胰腺囊性肿瘤的诊断与治疗

目的探讨胰腺囊性肿瘤的诊断和治疗。方法回顾性分析2008年1月-2012年7月间56例本院胰腺囊性肿瘤患者的临床资料,男性15例,女性41例,男女比例为1：2.73,其中浆液性囊腺瘤12例,黏液性囊腺瘤22例,黏液性囊腺瘤癌6例,导管内乳头状囊腺瘤3例和乳头状囊腺瘤癌1例,实性假乳头状瘤12例。结果所有患者均经手术治疗,胰十二指肠切除术13例,胰腺肿瘤节段切除术4例,1例因肿瘤侵及周围脏器及大血管行胃空肠及胆肠吻合术,1例行胰腺钩突部肿瘤切除、部分十二指肠空肠切除、十二指肠空肠吻合术,胰腺肿瘤局部切除术3例,胰体尾切除术18例,保留脾脏的腹腔镜胰体尾切除术8例,腹腔镜胰体尾加脾切除2例,腹腔镜胰腺肿瘤局部切除术6例。本组无围手术期死亡,腹腔感染2例,胃排空障碍3例,胰瘘4例,胆漏2例,均经保守治疗痊愈。结论 B超、CT和MRI是胰腺囊性肿瘤的主要诊断方法,具体手术方式应根据肿瘤所在部位、病理类型、与主胰管的关系以及患者全身情况综合考虑。     

Methylation of the O6-methylguanine-DNA methyltransferase promoter suppresses expression in mouse skin tumors and varies with the tumor induction protocol

Hypermethylation of CpG sites within the promoter region of the O6-methylguanine-DNA methyltransferase (MGMT) gene occurs frequently in human cancer, preventing both MGMT expression and repair of alkylation damage. To assess the role of MGMT in the development of mouse skin tumors induced by initiation-promotion protocols, methylation of the MGMT promoter was examined in tumor DNA using methylation-specific PCR. To determine whether MGMT promoter methylation was affected by the tumor induction protocol, tumors were initiated by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) or 7,12-dimethylbenz[a]anthracene (DMBA) and promoted by 12-O-tetradecanoylphorbol-13-acetate (TPA) or mezerein. Although the MGMT promoter was not methylated in normal skin, promoter methylation was found in 56 of 136 papillomas (41.2%) and in 19 of 37 squamous cell carcinomas (51.4%). When methylation of the MGMT promoter was compared in the 4 treatment groups, hypermethylation was found more frequently in tumors initiated by DMBA and promoted by mezerein, a protocol associated with a high frequency of malignant conversion. Methylation was found in some tumors as early as 5 weeks after initiation, but the methylation frequency increased with time. MGMT promoter methylation reduced MGMT expression as determined by immunohistochemistry. Although MGMT promoter methylation was not generally correlated with ras mutations, the frequency of MGMT methylation was higher in MNNG-initiated, mezerein-promoted papillomas with mutations in Ha-ras compared to papillomas with Ki-ras. Methylation of the MGMT promoter, associated with reduced MGMT expression, is found in nearly half of mouse skin tumors, but varies with both the tumor initiator and tumor promoter, and may be a key step in the progression from papillomas to carcinomas.     

Krebsrisiko bei papillären Proliferationen der Brustdrüse

Zusammenfassung Der Abschätzung des Krebsrisikos für Papillompatienten muß eine morphologische Differenzierung der excidierten Gewächse nach Lokalisation und Proliferationsgrad zugrundeliegen. Die nur mikroskopisch erkennbaren Papillome der distalen Milchgänge (sog. lobuläre Papillome) kommen am häufigsten vor und treten oft multipel auf. Durch sie wird das Krebsriskio aber nicht wesentlich gesteigert. Nach Lokalexcision eines Papilloms der Brustwarze ist gleichfalls nicht mit einem erhöhten Krebsrisiko zu rechnen, doch die vollständige Entfernung sollte gesichert sein. Papillome größerer vorwiegend proximaler Milchgänge (sog. duktale Papillome) zeigen häufig eine gesteigerte Proliferationsaktivität und gelegentlich Atypien. Der Excision eines Gangpapilloms sollten daher regelmäßige Nachkontrollen immer folgen, auch wenn eine Multizentrizität nicht vorauszusetzen ist. Proliferierende Papillome können morphologisch überdiagnostiziert werden. In Grenzfällen mit focalen Kernatypien sollten aber weitere chirurgische Maßnahmen diskutiert werden (gegebenenfalls mit subcutaner Mastektomie). Hierbei müssen neben den morphologischen Gegebenheiten die falleigenen Daten (Biopsie in sano, radiologische Befunde, Alter der Patienten usw.) berücksichtigt werden.

