Taichi Terai

Aim: We investigated the efficacy of quantitative evaluation of tumor signal heterogeneity on gadoxetic acid‐enhanced magnetic resonance imaging (EOB‐MRI) to predict prognosis and antitumor immunity in patients with hepatocellular carcinoma (HCC) undergoing liver resection. Methods: A total of 297 patients who underwent curative resection for primary HCC were included. Tumor signal heterogeneity in the hepatobiliary phase (HBP) of EOB‐MRI was quantified as the coefficient of variation (CV), calculated as the standard deviation divided by the mean signal intensity. Patients were classified into homogeneous (low CV) and heterogeneous (high CV) groups based on a cutoff value of 0.16 from receiver operating characteristic curve analysis. Tumor‐infiltrating CD4+ and CD8+ T cells and PD‐L1 expression were assayed by immunohistochemistry, and their associations with tumor signal heterogeneity were evaluated. Results: Among the 297 patients, 116 (39.1%) were classified into the heterogeneous group. The overall survival (OS) and recurrence‐free survival (RFS) rates were significantly lower in the heterogeneous group ( p < 0.001 for both). Multivariate analysis identified heterogeneous group as an independent prognostic factor for OS and RFS ( p < 0.001 and p = 0.012, respectively). Extrahepatic recurrence was significantly more frequent in the heterogeneous group (18.1% vs. 7.7%, p = 0.024). CD4+ and CD8+ T cells were significantly decreased, and the PD‐L1 positivity rate was significantly lower in the heterogeneous group ( p < 0.001 for all). Conclusions: The quantitative evaluation of tumor signal heterogeneity in the HBP of EOB‐MRI using CV is useful for predicting postoperative prognosis in patients with HCC. Tumor signal heterogeneity may also reflect impaired local immunity and an immunologically “cold” tumor.

Management of gastrointestinal perforation in patients with vascular Ehlers-Danlos syndrome (vEDS) is clinically challenging. A male in his 40s with vEDS presented with right lower abdominal pain. Computed tomography revealed a foreign body in the ileum with bowel perforation. A detailed inquiry revealed that he had consumed codfish six days prior. Based on these findings, he was diagnosed with a small bowel perforation caused by a fish bone. Emergency laparotomy was performed and intraoperative findings showed a fish bone in the ileum penetrating the mesentery. We resected ~5 cm of the small intestine, including the perforation site. Although the patient experienced postoperative paralytic ileus, he was discharged on postoperative Day 27. Gastrointestinal perforation caused by fish bones in patients with vEDS is extremely rare and requires careful assessment to determine the appropriate treatment. For surgeons, an individualized surgical strategy and optimal perioperative management are important to prevent fatal complications.

Background: Creatine kinase (CK) levels decrease with cancer progression and muscle wasting, but its association with pancreatic ductal adenocarcinoma (PDAC) remains unclear. The aim of this study was to investigate CK as a prognostic biomarker and surrogate marker for muscle mass in patients with PDAC.Methods: A retrospective analysis of 476 patients with PDAC was conducted. CK levels were categorized into low and high groups using receiver‐operating characteristic (ROC) curve analysis.Results: Among the 476 patients, 200 (42.0%) and 276 (58.0%) were classified into the low and high CK groups, respectively. The low CK group had significantly poorer overall survival (p < .001) and recurrence‐free survival (p < .001) compared to the high CK group. Multivariate analysis identified low CK as an independent poor prognostic factor (p < .001). The low CK group had significantly lower skeletal muscle index (p = .048) than the high CK group; however, the difference was slight and not significantly associated with sarcopenia. Additionally, combined risk assessment incorporating CK and resectability facilitated a more nuanced prognostic stratification.Conclusions: CK served as a reliable prognostic marker independent from resectability but was less effective as a marker for sarcopenia in PDAC.

Background: Central pancreatectomy (CP) is accepted as a function‐preserving procedure for benign tumors. However, the indication of CP for pancreatic cancers is limited. This multicenter study aimed to clarify the indications of CP for clinical T1 pancreatic body cancer.Methods: This multicenter study analyzed patients who underwent CP or distal pancreatectomy (DP) for clinical T1 pancreatic body cancer between 2013 and 2020 at three high‐volume centers.Results: A total of 50 patients were enrolled: nine patients, who underwent CP, were classified into the CP group, while 38 patients, who underwent DP, served as controls. Three patients converted CP to DP during operation were excluded. Five patients in the CP group and 15 patients in the control group underwent preoperative treatment. The 5‐year survival rate was 100% in the CP group, and 42% (p = .040) in the control group. Recurrence was found in three patients in the CP group. Importantly, insulin was not required after surgery in patients in the CP group.Conclusion: The clinical outcomes of CP were comparable to or even better than that of conventional pancreatectomy. Our collaborative study suggests that CP may be an acceptable therapeutic option for selected patients with clinical T1 pancreatic body cancer.

Background: Pancreatic lipomas (PLs) arising from the adipose tissue in the pancreatic parenchyma are rare among pancreatic tumors. Coexisting pancreatic ductal adenocarcinoma (PDAC) and PLs have not been previously reported. Herein, we report a case of PDAC arising from the pancreatic parenchyma with chronic pancreatitis compressed by a large PL. Case presentation: The patient was a 69-year-old male. He had been diagnosed with a PL using computed tomography (CT) 12 years previously. The tumor had been slowly growing and was followed up carefully because of the possibility of well-differentiated liposarcoma. During follow-up, laboratory data revealed liver damage and slightly elevated levels of inflammatory markers. Contrast-enhanced CT revealed the previously diagnosed 12 cm pancreatic head tumor and an irregular isodensity mass at the upper margin of the tumor that invaded and obstructed the distal common bile duct. Magnetic resonance cholangiopancreatography demonstrated no specific findings in the main pancreatic duct. Based on these imaging findings, the patient underwent endoscopic retrograde biliary drainage and bile duct brushing cytology, which revealed indeterminate findings. The differential diagnosis of the tumor at that time was as follows: (1) pancreatic liposarcoma (focal change from well-differentiated to dedifferentiated, not lipoma), (2) distal cholangiocarcinoma, and (3) pancreatic cancer. After the cholangitis improved, a pancreatoduodenectomy was performed. Histologically, hematoxylin–eosin staining revealed moderately differentiated PDAC compressed by proliferating adipose tissue. The adipose lesion showed homogeneous adipose tissue with no evidence of sarcoma, which led to a diagnosis of lipoma. Additionally, extensive fibrosis of the pancreatic parenchyma and atrophy of the acinar cells around the lipoma was suggestive of chronic pancreatitis. The pathological diagnosis was PDAC (pT2N0M0 pStage Ib) with chronic pancreatitis and PL. The postoperative course was uneventful, and the patient was discharged on the 15th day after surgery. The patient received adjuvant chemotherapy and has remained recurrence-free for more than 6 months. Conclusions: PL may be associated with the development of PDAC in the surrounding inflammatory microenvironment of chronic pancreatitis. In cases of growing lipomas, careful radiologic surveillance may be needed not only for the possibility of liposarcoma but also for the coincidental occurrence of PDAC.