壶腹部肿瘤局部切除的临床与病理探讨

目的：探讨局部切除治疗壶腹部肿瘤的疗效。方法：对本院1994年2月～2006年3月27例实施了局部切除术的壶腹部肿瘤患者进行分析。结果：手术均获得成功，最终病理诊断为16例绒毛状腺瘤，4例管状腺瘤，1例神经鞘瘤；术中冰冻对检查腺癌的敏感性和特异性分别为25％和100％．阳性预测值和阴性预测值分别为100％和84％；患者平均住院7.9天，术后7例（26％）出现并发症，无围手术期和住院期间死亡病例；良性肿瘤的5年、10年复发概率分别为8％，17％，恶性肿瘤的5年、10年复发概率分别为19％，59％。5例患者在随访期死亡，2例死于腺癌复发，3例死于其他疾病。恶性肿瘤的5年，10年总体生存率为49％，26％．结论：对于壶腹部良性肿瘤局部切除是首选的方式而对于壶腹部恶性肿瘤应采用Whipple手术，局部切除适合于难以耐受手术者。     

壶腹部癌的局部切除治疗--附11例报告

目的评价局部切除治疗壶腹部癌的效果.方法1996年5月-2000年12月,16例壶腹部癌的患者进行局部切除术,获随访11例,其中术后组织病理证实为高分化腺癌7例,其中中分化腺癌2例,低分化腺癌2例.11例均行十二指肠切开肿瘤切除术.结果本组无手术死亡,术后均获随访,随访时间6～53个月.3例分别于术后9、18、27个月死于其他病,1例21个月后复发死亡.其余7例均在随访中,平均生存期23.4个月.术后1年生存8例(72.7%),2年为5例(45.5%),4年为2例(18.2%).结论局部切除具有手术操作简单、创伤小、恢复快、手术并发症及死亡率低等特点.适应于肿瘤较小、无壶腹周围浸润及淋巴结转移,合并内科疾病而不能耐受胰十二指肠切除术的老年患者.     

壶腹部癌的局部切除治疗——附11例报告

目的：评价局部切除治疗壶腹部癌的效果。方法：1996年5月-2000年12月，16例壶腹部癌的患者进行局部切除术，获随访11例，其中术后组织病理证实为高分化腺癌7例，其中中分化腺癌2例，低分化腺癌2例。11例均行十二指肠切开肿瘤切除术。结果：本组无手术死亡，术后均获随访，随访时间6～53个月。3例分别于术后9、18、27个月死于其他病，1例21个月后复发死亡。其余7例均在随访中，平均生存期23、4个月。术后1年生存8例(72．7％)，2年为5例(45．5％)，4年为2例(18．2％)。结论：局部切除具有手术操作简单、创伤小、恢复快、手术并发症及死亡率低等特点。适应于肿瘤较小、无壶腹周围浸润及淋巴结转移，合并内科疾病而不能耐受胰十二指肠切除术的老年患者。     

骶尾部肿瘤手术治疗的中远期评价

目的 评价骶尾部肿瘤手术治疗的中远期效果.方法 回顾分析1993年4月至2010年2月收治的47例骶尾部肿瘤患者,其中包括脊索瘤13例,囊肿6例,骨巨细胞瘤4例,脂肪瘤3例,皮脂腺瘤3例,软骨肉瘤3例,恶性源性肿瘤3例,转移癌3例,纤维瘤2例,畸胎瘤2例,神经纤维瘤、纤维脂肪错构瘤、神经节细胞瘤、良性间叶瘤、低度恶性纤维母细胞瘤、孤立性纤维瘤、恶性神经鞘瘤各1例.术前主要临床症状：骶尾区疼痛37例,臀部及大腿麻痛33例,大小便障碍5例,双侧下肢肿胀、难以入睡1例.术前行选择性瘤血管栓塞术15例.6例行前后路联合手术,41例行后路手术.良性肿瘤全部为瘤外切除,恶性肿瘤为瘤内切除.结果 术中出血量500～5000ml,平均3000ml,术前行选择性瘤血管栓塞者术中平均出血量为1300ml.13例失访,余34例患者获得随访2-11年,平均随访时间6.4年.8例脊索瘤术后均反复出现局部复发,最快者为术后1个月复发,因其他脏器发生转移而死亡;4例骨巨细胞瘤3例失访,1例随访3年下肢功能、感觉活动良好,无大小便障碍.3例软骨肉瘤术后1例出现复发后死亡,2例无瘤生存;2例转移性癌和3例恶性源性肿瘤术后均死亡.全部良性肿瘤预后较好.结论 骶尾部肿瘤发病率较低,起病隐匿、症状轻微者占多数.术前行选择性瘤血管栓塞能够有效降低术中出血的风险.良性肿瘤可进行边缘完整的切除,预后良好;而单纯手术治疗对骶尾部恶性肿瘤来讲,复发率高,预后差,采用全骶骨切除或手术联合放化疗可望降低术后复发率,改善预后.     

