无功能性胰岛细胞瘤的诊断与治疗

报道8例无功能性胰岛细胞瘤。男女各4例,女性年龄平均为38岁,男性为57.25岁。肿瘤位于胰头部5例,体部3例;良性7例,恶性1例,发生囊性变者3例。肿瘤最大达25cm×15cm×13cm。3例行肿瘤摘除术;4例行胰头体部分切除、胰头断端缝闭,胰体断端与空肠Roux-en-Y吻合术:仅1例作活检。本组术前确诊为本病者仅1例,术前诊断率低主要是对本病的临床特征缺乏认识。根据临床特征,结合B超、ERCP、CT、血管造影以及囊液细胞学检查和囊液分析等,本病的术前诊断是可能的。本病如为良性,完整摘除肿瘤或连同肿瘤在内的胰腺部分切除;如为恶性,则手术适应证和手术方式的选择同胰腺癌。     

非功能性胰岛细胞瘤的诊治

对１５例非功能性胰岛细胞瘤进行回顾性分析，以探讨该病的诊断和治疗。钡餐、Ｂ超、ＣＴ、选择性腹腔动脉造影以及ＥＲＣＰ对该病有诊断价值。作者认为应将癌细胞异形性、核分裂相和瘤细胞侵犯被膜或血管作为诊断恶性的标准。手术切除是治疗非功能性胰岛细胞瘤的主要方法。１５例中单纯行肿瘤摘除术４例，胰体尾切除术８例，胰十二指肠切除术２例。手术切除率９３．３％（１４／１５），术后疗效满意     

Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

Background Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival. Methods Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes. Results Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023). Conclusions For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy. Presented in part at the annual meetings of the American Hepato-Pancreatico-Biliary Association on April 15, 2005 and The Pancreas Club on May 15, 2005.     

Small Nonfunctioning Islet Cell Tumor in the Body of the Pancreas: Report of a Case

Islet cell tumors of the pancreas are uncommon, and nonfunctioning tumors are even rarer than functioning ones. We report the case of a 67-year-old woman with a small nonfunctioning islet cell tumor, 6 × 5mm in diameter, which was detected incidentally by ultrasonography, and subsequently confirmed by double-helical computed tomography. Diagnosis was established by histopathological examination after 80% distal pancreatectomy with splenectomy, and by various laboratory tests. Histologically, the islet cell tumor showed highly cellular spindle or epithelioid cells, which were positive for Grimelius stain. Immunohistochemical examination revealed that the tumor cells were positive for chromogranin A, but negative for somatostatin, insulin, glucagon, and gastrin. Its small size, location, and benignity make this a very rare type of nonfunctioning islet cell tumor.     

Diagnostic Laparoscopy for Patients with Potentially Resectable Pancreatic Adenocarcinoma: Is It Cost-Effective in the Current Era?

Introduction  For patients with potentially resectable pancreatic cancer, diagnostic laparoscopy may identify liver and peritoneal metastases that are difficult to detect with other staging modalities. The aim of this study was to utilize a population-based pancreatic cancer database to assess the cost effectiveness of preoperative laparoscopy. Material and Methods  Data from a state cancer registry were linked with primary medical record data for years 1996–2003. De-identified patient records were reviewed to determine the role and findings of laparoscopic exploration. Average hospital and physician charges for laparotomy, biliary bypass, pancreaticoduodenectomy, and laparoscopy were determined by review of billing data from our institution and Medicare data for fiscal years 2005–2006. Cost-effectiveness was determined by comparing three methods of utilization of laparoscopy: (1) routine (all patients), (2) case-specific, and (3) no utilization. Results and Discussion  Of 298 potentially resectable patients, 86 underwent laparoscopy. The prevalence of unresectable disease was 14.1% diagnosed at either laparotomy or laparoscopy. The mean charge per patient for routine, case-specific, and no utilization of laparoscopy was $91,805, $90,888, and $93,134, respectively. Conclusion  Cost analysis indicates that the case-specific or routine use of laparoscopy in pancreatic cancer does not add significantly to the overall expense of treatment and supports the use of laparoscopy in patients with known or suspected pancreatic adenocarcinoma. This work was presented at the Annual Meeting of the American Hepato-Pancreato-Biliary Association, April 21, 2007, Las Vegas, Nevada. This study was approved by the Institutional Review Board of Oregon Health and Science University and the Research Committee at the Oregon State Cancer Registry.     

