Multiple solid pancreatic hamartomas:A case report and review of the literature

Non-neoplastic tumor-like lesions in the pancreas are uncommon.Here,we present a case of multiple solid pancreatic hamartomas in a 78-year-old Japanese woman.Her computed tomography revealed a pancreatic mass,measuring 1.8 cm in maximum diameter.However,no symptoms were found.She was not an alcoholic and had no history of pancreatitis.The patient underwent a pancreatoduodenectomy,and three well-demarcated solid nodules measuring 1.7 cm,0.4 cm,and 0.3 cm in diameter were found in the pancreatic head.Microscopically,the lesions were composed of non-neoplastic,disarranged acinar cells and ducts embedded in a sclerotic stroma with elongated spindle cells that lacked discrete islets.The stromal spindle cells were immunoreactive for CD34 and CD117.The histological diagnosis was multiple solid hamartomas of the pancreas.There has been no recurrence 30 mo after surgery.So far,18 cases of pancreatic hamartoma have been reported in the English literature,including our case.Six out of these 18 cases seemed to fit the criteria of solid pancreatic hamartoma.Although the number of cases was limited,solid pancreatic hamartomas seem to be benign tumor-like lesions,which are found incidentally in healthy middle-aged adults,but occasionally involve the whole pancreas,resulting in a poor prognosis.Solid pancreatic hamartoma was sometimes associated with minor pancreatic abnormality,and multiple small lesions other than the main tumors were detected in a small number of cases.From these findings,one may speculate that solid pancreatic hamartoma could be the result of a malformation during the development of the pancreas.     

胰腺癌:经腹腔镜肿瘤分期

Objective： Accurate staging of patients with pancreatic cancer is crucial to clarify whether meaningful resection is indeed possible. Staging laparoscopy has been suggested as a tool for staging which may spare up to two-fifth of these patients from undergoing nontherapeutic laparotomy. A controversy exists, however, as to whether the procedure should be used routinely or selectively in these patients with no evidence of metastasis on noninvasive staging. This review aims to evaluate the available literature critically, identify its limitations and address the existing controversies. Methods： The current available English literature was reviewed on this topic. Results： A direct and conclusive comparison of the controversial literature is difficult because of inconsistent use of high-quality CT scans, different study designs and dissimilarity of judgment for non-resectability among patients staged by laparoscopy. However, recent studies reveal that not more than 14% of the patients benefit from diagnostic laparoscopy when a dual-contrast thin cut and 3-D digital reformatting CT scan has been performed previously. Conclusion： We conclude that routine use of diagnostic laparoscopy does not appear warranted in all patients with pancreatic cancer, especially for patients with early-staged pancreatic cancer or non-pancreatic periampullary cancers, because diagnostic laparoscopy is costly and ultrasonography is largely operator-dependent. Rather, selective use is appropriate, especially in patients with a large primary tumor, a tumor in the body or tail of the pancreas, equivocal findings of metastasis on CT, the presence of ascites, severe weight loss, hypoalbuminemia, and a markedly elevated CA 19-9.     

Pancreatic cancer–Staging laparoscopy

Objective: Accurate staging of patients with pancreatic cancer is crucial to clarify whether meaningful resection is indeed possible. Staging laparoscopy has been suggested as a tool for staging which may spare up to two-fifth of these patients from undergoing nontherapeutic laparotomy. A controversy exists, however, as to whether the procedure should be used routinely or selectively in these patients with no evidence of metastasis on noninvasive staging. This review aims to evaluate the available literature critically, identify its limitations and address the existing controversies. Methods: The current available English literature was reviewed on this topic. Results: A direct and conclusive comparison of the controversial literature is difficult because of inconsistent use of high-quality CT scans, different study designs and dissimilarity of judgment for non-resectability among patients staged by laparoscopy. However, recent studies reveal that not more than 14% of the patients benefit from diagnostic laparoscopy when a dual-contrast thin cut and 3-D digital reformatting CT scan has been performed previously. Conclusion: We conclude that routine use of diagnostic laparoscopy does not appear warranted in all patients with pancreatic cancer, especially for patients with early-staged pancreatic cancer or non-pancreatic periampullary cancers, because diagnostic laparoscopy is costly and ultrasonography is largely operator-dependent. Rather, selective use is appropriate, especially in patients with a large primary tumor, a tumor in the body or tail of the pancreas, equivocal findings of metastasis on CT, the presence of ascites, severe weight loss, hypoalbuminemia, and a markedly elevated CA 19–9.     

