Cancer of the pancreas: Palliative operation,whipple procedure,or total pancreatectomy?

The choice of operation for ductal carcinoma of the pancreas is as yet not clear. Failure to make an early diagnosis still stands out as the major problem in the treatment of this disease and as a result the resectability rate is exceedingly low. Between 1964 and 1973, nineteen total pancreatectomies were performed at Peter Bent Brigham Hospital for all tumors of the pancreas. Sixteen of these were for ductal carcinoma. The mortality was 12.5 per cent. When total pancreatectomy is compared with the Whipple procedure and a simple bypass procedure and when the tumor disease encountered is corrected for stage of disease, it is apparent that total pancreatectomy carries a statistically significant longer survival for patients with Stages I and II disease (no lymph node involvement) than the other two procedures. For Stages III and IV, there is no difference in survival between the three different operations. We therefore conclude that total pancreatectomy carries a better survival prognosis than other procedures performed for Stage I and II ductal carcinoma of the pancreas.     

Influence of prior orchiopexy on stage and prognosis of testicular cancer.

Thirty-four cryptorchid testis cancer cases were studied, of whom 9 patients had prior orchiopexy at the time of cancer diagnosis. Disease stage in this group was: stage I = 4, stage II = 1 and stages III and IV = 4 cases. Seventy-eight percent of these cases (n = 7) had non-seminomas; 4 of these patients died. In the uncorrected cryptorchidism group (n = 25), disease stage was: stage I = 12, stage II = 9 and stages III and IV = 4 cases. Of these cases, 64% (n = 16) had seminomas and 6 patients died. Orchiopexy marginally reduced the symptomatic interval for subsequent cancer and probably decreased the risk of seminoma development. Orchiopexy did not lead to a more favourable disease presentation or prognosis because of the adverse bias of advanced-stage non-seminomas in this group.     

Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results

Regional pancreatectomy refers to an en bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic drainage. The pancreatic segment of portal vein is part of the en bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through 1982. They are a subset of the 270 patients with cancer of the pancreas, ampullary and periampullary regions, duodenum, or terminal portion of the common bile duct who were treated by the author during this period. The 61 consist of 35 patients who had an infiltrating duct adenocarcinoma of the pancreas and 21 who had other kinds of malignant tumors. In addition, four were classified as having pancreatitis and a fifth patient had a pseudolymphoma. The resectability rate is about 30%. The present operative mortality rate is 8%. Approximately one-third of the patients are alive; 43% of the 21 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 40 months (3-92 months). Forty-three per cent were Stage I but more than half were T3 or T4 lesions. Twenty-five per cent of patients with Stages II or III are alive. Twenty per cent of patients with infiltrating duct carcinoma of the pancreas are presently alive, 28% died of recurrent disease, and 26% died of other causes; more than 90% of these patients had advanced stage disease (Stage II or III).     

Carcinoma of the body and tail of the pancreas: is curative resection justified?

BACKGROUND. The role of resection in the treatment of carcinoma of the distal pancreas remains unclear. The less frequent occurrence of tumor in the distal gland, advanced tumor stage at diagnosis, and a lack of reported success have combined to produce therapeutic nihilism in the minds of many surgeons. The goal of this review was to assess long-term survival after distal pancreatectomy for carcinoma of the pancreas. METHODS. The records of all patients undergoing distal pancreatectomy at the Mayo Clinic for a primary pancreatic malignant tumor during the 25-year period from 1963 to 1987 were reviewed. Forty-four patients undergoing potentially curative distal pancreatectomies were identified: 26 patients for ductal adenocarcinoma, 12 patients for islet cell carcinoma, and six patients for cystadenocarcinoma. RESULTS. Major postoperative morbidity occurred in 9% of the patients and operative death in 2% of the patients. Patients with ductal adenocarcinoma frequently were admitted with advanced disease (stage II or III). The median overall survival for patients with ductal adenocarcinoma was 10 months. Fifteen percent of the patients survived 2 years after operation, and 8% of the patients survived 5 years. In contrast, the 5-year survival after resection of islet cell carcinomas and cystadenocarcinomas was excellent (83% and 100%, respectively). CONCLUSION. The prognosis for patients with ductal adenocarcinoma in the distal pancreas who were treated with potentially curative distal pancreatectomy is poor; however, the results are not substantially different from those reported after pancreaticoduodenectomy for malignant tumors of the proximal pancreas. Some patients with adenocarcinoma of the distal pancreas who were treated with resection may be long-term survivors. We recommend resection of carcinoma of the distal pancreas when the disease is limited to the gland and believe that all patients with ductal adenocarcinoma should be considered for postoperative adjuvant radiation and chemotherapy.     

