Diagnosis and fine needle aspiration of intraductal papillary mucinous tumor by endoscopic ultrasound

A recently established clinical entity, intraductal papillary mucinous tumor (IPMT) of the pancreas embraces a spectrum of pathology ranging from benign to malignant disease. IPMT must be differentiated from other cystic neoplasms of the pancreas, as well as inflammatory cystic lesions. As the pancreas lies in close proximity to the gastric and duodenal walls, endoscopic ultrasonography (EUS) is ideally suited for imaging the pancreas. Additionally, EUS facilitates fine needle aspiration of pancreatic cysts and/or a dilated pancreatic duct for cytologic and tumor marker analysis. This article presents a brief history of IPMT, differential diagnosis, current imaging modalities, findings of cytologic and tumor marker analysis, prognosis, and treatment strategy. Special emphasis is dedicated to the role of EUS, as well as EUS with fine needle aspiration.     

The role of laparoscopy and laparoscopic ultrasound in the diagnosis of cystic lesions of the pancreas

With the widespread use of advanced imaging techniques, cystic lesions of the pancreas are now diagnosed relatively frequently. The nature of these lesions vary from benign cysts (serous cvstadenoma) or an inflammatory process (pseudocyst), to premalignant (mucinous cystadenoma) or frankly malignant lesions (cystadenocarcinoma). Differentiation of various types of pancreatic cysts presents a diagnostic and therapeutic challenge, as clinical presentation may be vague. Laparoscopic ultrasonography (LAPUS), the biopsy of the cystic wall, and analysis of the cystic aspirate, although expensive and rather invasive procedures, significantly contribute to the differential diagnosis of pancreatic cystic lesions.     

Mucinous cystic neoplasms of the pancreas

Mucinous cystic neoplasms of the pancreas (MCNP) are rare tumors with presentation and findings that differ in most cases from pancreatic pseudocysts. A simple pancreatic cystic lesion in a younger-aged patient with a history of pancreatitis and endoscopic retrograde cholangiopancreatography (ERCP) demonstration of ductal communication with the cyst strongly suggests the diagnosis of a benign pseudocyst. MCNP may have extensive areas without an epithelial lining, adding histologic sampling error to the potential for confusing these two entities. Pancreatic pseudocysts are benign lesions treated by enteric drainage procedures, while MCNP have significant malignant potential, and resection is advised. Even when clinical presentation and imaging are persuasive for a benign cyst, MCNP of the pancreas should be considered in planning, evaluation, and treatment.     

合并部分十二指肠切除的胰头切除术的研究进展

胰十二指肠切除术(pancreaticoduodenectomy,PD)已成为医治胰头、壶腹周围良恶性肿瘤的经典标准术式。但因其有解剖复杂,手术时间长,创面大,术后患者康复慢,常有诸多并发症产生等特点,因此外科医生一直在寻找更合理的替代术式。合并部分十二指肠切除的胰头切除术(pancreatic head resection with segmental duodenectomy,PHRSD)对年老体弱、全身情况差、重要脏器功能较弱或过于肥胖的良性及恶性程度低的胰头肿瘤患者有一定的优势,PHRSD需根据病变部位选择术式。     

Cystic Tumors of the Pancreas: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Features

Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article aims to review the histopathologic and imaging findings of the relatively common lesions (serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor) and uncommon lesions (cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas) in this group.     

胰腺良性肿瘤23例临床治疗分析

目的 探讨胰腺良性肿瘤的诊断与治疗,手术方式的选择,术后并发症的防治.方法 回顾性分析我院2004年1月至2009年12月收治的23例胰腺良性肿瘤患者的临床资料.患者均接受外科手术治疗.5例行肿瘤摘除术,8例行胰体尾脾脏切除术,1例行胰腺中段切除术,5例行胰十二指肠切除术,4例行胰腺囊肿空肠R-Y吻合内引流术.18例患者手术后应用了生长抑素.结果 本组术后病理诊断:胰腺囊肿8例,胰岛细胞瘤4例,黏液性囊腺瘤6例,浆液性囊腺瘤3例,实质性假乳头状瘤2例.10例发生胰瘘的患者有7例出现继发的腹腔感染.死亡1例,死于胰十二指肠切除术后多脏器功能衰竭.结论 胰腺良性肿瘤无特异性症状和血清学实验室检查,CT及内窥镜下逆行性胰胆管造影术(ERCP)对临床诊断治疗有很大帮助.手术方式的选择取决于肿瘤生长部位及术中对肿瘤良恶性的判断,可行胰十二指肠切除术、胰腺中段切除术、保留或不保留脾脏的胰体尾切除术及肿瘤摘除术.胰瘘是手术后主要的并发症.可靠结扎主胰管、妥善处理胰腺创面、胰液外引流可以降低胰瘘发生率.     

Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions

Purpose

To facilitate a better understanding of incidentally noted cystic pancreatic lesions, since these lesions often pose a challenge regarding appropriate management.

Methods

This article reviews pathophysiology, prevalence, significance, and recommendations for management of the various pancreatic cystic lesions. Illustrative cases are demonstrated.

Results

Diagnostic benign lesions can be left alone. Cross-sectional imaging can be used to follow-up benign appearing lesions and to stage more aggressive ones. Endoscopic ultrasound with fine needle aspiration and cyst fluid analysis can be performed on certain indeterminate lesions. Lesions with high malignant potential should undergo resection.

Conclusions

A better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.     

远端胰腺切除术胰漏的三级预防策略

临床针对各种胰腺体尾部病变常需实施远端胰腺切除术,但胰漏的发生率仍居高不下,成为困扰外科临床医师的难题。为此,笔者提出预防胰漏的三级策略。一级预防针对胰腺本身,通过缝扎被切断的次级胰管开口和抑制胰液分泌,减少胰液分泌到胰腺组织外;二级预防针对胰腺断端,通过改进远端胰腺切除手术方式,利用带血管蒂浆肌瓣贴敷胰腺断面促进其愈合,防止胰液外漏到周围组织;三级预防是发生胰漏后及时采取切实有效的治疗措施,防止发生与胰漏相关的严重并发症导致病情恶化,使患者早日康复,提高治愈率。     

29例胰腺黏液性囊性肿瘤的超声诊断

目的探讨胰腺黏液性囊性肿瘤的超声表现与诊断。方法对2000年6月至2008年12月中山医院外科手术病理证实的29例胰腺黏液性囊性肿瘤的超声表现进行回顾性分析。结果超声表现囊性或囊性为主22例,囊实性实性为主5例,实性2例;病理诊断良性20例,交界性4例,恶性5例;超声诊断良性病变12例,恶性病变6例,良恶性诊断符合率72.4%(21/29),其中9例诊断囊腺瘤。结论胰腺黏液性囊性肿瘤的超声声像图表现多样,图像典型时超声可作出正确诊断,声像图表现不典型时要诊断黏液性囊性肿瘤及其良恶性确有困难。     

超声造影在鉴别诊断腹部良恶性占位病变中的应用价值

目的探讨实时超声造影对腹部良恶性占位病变的鉴别诊断价值。方法对250例腹腔脏器占位性病变进行实时超声造影研究,其中包括肝脏良恶性肿瘤196例,胆囊癌及胆囊良性病变39例,胰腺良恶性病变15例,所有病例均经过手术或其他影像学检查方法证实。结果造影剂Sono Vue2.4ml静脉注射后,肝癌动脉相表现为整体快速增强,并在门脉相快速消退,在实质相显示为低回声;血管瘤呈周围向心性环状或结节状增强,门脉相及实质相进一步增强,持续较长时间;局灶性结节增生表现为中央扩散型快速整体增强,部分病例显示为车轮状;肝硬化增生结节的造影增强特征与肝实质一致;胆囊癌快速不均匀增强,胆囊壁连续性中断,胆囊良性病变及慢性胆囊炎胆囊壁连续;胰腺癌造影剂快速进入,消退时间早于胰腺实质,胰腺炎性肿块造影后回声与胰腺一致,或造影剂不进入。结论实时超声造影能显示肿瘤内微小血管的血流灌注情况,对腹部良恶性占位病变的定性诊断具有重要的意义。     

胰腺黏液性囊性肿瘤的超声表现

目的探讨胰腺黏液性囊性肿瘤(MCNs)的超声表现。方法回顾性分析42例经手术病理证实的MCNs的超声表现。结果 MCNs多发生于中年女性,大部分位于胰体尾部,肿瘤体积较大,边界清晰,多数有包膜。42例MCNs中,22例为囊性或以囊性为主;18例囊实混合性;2例实性。病理诊断良性病变24例,交界性7例,恶性11例。超声诊断:20例考虑为良性,22例考虑恶性,超声诊断恶性MCNs的敏感度为77.78%(14/18),特异度为66.67%(16/24)。结论 MCNs超声图像表现复杂,肿物内分隔厚度、是否存在实性部分有助于鉴别良、恶性病变。     