用来评估医用电子直线加速器头部周围泄漏辐射剂量的两种方法的比较(英文)

Objective:The aim of this study was to measure the leakage by two methods with ion chamber and ready packs film,and to investigate the feasibility and the advantages of using two dosimetry methods for assessing leakage radiation around the head of the linear accelerators.Methods:Measurements were performed using a 30 cm3ion chamber;the gantry at 0°,the X-ray head at 0°,the field size at between the central axis and a plane surface at a FSD of 100 as a reference,a series of concentric circles having radii of 50,75,and 100 cm with their common centre at the reference point.The absorbed dose was measured at the reference point,and this would be used as the reference dose.With the diaphragm closed,the measurements were taken along the circumference of the three circles and at 45°intervals.Results:Leakage radiations while the treatment head was in the vertical position varied between 0.016%–0.04%.With the head lying horizontally,leakage radiation was the same order magnitude and varied between 0.02%–0.07%.In the second method,the verification was accomplished by closing the collimator jaws and covering the head of the treatment unit with the ready pack films.The films were marked to permit the determination of their positions on the machine after exposed and processed.With the diaphragm closed,and the ready packs films around the linear accelerator the beam turned on for 2500 cGy(2500 MU).The optical density of these films was measured and compared with this of the reference dose.Leakage radiation varied according to the film positions and the magnitude of leakage was between 0.005%–0.075%.Conclusion:The differences between the values of the leakage radiation levels observed at different measurement points do not only reflect differences in the effective shielding thickness of the head wall,but are also related to differences in the distances between the target and the measurement points.The experimental errors involved in dosimetric measurement also contribute to such differences.     

THE SELECTION OF SURGICAL PROCEDURE IN THE TREATMENT OF OBSTRUCTING CARCINOMA OF THE LEFT COLON

From 1973 to 1989, 90 cases of obstructing carcinoma of the left colon were treated with five different operative procedures, the Incidence of anastomotic leakage was 6.7%, the operative mortality was 7. 8%. Among all the patients, 14 cases were treated by primary resection with anastomosis. Anastomotic leakage occurred in 6 cases, and 5 of them were died. Of 25 cases with the traditional staged management, the tumors were resected only in 20 cases, and not resectable in the other 5 patients. 19 with modified Hartmann's procedure and 26 with extended right hemlcolectomy with ileorectal or low ileosigmoid anastomosis gave satisfactory results. In terms of this series, the five-year survival rate in primary resection group was significantly higher than that in staged resection group (P< 0. 05). It is suggested that extented right hemlcolectomy or modified Hartmann' s procedure in cases of acute cancerous obstruction of the left colon would be favord.     

胰脾胸腔易位在残胃食管吻合术中的应用

Objective： To investigate the value of spleen and pancreatic tail thorax translocation on the residual stomach esophagus anastomosis. Methods： 10 patients with esophageal carcinoma after gastrectomy were enrolled in this study. Lesions were removed through left thoracotomy and residual stomach was fully mobilized, with short gastric artery being reserved. Spleen and pancreatic tail were dissected from the back of peritoneum and transposed into thorax. Residual stomach esophagus anastomosis was performed. Results： All the operation went favorably. Patients were recovered rapidly and a relatively good prognosis was acquired. Late leakage and pleural effusion happened in one case respectively, but these com- plications were cured through conservative management without operation death. Conclusion： Residual stomach is an ideal candidate for the replacement of esophagus and residual stomach esophagus anastomosis is a simple operative alternative with few trauma and good results for the treatment of esophageal carcinoma after gastrectomy.     