胃癌根治手术联合脾脏切除远期疗效分析

目的探讨胃癌根治手术联合脾脏切除对胃癌患者预后的影响。方法1994年6月至2004年3月完成胃癌手术692例,其中在胃癌D2、D3手术基础上联合脾脏切除45例,选择同时期完成的具有可比性的仅行胃癌根治手术的343例病例进行分析,比较淋巴结转移的临床病理学因素、淋巴结转移率、切除脾脏后5年生存率。结果胃癌联合脾脏切除No10淋巴结转移率为15．6％,其中上1／3（U）区为11．5％,中1／3（M）区为33．3％,下1／3（L）区为0％。近端胃癌和胃体部癌、低分化及未分化腺癌、BorrmannⅢ、Ⅳ型、肿瘤浸润深度在T3、T4以及Ⅲ、Ⅳ期胃癌与远端胃癌、高中分化腺癌、Borrmann Ⅰ、Ⅱ型、肿瘤浸润深达度在T1、T2以及Ⅰ、Ⅱ期胃癌比较,其淋巴结转移率的差异有统计学意义。Ⅰ、Ⅱ期胃癌切除脾脏后平均生存时间和中位生存时间与单纯胃癌根治手术组比较降低并有统计学意义差异,Ⅲ、Ⅳ期胃癌切除脾脏以后平均生存时间和中位生存时间与单纯胃癌根治手术组比较差异无统计学意义。结论Ⅰ、Ⅱ期胃癌患者不应联合脾脏切除,Ⅲ、Ⅳ期胃癌联合切除脾脏也未能提高术后生存率,胃癌直接侵犯胰腺体尾部,脾门淋巴结明显肿大转移者,才有脾切除的指征。联合脾脏切除的手术适应证需进一步研究。     

胰腺实性假乳头状瘤47例临床分析

目的:探讨胰腺实性假乳头状瘤(SPTP)的临床特征、治疗及其预后。方法:回顾性分析南昌大学第一附属医院普通外科2007年1月—2018年12月经收治并经术后病理证实的47例SPTP患者的临床资料。结果:全组男11例,女36例,平均年龄(32±15)岁;肿瘤位于胰头部16例,胰颈部8例,胰体尾部23例;术前通过影像学初步诊断为SPTP者21例(44.7%),6例术前行超声内镜引导下细针穿刺活检术,仅1例(16.7%)确诊为SPTP;行胰十二指肠切除术10例,胰体尾联合脾脏切除术12例,保留脾脏的胰体尾切除术8例,胰腺中段切除术5例,肿瘤局部切除术10例,保留十二指肠胰头切除术1例,胰体尾联合脾脏、左肾及左肾上腺切除+下腔静脉切开取栓术1例。术后并发症发生率为19.1%(9/47),无再手术和手术相关死亡。肿瘤免疫组化结果显示,PR、CD56、NSE呈阳性表达居多。术后43例获随访,平均随访时间(41.7±31.4)个月,1例术后复发,所有随访患者均存活。结论:SPTP是一种好发于年轻女性的潜在低度恶性肿瘤,其临床表现无特异性,确诊有赖于病理组织学检查,手术切除是首选治疗方法,预后良好。     