Portal Vein Resection for a Portal Vein Thrombus Caused by Nonfunctioning Islet Cell Carcinoma: Report of a Case

We report a case of nonfunctioning islet cell carcinoma of the pancreas causing a tumor thrombus in the portal vein. The patient was a 60-year-old woman whose presenting symptoms were abdominal pain, vomiting, and weight loss. We performed a subtotal pancreatectomy and splenectomy combined with partial resection of the portal vein. Histopathological studies confirmed the diagnosis of nonfunctioning islet cell carcinoma of the pancreas with a tumor thrombus in the portal vein. The patients postoperative course was uneventful and she is doing well 25 months after the operation.     

露蜂房对淋巴细胞与胰岛混合培养系统中淋巴细胞转化的影响

目的初步探索露蜂房对淋巴细胞与胰岛混合培养系统中淋巴细胞转化的影响。方法露蜂房水提取液系利用其生药通过水提醇沉法制备获得。无菌制备大鼠淋巴细胞及猪胰岛组织悬液,并对二者进行混合培养,在37℃、5%CO2的培养箱中进行,培养过程中分别加入3种浓度(4.0、0.4及0.2g/ml)的露蜂房水提取液,即露蜂房Ⅰ、Ⅱ及Ⅲ组,应用3H-TdR掺入法测定放射性核素每分钟脉冲数(cpm),观察大鼠淋巴细胞的转化情况,并设立空白组和环孢素A(CsA)组作为对照。结果3种浓度的露蜂房水提取液对大鼠淋巴细胞的转化均有明显抑制作用(P<0.001),3组抑制率分别为45.3%、29.6%和9.2%;但与CsA相比,免疫抑制作用较弱(CsA抑制率为80.7%)。结论露蜂房对淋巴细胞胰岛混合培养系统中的淋巴细胞转化有抑制作用,且随浓度增加抑制作用增强,提示露蜂房可以抑制T细胞介导的免疫功能。     

Clinicopathologic Features and Treatment Trends of Pancreatic Neuroendocrine Tumors: Analysis of 9,821 Patients

The natural history of pancreatic neuroendocrine tumors (PNET) remains poorly defined. Our objectives were to examine the clinicopathologic features of PNETs, to assess treatment trends over time, and to identify factors associated with undergoing resection. From the National Cancer Data Base (1985–2004), 9,821 patients were identified with PNETs. Clinicopathologic features and treatment trends were examined. Multivariable logistic regression was used to assess factors associated with undergoing resection. Of 9,821 patients with PNETs, 85% were nonfunctional, 7.1% were functional, and 7.9% were carcinoid tumors. Of the 3,851 (39.0%) patients who underwent pancreatectomy, 449 (11.7%) received adjuvant chemotherapy, and 254 (6.6%) received adjuvant radiation. From 1985 to 2004, utilization of pancreatectomy increased from 39.4 to 44.3% (P < 0.0001). Patients were less likely to undergo resection if they were >55 years old, had tumors in the head of the pancreas, tumors ≥4 cm, or had distant metastases (P < 0.0001). Patients treated at NCCN/NCI, academic, or high-volume hospitals were more likely to undergo resection. There are disparities in the utilization of pancreatectomy for PNETs. As PNETs have a better prognosis than adenocarcinoma, concerns regarding the morbidity and mortality of pancreatic surgery and neoplasms should not preclude resection.     

Pancreatic Resection for Metastatic Renal Cell Carcinoma: Presentation,Treatment, and Outcome

Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients.Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases.Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease.Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.     