胰、胆、胃、空肠Roux-Y吻合型胰十二指肠切除术30例报告

Objective To explore the ways how to decrease the morbidity and mortality of pancreaticoduodenectomy(PD).Medthods In 30 cases of PD,a free vascularized jejunal loop was used to pefform single loop Roux-Y anastomosis to reconstruct the digestive tract.Results The morality rate was xero and there were no cases of leakage at the pancraticojejunostomy and choledocojejunostomy.All patients were discharged from hospita 10-14 days after operation.Postoperative follow-up of long-term choronic complications showed only one patient(3.33%)suffered from chronic steatorrhea and malnutrition,the remaining 29 cases(96.67%)had a good function of digestion and normal nutrition.There were no cases of biler reflux gastric disease,retrograde infection,anastomostic ulcer of gastrojejunostomy,and dumping syndrome.Conclusion This surgical procedure can effectively reduce the morbidity and the mortality of PD.     

Endoscopic Mucosal Resection

Endoscopic mucosal resection is indicated in limited esophageal carcinomas with infiltrationof the mucosa.As submucosal cancer is combined with a rate of lymph node metastasis in up to 30%mucosectomy is not the procedure of choice.The main techniques of endoscopic mucosal resection arethe “suck and cut” technique using a cap on the endoscope or a ligation device to create a pseudoeroupof the carcinoma.Submucosal injection of saline or other solutions is recommended prior to diathermicmucosectomy in order to reduce the risk of perforation or haemorrhage.The long term results of endoscopicmucosal resection show tumor specific 5 year survival rates of about 97% especially if the indication isrestricted to ml and m2 mucosal carcinomas.     

内窥镜黏膜切除术

Endoscopic mucosal resection is indicated in limited esophageal carcinomas with infiltration of the mucosa. As submucosal cancer is combined with a rate of lymph node metastasis in up to 30%,mucosectomy is not the procedure of choice. The main techniques of endoscopic mucosal resection are the “suck and cut” technique using a cap on the endoscope or a ligation device to create a pseudocroup of the carcinoma. Submucosal injection of saline or other solutions is recommended prior to diathermic mucosectomy in order to reduce the risk of perforation or haemorrhage. The long term results of endoscopic mucosal resection show tumor specific 5 year survival rates of about 97% especially if the indication is restricted to ml and m2 mucosal carcinomas.     

Pancreatic pseudocyst or a cystic tumor of the pancreas？

Pancreatic pseudocysts are the most common cystic lesions of the pancreas and may complicate acute pancreatitis, chronic pancreatitis, or pancreatic trauma. While the majority of acute pseudocysts resolve spontaneously, few may require drainage. On the other hand, pancreatic cystic tumors, which usually require extirpation, may disguise as pseudocysts. Hence, the distinction between the two entities is crucial for a successful outcome. We conducted this study to highlight the fundamental differences between pancreatic pseudocysts and cystic tumors so that relevant management plans can be devised. We reviewed the data of patients with pancreatic cystic lesions that underwent Jntervention between June 2007 and December 2010 in our hospital. We identified 9 patients （5 males and 4 females） with a median age of 40 years （range, 30-70 years）. Five patients had pseudocysts, 2 had cystic tumors, and 2 had diseases of undetermined pathology. Pancreatic pseudocysts were treated by pseudocystogastrostomy in 2 cases and percutaneous drainage in 3 cases. One case recurred after percutaneous drainage and required pseudocystogastrostomy. The true pancreatic cysts were serous cystadenoma, which was treated by distal pancreatectomy, and mucinous cystadenocarcinoma, which was initially treated by drainage, like a pseudocyst, and then by distal pancreatectomy when its true nature was revealed. We conclude that every effort should be exerted to distinguish between pancreatic pseudocysts and cystic tumors of the pancreas to avoid the serious misjudgement of draining rather than extirpating a pancreatic cystic tumor. Additionally, percutaneous drainage of a pancreatic pseudocyst is a useful adjunct that may substitute for surgical drainage.     