隆突性皮肤纤维肉瘤复发与转移的临床病理研究

本文通过46例隆突性皮肤纤维肉瘤(DFSP)的研究，发现它的特征为肿瘤位于真皮,病程长，术后局部复发率高(47．8%)、转移率较低(6．5%);多次复发率导致转移。对复发22例和转移3例的研究，并结合文献临床与病理相关因素：(1)肿瘤生长时间长，瘤体较大，无完整包膜．呈浸润性生长而不易彻底切除干净;(2)对DFSP临床病理特性了解不够常误诊为良性肿瘤，使首次手术多在门诊进行而切除不彻底;少数病例病理亦误诊为良性肿瘤，使病人失去及时作进一步扩大切除机会；(3)部分DFSP复发后瘤细胞异型和核分裂增多，并出现纤维肉瘤区域，肿瘤恶性程度增高;(4)转移者除以上因素外,还可能与局部外伤和多次复发手术致使血管、淋巴管损伤以及DFSP有侵犯血管、淋巴管潜能密切相关。     

275例原发性心脏肿瘤临床诊断与治疗

目的总结原发性心脏肿瘤的临床特征及治疗结果。方法回顾性分析275例原发性心脏肿瘤患者的临床资料。275例中良性肿瘤251例(91.27%,其中左房黏液瘤237例),恶性肿瘤24例(8.72%)。主要临床表现为心悸、气短,共245例,占89.09%。272例行手术治疗,其中完整切除258例,局部切除6例,8例因肿瘤无法切除仅行活检术。7例实性瘤体患者同期行二尖瓣置换术,2例同期行肺动脉瓣置换术,5例同期行经股动脉取瘤栓术。结果术前死亡2例,术中死亡3例。术后随访230例(83.63%),时间6个月～31年,死亡35例,其中良性肿瘤15例,恶性肿瘤20例,4例复发(良性1例、恶性3例),其余均恢复良好。结论原发性心脏肿瘤中左房黏液瘤最为常见,主要临床表现为心悸、气短。一经确诊应尽早手术,良性肿瘤手术效果好,恶性肿瘤预后差。     

101例原发性腹膜后肿瘤外科治疗

目的探讨原发性腹膜后肿瘤的外科治疗。方法回顾性分析1992年来原发性腹膜后肿瘤手术切除101例，总结提高手术治疗效果的策略。结果其中良性肿瘤38例，恶性肿瘤63例，均经术后病理证实。肿瘤完整切除率71．29％。良性肿瘤的手术完整切除率高于恶性肿瘤，术中失血少，需要合并切除的脏器少，术后复发率相对低。全部病人无一例术中死亡。术后复发33例，再次手术19例。结论手术完整切除是腹膜后肿瘤治疗首选的方法，术前准备非常重要，对复发的肿瘤应该争取再次手术。     