Recent trends in treatment of TS1 carcinoma of the pancreas

Between July 1974 and June 1994, we resected ductal cell carcinoma of the pancreas in 149 patients. From their formalin-fixed specimens, we selected those of 19 patients with tumor size (TS)1 pancreatic cancer of, at most, 2 cm in maximum diameter. All the patients had cancer in the head of the pancreas. The chief complaint on presentation at the hospital was jaundice, in 17 of 19, the majority of patients. According to the pTNM, 4 were stage I, 1 was stage II, 13 were stage III, and 1 was stage IV. Thus, the majority of the patients had progressive cancer. Pancreatoduodenectomy was employed in 10 patients, pancreatoduodenectomy with resection of the portal vein in 7, and total pancreatectomy with resection of the portal vein in 2. D2 dissection was performed in all of these patients. Since 1985, intraoperative irradiation has been performed in 5 patients, and since 1986, the continuous administration of 5-fluorouracil by portal catheterization through the ligamentum teres hepatis has been performed in 6 patients. We compared the pathern of recurrence in the patients treated before 1985 (1974–1984), was intraoperative irradiation was initiated, with that in patients treated in 1985 and later (1985–1994). There were no effects of intraoperative irradiation on local recurrence. The incidence of hepatic metastases was significantly lower in the patients treated by portal catheterization in the latter period. There were four 5-year survivors; the overall 5-year survival rate in the 19 patients was 33%, and the mean survival period was 39 months.     

The results and problems of surgical treatment of cancer of the duodenal papilla of Vater]

Twenty six of 28 cases (92.9%) of cancer of duodenal papilla of Vater were resected from 1981 to 1990. Twenty five pancreatoduodenectomy and one total pancreatectomy were performed. Operative death and hospital death were not observed. Three year and five year cumulative survival rates of resected cases were 58% and 52% respectively. There was relatively good correlation between pathological cancer extension and postoperative prognosis. Postoperative prognosis of the cases which had cancer extension to the pancreas was extremely poor. But the prognosis of the cases of cancer within Oddi muscle was extremely good. Immunohistochemical staining using anti CEA, anti CA19-9 and anti DUPAN 2 was studied and Grade III staining pattern was observed only in the cases which had cancer invasion to the pancreas. Preoperative diagnosis of cancer extension using endoscopic ultrasonography and appropriate choice of the operative procedure are important. Extended operation and effective adjuvant therapy are necessary for advanced cases of cancer of the duodenal papilla.     

Regional pancreatectomy for cancer of the pancreas,ampulla and other related sites

Regional pancreatectomy refers to anen bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic draingae. The pancreatic segment of portal vein is part of theen bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through December 1982. Thirty-four patients had an infiltrating duct adenocarcinoma of the pancreas, 22 had other malignant tumors, 4 were classified as having pancreatitis, and a fifth had a pseudolymphoma. The resectability rate is about 30 per cent. The present operative mortality rate is 4 per cent by 30 days and 8 per cent after 30 days. One-third of the patients are presently alive; 45 per cent of the 22 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 39 1/2 months ranging from 3 to 92 months. More than 80 per cent of patients with infiltrating duct adenocarcinoma of the pancreas had advanced stage of the disease (T3 or T4 and Stage II or III cancers); twenty-one per cent are presently alive, 29 per cent died of recurrent disease, and 24 per cent died of other causes. The optimal treatment for patients with cancers in the region of the head of the pancreas is a regional subtotal pancreatectomy Type I or Type II followed by adjuvant chemotherapy.     

Prognostic value of cytokeratin-positive cells in the bone marrow and lymph nodes of patients with resected nonsmall cell lung cancer: a multicenter prospective study