Pancreatic cancer–Laparoscopic resection

Objective: To assess current role of laparoscopic resection for pancreatic cancer, so as to improve the surgical management of pancreatic cancer. Methods: A comprehensive review of articles from PubMed was carried out. Results: Cur- rently, the advantages of a complete laparoscopic pancreatoduodenectomy (LPD) are still outweighed by the morbidity associ- ated with the procedure. However, laparoscopic distal pancreatectomy (LDP) offers patients benefits in terms of postoperative recovery and the length of hospital stay with similar morbidity and mortality to open surgery. Hand-assisted laparoscopic sur- gery can help to overcome the limitation of a complete laparoscopic surgery while maintaining a minimally invasive approach. Conclusion: Current literature suggests that laparoscopic resection of pancreatic cancer is feasible and safe in experienced hands. The hand-assisted laparoscopic surgery shows a promising future in pancreatic cancer surgery.     

胰腺癌:腹腔镜切除术

Objective： To assess current role of laparoscopic resection for pancreatic cancer, so as to improve the surgical management of pancreatic cancer. Methods： A comprehensive review of articles from PubMed was carried out. Results： Currently, the advantages of a complete laparoscopic pancreatoduodenectomy （LPD） are still outweighed by the morbidity associated with the procedure. However, laparoscopic distal pancreatectomy （LDP） offers patients benefits in terms of postoperative recovery and the length of hospital stay with similar morbidity and mortality to open surgery. Hand-assisted laparoscopic surgery can help to overcome the limitation of a complete laparoscopic surgery while maintaining a minimally invasive approach. Conclusion： Current literature suggests that laparoscopic resection of pancreatic cancer is feasible and safe in experienced hands. The hand-assisted laparoscopic surgery shows a promising future in pancreatic cancer surgery.     

食管上皮高度不典型增生的处理

Objective： Early detection and treatment in patients with esophageal cancer is the most effective way to improve the prognosis. Patients with high-grade dysplasia （HGD） in esophageal mucosa might be involved with early esophageal cancer, but the management of the disease is controversial. The purpose of our study was to explore the management of esophageal mucosa with HGD. Methods： We retrospectively analyzed 10 patients with HGD in esophageal mucosa, who underwent esophagectomy in Cancer Hospital of Fudan University from 1999 to 2006. The surgical approach, postoperative morbidity, in-hospital complications and pathological results of the patients were analyzed. Basing on our data together with other studies, we aimed at looking for an appropriate management for patients with HGD. Results： Of the 10 patients who received esophagectomy, the pathological results showed that 2 （20%） cases were in situ carcinoma and 8 （80%） cases were invasive cancer with no regional lymph nodes involved. 30-day mortality was 0. One patient experienced cervical anastomotic leakage, but healed in 2 weeks. There was no pulmonary complication. Conclusion： Most patients with HGD actually have occult carcinoma. High percentage of patients with HGD would develop into cancer during their lifetime. Esophagectomy is now a selective approach for the treatment of the patients with HGD.     

IMMUNOCHEMICAL IDENTIFICATION AND LOCALIZATION OF CYTOCHROME P-450HSjISOZYME, AN ENZYME RELATED TO NITROSAMINE METABOLISM, IN HUMAN GASTRIC MUCOSA AND GASTRIC CARCINOMA

Monoclonal antibody (MAb) to rat liver cyto-chrome P-450j isozyme, an activating enzyme specific to nitrosamine metabolism, was used coupled with immunoblotting, densitometer scanning of SDS-PAGE gels and immunohistochemical technique. The trace P-450HSj isozyme (Mr. 51.5 Kd) was found in human gastric mucosa. It was similar to P-450j in molecular weight, catalytic and immunochemical properties. The concentrations of P-450HSj in mucosa of lesser curvature were higher than those in greater curvature. This might be one of the important reasons that lesser curvature is the commonest area for gastric carcinoma. But there was possibly less P-450HSj in gastric mucosa with cancer. Im-munohistochemically, P-450HSj was discovered in the cytoplasm of some glandular epithelial cells, especially in the glands with hyperplastic and intestinal metaplastic changes adjacent to carcinoma. It was also found in some normal glands and in tumor cells of high-differentiated adenocarcinoma, but not in those of low-differentia     