肺腺癌中央区转移瘤的手术治疗

目的 探讨肺腺癌中央区转移瘤手术治疗的可行性。方法 选取23例肺腺癌中央区转移瘤手术患者,分析其临床资料、手术结果、术后综合治疗及随访结果。结果 23例患者中,22例患者位于中央区的转移瘤全切除,1例患者部分切除。术后1个月肌力好转14例,肌力无变化7例,肌力下降2例;中位总生存期为30.3个月,中位无进展生存期为22.0个月。结论 肺腺癌中央区转移瘤可开展手术切除为主的综合治疗。运用多模态影像神经导航等技术有利于保护重要神经功能,多学科综合治疗有利于改善肺腺癌中央区转移瘤预后。     

胰头十二指肠切除术26例分析

目的 提高胰头及壶腹部癌手术切除术，减少并发症及提高术后生存率。方法 总结26例胰头十二指肠切除术的治疗经验。结果 对26例胰头及壶腹部癌患者根据肿瘤不同分期行不同范围扩大切除及淋巴结清扫术，并行改良Child重建术。切除范围注重区域性整块切除，包括周围淋巴结清扫。消化道重建采用胰肠、胆肠端侧吻合。手术时间4.0-6.5h(平均4.6h)，术中平均失血500ml，手术并发症发生率为15．4％（4／26）。术后1、3、5年生存率分别为69．2％（18／26）、46．2％（12／26）、23．1％（6／26）。结论 胰头十二指肠切除术应由专业组人员完成。不同范围的清扫可降低肿瘤局部复发率。胰肠、胆肠端侧吻合操作不复杂，术后并发症发生率较低。     

腮腺癌侵入颅内的手术治疗

目的研究腮腺癌侵入颅内的特征及其手术治疗的注意事项.方法6例腮腺癌侵入颅内的病人均有腮腺癌手术史,其中2例曾接受2次腮腺癌手术.本组病历病程1年至2.5年,都有乳突部及枕骨破坏、肿瘤突起.2例岩骨及内听道受压破坏.4例局限于幕下,2例侵及幕上下.结果6例中4例行全切,2例因肿瘤包绕横窦行次全切除.术后病理诊断:恶性混合瘤5例,腮腺腺癌1例.术后病人恢复良好,无1例死亡.随访6个月～30个月,无1例复发.结论腮腺癌如其侵入颅内,根据肿瘤特征,选择最佳的手术方法,尽可能切除肿瘤,能明显降低病人的死亡率和延长生存期.     

Vater壶腹癌局部切除52例临床分析

探讨总结Ｖａｔｅｒ壶腹癌局部切除的理论依据,复发原因,适应证,术式评价。方法收集并分析国内１９９２－１９９７年报告的４８例和我院经治的４例,共５２例局部切除治疗Ｖａｔｅｒ壶腹癌的临床资料。结果５２例Ｖａｔｅｒ壶腹癌行局部切除术,并发症发生率９．６％,手术死亡率３．８％。随访７个月至８年,１２例复发,其中７例切缘有癌组织残存;低分化腺癌３例,侵袭性腺癌１例;１９例死亡（包括２例手术死亡）,余生存８个     

Skull metastasis of ampulla of Vater adenocarcinoma 5 years after Whipple operation: case report and literature review

Skull metastases can occur with nearly all types of tumor. They frequently are asymptomatic, causing local swelling, which is usually painless and rarely leads to neurological dysfunction. Carcinoma of the ampulla of Vater is an uncommon tumor accounting for approximately 0.2% of all gastrointestinal malignancies, with an estimated incidence of less than 6 cases per 1,000,000 population per year. We report about an extremely rare case of a 54-year-old female patient with a right frontal skull metastases of an ampulla of Vater adenocarcinoma 5 years after pylorus-preserving pancreaticoduodenectomy. Literature review revealed only one published case of cranial bone metastases of carcinoma of the ampulla of Vater. To the best of our knowledge this is the first case report of skull metastases of ampullary adenocarcinoma after a symptom-free interval of 5 years after R0 resection of the primary tumor, and the second published case that involves the skull.     

