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Iso- or hypo-attenuating areas in the arterial phase on contrast-enhanced computed tomography (CE-CT) have been reported to be negative prognostic features in pancreatic neuroendocrine tumors (PNETs). Given that the optimal indication for lymph node dissection in patients with PNET remains unclear, we sought to utilize enhancement characteristics on CE-CT as a preoperative predictor of regional lymph node metastasis in PNETs.The medical records of patients with well-differentiated PNETs who underwent pancreatectomy along with lymphadenectomy were retrospectively analyzed. We divided PNETs into two groups based on the extent of attenuation in the late arterial phase on CE-CT imaging. PNETs that showed hyper-attenuation over the entire area compared to the adjacent normal pancreas were categorized as hyper-PNETs. PNETs that contained both hyper and iso- or hypo-attenuation regions as well as those that showed only iso- or hypo-attenuation over the entire area were categorized as hetero/hypo-PNETs.Forty-one patients with a median age of 64 years were enrolled, including 11 with hyper-PNETs and 30 with hetero/hypo-PNETs. Hetero/hypo-PNETs were significantly larger than hyper-PNETs (P = 0.022), and the former group more frequently comprised G2 tumors, according to the World Health Organization 2010 classification (P 0.001). On univariate and multivariate analyses, hetero/hypo-PNETs were independently associated with regional lymph node metastasis.The presence of iso- or hypo-attenuating regions appears to be associated with regional lymph node metastasis in PNETs. Tumor enhancement characteristics should be assessed in patients with PNET so as not to miss those at high risk of lymph node metastasis.

A 47-year-old woman who had unresectable locally advanced gallbladder cancer(GBC)accompanied with liverinvasion, duodenum invasion, transverse colon invasion, and surrounding lymphatic metastasis received 5 courses of chemotherapy with gemcitabine plus cisplatin. Afterthe chemotherapy, imaging showed down-staging of the GBC, indicating tumor shrinkage. The initial laparoscopic examination revealed no peritoneal seeding or distant metastasis. Subsequently, we performed cholecystectomy with a partial hepatectomy at the gallbladder bed. Malignant findings were not observed in the histopathological examination and the pathological diagnosis was CR with pT0N0M0, Stage 0. The patient was discharged on day 11 after the operation. There has been no recurrence at 14 months after surgery. Although the prognosis of advanced GBC with local invasion is generally poor, chemotherapy might be an effective treatment for patients with initially unresectable locally advanced gallbladder carcinoma.

The patient was a 63-year-old man with hepatitis C. He discontinued combination therapy containing interferon and ribavirin because of the development of skin symptoms. A screening examination showed multiple early-stage hepatocellular carcinomas. He refused treatment and was followed up as an outpatient. During follow-up, his PIVKA-Ⅱ level remarkably elevated to 59,994mAU/mL. Computed tomography(CT)showed an enlarged tumor with portal invasion(vp2)in segment 8 and intrahepaticmetastasis. We performed right and partial hepatectomy. Three months later, CT showed multiple lung metastases. We initiated the daily administration of 800 mg of sorafenib. However, 6 months after hepatectomy, the lung metastases increased in size and number. We considered the therapeutic effect as progressive disease(PD)according to the RECIST criteria. We then initiated administering 120 mg of regorafenib daily as second-line therapy. In a course of the treatment containing sorafenib and regorafenib, the dose was reduced due to hand-foot skin reactions. 8.5 months after hepatectomy, the lung metastases significantly decreased in size. One year after hepatectomy, almost complete response(CR) was obtained, and no intrahepatic recurrence was found.

A 71-year-old woman underwent right nephrectomy for the treatment of clear cell renal cell carcinoma at the age of 53. After 15 years, surgical removal of a solitary tumor was performed in the right adrenal gland and thyroid gland; both were diagnosed as metastases of renal cell carcinoma. Eighteen years after the initial resection, computed tomography(CT) showed multiple hypervascular tumors spreading across the entire area of the pancreas. She was referred to our hospital, and endoscopic ultrasound-guided fine needle aspiration biopsy(EUS-FNA)revealed that they were metastases from the renal cell carcinoma. Total pancreatectomy and splenectomy were performed, and the patient remains alive and well with no evidence of recurrent disease 7 months after the pancreatectomy. Furthermore, her blood glucose level is well controlled with insulin therapy.

We report a case of bilobar multiple hepatocellular carcinoma(HCC)with peritoneal dissemination successfullytreated by dual treatment with reductive surgeryplus percutaneous isolated hepatic perfusion(PIHP). A 73-year-old man had sudden abdominal pain and was diagnosed bilobar multiple HCC through some examinations. The abdominal CT scan demonstrated onlya peritoneal dissemination under the liver. We performed partial hepatectomyof the lateral segment and the Spiegel lobe, and resected a peritoneal dissemination. Subsequently, we underwent PIHP twice. The tumor marker was normalized, and CT images demonstrated complete response according to the RECIST. Dual treatment is considered to be a unique therapeutic modalityfor severe advanced HCC.

