孤立性纤维性肿瘤35例临床病理研究

目的 观察孤立性纤维性肿瘤(SFT)的临床病理及免疫表型特点,探讨其诊断、鉴别诊断及预后.方法 对35例SFT进行光镜及免疫组化检测,并结合临床及病理特点进行分析.结果 35例SFT的发病年龄为9～79岁,平均47.5岁,男女之比为1.2:1,发生于13个部位.镜下可见多种改变并存的现象:肿瘤由梭形细胞构成的细胞稀少区和富于细胞区交替分布,有粗大的瘢痕样玻璃变性的胶原、分支状的血管外皮瘤样结构及大量增生的呈血管瘤样改变的薄壁血管;偶见黏液变、小囊性变及脂肪细胞分化.其中9例为恶性SFT.结论 孤立性纤维性肿瘤大部分为良性,肿瘤的病理形态与生物学行为之间不是绝对相关的(形态学为良性的SFP也可以有浸润),因此必须进行长期随访.一般情况下肿瘤有蒂和可以完整手术切除是良好的预后因素.     

外阴原发性孤立性纤维性肿瘤临床病理观察

目的探讨外阴原发孤立性纤维性肿瘤(SFT)的临床病理特点及鉴别诊断。方法分析2例外阴原发性SFT临床资料、病理学特征并复习相关文献。结果患者均为女性,年龄53岁和65岁。病变均位于左侧外阴靠近大阴唇。临床表现为渐进性增大包块,无痛或轻压痛,表面皮肤正常。肿瘤最大径3.5 cm和4.5 cm。低倍镜下,由交替分布的细胞丰富区和细胞稀疏区组成,瘤细胞呈席纹状、束状、无序状排列;细胞稀疏区间质内含有透明变性胶原纤维,间质血管丰富,可见厚壁扩张血管,但血管外皮瘤样结构不明显,未见坏死及核分裂象,灶区间质可见明显的黏液样变性。免疫组化:CD34、STAT6、CD99、bcl-2和vimentin(+)。2例术后均获得随访,无肿瘤复发或转移。结论外阴SFT是一种少见的肿瘤,发生间质黏液变性更为少见。患者预后较好,免疫组化CD34和STAT6(+),需与其他梭形细胞肿瘤相鉴别。     

鼻腔孤立性纤维性肿瘤3例临床病理分析

目的探讨鼻腔孤立性纤维性肿瘤(SFT)的临床特点、病理诊断及鉴别诊断、治疗与预后。方法回顾性分析3例鼻腔SFT的临床资料、组织学形态和免疫组化标记,并复习相关文献。结果3例SFT均为男性,均发生于右鼻腔。主要症状为鼻塞、流涕。肿块最大径3 cm～5 cm。镜下见病变位于黏膜下,边界较清,由交替分布的细胞密集区与稀疏区组成,瘤细胞呈梭形或卵圆形,似纤维母细胞,形态温和,无明显异型性,胞质少,淡嗜红色,核呈卵圆形,核仁不明显,偶见核分裂像(1个/10HPF),组织结构多样,多杂乱排列,局部呈束状或席纹状,间质见大量红染的胶原纤维束沉积。肿瘤组织内血管丰富,管壁薄,局部呈裂隙状,形成血管外皮瘤样结构,其中1例局部血管壁增厚,玻璃样变性。3例均未见坏死。免疫组化示3例肿瘤细胞CD34、STAT6、CD99、BCL-2均阳性,S100、SMA阴性,术后随访6～54个月,未见复发。结论发生于鼻腔的孤立性纤维性肿瘤(solitary fibrous tumor,SFT)少见,应注意与该部位的其他梭形细胞肿瘤鉴别,该肿瘤属于中间性肿瘤,局部可复发,偶见转移,应对其进行长期密切随访。     

胸膜孤立性纤维性肿瘤临床病理特征及免疫组化研究

目的:探讨胸膜孤立性纤维性肿瘤(SFT)的临床表现、组织学特征、免疫组化表达及鉴别诊断.方法:对12例SFT病例进行组织学观察,并行免疫组化CD34、Vim、CD99、Bcl-2、SMA、CK5/6、CD68、CD117、S-100、Mesothelial Cell (MC)和Calretinin (Cal)蛋白染色.结果:免疫组化染色示12例SFT CD34 100%阳性(12/12)、Vim 100%阳性(12/12)、CD99 75.0%阳性(9/12)、Bcl-2 83.3%阳性(10/12);SMA、CK5/6、CD68、CD117、S-100、MC和Cal均阴性.结论:SFT是一组形态多样,起源于一种CD34阳性的树突状间叶细胞的良性肿瘤,确诊有赖于组织学及免疫组织化学检查.SFT的生物学行为取决于肿瘤的大小及生长方式,手术切除肿瘤是治疗SFT最好的治疗手段,完全切除肿块者预后较好.     

