结直肠无蒂锯齿状病变的特征和临床问题

无蒂锯齿状息肉/腺瘤（SSL）曾经被认为是良性病变,而现有研究表明,通过锯齿状瘤变途径,约15%～30%的SSL最终发展为结直肠癌。锯齿状息肉分为增生性息肉、无蒂锯齿状病变、伴发育不良的无蒂锯齿性病变、传统锯齿状腺瘤和未分类锯齿状腺瘤,每一种都具有不同的形态学和分子特征。尽管对SSL的理解有所提高,但由于频繁的病理错误分类、结肠内镜检测不足和不完全切除率高,SSL仍然是内镜和病理医生面临的诸多临床挑战。本文总结了目前对锯齿状息肉的新认识和诊断问题。     

Pathology of colorectal polyps and cancer

Colorectal adenomas and cancers are common. Diagnosis and management of these lesions requires close clinical-pathological correlation. This article emphasizes clinically important issues in management of adenomas, including serrated lesions, and early stage cancers removed by local excision. Pathological interpretation and staging of formal resection specimens is also discussed. The biology of colorectal cancer is emphasized, particularly reflecting the need for molecular analysis to guide adjuvant oncological treatment.     

Serrated polyp detection rate during screening colonoscopy

Aim The adenoma detection rate is an important quality indicator for colonoscopy, but recently, serrated polyps of the large bowel have been recognized as important premalignant lesions. As they are often more difficult to see than adenomas, the detection rate of serrated polyps is set to become a more stringent indicator of quality in colonoscopy than adenoma detection rate. Here we aim to provide preliminary data on serrated polyp detection. Method This is a retrospective review of prospectively collected data. Colonoscopies were stratified by one of six colorectal surgeons, each of whom had performed more than 1000 colonoscopies. Exams were separated by indication and the number of patients with at least one adenoma or one serrated polyp recorded. Time of withdrawal in normal examinations was noted. Results Eighteen thousand and three colonoscopies were included. Average completion rate was 96.3 ± 1.2%. Mean serrated detection rate for all examinations was 20.6 ± 4.8% and for screening examinations only was 13.9 ± 5.0%. Corresponding means for adenoma detection were 31.5 ± 6.7% and 20.7 ± 4.1%, respectively. Simple regression of overall adenoma detection rate versus overall serrated detection rate was not significant (R = 0.571, P = 0.237), but was significant for screening exams (R = 0.854, P = 0.031). There was a strong relationship between time of withdrawal and serrated detection rate (screening, R = 0.908, P = 0.012; overall, R = 0.956, P = 0.003). Conclusion Taking time to withdraw the colonoscope is essential for maximum detection of serrated polyps. The ability to find adenomas does not necessarily correlate with an ability to find serrated polyps.     

Pathology of colorectal neoplasia

Colorectal adenomas and cancers are common. Diagnosis and management of these lesions requires close clinicopathological correlation. This article emphasizes clinically important issues in management of adenomas, including serrated lesions, and early stage cancers removed by local excision. Pathological interpretation and staging of formal resection specimens is also discussed. The biology of colorectal cancer is emphasized, particularly reflecting the need for molecular analysis to guide adjuvant oncological treatment.     

Bcl-2蛋白在结直肠锯齿状病变伴癌变组织中的表达及其临床意义

为探讨Bcl-2蛋白在结直肠锯齿状病变伴癌变组织中的表达及其临床意义,本研究采用免疫组织化学Envision法检测Bcl-2蛋白在75例锯齿状息肉／腺瘤伴癌变组织及10份健康结直肠黏膜组织中的表达情况。结果显示,Bcl-2蛋白在75例锯齿状息肉／腺瘤伴癌变组织中均有表达,阳性细胞定位于细胞质、细胞膜及细胞核;10份正常结直肠黏膜组织中仅在腺窝基底部有少量细胞见Bcl-2阳性表达,其余腺上皮均不表达。在病变的不同区域,低级别上皮内瘤变、高级别上皮内瘤变及癌变区域中,Bcl-2的阳性表达率分别为44．0％、82．7＇％和78．7％,Bcl-2在癌变及高级别上皮内瘤变区域中的阳性表达率明显高于其在低级别上皮内瘤变区域中的表达（P〈0．05）,而Bcl-2在癌变及高级别上皮内瘤变区域中的阳性表达率差异无统计学意义（P〉0．05）。结果表明,Bcl一2蛋白在结直肠锯齿状息肉／腺瘤伴癌变组织中的不同病变阶段有不同程度的表达,Bcl一2蛋白可作为早期诊断结直肠锯齿状息肉／腺瘤伴癌变的重要指标之一。     