Factors influencing recurrence after curative resection for ampulla of Vater carcinoma

BACKGROUND: Carcinoma of the ampulla of Vater has a relatively higher resection rate, lower recurrence rate, and more favorable prognosis than other malignant tumors of the periampullary region. Because of the relative low incidence of carcinoma of the ampulla of Vater, there have been few reports on the patterns and risk factors of recurrence after curative resection. The aim of this study was to evaluate the patterns and risk factors of recurrence after curative resection of ampulla of Vater carcinoma. MATERIALS AND METHODS: Between January 1992 and December 2002, 102 patients received radical resection for ampulla of Vater carcinoma at Yonsei University Medical Center. Fifteen patients were excluded because of incomplete clinicopathologic data. Finally, 87 patients were reviewed and analyzed to assess predictors of tumor recurrence. RESULTS: Among the 87 patients, 37 patients (42.5%) experienced recurrent disease. The mean length of time to recurrence was 29.3 +/- 35.3 months, and the most common sites of recurrence were the intra-abdominal organs: liver and loco-regional lymph nodes. The patients were divided into two groups: early recurrence (18 months). In the early recurrence group, ulcer formation tumors and poorly differentiated tumors were more common in comparison with the late recurrence group. Lymph node metastasis was identified as an independent factor of tumor recurrence after curative resection for ampulla of Vater carcinoma. CONCLUSION: Lymph node metastasis is the most important risk factor for recurrence after a curative resection. Also, the fact that a higher probability of recurrence is anticipated in cases of ulcer formation and poorly differentiated tumors, there exists a need for a close-up follow-up program.     

Pedunculated Early Ampullary Carcinoma Treated by Ampullectomy: Report of a Case

Case Report

A 30-year-old woman was admitted to our hospital for treatment of an ampullary tumor. Upper gastrointestinal endoscopy revealed a pedunculated tumor in the ampulla of Vater with a diameter of 50 mm, which was biopsied and diagnosed as tubulovillous adenoma with moderate atypia. Endoscopic ultrasonography demonstrated a hypoechoic tumor limited to the mucosa and without evidence of lymph node metastasis. Since endoscopic resection was not indicated because of the large size and pedunculated morphology with a long stalk, the patient underwent ampullectomy and papilloplasty. Histological examination revealed well-differentiated tubular adenocarcinoma in tubular adenoma with severe atypia limited to the mucosa. The patient remains well with no evidence of recurrence 10 months after resection.

Discussion

Ampullectomy is an established method for ampullary tumor, but such a tumor with a long stalk is rare.     

Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater

In a series of 52 patients presenting with tumors of the ampulla of Vater, endoscopic procedures, especially endoscopic sphincterotomy and snare biopsies, permitted histologic classifications as follows: adenocarcinoma: 50%, adenoma: 35%, and adenoma with cancer: 15%. In 37% of cases, the papilla was normal endoscopically and the tumor was detected only after sphincterotomy. Destruction of adenomas by snare resection, laser photoradiation, or both after sphincterotomy was attempted in 11 patients. Subsequent biopsies revealed persistence or recurrence of adenomatous tissue in only one case and complete destruction of adenomas, with a mean duration of follow-up of 39 months, in the 10 other cases. Palliative treatment by endoscopic procedures was performed in 21 patients and was effective for a mean of 45 months for adenomas and for a mean of 6 months for adenocarcinomas, with a mortality of 10%. To avoid repeated sphincterotomy in patients requiring palliative treatment, the data support the early use of endobiliary prostheses. Endoscopic palliative treatment is not indicated, however, for infiltrative tumors that can induce rapid duodenal obstruction.     

扩大乏特氏乳头切除术的临床应用

目的 介绍扩大乏特氏乳头切除术（ｅｘｔｅｎｄｅｄ ｒｅｓｅｃｔｉｏｎ ｏｆ Ｖａｔｅｒ ｐａｐｉｌｌａ,ＥＲＶＰ）,探讨其临床使用价值。方法 １９９３～１９９５年间,按以下标准选择１２例Ｖａｔｅｒ壶腹部肿瘤行ＥＲＶＰ：（１）术前检查无远处转移征象。（２）术中探查无肝脏以及腹腔转移,胰十二指肠周围淋巴结活检阴性。（３）肿瘤直径≤２ｃｍ,术中病理报告为腺癌或腺瘤,并且切缘阴性。对患进行临床观察和随访,结合献进行分析。结果 １２例ＥＲＶＰ无手术死亡和并发症,平均手术时间２ｈ２０ｍｉｎ,平均输血４３３ｍｌ,平均住院时间１５．８ｄ。１０例Ｖａｔｅｒ壶腹部腺癌中,５例平均存活４２个月（３６～６２个月）;５例无瘤健存２０～６４个月,有２例Ｖａｔｅｒ壶腹部腺瘤已分别存活４２个月和３６个月。结论 ＥＲＶＰ手术易掌握,创伤小     