眼眶多次复发恶变的孤立性纤维性肿瘤临床病理分析

目的探讨眼眶多次复发恶变的孤立性纤维性肿瘤(SFT)的临床特征、病理学特征、免疫表型、鉴别诊断、治疗及预后。方法应用常规HE及免疫组织化学染色法分析眼眶多次复发恶变SFT的临床病理特点及免疫组织化学表型,并总结相关文献。结果患者女,53岁,左眼上、下睑多次复发性肿物,主要临床表现为视力下降、夜间眼胀不适,向下视物时偶有重影。光镜下肿瘤主要由排列较为密集的梭形和类圆形细胞组成,浸润周围纤维结缔组织及脂肪,可见大量血管瘤样结构及池状扩张,另见小灶坏死区,核分裂计数约5个/10HP;未见明显血管壁玻璃样变及间质胶原纤维沉积。免疫组化:STAT6胞核弥漫强(+)、CD34弥漫强(+)、CD31、ERG、SMA示丰富血管(+),Ki-67约10%(+),p53(野生型)。结论眼眶多次复发恶变的SFT极为少见,其复发主要与切除不净相关。其形态学表现多样,主要由梭形和类圆形细胞组成,无特殊结构模式。本例无明显血管壁玻璃样变及间质胶原沉积,形态学上不够典型,应注意避免漏诊;应与纤维型脑膜瘤、恶性周围神经鞘瘤、梭形细胞恶性黑色素瘤、单相性纤维型滑膜肉瘤鉴别。恶性SFT尚无统一的诊断标准,核分裂为其最重要的参数,临床工作中可参照安德森癌症中心单变量模型及危险分层模型作为评估SFT是否为恶性及其预后的标准。     

孤立性纤维性肿瘤6例临床病理分析

目的探讨孤立性纤维性肿瘤(SFT)的临床病理特征、诊断、鉴别诊断、治疗及预后。方法回顾分析6例SFT患者的临床及病理资料,并复习相关文献。结果 6例患者中,男性3例,女性3例。年龄:18~61岁,平均年龄47.8岁。肿物位置:3例原发肿瘤分别位于右胸壁、右肺下叶和颅内,另外,1例为右耳前肿物切除术后2年复发,1例为颅内肿物切除术后2年转移至右颌下,1例为左眼眶内肿物切除术后7年、第2次复发。2例表现为经典型SFT、其中一例间质有明显的黏液样变性,其余4例形态学均表现为恶性。免疫组化示肿瘤细胞STAT6、Vimentin、Bcl-2均(+),CD34、CD99不同程度(+),1例CK(+)。结论 SFT可发生于全身各个部位,其病理形态特征多样,易与其他软组织肿瘤混淆,结合形态学特征和免疫组化有助于其诊断。SFT属于中间生物学行为肿瘤,可复发或转移,需长期随访。     

胸外恶性孤立性纤维瘤2例临床病理学观察

目的探讨胸膜外恶性孤立性纤维性肿瘤(SFT)的临床病理特征、诊断、鉴别诊断及预后。方法回顾性分析2例胸外恶性孤立性纤维性肿瘤,并复习相关文献。结果 2例患者均为男性,年龄分别为59岁和76岁,1例肿瘤位于右顶部大脑镰旁,另1例位于右肩部,肿瘤大小分别为3 cm×3 cm×2 cm和8 cm×6 cm×3 cm。镜下肿瘤组织呈席纹状、编织状、漩涡状结构,散在有胶原分布。瘤细胞以梭形细胞为主,细胞核呈短梭型或卵圆形,颅内肿瘤细胞异型性不明显,肩部肿瘤细胞异型性非常明显,可见巨核、染色质粗颗粒状的细胞。2例核分裂象均易见。免疫组化:肿瘤细胞vimentin、CD34、STAT6、bcl-2和CD99均(+),S-100、desmin、EMA和Actin均(-)。结论发生在颅内及肩部的恶性SFT临床较少见,易与其它软组织肿瘤混淆,需与脑膜瘤、周围神经鞘膜瘤、多形性脂肪肉瘤、滑膜肉瘤鉴别,确诊需要依靠病理学形态及免疫表型。     