Comparing Surgical Outcomes in Obese Women Undergoing Laparotomy,Laparoscopy, or Laparotomy With Panniculectomy for the Staging of Uterine Malignancy

Background Limiting surgical morbidity while maintaining staging adequacy is a primary concern in obese patients with uterine malignancy. The goal of this study was to compare the surgical adequacy and postoperative morbidity of three surgical approaches to staging the disease of obese women with uterine cancer. Methods The records of all patients with a body mass index (BMI) of ≥35 undergoing primary surgery for uterine corpus cancer at our institution from January 1993 to May 2006 were reviewed. Patients were assigned to three groups on the basis of planned surgical approach—standard laparotomy, laparoscopy, or laparotomy with panniculectomy. Standard statistical tests appropriate to group size were used to compare the three groups. Results In all, 206 patients with a BMI of ≥35 were grouped as follows: laparotomy, 154 patients; laparoscopy, 25 patients; and laparotomy with panniculectomy, 27 patients. Median BMI was 41 (range, 35–84). Regional lymph nodes were removed in 45% of the laparotomy patients, 40% of the laparoscopy patients, and 70% of the panniculectomy patients (P = .04). Compared with laparotomy, both laparoscopy and panniculectomy yielded higher median pelvic and total lymph node counts (P = .001). Operative time was shortest after standard laparotomy, and blood loss was greatest after panniculectomy. The incidence of all incisional complications was lower for panniculectomy (11%) and laparoscopy (8%) compared with standard laparotomy (35%) (P = .002). On multivariate analysis, a significantly lower risk of total incisional complications was seen for patients undergoing panniculectomy (risk ratio, .25; 95% confidence interval, .071–.88) and laparoscopy (risk ratio, .19; 95% confidence interval, .04–.94). Conclusions Both laparoscopic staging and panniculectomy in a standardized fashion were associated with an improved lymph node count and a lower rate of incisional complications than laparotomy alone. Although definitive conclusions are limited by low patient numbers, the substantial decrease in wound complications suggests that these two approaches should be considered for obese patients undergoing uterine cancer staging. Presented in part at the Society of Gynecologic Oncologists Winter Meeting; Beaver Creek, CO; February 1–3, 2007.     

内镜超声联合腹腔镜诊治早期胃间质瘤

目的探讨内镜超声(endoscopic ultrasonography,EUS)联合腹腔镜诊治早期胃间质瘤(gastric stromal tumors,GSTs)的价值。方法2004年8月~2008年12月,应用EUS对18例早期GSTs(直径2cm)进行诊断,然后采用腹腔镜联合胃镜进行肿物定位,应用内镜切割吻合器(Endo-GIA)行肿物局部切除。结果18例手术均获得成功,术后无严重并发症。手术时间平均56min(35~110min),术后住院平均4.4d(3~7d)。1例术后病理为神经鞘瘤;17例术后病理证实为GSTs,直径均2cm,核分裂像5个/50HPF,属极低度恶性,免疫组化检查显示17例CD117阳性,15例CD34阳性;EUS诊断阳性预测值为94.4%(17/18)。17例随访3~55个月,平均26.4月,无肿瘤复发及转移。结论EUS对早期GSTs有较高的诊断价值。对于早期发现的GSTs,应用腹腔镜局部切除,术中联合胃镜进行定位,提高手术操作效率和手术安全性。     

Predicting Distant Metastasis in Patients With Suspected Pancreatic and Periampullary Tumors for Selective Use of Staging Laparoscopy

Background  

In patients with pancreatic or periampullary tumor, staging laparoscopy (SL) can detect metastases that are occult on computed tomography (CT), thereby precluding nontherapeutic laparotomy. Routine SL is not advocated, but some studies suggest its selective use. The aim of this study was to identify patients at risk for metastasis in whom SL could be beneficial.     

Pancreatic Cystic Neuroendocrine Tumors: Preoperative Diagnosis with Endoscopic Ultrasound and Fine-Needle Immunocytology

Background Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fine-needle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. Methods Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. Results Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3 + 0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. Conclusions EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short- and long-term outcomes after resection are excellent. This article was presented as a poster at the AHPBA meeting this past May (2007).     