BACKGROUND: This study was designed to prospectively substantiate the prognostic value of cytokeratin-positive (CK(+)) cells in the bone marrow (BM) and regional lymph nodes (LNs) in resected nonsmall cell lung cancer (NSCLC) patients from a large population within a multicenter study. METHODS: The study population consisted of 351 patients with stages I to IIIA NSCLC from 15 Japanese institutes. BM aspirates were stained immunocytochemically with the anti-cytokeratin antibody, CK2. The hilar and mediastinal LNs of 216 patients with stage I NSCLC were stained immunohistochemically with the anti-CK antibody, AE1/AE3. RESULTS: CK(+) cells were detected in 112 patients (31.9%) of the 351 BM aspirate patients. The frequency of CK(+) cells showed no differences among pathologic stages. The patients with CK(+) cells in the BM had a tendency to have shorter survival periods than those without CK(+) cells (p = 0.076). Although the presence of CK(+) cells in the BM of patients with stage I did not allow the prediction of overall survival, it reduced the overall survival significantly in patients with stages II to IIIA. CK(+) cells in the LNs were detected in 34 of 216 patients (15.7%) with stage I. The patients with CK(+) cells in the LNs had a poor prognosis by both univariate (p = 0.004) and multivariate analyses (p = 0.018). CONCLUSIONS: The presence of CK(+) cells in the BM was related to a poor prognosis for patients with stages II to IIIA NSCLC; however, it did not predict the prognosis of patients with stage I. For stage I NSCLC, the detection of CK(+) cells in the LNs implied a poor prognosis for the patients.     

Surgical treatment for esophageal cancer in elderly patients over 75 years of age

We performed 127 esophageal resections for the esophageal cancer patient from December 1995 to September 2001. It was separated to under 70 years old patients group (group I), 71-74 years old patients group (group II), and over 75 years old patients group (group III). RESULTS: Postoperative complication was occurred in 53 cases (41.7%) within all of 127 esophageal resected cases. It was 33.7% in group I, 53.6% in group II, 62.5% in group III. Four years survival rate of each group is 38.3% in group I, 44.6% in group II, 31.3% in group III. It is significantly better in group II rather than in group III. Operative death rate is 12.5% (2 cases) in group III, 7.1% (2 cases) in group II, 3.6% (3 cases) in group I, and it is gradually higher and higher by patient's age. CONCLUSIONS: (1) In the esophageal cancer patient over 75 years old, postoperative complication rate is higher than under 74 years old patients, and prognosis is significantly poor rather than in 70-74 years old patients group. (2) In the esophageal cancer patient over 75 years old, we considered it is good indication of esophagectomy for stage I and stage II patient without preoperative complication, however, there are no operative indication for stage III and stage IV patient.     

Large cell neuroendocrine carcinoma of the lung: a 10-year clinicopathologic retrospective study

BACKGROUND: Large cell neuroendocrine carcinoma is a recently recognized histologic entity whose clinical features and optimal treatment have not yet been well defined and are still being assessed. We report our retrospective assessment of cases of large cell neuroendocrine carcinoma observed from 1989 to 1999 in terms of survival. METHODS: Cases of large cell neuroendocrine carcinoma diagnosed between 1989 and 1999 were reassessed retrospectively according to the World Health Organization classification. The clinical outcome and pathologic features of all cases are described. Survival rates of patients with large cell neuroendocrine carcinoma are compared with those patients with small cell lung cancer treated in the same period. RESULTS: Patients were 41 men and 7 women with an average age of 63.7 years. Twenty-nine patients (60.4%) had pathologic stage I disease, 11 patients (22.9%) had pathologic stage II disease, and 7 patients (14.6%) had pathologic stage IIIA disease. One patient (2.1%) had pathologic stage IIIB disease. No patient underwent induction chemotherapy. Two patients underwent adjuvant chemotherapy and 2 underwent mediastinal radiotherapy for N2. No death was reported in the perioperative period. The median follow-up was 5 years. The actuarial survival for the entire group was 60.4% at 1 year, 27.5% at 3 years, and 21.2% at 5 years. The actuarial survival of accurately staged, stage I patients at 5 years was 27%. CONCLUSIONS: The findings suggest that treating large cell neuroendocrine carcinoma by means of applying treatment for nonsmall cell lung cancer leads to a prognosis that is worse than that for nonsmall cell lung cancer, even in terms of low pathologic stages.     