热塑膜对X射线治疗剂量影响的研究

Objective To calculate the effects of thermoplastic mask on X-ray surface dose.Methods The BEAMnrc Monte Carlo Code system, designed especially for computer simulation of radioactive sources, was performed to evaluate the effects of thermoplastic mask on X-ray surface dose.Thermoplastic mask came from our center with a material density of 1.12 g/cm2. The masks without holes,with holes size of 0. 1 cm× 0. 1 cm, and with holes size of 0. 1 cm × 0. 2 cm, and masks with different depth (0.12 cm and 0.24 cm) were evaluated separately. For those with holes, the material width between adjacent holes was 0. 1 cm. Virtual masks with a material density of 1.38 g/cm3 without holes with two different depths were also evaluated. Results Thermoplastic mask affected X-rays surface dose. When using a thermoplastic mask with the depth of 0. 24 cm without holes, the surface dose was 74. 9% and 57.0% for those with the density of 1.38 g/cm3 and 1.12 g/cm3 respectively. When focusing on the masks with the density of 1.12 g/cm3, the surface dose was 41.2% for those with 0.12 cm depth without holes;57.0% for those with 0. 24 cm depth without holes;44. 5% for those with 0. 24 cm depth with holes size of 0.1 cm ×0.2 cm;and 54.1% for those with 0.24 cm depths with holes size of 0.1 cm ×0.1 cm.Conclusions Using thermoplastic mask during the radiation increases patient surface dose. The severity is relative to the hole size and the depth of thermoplastic mask. The surface dose change should be considered in radiation planning to avoid severe skin reaction.     

A NEW TECHNIQUE OF ESOPHAGOGASTROSTOMY ABOVE THE AORTIC ARCH—COVERING AND SUSPENDING OF THE ANASTOMOTIC AREA WITH MEDIASTINAL PLEURAL FLAP

The postoperative anastomotic leakage is the mostsevere complication and the principal cause of death afterresection of esophageal carcinoma. Especially, anasto-mosis above the aorta arch is accompanied by highincidence of anastomotic leakage usually with fatalprognosis. The authors improved the conventionalmethod of anastomosis by using a mediastinal pleural flapto cover and suspend the anastomotic area with excellentresult. From January 1990 to April 1995, total 210patients with esophageal carcinoma underwent surgeryresection with this procedure. No anastomotic leakageor stricture developed. Only one patient died of exten-sive myocardial infarction with an overall mortality of0.47%. The major merit of this procedure was that themediastinal pleural flap could cover the area of anasto-mosis and sustain dragging force acting on this area,providing a better condition for the anastomosis to healand thus reducing the possibility of anastomotic leakage.     

热塑膜对X射线治疗剂量影响的研究

Objective To calculate the effects of thermoplastic mask on X-ray surface dose.Methods The BEAMnrc Monte Carlo Code system, designed especially for computer simulation of radioactive sources, was performed to evaluate the effects of thermoplastic mask on X-ray surface dose.Thermoplastic mask came from our center with a material density of 1.12 g/cm2. The masks without holes,with holes size of 0. 1 cm× 0. 1 cm, and with holes size of 0. 1 cm × 0. 2 cm, and masks with different depth (0.12 cm and 0.24 cm) were evaluated separately. For those with holes, the material width between adjacent holes was 0. 1 cm. Virtual masks with a material density of 1.38 g/cm3 without holes with two different depths were also evaluated. Results Thermoplastic mask affected X-rays surface dose. When using a thermoplastic mask with the depth of 0. 24 cm without holes, the surface dose was 74. 9% and 57.0% for those with the density of 1.38 g/cm3 and 1.12 g/cm3 respectively. When focusing on the masks with the density of 1.12 g/cm3, the surface dose was 41.2% for those with 0.12 cm depth without holes;57.0% for those with 0. 24 cm depth without holes;44. 5% for those with 0. 24 cm depth with holes size of 0.1 cm ×0.2 cm;and 54.1% for those with 0.24 cm depths with holes size of 0.1 cm ×0.1 cm.Conclusions Using thermoplastic mask during the radiation increases patient surface dose. The severity is relative to the hole size and the depth of thermoplastic mask. The surface dose change should be considered in radiation planning to avoid severe skin reaction.     