---

Mammary cancer risk subsequent to papillary proliferations

Summary Morphological differentiation according to localization and degree of proliferation must precede any estimate of the probability of cancer occurring in patients suffering of papilloma. The most frequently occurring papillomas are those of the distal lacteal ducts (so-called lobular papillomas). These can only be seen microscopically and they are often multiple, but they do not essentially heighten the risk of cancer. There is, furthermore, no greater risk of cancer to be reckoned following local excision of a papilloma of the nipple, but one should be certain of total excision. Papillomas of the larger preponderant proximal ducts (so-called ductal papillomas) often show an increased rate of proliferation and occasionally display atypias. Although a multicentric occurrence cannot be generally presupposed, controls should be carried out constantly after local exstirpation. Proliferating papillomas can be overdiagnosed morphologically. In borderline cases with focal nuclear atypias, however, further surgical measures (subcutaneous mastectomy, if possible) should be discussed. Apart from morphological facts individual datas (biopsy in sano, radiological findings, age of the patient etc.) must be considered in this discussion.

     

Feasibility and Technical Considerations of Mammary Ductoscopy in Human Mastectomy Specimens

Abstract: Recent advances in endoscopic technology have made visualization of human mammary ducts possible. The purpose of this study was to assess the feasibility and technical factors influencing the ability to successfully visualize the epithelium of the human mammary ductal system. Lacrimal duct probes were used to dilate nipple orifices to 1.2 mm on 42 mastectomy specimens. The Depth of Field Imaging Micro-Minimally Invasive (DOFI® MMI) system consisting of a 1.2 mm rigid ductoscope with a 350 μm working channel was introduced into mammary ducts under air insufflation or saline irrigation. At least one major duct could be dilated and cannulated in all 42 specimens. Visualization of the proximal duct was accomplished in 34 of 42 (81%) specimens, whereas more extensive navigation through the distal subsegmental ducts was achieved in 22 of 42 (52%) specimens. Ductoscopy into the terminal ducts was accomplished in all patients with a previous history of nipple discharge or discharge at the time of the procedure (10 of 10). In three patients with no history of nipple discharge prior to ductoscopy, incidental papillomas were discovered and confirmed by the pathologist. In conclusion, mammary ductoscopy is technically feasible and may have an application as an additional diagnostic modality for patients with pathologic nipple discharge.     

Laryngopharyngeal reflux and laryngeal web formation in patients with pediatric recurrent respiratory papillomas

OBJECTIVE: To determine whether treatment of laryngopharyngeal reflux reduces the laryngeal soft tissue complications encountered in surgery for recurrent respiratory papillomas. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective chart review of all pediatric patients treated for laryngeal recurrent respiratory papillomas between 1984 and 1999 was performed. Thirty-one such patients were identified. Twenty-four were at "high risk" for developing complications based on the number of operating suite visits and the presence of disease at the anterior commissure. Twelve patients underwent 24-hour double pH probe testing. RESULTS: Overall, 13 of 31 patients (42%) developed laryngeal webs. No other soft tissue complications were encountered. Of the patients who had pH probe testing, 12 of 12 (100%) had at least one pharyngeal episode of acid exposure. Of the "high-risk" patients, 10 were treated for reflux and only 2 of 10 (20%) developed webs. Eleven of 14 (79%) of the "high-risk" patients who were not treated for reflux developed webs. The difference in rate of web formation between patients treated for reflux and those not treated for reflux was statistically significant (P =.011). CONCLUSIONS: Antireflux treatments for patients undergoing surgery for laryngeal recurrent respiratory papillomas may reduce the soft tissue complications, especially scarring and web formation. Prophylactic antireflux therapy may be warranted in any patient undergoing surgery during which laryngeal mucosal disruption is anticipated.     

Cell proliferation and p27Kip1 expression in endophytic schneiderian papillomas

OBJECTIVE: To clarify epithelial cell proliferation and p27Kip1 expression along the stepwise histological changes from endophytic schneiderian papillomas to associated carcinomas. STUDY DESIGN: Retrospective investigation involved surgical specimens from 58 patients. METHODS: Immunohistochemical assessment involved the nuclear Ki67 antigen expressed in proliferating cells. Further, the cyclin-dependent kinase (cdk) inhibitor p27Kip1 was assessed. Binding of p27Kip1 to the cyclin E-cdk2 complex inhibits this kinase, which results in cell cycle arrest. The expression rates of both proteins were compared between nonpapillomatous nasal mucosa, endophytic schneiderian papillomas, carcinoma in situ, and invasive squamous cell carcinomas. Statistics involved the Wilcoxon and Mann-Whitney u tests. Significance was set at P <.05. RESULTS: Comparable cell proliferation rates were observed between non-papillomatous nasal mucosa and cylindrical cell papillomas. Significant increases in cell proliferation were found along the stepwise series of histological changes involving non-papillomatous nasal mucosa, columnar epithelium in inverted papillomas, transitional and squamous metaplasia in inverted papillomas, and dysplastic inverted papillomas (P <.05, respectively). A tendency toward increased cell proliferation in carcinoma in situ compared with dysplastic inverted papillomas was present; however, this was not statistically significant. The expression rates of p27Kip1 were comparable between non-papillomatous nasal mucosa and all histological subtypes within nondysplastic endophytic schneiderian papillomas. Significantly reduced p27Kip1 expression was found in surface cells in dysplastic compared with non-dysplastic inverted papillomas, as well as in the total number of cells in carcinoma in situ compared with dysplastic inverted papillomas (P <.05, respectively). CONCLUSIONS: Inverted papillomas but not cylindrical cell papillomas show increased cell proliferation compared with nonpapillomatous nasal mucosa. Stepwise increases in cell proliferation accompany the consecutive histological changes within inverted papillomas. Among them, increased cell proliferation along with the development of dysplasia and carcinoma in situ is associated with reduced p27Kip1 expression.     