误诊为胆囊良性疾病的胆囊癌二次根治术

目的探讨误诊为胆囊良性疾病的胆囊癌二次手术方式以及对预后的影响。方法对于1995年6月-2002年12月因误诊为胆囊良性疾病而切除胆囊,因术后病理证实为胆囊癌而二次行胆囊癌扩大根治术的41例患者进行回顾性分析。41例患者中,男12例,女29例,平均年龄51岁,均因胆囊炎(41例)或并发胆囊结石(32例)、胆囊息肉或腺瘤(9例)在第一次手术时行单纯胆囊切除。术后病理：胆囊腺癌32例,鳞癌6例,鳞腺癌3例;Nevin Ⅰ期6例,Ⅱ期16例,Ⅲ期17例,Ⅳ期2例,Ⅴ期0例。二次手术距一次手术间隔时间为6—30d。二次手术均行以改良的Glenn根治性胆囊癌切除术为标准的胆囊癌根治术式。结果二次手术时发现14例患者有淋巴结转移,14例患者有胆囊床转移,6例患者有胆管转移,2例患者有胰腺转移;Nevin Ⅳ期14例,Ⅴ期9例,无Ⅰ、Ⅱ、Ⅲ期者。二次手术后1年后存活率100％(41例),3年存活率53、8％(22例),5年存活率17．5％(7例)。结论扩大根治术是治疗误诊为胆囊良性疾病的胆囊癌的重要方法之一。     

Preoperative staging of carcinoma of the bronchus: can computed tomographic scanning reliably identify stage III tumours?

BACKGROUND--The aim of preoperative computed tomographic (CT) assessment of patients with carcinoma of the bronchus is to stage the tumour accurately, and forewarn the surgeon of any possible local extrapulmonary extension of tumour in patients considered to have potentially resectable disease. The ability of CT scanning to differentiate between conventionally resectable lung cancer (TNM stages I and II), locally advanced but resectable lung cancer (TNM stage IIIa), and locally advanced but unresectable lung cancer (TNM stage IIIb) was determined in a group of patients accepted for surgery. METHODS--Computed tomographic scans of 110 patients who underwent thoracotomy for intended resection of carcinoma of the bronchus, including 52 cases with stage III and 58 cases with stage I or II disease, were reviewed and the CT features and radiological interpretations correlated with the surgical and pathological findings. RESULTS--Thirteen CT scans were judged not to have been of diagnostic quality: of the remaining 97 cases 45 had stage III lung cancer, of whom 30 had successful resections, and 52 had stage I or stage II tumours. There was no difference in the frequencies of CT observations--including contiguity of tumour and mediastinum or chest wall, apparent mediastinal or chest wall invasion, proximity of tumour to the carina, mediastinal nodal enlargement, pulmonary collapse or consolidation and pleural effusion--in patients with stage I/II disease and patients with stage III disease. Similar results were found when the same observations were compared in all patients with resected disease and those with unresectable tumour. Sensitivity and specificity of CT was 27% and 96% respectively for tumour unresectability, 50% and 89% for mediastinal invasion, 14% and 99% for chest wall invasion, and 61% and 76% for mediastinal nodal metastases. Only 19 of 45 stage III tumours were correctly identified as being stage III and resectable or unresectable. CONCLUSIONS--In patients being considered for thoracotomy for resection of lung cancer, CT scanning used as the sole method of staging is of limited value for differentiating between stage I/II and stage III tumours. Patients should not be denied the opportunity for curative surgery on the basis of equivocal CT signs.     

Unsuspected residual disease at the resection margin after surgery for lung cancer: fate of patients after long-term follow-up.