Importance of serrated polyps in colorectal carcinogenesis

Colorectal cancer is an invasive neoplasm of the glandular epithelium of the colon and rectum that begins in a precursor lesion and expands to replace its lesion of origin. The majority of colorectal cancers arise from an adenoma, and the ‘adenoma to carcinoma’ pathway has been acknowledged for decades. More recently, another precursor lesion has been recognized: the serrated polyp. Serrated polyps are characterized by a sawtooth appearance of the crypt epithelium resulting from failure of apoptosis and a build‐up of aging colonocytes. Although initially felt to be innocent of involvement in colorectal carcinogenesis, some types of serrated polyp are being increasingly recognized as precursor lesions, prone to develop into cancer, and likely to be a cause of ‘missed’ or interval cancers after colonoscopic screening. It is essential that gastrointestinal specialists appreciate the clinical significance of these lesions and what that means for colorectal cancer screening, and prevention. The purpose of this review is to highlight the importance serrated lesions of the colon and rectum, and to summarize current opinion on their natural history, diagnosis, surveillance and treatment.     

Endoscopic characteristics of gastric adenomas suggesting carcinomatous transformation

Background  Currently, endoscopic resections, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), are widely performed for the management of gastric neoplasia. This study aimed to evaluate the potential predictive factors for carcinomas on the basis of endoscopic features. Methods  This study investigated 114 samples from 114 patients. Gastric adenoma was diagnosed initially for all the patients. The endoscopic findings were reviewed for location, size, gross appearance, surface nodularity, ulceration, surface color, and number of biopsy samples. These variables were analyzed and compared between an adenoma group (51 cases) and a carcinoma group (63 cases) on the basis of postresection diagnosis. Results  The mean age of the patients was 62 years (range, 43–82 years), and 83 of the patients were men. The diameter of the lesions was 14.6 ± 8.2 mm in the adenoma group and 15.4 ± 7.4 mm in the carcinoma group. Depressed type, combined high-grade dysplasia, red discoloration, and mucosal ulceration were significant variables associated with carcinomas. In the multivariate analysis, combined high-grade dysplasia was a significant independent predictor of carcinomas. Conclusions  The results suggest that patients with high-grade dysplasia on forceps biopsies should be considered candidates for endoscopic resection. Characteristics of gastric adenomas such as a depressed type, red color, and ulceration that may have foci of carcinomas in other parts of the adenomas also should be considered for endoscopic resection.     

原发腺瘤的病理学特征预测直肠异时性腺瘤的发生

目的　探讨直肠原发腺瘤的病理学特征与直肠异时性腺瘤再发的关系。方法　自 1977年至 1978年用 15cm直肠镜对海宁县 185 85 1居民进行直肠肿瘤筛查 ,共发现 1490例直肠腺瘤患者。这些患者在直肠腺瘤切除后 ,用内镜检查方法分别于第 2、4、6、11及 16年进行随访 ,观察直肠有无新生的异时性腺瘤。并分析首次筛查发现直肠腺瘤的病理学特征与发生直肠新生异时性腺瘤、重度不典型增生腺瘤和癌的关系及相对危险性。结果　随访中发现 2 80例患者在直肠内发生了新腺瘤。具有 2个以上的原发腺瘤、原发腺瘤直径大于 1cm、绒毛状 /混合型和中、重度不典型增生腺瘤患者发生异时性腺瘤的危险性升高 2～ 3倍 ,具有统计学意义。大于 1cm腺瘤 ,绒毛状 /混合型腺瘤及重度不典型增生腺瘤与发生癌或异时性重度不典型增生腺瘤明显相关 ,其相对危险性分别为 4 2 (1 8～ 9 9)、8 1(4 2～ 15 6 )和 14 4(5 0～ 41 3)。与伴轻度不典型增生、小于或等于 1cm腺瘤的患者相比 ,伴重度不典型增生、超过 1cm腺瘤的患者发生异时性直肠肿瘤的相对危险性为 37(7 8～174 7)。结论　直肠异时性腺瘤的危险性与原发腺瘤的病理学特征密切相关 ,因此 ,在高危组腺瘤患者的原发腺瘤切除后 ,应对他们进行密切监视。     