Cystic pancreatic neoplasms evaluation by CT and magnetic resonance cholangiopancreatography

CT provides limited assistance in the differentiation between serous and mucinous neoplasms. Because of the variability in the radiographic appearance of serous cystadenomas and overlap in CT characteristics with mucinous neoplasms, most serous neoplasms still require ancillary testing such as biopsy to reach a definitive diagnosis. MRCP is useful in differentiating benign and malignant mucinous tumors including IPMT of the pancreas. The presence of mural nodules is suggestive of malignancy; however, the absence of mural nodules does not indicate that the tumor is benign. A maximum main pancreatic duct diameter of greater than 15 mm and diffuse dilatation of the main pancreatic duct are suggestive of malignancy in main duct-type tumors. Among branch duct-type tumors, malignant tumors tend to be larger than benign tumors; however, this finding is variable. The presence of main pancreatic duct dilatation may be helpful in determining malignancy of branch duct-type tumors.     

Malignant insulinoma: Can we predict the long-term outcomes?

Insulinomas are the most frequent type of functional pancreatic neuroendocrine tumors with a variety of neuroglycopenic and autonomic symptoms and well-defined diagnostic criteria; however, prediction of their clinical behavior and early differentiation between benign and malignant lesions remain a challenge. The comparative studies between benign and malignant cases are limited, suggesting that short clinical history, early hypoglycemia during fasting, high proinsulin, insulin, and C-peptide concentrations raise suspicion of malignancy. Indeed, malignant tumors are larger with higher mitotic count and Ki-67 proliferative activity, but there are no accurate histological criteria to distinguish benign from malignant forms. Several signaling pathways have been suggested to affect the pathophysiology and behavior of insulinomas; however, our knowledge is limited, urging a further understanding of molecular genetics. Therefore, there is a need for the identification of reliable markers of metastatic disease that could also serve as therapeutic targets in patients with malignant insulinoma. This opinion review reflects on current gaps in diagnostic and clinical aspects related to the malignant behavior of insulinoma.     

Ectopic pancreas bleeding in the jejunum revealed by capsule endoscopy

Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evident when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas located in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.     

胰腺导管内乳头状黏液性肿瘤良恶性的术前鉴别

目的：比较良恶性胰腺导管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplsms,IPMN）的不同临床特征。方法：回顾总结分析复旦大学附属中山医院1999年1月—2008年12月手术切除并经病理证实的70例资料完整的胰腺导管内乳头状黏液性肿瘤患者在临床表现？实验室检查结果及影像学特征等方面的差异,并对相关数据进行统计学分析。结果：70例IPMN患者中,良性21例（腺瘤15例,交界性肿瘤6例）,恶性49例（原位癌8例,浸润癌41例）;良恶性病例组在发病年龄、临床表现（皮肤及巩膜黄染、体质量下降、无症状患者、糖尿病）及实验室检查结果[癌抗原19-9（CA19-9）升高、血糖升高、血总胆红素升高）]及影像学特征（囊肿附壁结节病例所占比率及肿瘤和主胰管平均直径）方面均有显著差异;两者在性别、肿瘤部位、腹痛及急性胰腺炎发病率、癌胚抗原（CEA）异常比率等方面无显著差异。结论：良恶性胰腺导管内乳头状黏液性肿瘤在临床表现,实验室检查及影像学特征方面存在一定的差异,对于术前两者的鉴别有一定的借鉴意义,并有助于治疗方式的选择。     

Paraduodenal pancreatitis: benign and malignant mimics at MRI

Paraduodenal pancreatitis, also known as groove pancreatitis, is a rare form of chronic pancreatitis that masquerades as pancreatic adenocarcinoma affecting the pancreaticoduodenal groove, a potential space between the head of the pancreas, duodenum, and common bile duct. Two forms of groove pancreatitis have been described. The segmental form involves the pancreatic head with development of scar tissue within the groove, whereas the pure form affects the groove only, sparing the pancreatic head. Imaging findings of groove pancreatitis often overlap with primary duodenal, ampullary, or pancreatic neoplasms, which often results in a diagnostic challenge. In addition, paraduodenal pancreatitis can be mistaken for cystic pancreatic lesions, especially when there is involvement of the duodenal wall. Preoperative recognition of this entity is very important in order to avoid unnecessary procedures, although surgery, such as pancreaticoduodenectomy, may still be required to relieve obstructive symptoms. In this article, the pathophysiology and magnetic resonance imaging characteristics of paraduodenal pancreatitis and important benign and malignant mimics are discussed.