Carcinoma of the ampulla of vater. A clinicopathologic study and pathologic staging of 109 cases of carcinoma and 5 cases of adenoma

A total of 109 cases of carcinoma and 5 cases of adenoma of the ampulla of Vater were studied by preparing 5-mm step-wise whole tissue sections in each case. Carcinoma of the ampulla of Vater could be divided into four stages (I, II, III and IV), according to the microscopically verified extent of involvement by the tumor. All 12 patients with a Stage I tumor, defined as one restricted to within the muscle of Oddi as a boundary, showed no lymph node involvement and carried an excellent life expectancy with a relative 5-year survival rate of 85%. Thus, categorization of such a tumor as early carcinoma of the ampulla of Vater is valid. Excluding two unclassifiable cases, the remaining 95 patients with Stage II, III, or IV tumors extending beyond the boundary of Oddi carried relative 5-year survival rates of 11%, 25%, or 24%, respectively. Of the 109 carcinomas, 20 had areas of unequivocal adenoma at the margins, and of the five adenomas, two larger ones had foci of atypical epithelium suggestive of carcinoma in situ. These findings show the close relationship between adenoma and adenocarcinoma of the ampulla of Vater.     

Metastatic Adenocarcinoma of Parotid Gland Originating from the Ampulla of Vater: Case Report and Review of the Literature

Aim

To report a rare case of metastasis from an adenocarcinoma of the ampulla of Vater to the parotid gland.

Patients and Methods

In February 2004, a 61-year-old male underwent Whipple surgery due to a grade II adenocarcinoma of the ampulla of Vater (stage IB:pT₂N₀M₀). Post surgery, the patient did not receive any adjuvant treatment, but was followed up regularly. Two years post surgery, an abdominal computed tomography (CT) revealed metastatic hepatic lesions. The patient subsequently underwent three lines of chemotherapy without significant response. Two months after chemotherapy (April 2007), the patient complained of a painless lump in the parotid region that was progressing fast. Not long after presentation, the mass caused severe local pain that was hardly managed with opioid analgesics. A head and neck CT depicted a 5?×?4?×?3 cm solid mass that was infiltrating the masseter and pterygoid muscles, the mandible, and parotid gland. Fine needle aspiration showed that the infiltrating mass was due to an adenocarcinoma of the ampulla of Vater. The patient subsequently received palliative radiotherapy (50.4 Gy), achieving a considerable therapeutic response.

Conclusions

Metastasis of adenocarcinoma of the ampulla of Vater to the parotid gland has not to our knowledge been previously reported. Radiotherapy offers an excellent means of palliation with minimal morbidity.     

Coincidence of GIST and pancreatic endocrine neoplasm in neurofibromatosis

Carcinoids of the ampulla of Vater are infrequent tumors of which a quarter of cases have been detected in patients with type I neurofibromatosis. This hereditary disease is also associated with gastrointestinal stromal tumors (GIST). However, the coincidence of these three entities together have only been formerly detected in five cases. A 53 year-old female patient, diagnosed with type I neurofibromatosis, with a malignant carcinoid of ampulla of Vater and multiple gastrointestinal stromal tumors in the duodenum and jejunum, was treated with total pancreatectomy and the excision of her intestinal tumors. Five-years on, a follow-up showed the patient to be well, and free from tumor recurrence. The coexistence of an ampullary carcinoid tumor, GIST and neurofibramatosis is very rare. Radical curative surgical resection is a good treatment option, but the optimal management of this is not yet well established.