Choroid plexus papillomas in infancy and childhood

The present study deals with 15 cases of choroid plexus papilloma, out of approximately 500 cases of brain tumors observed in children up to 16 years old. Several features are considered, including clinical symptoms and signs—mostly related to increased intracranial pressure—radiological diagnosis, pathology and surgical treatment, and results. Surgery may be radical in most cases, with the exception of histologically malignant papillomas. The management results are usually satisfactory. An adequate choice of surgical approach is mandatory and surgical technique should be meticulous, also in order to avoid the risk of intraoperative tumoral seeding.Presented in part at the 11th Meeting of the European Society for Paediatric Neurosurgery, Naples 1988     

Malignant tumours in patients with a history of multiple laryngeal papillomas: the significance of irradiation

Malignant tumours in patients with a history of multiple laryngeal papillomas: the significance of irradiation For a period of more than 30 years irradiation was used in the treatment of multiple laryngeal papillomas, especially in children. The treatment was discontinued because a number of irradiated patients developed laryngeal carcinomas. There are however a number of reports of laryngeal and even bronchial carcinomas arising in patients with laryngeal papillomas who had not been irradiated. In addition, HPV type 11 has recently been found in laryngeal papillomas as well as in laryngeal and bronchial carcinomas, subsequently arising in the same patients, both irradiated and non-irradiated. The analysis of a series of 113 patients with laryngeal papillomas has shown that irradiated patients have a 16-fold increased risk of a subsequent carcinoma in the respiratory system.     

Recurrent respiratory papillomatosis: a review

Recurrent respiratory papillomatosis (RRP), which is caused by human papillomavirus types 6 and 11, is the most common benign neoplasm of the larynx among children and the second most frequent cause of childhood hoarseness. After changes in voice, stridor is the second most common symptom, first inspiratory and then biphasic. Less common presenting symptoms include chronic cough, recurrent pneumonia, failure to thrive, dyspnea, dysphagia, or acute respiratory distress, especially in infants with an upper respiratory tract infection. Differential diagnoses include asthma, croup, allergies, vocal nodules, or bronchitis. Reports estimate the incidence of RRP in the United States at 4.3 per 100,000 children and 1.8 per 100,000 adults. Infection in children has been associated with vertical transmission during vaginal delivery from an infected mother. Younger age at diagnosis is associated with more aggressive disease and the need for more frequent surgical procedures to decrease the airway burden. When surgical therapy is needed more frequently than four times in 12 months or there is evidence of RRP outside the larynx, adjuvant medical therapy should be considered. Adjuvant therapies that have been investigated include dietary supplements, control of extra-esophageal reflux disease, potent antiviral and chemotherapeutic agents, and photodynamic therapies; although several have shown promise, none to date has "cured" RRP, and some may have serious side effects. Because RRP, although histologically benign, is so difficult to control and can cause severe morbidity and death, better therapies are needed. The potential for a quadrivalent human papilloma vaccine is being explored to reduce the incidence of this disease.     

1.5T乳腺专用磁共振诊断乳腺导管内乳头状瘤的应用价值

目的:探讨乳腺专用磁共振诊断导管内乳头状瘤的应用价值。方法:收集我院经手术病理证实的31例乳腺导管内孤立/多发乳头状瘤病例进行回顾性分析。所有病人术前均行乳腺X线、超声检查及AURORA乳腺专用磁共振平扫及动态增强扫描。参照乳腺影像报告和数据系统(BI-RADS),评价其病灶的形态学(包括病灶大小、形状、部位、边缘、多形性及与导管的关系)、动态增强扫描的强化模式及其他相关的特征,并与X线、超声检查相对照。结果:31例病人孤立导管内乳头状瘤23例,多发导管乳头状瘤8例。MRI共检出30个病灶,其中2例导管内乳头状瘤MRI为阴性,1例双侧多发导管乳头状瘤MRI检出双侧病灶。其MRI形态学表现最多见是沿导管分布多发小结节样或环形强化(38.7%),其次为乳晕后区孤立或多发结节样强化(22.6%)及乳晕后方导管样、线状、分支样强化(12.9%),伴或不伴导管扩张,MRI增强信号-时间曲线以平台型和流出型为主,具有一定的特征性。部分(4例)表现为类似恶性肿瘤的MRI征象(12.9%),难以与恶性肿瘤区分。结论:乳腺专用MRI检查对检出导管内乳头状瘤(病)具有较大的优势,能为临床手术治疗提供准确定位,具有较好的应用价值。