THE FACTORS AND TREATMENT OF LOCAL RECURRENCE AFTER RADICAL RESECTION RESERVING THE ANUS IN THE PATIENTS WITH RECTAL CANCER

Of seventy-one patients with rectal cancer after radical resection retaining the anus, 15 developed local recurrence with a recurrence rate of 21.1%. Local recurrence was correlated with improper safety margin from the lower edge of cancer to the anal end. There was statistical significant difference between 3 cm or more and 2 cm or less. The local recurrence was also related to the pathologic stage, histologic differentiation and implant of free cancer cells. It is suggested that the surgical indication of saving the anus be strict and without stretching, the safety margin from the lower edge of cancer to the anal end should not be less than 2 cm in early rectal cancer and not less than 4 cm in advanced lesions. During the operation, no touching tumor technique, thorough rinsing of the peritoneal cavity and pre- or post-operative radiotherapy are important for prevention of local recurrence. Early local recurrent rectal cancer can be detected by periodic examinations.     

胰管内黏液乳头状瘤的MSCT和MRCP表现

Objective:To study the multi-slice CT(MSCT) and magnetic resonance cholangio-pancreatography(MRCP) features of intraductal papillary mucinous tumor(IPMT) of the pancreas.Methods:The clinical information,laboratory val-ues,imaging features and pathological findings of 8 cases were reviewed.Results:There were 6 males and 2 females with average 71.3 years old in this series.These lesions involved pancreatic branch ducts or main duct.Among them,2 cases were involved in the pancreatic uncinate process,1 case in the pancreatic head,1 in the pancreatic body,2 in the pancreatic tail and 2 cases involved multiple pancreatic duct.The common complaint was chronic upper abdominal pain.The imaging features included cystic lesion and it's association with the dilated pancreatic main duct,and bulging of the duodenal papilla.Mucin plug,septa or mural nodule were found in these cystic lesions.5 cases were confirmed with endoscopic retrograde cholangio-pancreatography(ERCP).3 cases had undergone surgery.Pathological findings of the 3 cases were adenoma,adenocarcinoma and borderline tumor,respectively.Conclusion:The MSCT and MRCP features of IPMT are somewhat characteristic,and the correct diagnosis can be made with the combination of clinical features.Diameter of branch duct ≥ 3 cm with multiple or large mural nodules,or severe dilated main duct indicates the probability of malignant IPMT.     

PROLIFERATION RATE OF COLONIC NEOPLASMS AND MUCOSA ADJACENT TO NEOPLASMS: IMMUNOHISTOCHEMICAL STUDY

Biopsy specimens of normal mucosa (n=5). adenomas (n -13), adenocarcinomas (n = 8). mucosa adjacent to adenoma (n=10) mucosa adjacent to adenocarcinoma (n = 7 ) at the large bowel were investigated by an iminunohistochemical method using 5- bromodeoxynldine (BrdUrd) . The labeling index (LI) was significantly lower in normal nucosa than mucosa adjacent to neoplasms and adenomas and adenocarcinomas. The proliferative zone was confined to the lower two- third at the crypt in normal mucosa and in mucosa adjacent to neoplasms. The labeled cells were either present in the upper third or scattered along the crust and in surface epithelium. The results support the adenmo-carcinoma sequence.