties and complications. We compared outcomes and complications after resection of colorectal tumors larger than 20 mm diameter by ESD and EMR. MATERIALS AND METHODS We retrospectively studied 104 colorectal tumors treated with EMR from 1995 to 2004, and 85 colorectal tumors treated with ESD from 2005 to 2009. We compared the tumor location, shape, size, procedure time, en bloc resection rate, recurrence rate, and associated complications between the treatments. RESULTS Tumors treated with ESD were larger (31.6 ± 9.0 vs. 25.5 ± 6.8 mm, P

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has recently been reported as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction, when endoscopic biliary drainage (EBD) is unsuccessful. However, prospective studies of EUS-CDS have not yet been performed. We conducted a prospective study to evaluate the safety, feasibility, and efficacy of EUS-CDS in patients with malignant lower biliary tract obstruction.A prospective study to confirm the safety of EUS-CDS was carried out in 6 patients, followed by a trial to evaluate the feasibility and efficacy of EUS-CDS in 12 additional patients. We placed a plastic stent from the duodenal bulb into the extrahepatic bile duct under EUS guidance using an oblique viewing echoendoscope, needle knife, guidewire, and biliary dilators.The site of extrahepatic bile duct puncture was the common hepatic duct in 15 patients and the common bile duct in 3 patients. Mean diameter of the punctured extrahepatic bile ducts was 10 mm (range: 6-20 mm). Technical and functional success rates were 94% (17/18) and 100% (17/17), respectively. Median procedure time was 30 min (range: 10-52 min). Median duration to first oral intake after the procedure was 1 day (range: 1-3 days). Early complications were encountered in three (17%) patients, including focal peritonitis in two patients and hemobilia in one patient. During the follow-up period (median: 163 days; range: 46-484 days), 12 stent occlusion events were observed in nine patients. Re-intervention with exchange of the occluded stent was successful in 8 of 12 (66%) times. Severe early and late complications were not encountered in any patients in this study. Median duration of stent patency by Kaplan-Meier analysis was 272 days.EUS-CDS is safe, feasible, and effective as an alternative to PTBD and EBD in cases of malignant distal biliary tract obstruction. Prospective randomized studies are needed to compare the safety and efficacy of various kinds of endoscopic devices used in EUS-CDS and to compare EUS-CDS with PTBD or EBD.

The aim of this study was to elucidate the clinicopathological features and prognosis of mucinous cystic neoplasms (MCNs).We performed a multi-institutional, retrospective study on a collected series of patients with MCN pathologically defined by ovarian-type stroma. Clinicopathological features and prognosis were investigated.Mucinous cystic neoplasm was confirmed in 156 cases, including 129 adenomas (82.7%) and 21 noninvasive (13.4%) and 6 invasive carcinomas (3.9%). Patients with MCN were exclusively women (98.1%) with the mean age of 48.1 years. All but 1 MCN were in the pancreatic body/tail region with a mean size of 65.3 mm. Communication between the cyst and the pancreatic duct was found in 18.1%. The 3-, 5-, and 10-year survival rates were 97.6%, 96.6%, and 96.6%, respectively. A significant difference in the survival rates was observed between adenomas and carcinomas and between minimally invasive carcinomas and invasive carcinomas. Cyst diameter and presence of mural nodule were predictive of malignant MCN.Mucinous cystic neoplasm is a rare but distinctive pancreatic cystic neoplasm with a favorable overall prognosis. All MCNs should be resected to prevent malignant changes but can be observed for an appropriate time when the lesion is small without the presence of mural nodules.

A pilot study to evaluate stomach cancer risk reduction by Helicobacter pylori eradication

症例は50歳代，女性．糖尿病と体重減少で2007年9月に前医を受診，膵尾部に嚢胞性腫瘍を指摘され精査加療目的で当院紹介．US，CT，EUSで膵尾部から腹側に突出する径8cm，比較的厚い被膜を有する嚢胞を認めた．嚢胞と膵の境界部には2cm大の充実性腫瘤が存在し，脾静脈は閉塞し，膵後面結合織への浸潤が疑われた．以上の所見から，浸潤性粘液性嚢胞腺癌を第一に考え，10月膵体尾部·脾切除，横行結腸切除，左腎部分切除を施行した．切除割面で嚢胞は単房性で，嚢胞壁に連続して3.5cmの結節が存在した．病理所見では充実性部分は管状腺癌の所見で，癌は3/4周にわたり嚢胞壁に沿って浸潤，また脾静脈，横行結腸，腎被膜にも浸潤していた．嚢胞上皮は腺腫∼癌の所見を認めたがovarian-like stromaは認めなかった．本例の病態としては浸潤性粘液性嚢胞腺癌，膵管内腫瘍由来浸潤癌，通常型膵癌+貯留嚢胞の可能性が考えられたが，いずれかに決定できる所見は得られなかった．

症例は59歳，男性．分枝型IPMNにて膵頭十二指腸切除を施行した．病理検査で腺腫から上皮内癌までの病変からなるIPMN，膵実質浸潤，およびリンパ節転移を認めた．膵実質浸潤は微量かつ散在性でIPMNとの連続性が確認できなかった．正常膵管上皮，腺腫，上皮内癌，微量な膵実質浸潤，およびリンパ節転移にてK-ras codon12の遺伝子変異を検索した．正常膵管上皮はwild type GGT（Gly）であったが，腺腫，上皮内癌，およびリンパ節転移はすべてGGT（Gly）→CGT（Arg）と変異が一致した．微量な膵実質浸潤はDNA抽出不良で評価できなかったが本症例はIPMN由来浸潤癌であると強く推察された．K-ras codon12の遺伝子変異の検索は病理形態学的に通常型膵癌との鑑別が困難なIPMN由来浸潤癌の厳密な診断に有用と考えられ，今後多くの症例で病理学的な連続性との相関を検証する必要がある．

症例は41歳，女性．腹部の鈍痛，褐色尿，および左眼瞼腫大を主訴に当院紹介となった．血液検査にて高IgG4血症，腹部CTにてびまん性膵腫大および膵内胆管壁肥厚，ERPにて主膵管のびまん狭細像，FDG-PETで膵へのFDGのびまん性集積を認め，自己免疫性膵炎が疑われた．EUS-FNAでは悪性所見を認めず，またUS-TCBにてlymphoplasmacytic sclerosing pancreatitisを認め，自己免疫性膵炎と診断した．また，ステロイド投与後3日目にFDG-PETを施行し治療前と比較したところ，膵および膵外病変はともにFDG集積の著明な低下を認めた．ステロイド治療前後のFDG-PET検査は，自己免疫性膵炎における早期の治療効果判定，および癌との早期鑑別診断に有用な検査法になり得ると考えられた．

Early surgical intervention in acute cholecystitis is sometimes fatal to patients in the high-risk group. Since the technical development of ultrasonically guided puncture of the gallbladder, percutaneous transhepatic cholecystostomy has become a safer method for the treatment of acute cholecystitis. We have been developing percutaneous transhepatic cholecystoscopy procedures since 1981, and have used this method in 11 patients with cholecystolithiasis. In all cases, we were able to destroy the stones with the Nd-YAG laser, and remove the fragments with a basket catheter through the fistula. There were no severe complications from percutaneous transhepatic cholecystostomy or cholecystoscopy. This lithotomy technique is a safe and reliable nonsurgical technique for patients with cholecystolithiasis, especially the elderly high-risk group.