锯齿状缝线皮下埋置面部提升术--附168例临床应用观察

目的：应用特制的锯齿状缝线置于皮下，拉紧松弛组织，以研究一种微创面部皮肤松弛提升的术式。方法：将两端具有细微的、向中央倾斜的锯齿状缝线，通过含有针芯的穿刺导引针，置于皮下，治疗面部松弛者168例，观察临床效果。结果：随防观察，根据术者和求术者的综合判断，显示效果满意，总有效率92．26％。结论：此方法治疗面部皮肤松弛具有良好效果，且操作简便、安全、省时、创伤轻、痛苦小、费用低，值得推广应用。     

Functional classification of pituitary adenomas

Summary Results of clinical, endocrinological, and ultrastructural studies of 60 cases of pituitary tumours are presented. A functional classification of such tumours that would: allow a clear correlation between clinical symptoms and the adenoma type, is discussed together with data available from the literature.A case of pituitary adenoma secreting more than two hormones is presented.     

散发性甲状旁腺腺瘤基因改变的研究进展

散发性甲状旁腺腺瘤是引起原发性甲状旁腺功能亢进的重要原因.但甲状旁腺腺瘤发病机制不清且缺乏早期特异性诊断指标.近年来随着分子生物学的发展,甲状旁腺腺瘤在基因水平的研究取得了很大的进展.本文就其在分子生物学的改变做一综述.     

大型垂体腺瘤的显微手术治疗

目的 探讨大型垂体腺瘤的显微手术治疗方法。方法 根据肿瘤的部位、质地、内分泌测定和MRI检查T2信号特点选择手术入路切除肿瘤，其中82例经翼点入路，22例经额下入路，6例经蝶窦入路，3例行额下经蝶窦入路。术后全部进行放疗。结果 102例(90．3％)显微镜下全切，11例(9．7％)次全切除。术后死亡2例(1．8％)。术后视力视野改善98例(86．7％)，无变化15例(13．3％)。术后5年内复发6例(6．3％)。结论 采用显微外科技术，针对肿瘤的特点选择不同的手术入路及综合治疗是提高大型垂体肿瘤全切率、降低死亡率和复发率的关键。     

Primary aldosteronism and hypercortisolism due to bilateral functioning adrenocortical adenomas

A 50-year-old male patient with a 15-year history of hypertension was referred to our hospital for evaluation of bilateral adrenal tumors. No Cushingoid features were observed. Computed tomographic scan showed 10-mm masses in each adrenal gland. Preoperative endocrinological examinations revealed autonomous cortisol and aldosterone secretion in this patient. The results of a subsequent adrenal venous catheterization study were consistent with the presence of a left cortisol-producing tumor and a right aldosterone-producing tumor. A left partial adrenalectomy was performed initially, but cortisol and aldosterone over-secretion persisted. Accordingly, the patient underwent a right adrenalectomy. Pathological examination of the resected specimens, including immunohistochemical analysis, demonstrated that both adenomas possibly produced cortisol and aldosterone. This is an extremely rare case of bilateral adrenal tumors, in which the left adrenocortical tumor produced and secreted cortisol or both cortisol and aldosterone and the right one produced and secreted both aldosterone and cortisol, as confirmed by clinical findings and pathological studies using immunohistochemical analysis.     

