Nonfunctioning neuroendocrine pancreatic tumors: our experience and management

Background and purpose

We present our experience in the treatment of nonfunctioning neuroendocrine pancreatic tumors (NFNPTs) to define the clinical and pathological characteristics and to suggest proper management.

Methods

The records of 17 patients with NFNPTs operated on between 1998 and 2008 were retrospectively reviewed, and all tumors were classified clinicopathologically as benign, uncertain, and malignant, based on the World Health Organization (WHO) classification of neuroendocrine tumors.

Results

There were four benign, six uncertain, and seven malignant NFNPTs. The most frequent symptoms were abdominal pain (five patients) and obstructive jaundice (one patient). Most of these symptomatic patients had malignant tumors. Mean tumor size of benign, uncertain, and malignant tumors were 1.0 ± 0.3, 3.2 ± 1.6, and 5.3 ± 2.4 cm, respectively. Metastatic lesions of malignant tumors were lymph node (six patients), liver (four patients), and adrenal gland (one patient). Six of seven patients with malignant tumors underwent curative rejection. There were recurrences in four of six patients with curatively rejected malignant tumors. Two patients underwent more rejection, three patients received systemic chemotherapy, and two patients underwent radiofrequency ablation and transcatheter arterial chemoembolization for liver metastases. Survival of patients with malignant tumors was significantly shorter than that of patients with benign and uncertain tumors. However, three patients with malignant tumors had long survival of more than 3 years, even with metastases or recurrences.

Conclusions

Aggressive surgical resection should be performed in patients with resectable NFNPTs, even with metastases. Even when a tumor was unresectable or there were recurrences, long-time palliation could be achieved by a multidisciplinary approach.     

Normotest and abnormal prothrombin in liver transplantation

Abstract: Postoperative changes in coagulation parameters, including the abnormal plasma prothrombin level, were studied in 95 patients who underwent liver transplantation, and the results were compared with the clinical outcome. The patients were classified into four groups: Group I had a satisfactory postoperative course, (n=76), Group II suffered graft failure or death at 31 days or more after transplantation (n=9); Group III suffered graft failure or death from 8 to 30 days after transplantation (n=4); and Group IV suffered graft failure or death within 7 days of transplantation (n=6). The Normotest, which closely reflected liver graft function, showed an increase immediately after transplantation in Group I, II, and III, but showed a marked decrease in Group IV. In patients with severe acute cellular rejection, the plasma level of abnormal prothrombin (desgamma-carboxy prothrombin) was compared with the histology of the liver biopsy specimen. When liver graft function was good after orthotopic transplantation, the Normotest value recovered to the normal range of 70% or more. Subsequently, graft function remained good when the desgamma-carboxy prothrombin level stayed low, whereas acute cellular rejection was indicated by an elevation of des-gamma-carboxy prothrombin. When the Normotest value was lower than 20% for the first 2 days after transplantation, graft failure was likely. Because des-gamma-carboxy prothrombin was not produced by graft with early failure, the des-gamma-carboxy prothrombin level also remained low. Thus, the Normotest value and the des-gamma-carboxy prothrombin level were both useful parameters for assessing hepatic function and rejection after transplantation.     

Matrix metalloproteinase-9 in the initial injury after hepatectomy in mice

AIM:To investigate the role of matrix metalloproteinase(MMP)-9 in the pathogenesis of postoperative liver failure(PLF) after extended hepatectomy(EH).METHODS:An insufficient volume of the remnant liver(RL) results in higher morbidity and mortality,and a murine model with 80%-hepatectomy was used.All investigations were performed 6 h after EH.Mice were first divided into two groups based on the postoperative course(i.e.,the PLF caused or did not),and MMP-9 expression was measured by Western blotting.The source of MMP-9 was then determined by immunohistological stainings.Tissue inhibitor of metalloproteinase(TIMP)-1 is the endogenous inhibitor of MMP-9,and MMP-9 behavior was assessed by the experiments in wild-type,MMP-9(-/-) and TIMP-1(-/-) mice by Western blotting and gelatin zymography.The behavior of neutrophils was also assessed by immunohistological stainings.An anti-MMP-9 monoclonal antibody and a broadspectrum MMP inhibitor were used to examine the role of MMP-9.RESULTS:Symptomatic mice showed more severe PLF(histopathological assessments:2.97 ± 0.92 vs 0.11 ± 0.08,P < 0.05) and a higher expression of MMP-9(71085 ± 18274 vs 192856 ± 22263,P < 0.01).Nonnative leukocytes appeared to be the main source of MMP-9,because MMP-9 expression corresponding with CD11b positive-cell was observed in the findings of immunohistological stainings.In the histopathological findings,the PLF was improved in MMP-9(-/-) mice(1.65% ± 0.23% vs 0.65% ± 0.19%,P < 0.01) and it was worse in TIMP-1(-/-) mice(1.65% ± 0.23% vs 1.78% ± 0.31%,P < 0.01).Moreover,neutrophil migration was disturbed in MMP-9(-/-) mice in the immunohistological stainings.Two methods of MMP-9 inhibition revealed reduced PLF,and neutrophil migration was strongly disturbed in MMP-9-blocked mice in the histopathological assessments(9.6 ± 1.9 vs 4.2 ± 1.2,P < 0.05,and 9.9 ± 1.5 vs 5.7 ± 1.1,P < 0.05).CONCLUSION:MMP-9 is important for the process of PLF.The initial injury is associated with MMP-9 derived from neutrophils,and MMP-9 block     