Initial Clinical Response Predicts Outcome and Is Associated With Dose Schedule in Metastatic Melanoma and Renal Cell Carcinoma Patients Treated With High-Dose Interleukin 2

Background High-dose interleukin (IL)-2 is an effective agent for the treatment of metastatic malignant melanoma and renal cell carcinoma. This study evaluated the outcomes of patients receiving two commonly used intravenous IL-2 schedules that have never been directly compared.Methods Forty-seven metastatic malignant melanoma and renal cell carcinoma patients were identified from a prospective database who underwent high-dose IL-2 therapy (720,000 or 600,000 IU/kg) during 1999 to 2003. Disease-specific survival (DSS) was calculated by the Kaplan-Meier method with the log-rank test on an intention-to-treat basis. Multivariate Cox regression analysis of prognostic variables associated with outcome was performed. Factors associated with initial response and prevention of disease progression were determined.Results Objective response (5 partial and 5 mixed) or disease stabilization was noted in 9 (20%) and 10 (22%), respectively, of 46 assessable patients after 1 course of therapy. Four patients (22%) achieved disease-free status after the third course of IL-2 (n = 1) or surgical resection of confined metastatic disease (n = 3). At 19.1 months median follow-up, factors associated with improved DSS included an initial clinical response to IL-2 therapy (P < .001) and a higher administered dose (P = .04). Patients who received 720,000 IU/kg were more likely to experience an initial major objective response (P = .03) and disease stabilization (P = 0.03) independent of the tumor treated. Objective response early in the course of therapy was the only independent predictor of tumor-related mortality (P = .004).Conclusions The initial clinical response to IL-2 therapy is an independent predictor of improved outcome associated with DSS and the 720,000 IU/kg dose. These results support further prospective trials with increased IL-2 dose schedules in a larger cohort of patients.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

Laparoscopy Shortens Length of Stay in Patients With Gastric Electrical Stimulators

Background:

Gastric electrical stimulation has been proven effective for drug-refractory gastroparesis. Placement of stimulator leads and device usually requires a laparotomy, although laparoscopic placement has also been used.

Methods:

To compare laparotomy with laparoscopy, we examined 36 patients, 18 undergoing laparoscopy and 18 undergoing laparotomy, matched for primary diagnosis and health resource usage. We compared baseline symptoms, length of surgery, length of postoperative hospital stay, gastric emptying, and health resources in each of the 2 groups over time, to see what variables, if any, differed.

Results:

Baseline symptoms, gastric emptying, and health resource usage were similar. Operative times were also similar, but length of stay declined from a mean of 6.4 days for laparotomy to 1.1 days for laparoscopy. Long-term outcome, via symptoms, gastric emptying, and health resource utilization were comparable between the 2 groups.

Conclusion:

Laparoscopic placement of gastric electrical stimulator leads and device is associated with shorter lengths of postoperative hospital stay. However, the patients who underwent laparotomy had higher vomiting scores and more previous abdominal surgeries at baseline, and higher long-term mortality at follow-up, suggesting that they may be more ill, as a group, than the laparoscopic patients. Laparoscopic placement of devices may be preferable when technically feasible.     

Pancreatic polypeptide islet cell tumor: Case report and review of the literature

Pure pancreatic polypeptide-containing tumors (PPomas) are quite rare. Only 20 cases have been described. In this article we report a 75-year-old woman with such an endocrine islet cell tumor. The patient had no specific symptoms that could be ascribed to the tumor. An abdominal CT scan revealed a 3 cm soft tissue mass arising inferiorly from the tail of the pancreas. Local resection by way of a distal pancreatectomy was performed. A well-circumscribed hemorrhagic multiloculated mass, 3.7 cm in greatest dimension, was present in the tail of the pancreas. The patient has remained well and tumor free for the past 22 months. The endocrine characterization of the tumor was achieved by means of immunohistochemical analysis. Staining specific for insulin, ghicagon, somatostatin, and gastrin was negative. In contrash staining of the tumor for pancreatic polypeptide was strongly positive. A number of nonfunctioning islet cell tumors of the pancreas have been described. The lack of fimction has previously been suggested to indicate the lack of secretion of an endocrine product. This report documents that islet cell tumors may function by secreting pancreatic polypeptide but not cause symptoms.