Filiform serrated adenomas: a clinicopathologic and immunophenotypic study of 18 cases

In this study, we describe a previously uncharacterized type of adenomatous polyp of the colorectum that shows prominent, thin, elongated projections of neoplastic epithelium with a serrated contour, which we have termed "filiform serrated adenoma" (SA). Routinely processed polypectomy specimens from 18 patients with filiform SA and 23 controls with traditional (nonfiliform) SA were evaluated for their clinical and pathologic features, and immunohistochemically stained for a variety of markers (O-methylguanine methyltransferase, MLH1, MSH2, CDX2, nuclear beta-catenin, p53, and Ki-67) designed to evaluate their molecular and proliferative characteristics. DNA was extracted from the paraffin-embedded materials, amplified by polymerase chain reaction, and analyzed for microsatellite instability, BRAF, K-ras, and p53 mutational status. Five cases contained sufficient non-neoplastic tissue for dissection and DNA extraction, allowing analysis of loss of heterozygosity. The study group consisted of 7 males and 11 females of mean age 64 years (range: 42 to 89 y). All 18 filiform SAs were located in the left colon, including 15 (83%) that occurred in the rectum, compared with 43% of the control group (P=0.03). Filiform SAs were also larger (1.6 cm) than SAs (mean: 1.2 cm, P=0.02), but no other clinical differences were noted. Most (56%) filiform SAs contained marked stromal edema and tall nonmucinous cells with abundant eosinophilic cytoplasm (61%). High-grade dysplasia was present in 4/18 (22%) cases. Four (22%) filiform SAs also contained nonserrated adenomatous elements with a villous (3 cases) or tubular (1 case) growth pattern. Two (11%) cases contained adjacent areas of sessile SAs and 4 (22%) had hyperplastic areas. None of the polyps in the control group showed stromal edema, high-grade dysplasia, or mixed elements. Polyps in both groups demonstrated comparable staining patterns for O-methylguanine methyltransferase, MLH-1, MSH-2, CDX2, beta-catenin, and Ki-67, and none showed increased nuclear p53 expression. Low-frequency microsatellite instability was present in 5/12 (42%) filiform SAs, 7/12 (58%) were microsatellite stable. Mitogen-activated protein kinase pathway abnormalities were present in 71% of the cases [7/14 (50%) with BRAF and 3/14 (21%) with K-ras mutations]. Four cases showed silent p53 mutations upon direct sequencing and 4 revealed loss of heterozygosity at the loci evaluated, including 1 at D5S346 [adenomatous polyposis coli (APC) gene], 1 at D17S250 (p53 gene), and 2 at MYCL (chromosome 1p34). We conclude that filiform SA potentially represents an unusual variant of SA with a predilection for the left colon, particularly the rectum.     

替莫唑胺治疗难治性垂体腺瘤

目的 探讨替莫唑胺在难治性垂体腺瘤中的疗效。方法 回顾性分析近年收治的3例难治性垂体腺瘤患者,包括1例侵袭性无功能腺瘤,1例肢端肥大症,1例库欣病,总结其临床过程及应用替莫唑胺治疗后的效果并结合文献进行分析。结果 侵袭性无功能腺瘤患者经12个月替莫唑胺治疗,肿瘤明显缩小,随访1年,未见肿瘤进展;肢端肥大症患者经过6个月治疗,随访3月,肿瘤有所缩小,激素水平无明显下降;库欣病患者经过4个月治疗,肿瘤无明显变化,激素水平无下降。结论 替莫唑胺在控制难治性垂体腺瘤大小可能有一定作用,但短疗程的治疗对肢端肥大症和库欣病患者的激素水平控制效果不理想,日后仍需继续研究。     

经蝶入路显微手术治疗垂体腺瘤22例

目的探讨经蝶入路显微手术治疗垂体腺瘤的价值. 方法回顾性分析我院1990年1月～2001年12月22例经蝶入路显微手术治疗垂体腺瘤的临床资料. 结果肿瘤全切率68.2%(15/22).17例随访1～13年,视力视野障碍均有不同程度改善12例,5例失明均不能恢复. 结论经蝶入路显微手术治疗垂体腺瘤是微创、安全和有效的方法.