A 72-year-old woman had severe watery diarrhea and weight loss. Computed tomography demonstrated a 55mm tumor in pancreatic tail with enlargement of para-aortic lymph nodes. There was no apparent liver metastasis. Endoscopic ultrasound demonstrated a well-circumscribed heterogenous tumor, which was diagnosed neuroendocrine tumor by endoscopic ultrasound-guided fine needle aspiration biopsy. For suspected VIPoma with para-aortic lymph node involvement, distal pancreatectomy and para-aortic lymphadenectomy was performed. The tumor was diagnosed as VIPoma by immunohistochemistry. The diarrhea improved after surgery. No evidence of recurrence was detected after a follow-up of 11 months.

A 69-year-old woman who was identified the tumor of the pancreas tail by CT scan for postoperative inspection of breast cancer. Pancreas tail cancer with para-aortic lymph node metastases was diagnosed by close inspection. She consulted a different hospital to receive their second opinion. She was diagnosed of sarcoidosis from points with lymphadenopathy in hilar region and para-aorta for 3 years and uveitis. The patient was referred to our institution for treatment. We performed distal pancreatectomy in March, 2014. No.16 lymph nodes were cancer-negative, but lymph nodes around the pancreas were cancer positive. Abdominal CT, 9 months after surgery, showed lymph node swelling. We recommended a definitive diagnosis by EUS-FNA, but she refused the inspection. She was checked by CT scan regularly afterwards and is alive without recurrence 39 months after the operation. Diagnosis for lymph node metastases is difficult for a malignant tumor when the sarcoidosis coexisted.

症例は61歳の男性で，膵頭部癌に対して膵頭十二指腸切除術（Pancreatoduodenectomy；以下，PDと略記）を施行した．術後10日目に膵空腸吻合部ドレーンから大量出血を認め，出血性ショックとなった．血管造影検査で上腸間膜動脈（Superior mesenteric artery；以下，SMAと略記）根部に径1 cmの仮性動脈瘤を認め，同部からの出血と判明した．仮性動脈瘤がSMA根部にあったため，Interventional radiology（以下，IVRと略記）による止血は不可能と判断し，緊急手術を施行した．手術は残膵全摘，SMA縫合閉鎖，左大伏在静脈による右総腸骨動脈-SMAバイパス術を施行した．術後CTではSMA本幹からの血流はなく，腸管血流はグラフト経由で供給されていた．PD術後の仮性動脈瘤大量出血に対しIVR施行困難例では躊躇なく積極的な外科手術を考慮すべきと考えられた．

Autophagy has recently emerged as a significant mechanism in cancer treatment. Although gemcitabine and/or ionizing radiation are important modalities in the treatment of pancreatic cancer, the contribution of autophagy in such treatment has not been fully elucidated. This study investigated the role of autophagy in the treatment of pancreatic cancer with gemcitabine and ionizing radiation. To evaluate the effect of gemcitabine and/or ionizing radiation on autophagy, several human pancreatic cancer cell lines were used. The treatment of pancreatic cancer cell cultures in vitro and in vivo with gemcitabine and ionizing radiation resulted in synergistic cytotoxicity. After treatment with gemcitabine, the autophagy-related protein light chain 3-II (LC3-II) was upregulated. When gemcitabine was combined with ionizing radiation treatment, LC3-II upregulation was enhanced. In addition, electron microscopy of pancreatic cancer cells treated with gemcitabine and/or ionizing radiation detected the induction of autophagy. The blockage of autophagy by 3-methyladenine indicated that autophagy contributed to cell death after gemcitabine treatment and enhanced its cytotoxicity. The inhibitory effect and immune reactivity of the autophagy-related proteins LC3 and beclin-1 were the strongest after the combination treatment. In conclusion, these results suggest that autophagy can be activated by gemcitabine and/or ionizing radiation in the treatment of pancreatic cancer cells and that activated autophagy plays a role in cancer suppression. These findings may have important implications for future therapeutic strategies using gemcitabine and ionizing radiation against pancreatic cancer.

To evaluate ambulatory patient cancer chemotherapy, the clinical response, toxicities and survival time were analysed among 19 patients with non-curative or recurrent colorectal cancer who were treated by Uracil/Tegafur (UFT) plus oral Leucovorin (UZEL) for the past 2 years. The patients were administered UFT (300 mg/m2/day) and UZEL (75 mg/body/day) for 28 days with a one-week interval every 35 days as one course.A partial response (PR) was observed in 6 patients (31.6%) and stable disease (SD) in 8. The median survival time was 16 months. Although nausea/vomiting, diarrhea and leucopenia were noted, no severe side effects were observed. These results suggested that UFT plus Leucovorin therapy might be a useful cancer chemotherapy for ambulatory patients with advanced colorectal cancer.