Involvement of glutamate receptors on hyperexcitability of wide dynamic range neurons in the gracile nucleus of the rats with experimental mononeuropathy.

In order to clarify the functional role of glutamate receptors of the gracile nucleus neurons in rats with nerve injury-induced hyperalgesia, pharmacological, electrophysiological and in situ hybridization techniques were used in rats with chronic constriction nerve injury (CCI) of the sciatic nerve. A total of 54 wide dynamic range neurons were recorded from the gracile nucleus in the rats with CCI. Mechanical evoked responses were significantly depressed following application of AMPA receptor antagonist, CNQX, with noxious and non-noxious responses being similarly affected. AP-5, an NMDA receptor antagonist, induced depression of the pressure-evoked response only after application of the 1-microM concentration of this drug. The size of the receptive fields was significantly decreased after CNQX, but not MK-801 or AP-5, application. Afterdischarge was significantly depressed following the application of CNQX (1000 microM). The expression of ionotropic glutamate receptor subunit mRNAs in the gracile nucleus was studied using the in situ hybridization technique. The signals for NMDA subunits, NR2A, -2B and -2C, in the gracile nucleus neurons were not prominent, suggesting a low level expression of functional NMDA receptor complex. AMPA receptor subunits GluR1, -R2, -R3 and -R4 mRNAs were expressed in a large number of gracile nucleus neurons. These data are consistent with the pharmacological results that AMPA receptor antagonists depressed nociceptive neuronal activity, but NMDA receptor antagonists showed limited effects. These results suggest that the ionotropic glutamate receptors, i.e. the AMPA and NMDA receptors, are differentially involved in modulation of the wide dynamic range neuronal activity in the gracile nucleus following peripheral nerve injury.     

13C-Labeled Trioctanoin Breath Test for Exocrine Pancreatic Function Test in Patients after Pancreatoduodenectomy

To assess exocrine pancreatic function in patients before and after pancreatoduodenectomy (PD), we used the breath test, with nonradioactive ¹³C-labeled trioctanoin, in 14 patients before pancreatic resection because of localized pancreatic mass (preop-PD group), and in 13 patients who had undergone pancreatoduodenectomy more than 5 yr before (post-PD group). The results were compared with those of the secretin test, N-benzolyl-L-tyrosyl-p-amino benzoic acid (BT-PABA) test, and fecal chymotrypsin. Means ± SD and frequencies of low values of the recovery of the breath test were 42.0 ± 3.4%, 0/5 in the control; 24.2 ± 10.5%, 14/14 in the preop-PD group; and 18.6 ± 8.0, 13/13 in the post-PD group. The overall sensitivities in the preop- and post-PD groups were 100% for the recovery and 93% for the maximal mass ratio of the breath test, 89% for the secretin test, 67% for the BT-PABA test, and 64% for fecal chymotrypsin. The recovery of the breath test correlated significantly with the duodenal outputs of lipase, amylase, and chymotrypsin, and was not affected in patients with obstructive jaundice or with low D-xylose absorption. The breath test is as sensitive as the secretin test, more reliable than the conventional tubeless tests, and is available to follow up the exocrine pancreatic function before and after pancreatoduodenectomy.     

Novel translucent monolithic zirconia fixed restorations in the esthetic zone

Novel translucent monolithic zirconia has improved optical properties, and it may fulfill patient''s esthetic demands and overcome the chipping risk of bilayer metal‐ceramic restorations. New zirconia''s microstructures allow us to mimic natural teeth.     

Esthetic outcome for implant therapy of a maxillary lateral incisor using prefabricated titanium and customized zirconia abutments: 4‐year clinical reports

The reported clinical scenarios presented two patients, one managed with a prefabricated abutment and the other with a customized abutment, and both patients were pleased with the outcome. However, from a professional viewpoint, the esthetic outcome using the custom zirconia abutment was superior to that using the prefabricated titanium abutment.