OBJECTIVE: This retrospective study evaluates the survival impact of the residual margin disease after bronchial resection for cancer and suggests tactics in cases of microresidual disease. METHODS: Between March 1988 and 1998, 4530 consecutive patients underwent surgery for non-small cell lung cancer at our institution. Only incomplete resections after microscopic evaluation (R1) were included in the study. Residual tumour cells were found on the bronchial resection margins of 39 lobectomies, 12 pneumonectomies, 4 segmental resections and one bilobectomy. Histological findings were: squamous cell carcinoma in 38 cases, adenocarcinoma in 15 and large cell carcinoma in three. In all 56 cases, invasive mucosal carcinoma was found exclusively on the bronchial resection margin. Nineteen tumours were stage I; 12, stage II; 17, stage IIIa; 5, stage IIIb; and three, stage IV. Nineteen patients (59.3%) with early stage tumours (I and II) received adjuvant radiation therapy and only three chemotherapy. RESULTS: The prognosis in these cases was disease-stage related (21 and 38.4% of deaths due to the disease). Forty-one percent of the stage IIIa patients received radiation therapy and 17.6% chemotherapy: 70.6% died of tumour relapse. Forty percent of the stage IIIb patients received radiation therapy and 20% chemotherapy: 60% died of disease progression. All of the stage IV patients died within 3 months from surgical resection. At the end of the study, 21 patients were alive after an interval of 22-142 months (18 in stage I or II). The 10-year actuarial survival rate was 44%. The percentage survival for stage IIIa was 16.8, after 10 years, and fell to 45 months for stage IIIb. CONCLUSIONS: The prognosis of our stage I or II patients with microresidual tumour on the bronchial resection margin (R1) was similar to that of the patients in the same disease stage, whose resection was microscopically radical (R0) and the same was true of the patients in stage III. In patients with residual tumour cells on the bronchial stump we did not observe worsened long-term survivals.     

脾脏保留对胰体尾切除术治疗胰腺神经内分泌肿瘤预后的影响

目的：脾脏保留对胰腺神经内分泌肿瘤（PNEN）患者行胰体尾切除术治疗后预后的影响。 方法：回顾性分析2007年2月—2012年7月行胰体尾切除术治疗的PNEN患者32例的临床资料,其中联合脾脏切除21例,脾脏保留11例,比较两组患者术后的生存情况,并对影响患者术后预后的相关因素进行分析。 结果：术后随访时间为13~62个月,平均（41.86±5.14）个月,脾脏保留患者1、3、5年总生存率分别为100%、90.91%、81.82%,而脾脏切除组患者分别为90.48%、80.95%、76.19%,脾脏保留患者的生存率明显优于脾脏切除患者（P<0.05）。单因素分析显示,TNM分期、淋巴结转移及神经或血管浸润、脾脏切除是影响患者预后的相关因素（均P<0.05）,而多因素分析显示,仅肿瘤TNM分期为影响患者预后的独立因素（P<0.05）。 结论：胰体尾切除术中予保留脾脏治疗对PNEN患者术后生存有益,但并不是术后预后的独立影响因素。     

Can survival in pancreatic adenocarcinoma be predicted by primary size or stage?

Evaluation of diagnosis and treatment modalities in pancreas cancer is hampered by the lack of a suitable staging system. The current staging protocol of the American Joint Committee is arranged as follows: intrapancreatic disease (stage I), localized invasion (stage II), positive regional lymph nodes (stage III), and distant metastases (stage IV). Primary size is not taken into account and may represent an important determinant of survival, as it does in other malignancies. Primary size as a criterion of operability may assume increasing importance, given the demonstrated accuracy of sonography and computed tomography. Chart review was undertaken of the 119 consecutive patients with pancreas cancer presenting at Grady Hospital between 1976 and 1981. Ninety-one per cent were histologically confirmed. The presence or absence of metastases continues to be the most important factor predicting survival (P less than 0.001). It was demonstrated, however, that patients with primary lesions less than 5 cm lived significantly longer than those with primaries greater than or equal to 5 cm (P less than 0.02). Using the currently recommended American Joint Committee protocol, there was no difference in survival curves among stages, I, II, and III. The median survival times were 7.5 months, 5 months, and 5 months, respectively. Between combined stages I, II, and III and stage IV (median survival, 1.0 month), there was a significant difference (P less than 0.001) in survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas

The aims of this study were to investigate morbidity, mortality, and survival of patients with ductal adenocarcinoma of the pancreas who underwent pancreatectomy without (group 1) or with (group 2) en bloc portal vein resection and to study the degree of carcinoma invasion of the portal vein in group 2. The medical records of 46 and 28 patients in groups 1 and 2, respectively, were reviewed. In addition, the degree of invasion of the wall of the portal vein was categorized histologically into three types: type I, transmural invasion involving the intima; type II, invasion of the wall of the vein without intimal involvement; and type III, compression of the wall of the vein by surrounding carcinoma without true invasion. The morbidity and mortality in group 1 (26% and 4%) were not different from those in group 2 (32% and 4%). Similarly, there was no difference in survival between the two groups. Survival tended to vary directly with the depth of invasion of the wall of the portal vein: type I 6.8 ± 1.9 months; type II 15.3 ± 6.4 months; type III 20.6 ± 13.0 months. These findings suggest that en bloc resection of the pancreas and the portal vein does not increase mortality and morbidity after pancreatectomy; survival after en bloc resection was similar to that of patients not requiring portal vein resection. Combined resection of the pancreas with the portal vein could be an option in the treatment of pancreatic cancer with direct invasion of the portal vein.     

Clinicopathologic Correlation of p53 Protein Overexpression in Adenoma and Carcinoma of the Ampulla of Vater

It has been well documented that ampullary carcinoma arises from a precancerous lesion, but there have been few studies concerning changes at the molecular level during the adenoma-carcinoma sequence. In this study, p53 overexpression during the progression of carcinoma was compared and the relation between p53 expression and prognosis was analyzed. Ninety-four cases of adenocarcinoma of the ampulla of Vater were reviewed histopathologically and examined for overexpression of p53 protein using the DO-7 (mouse monoclonal; DAKO, Glostrup, Denmark) antibody. The correlation of p53 overexpression with the existence of adenoma, clinical stage, histologic grade, and overall survival was investigated. The proportion of p53-positive cases among normal mucosa, adenoma, early stage carcinoma (I and II), advanced stage carcinoma (III and IV), and metastatic lesion was 0% (0/94), 14.3% (6/42), 32.3% (20/62), 53.1% (17/32), and 63.3% (19/30), respectively. The existence of adenoma or histologic grade of carcinoma did not correlate with p53 overexpression. The carcinoma having adenomatous component was more common in early stages (54.8% in stages I and II, 25% in stages III and IV; p= 0.006) and in well-differentiated carcinoma (p= 0.001). The existence of adenoma or p53 overexpression did not independently correlate with prognosis. In contrast, the p53 overexpressed group without adenoma showed a worse prognosis than the remaining patients (p= 0.0006) and this trend was still demonstrable when the groups were compared stage by stage. In ampullary carcinoma, p53 abnormality occurs during malignant transformation from the adenoma and continues during the tumor progression in carcinoma. The clinical prognosis of de novo carcinomas with p53 overexpression was worse than that of the remaining patients.     

Resection strategies for neuroendocrine pancreatic neoplasms

Introduction

Due to their rarity and lack of prospective trials, the optimal treatment of pancreatic neuroendocrine neoplasms (PNENs) is still debated. Recommendations gathered by retrospective analyses of patient data should be based on the new classification of neuroendocrine neoplasms.

Methods

In a retrospective single-center study (1990 to 2012), 127 patients with PNENs were included. Tumor stage and type of resections were analyzed to evaluate successful treatment strategies.

Results

Seventy-nine patients (62 %) were diagnosed with stage I or II, 48 patients (38 %) with stage III or IV disease; 49.6 % of all PNENs were nonfunctional. Surgical interventions consisted of 50 enucleations, 27 distal resections, and 2 partial duodenopancreatectomies in patients with stage I or II disease. Twenty-eight patients with stage III or IV disease received a distal resection and in 13 patients, a partial duodenopancreatectomy was carried out. Exploration with debulking was performed in seven patients in stages III and IV. Stage-dependent 10-year survival rates were 93.7 (stages I and II, n?=?79) and 56.0 % (stages III and IV, n?=?48).

Conclusions

PNENs have a good prognosis if they are well-differentiated and resected completely. Organ-preserving resection does not impair the prognosis in selected cases with stage I or II. In case of hepatic metastasis and advanced tumor stage, surgical reduction can reduce symptoms and improve the survival.