Determining Pattern of Recurrence Following Pancreaticoduodenectomy and Adjuvant 5-Flurouracil-Based Chemoradiation Therapy: Effect of Number of Metastatic Lymph Nodes and Lymph Node Ratio

Background  There are limited data on patterns of recurrence and factors associated with local recurrence following pancreaticoduodenectomy for pancreatic adenocarcinoma and adjuvant 5-flurouracil-based chemoradiation therapy. Methods and Materials  Between 1995 and 2005, 905 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma; 154 patients had complete pattern of recurrence data available. Results  At median follow-up of 20.2 months, 103 (66.9%) patients recurred with median time to recurrence of 16.2 months. Most patients recurred with distant disease only (68.9%), while 21.4% patients recurred with local disease only; ten (9.7%) patients recurred with local and distant disease. Several factors were associated with local recurrence: poor tumor differentiation (hazards ration [HR] 2.39) and presence of metastatic lymph nodes (HR 1.89, both p < 0.05). Among N1 patients, poor tumor differentiation (HR 3.92), >5 metastatic LN (HR 3.75), and lymph node ratio (LNR) >0.4 (HR 2.96) had the highest risk of local recurrence (all p < 0.05). Increasing LNR was associated with an incremental increased risk of local recurrence (LNR <0.2, 21.3% versus LNR ≥0.2 to 0.4, 25.2% versus LNR >0.4, 40.4%; p < 0.05). Conclusions  Although most patients who receive standard 5-flurouracil-based chemoradiation therapy will ultimately succumb to distant disease, about 30% recur locally. Poor tumor differentiation, a high number of metastatic LN (>5), and LNR >0.4 are associated with the highest risk of local failure. In these patients, radiation dose escalation and/or a combination of radiation with novel chemotherapeutic agents may be necessary to improve outcomes. Presented at the American Hepato-Pancreato-Biliary Association Annual Meeting, Ft. Lauderdale, Florida, March 29th, 2008     

胰腺肌周细胞瘤的病理特征及诊治（附1例报告并文献复习）

目的探讨胰腺肌周细胞瘤的病理特征及其诊治。方法报告本院收治的1例胰腺肌周细胞瘤,并复习近年来国内外文献肌周细胞瘤的临床病理特征、诊断、鉴别诊断、治疗及预后。结果胰腺肌周细胞瘤为具有嗜酸性/嗜双性的圆形、卵圆形细胞围绕血管腔形成的典型的同心圆状结构。血管周同心圆Υ排列的肌样细胞表达SMA及Actin阳性,而其他肌性标记物Desmin、S-100蛋白、HBM45及CD34等为阴性。结论胰腺肌周细胞瘤属于良性肿瘤,临床表现无特异性,确诊须靠病理组织学检查,完整切除肿瘤是本病的理想治疗方法。     

Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels

Background/purpose  Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option. Methods  After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy. Results  The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH. Conclusions  The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.     

Liver metastasis as an initial recurrence has no impact on the survival of patients with resectable pancreatic adenocarcinoma

Background  Prognosis of the patients with pancreatic adenocarcinoma is still poor due to a recurrence, and liver metastasis is a distant metastasis that is foreboded the short survival period. Methods  Between 1999 and 2005, 68 patients for pancreatic adenocarcinoma underwent a pancreaticoduodenectomy (n = 17), a pylorus-preserving pancreaticoduodenectomy (n = 27), distal pancreatectomy (n = 22), or total pancreatectomy (n = 2) with an extensive lymph node dissection. Results  A tumor recurrence occurred to 55 patients (13 of the liver, 21 of the local recurrence, 16 of peritoneal dissemination, three of the lymph node, and two of lung). The low tumor grade and female demonstrated a risk factor for a liver metastasis (P = 0.043, P = 0.031). A logistic regression analysis demonstrated female (P = 0.02) and low tumor grade (P = 0.04) as independent risk factors for recurrence with liver metastasis. The median survival time (MST) was 13.6 months, and MST of patients with a liver metastasis as an initial recurrent site was 13.7 months; the liver metastasis as an initial recurrent site has no impact on the MST after pancreatic resection. Conclusions  We concluded potentially supporting the hypothesis that even patients thought to be at higher risk of liver metastasis may still be given the chance of resection, considering the satisfying survival.     