伴FET-CREB融合的颅内间叶性肿瘤1例报告并文献复习

目的 探讨颅内间叶性肿瘤，FET-CREB融合阳性型的临床病理特征、免疫表型及鉴别诊断。方法 回顾性分析1例颅内间叶性肿瘤，FET-CREB融合阳性型的临床病理特征及免疫表型。运用高通量测序检测其基因改变并复习相关文献。结果 肿瘤呈漩涡状、结节状分布，肿瘤细胞疏密不等，部分区域瘤细胞稀疏，稀疏区间质黏液样变性；部分区域细胞致密，呈弥漫片状分布，间质可见胶原化改变，局灶可见血管瘤样结构区及带状淋巴细胞浸润灶。免疫组化：瘤细胞CD99、Desmin弥漫阳性，MUC-4部分阳性，INI-1表达未缺失。高通量测序检测出肿瘤EWSR1:CREB1基因融合。结论 颅内间叶性肿瘤，FET-CREB融合阳性型组织形态多样，缺少特异性的免疫表型，需结合组织病理、免疫表型及分子病理综合诊断。     

7例颅内孤立性纤维性肿瘤/血管周细胞瘤临床病理分析

目的讨论颅内孤立性纤维性肿瘤/血管周细胞瘤(SFT/HPC)的临床病理学特征及鉴别诊断。方法回顾分析7例颅内SFT/HPC临床及影像学特征、病理学特征及免疫表型。结果本组病例中男性3例,女性4例,中位年龄52岁(38~59岁)。临床症状多为头晕头痛、肢体麻木、颅内高压等;MRI/CT示与脑膜关系密切,为富于血供肿瘤,增强扫描呈明显强化。5例为WHOⅡ级,镜下见肿瘤细胞丰富,由梭形或多角形细胞构成,间质富含薄壁"鹿角状"血管及胶原纤维,瘤细胞围绕血管呈车幅状或同心圆样排列,核分裂象0~3个/10HPF;2例为WHOⅢ级,镜下见细胞密集,异型性明显,核分裂象8~10/10HPF。免疫组化结果示7例CD34、vimentin、STAT6(+)(7/7,100%),CD99(5/7,71.4%)及bcl-2(4/7,57.1%)部分(+),PR及EMA分别有1例(+),S-100、SMA均为(-),Ki-67(2%~10%)。随访13~87个月,2例患者术后复发,其中1例术后72个月复发并发生肺转移死亡。结论SFT/HPC为颅内罕见肿瘤,与脑膜关系密切,组织学形态多变,STAT6阳性可为特异性指标。应结合免疫组化、融合基因检测与脑膜瘤等鉴别。术后可复发转移,需长期随访。     

近端型上皮样肉瘤5例临床病理分析

目的 探讨近端型上皮样肉瘤(PES)的临床病理特点、免疫表型、诊断及鉴别诊断.方法 收集5例PES患者的临床资料,观察其组织病理学形态、免疫组化特征并进行随访.结果 5例PES中男性3例,女性2例,发病年龄28～54岁,分别位于头部、臀部、腹股沟、胸壁、胸椎.临床均表现为无痛性生长的结节状肿块.镜下肿瘤由上皮样细胞、梭形细胞混合并相互过渡组成,呈结节状或结节融弥漫合成片状,中央常见坏死;其中2例周边可见肉芽肿性改变.细胞间见明显的胶原纤维沉积.细胞呈上皮样或梭形,胞质丰富,嗜酸性;细胞核卵圆形、空泡状,核仁明显,一个或多个,核分裂象多见,常见横纹肌样细胞.免疫表型:5例瘤细胞vimentin、CKpan、EMA和β-catenin(+),3例CD34(+),1例desmin(+),2例CD99(+),而S-100、HMB45、melanA、SMA、myogenin、CD31、FⅧ、HHF35和bcl-2均(-).5例PES均行肿物局部切除或扩大切除,其中3例辅以放疗或化疗,5年的随访中均有复发和转移.结论 PES因肿瘤组织主要由上皮样细胞、横纹肌样细胞及梭形细胞构成,形态复杂多样,极易与具有类似形态的多种肿瘤混淆,故其鉴别诊断显得尤为重要.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.