     

肝胆胰恶性肿瘤病人血清CA199的测定及其意义

目的 评价血清糖类抗原199（CA199）水平在肝胆胰恶性肿瘤诊断中的意义。方法 对70例胰腺癌、28例胰腺良性疾病、26例原发性肝癌、16例肝脏良性病变、14例胆管癌、35例胆管良性疾病病人的血清CA199水平进行检测并分析比较。结果 胰腺癌、胆管癌CA199水平与对应良性疾病组比较均有明显升高（t=5.294、2.863,P〈0.05）,而肝癌与对照组比较,差异无统计学意义。CA199对胰腺癌、胆管癌、肝癌诊断的灵敏度分别为75.71%、64.28%、30.77%,胰腺癌与胆管癌CA199诊断的灵敏度比较无差异性,但是二者与肝癌相比,均有显著性差异（χ2=19.390、4.183,P〈0.05）。结论 CA199对胰腺和胆管系统的恶性肿瘤有一定的诊断参考价值,而对肝癌的诊断价值不大。     

超声造影定量分析鉴别诊断胰腺局灶性占位性病变

目的：探讨超声造影结合时间-强度曲线（TIC）在鉴别胰腺局灶性占位性病变良恶性中的应用价值.方法：对40例疑有胰腺占位性病变的患者进行超声造影检查,作TIC分析,获得以下定量参数：曲线下面积、达峰时间及梯度.结果：良性组中胰腺病灶与病灶周围胰腺实质的达峰时间、梯度、曲线下面积之间比较,差异均无统计学意义（P＞0.05）.恶性组中胰腺病灶与病灶周围胰腺实质的达峰时间比较,差异无统计学意义（P＞0.05）;曲线下面积、梯度之间的比较,差异有统计学意义（P＜0.05）.结论：不同病理类型胰腺局灶性占位性病变的超声造影定量参数存在差异,超声造影定量分析技术可以对胰腺局灶性占位性病变进行量化分析,并有较好的临床应用价值.     

超声造影和增强CT诊断胰腺局灶性病变的Meta分析

目的 运用Meta分析评价超声造影(CEUS)和增强CT(CECT)对良、恶性胰腺局灶性病变的诊断价值。方法 对PubMed、中国期刊网CNKI数据库有关CEUS及CECT诊断及鉴别诊断良、恶性胰腺局灶性病变的中英文文献进行评价和筛选,同时应用Meta-disc 1.4软件对入选文献的试验数据进行分析。结果 14篇文献符合纳入标准。CEUS与CECT诊断良、恶性胰腺局灶性病变的合并敏感度、特异度、SROC曲线下面积(AUC)分别为89.20%、94.00%、0.9545和85.50%、84.60%、0.9116。CEUS与CECT诊断良、恶性胰腺局灶性病变的准确率差异有统计学意义(P<0.005)。结论 对于胰腺局灶性病变,CEUS是一种准确性较高的无创性检查方法。     

Differentiation of pancreatic cysts with optical coherence tomography (OCT) imaging: an ex vivo pilot study

We demonstrate for the first time that optical coherence tomography (OCT) imaging can reliably distinguish between morphologic features of low risk pancreatic cysts (i.e., pseudocysts and serous cystadenomas) and high risk pancreatic cysts (i.e., mucinous cystic neoplasms and intraductal papillary mucinous neoplasms). In our study fresh pancreatectomy specimens (66) from patients with cystic lesions undergoing surgery were acquired and examined with OCT. A training set of 20 pathology-OCT correlated tissue specimens were used to develop criteria for differentiating between low and high risk cystic lesions. A separate (validation) set of 46 specimens were used to test the OCT criteria by three clinicians, blinded to histopathology findings. Histology was finally used as a 'gold' standard for testing OCT findings. OCT was able to reveal specific morphologic features of pancreatic cysts and thus to differentiate between low-risk and high-risk cysts with over 95% sensitivity and specificity. This pilot study suggests that OCT could be used by clinicians in the future to more reliably differentiate between benign and potentially malignant pancreatic cysts. However, in vivo use of OCT requires a probe that has to fit the bore of the pancreas biopsy needle. Therefore, we have developed such probes and planned to start an in vivo pilot study within the very near future.