螺旋CT和彩色多普勒血流显像检查对胰腺癌可切除性的评估价值

Objective To determine the value of helical computed tomography (HCT) and color doppler flowing imaging (CDPI) in evaluating the resectability of pancreatic cancer. Methods The clinical data of 114 patients with pancreatic cancer who had been admitted to the Affiliated Hospital of North Sichuan Medical College from January 1995 to December 2002 were retrospectively analyzed. The values of HCT and CDPI in assessing the resectability of pancreatic cancer were determined according to the results of operation and pathological examina-tion. All the data were analyzed by chi-square test and Fisher exact probability. Results Of all patients, 109 were examined by HCT, 97 by CDPI and 96 by HCT+CDPI. For patients examined by HCT, the resection rates of pancreatic head cancer, pancreatic body and tail cancer and total pancreatic cancer were 45.3% (39/86), 26.3% (5/19) and 0 (0/9), respectively. The resection rate of pancreatic head cancer was higher than that of pancreatic body and tail cancer (χ2=8.965, P<0.05). With the increase of tumor size, the invasion rate and metastasis rate were increased and the resection rate was decreased (z=6.15, 5.35, 7.18, P<0.01). The sensitivity rate and specificity rate were 77.8% and 82.2% of HCT, 73.3% and 80.6% of CDPI, 90.6% and 92.4% of HCT+CDPI in assessing the resectability of pancreatic cancer. The values of Kappa identity test of HCT, CDPI and HCT+CDPI were 0.58, 0.52 and 0.82, respectively. Conclusions Combined application of HCT and CDPI can further improve the accuracy in assessing the resectability of pancreatic cancer.     

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

BACKGROUND/PURPOSE: The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis. METHODS: A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas. RESULTS: Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula. CONCLUSIONS: We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.     

二维电泳及质谱法分离和鉴定胰腺癌差异表达蛋白质

目的 通过分离并鉴定胰腺癌组织、癌旁组织和正常胰腺组织的差异表达蛋白质,发现可能用于早期诊断的胰腺癌肿瘤标志物.方法 用双向电泳分离胰腺癌、癌旁和人正常胰腺组织的总蛋白质.对胰腺癌组织中明显差异表达的蛋白点,行质谱鉴定和生物信息学分析.并对鉴定出的部分蛋白质行免疫印迹验证.结果 建立了稳定、重复性好的凝胶蛋白图谱.对分离出的在胰腺癌组织中明显差异表达的20个蛋白点,成功鉴定出11个蛋白点,其中高表达的有6个,包括:galectin-1、SLP-2、sorcin、3BP-2、BB1和NCC27.Galectin-1和SLP-2在胰腺癌组织中的高表达通过免疫印迹得到验证.结论 胰腺癌组织相对于癌旁、正常胰腺组织蛋白存在明显的表达差异.胰腺癌差异表达蛋白质可能成为用于早期诊断和评价预后的胰腺癌标志物.     

胰腺内分泌肿瘤术前影像学定位诊断方法的选择

目的:评估经腹部超声(TAUS)、内镜超声(EUS)、CT、MR、选择性血管造影(SAG)及动脉钙刺激静脉采血测定胰岛素(ASVS)在胰腺内分泌肿瘤(PET)术前定位中的价值。方法:对65例经手术及病理证实的PET的术前影像学检查资料进行回顾性分析,比较不同检查方法对PET的定位结果,并探讨PET的影像学表现和特点。结果:各种检查方法术前定位的敏感性和准确性分别为:TAUS为47.4%和41.5%,EUS为90.0%和75.0%,CT为86.9%和82.8%,MR为85.7%和77.4%,SAG为16.7%和16.7%及ASVS为83.3%和83.3%。结论:PET的术前影像学检查方法的选择应从易到难,先行非侵入性的TAUS、MSCT或MR检查;如仍为阴性,则考虑EUS或ASVS;最后为手术探查及术中超声检查。     

36例青年胰腺癌临床分析

目的探讨青年胰腺癌的临床特点，以提高青年胰腺癌早期诊断水平和治疗效果。方法分析36例青年胰腺癌的临床表现、误诊情况、临床病理、治疗与预后，与老年胰腺癌152例进行回顾性临床对比分析。结果①青年组胰腺癌首发主要表现上腹饱胀不适，上腹痛或背部痛；②青年组胰腺癌误诊率为77．78％，明显高于老年组（P〈0．01）；③根治性手术率低、预后差。结论青年胰腺癌首发临床表现主要为上腹痛及背部痛或上腹饱胀不适，这些症状的发生率明显高于老年胰腺癌病人；首发黄疸症状少，误诊率高；根治性手术率低，预后差。故应重视青年胰腺癌的临床早期诊断。     

胰腺导管内乳头状黏液性肿瘤13例临床分析

目的总结胰腺导管内乳头状黏液性肿瘤(IPMT)的诊治经验,提高对该病治疗水平。方法自1985年5月至2004年3月共收治IPMT病人13例,男8例,女5例。所有病人均有不同程度的胰管扩张,8例进行了ERCP检查,发现胰管扩张,胰液溢出5例。结果除1人外,其他病人均接受了手术治疗,手术效果良好。术后病理诊断为胰头导管乳头状黏液性腺癌3例;胰头导管内乳头状黏液性腺瘤伴局部癌变2例;胰头导管内乳头状黏液性腺瘤伴不典型增生2例;胰头导管内乳头状黏液性腺瘤5例。结论IPMT与胰腺导管癌不同,ERCP有助于诊断本病,积极的手术治疗可获得良好的预后。