Pathology of liver tumours

Histopathological assessment of liver tissue is essential for the management of patients with a whole range of liver tumours. Biopsies are often helpful in establishing the initial diagnosis of a lesion. Intraoperative frozen sections can provide the surgeon with valuable information regarding the nature of a liver lesion and/or the clearance of surgical margins. Examination of tissue from resection and transplant operations is important in confirming the preoperative diagnosis and for providing additional prognostic information. This article outlines the pathway for processing liver tumour tissue in the histopathology laboratory, before discussing the pathological features of the more commonly encountered benign and malignant liver tumours. Included within this discussion are epithelial tumours of hepatocellular and biliary derivation, mesenchymal lesions and metastatic liver lesions. The age of the patient and the presence or absence of background liver disease are major determinants of the likely differential diagnosis of a liver lesion. The article also summarizes the key data items included in a histopathology report for surgical excision specimens.     

后腹腔镜肾上腺手术401例

目的探讨后腹腔镜肾上腺肿瘤切除的方法和临床应用价值。方法2002年8月～2007年12月，行后腹腔镜肾上腺肿瘤切除术401例，其中无功能腺瘤151例，原发性醛固酮增多症139例，皮质醇增多症37例，嗜铬细胞瘤19例，髓样脂肪瘤13例，其他42例。结果5例中转开放手术，其中1例瘤体过大腹腔镜操作困难，2例肿瘤与下腔静脉粘连紧密，2例出血；余396例手术成功，手术时间30～270min，平均105min，术中失血20～1000ml，中位数45ml，2例术中各出血1000、800ml，输红细胞2U。术中下腔静脉破裂1例，膈肌破裂1例，均在腹腔镜下完成修补。364例随访1～64个月，平均23．9月，无远期并发症，361例良性肿瘤未见复发。结论后腹腔镜肾上腺肿瘤切除术安全，有效，创伤小，恢复快，应为肾上腺良性疾病的首选治疗方法。     

经单鼻孔-蝶窦入路垂体腺瘤显微手术治疗及其策略

目的 总结采用经单鼻孔-蝶窦入路显微手术治疗垂体腺瘤的临床疗效.方法 从2003年1月至2007年12月,经单鼻孔-蝶窦入路显微手术治疗垂体腺瘤241例,并对其临床表现、肿瘤病理、肿瘤切除率、术后并发症进行总结分析.结果 垂体腺瘤241例中,全切除171例(71%),次全切除28例(11.6%),大部分切除26例(10.7%),部分切除16例(6.6%).术后多饮、多尿38例(15.8%)、术后视力一过性下降12例(4.9%)、术后脑脊液漏4例(1.6%)、一侧动眼神经损伤2例(0.8%),无死亡病例.除动眼神经损伤的2例外,其余病例的术后并发症在出院时已治愈.随访1-36个月,所有病例的临床症状均有不同程度改善.结论 经单鼻孔-蝶窦人路显微切除垂体腺瘤手术时间缩短,创伤小,手术效果好.     

Do forceps biopsies truthfully reflect the nature of endoscopically uncovered polypoid lesions of the colon?

BACKGROUND: Total excision of colonic polyps is not always attainable and in some patients it is clinically contraindicated. Also, a resected polyp may be lost at any step between its endoscopic removal and its embedding in paraffin. The aim of this study was to compare the histological features of colonic polyps as analysed by the study of biopsy-forceps obtained samples with those assessed on scrutinizing the totally resected growths. PATIENTS AND METHODS: This prospective study included a cohort of 59 patients in whom, in the course of an elective colonoscopy, a total excision of a 6 mm-sized or larger polyp was called for. Sizeable biopsies were obtained by means of an Olympus Multibyte forceps prior to the total polypectomy. Subsequent to the study of the polypectomy specimens, the forceps biopsy samples were submitted for histological examination. The pathologists were blinded as to the source of the tissue they were studying. The diagnoses rendered by evaluating the biopsy samples and polypectomy specimens of each patient were contrasted with each other. RESULTS: Major discrepancies between the histological features of the fragments captured by the biopsy-forceps and the factual nature of the totally removed polyps were uncovered in 11 (18.6%) of 59 cases. Intriguingly, the grade of the tumours was underrated in all the 11 cases, as judged by contrasting the tentative diagnoses of the forceps-biopsies with the decisive diagnoses of the polypectomies. Importantly, 2 adenocarcinomas would have been missed by just looking at the forceps-retrieved sample. CONCLUSIONS: In our experience, a discordance of 18.6% is to be expected between the diagnoses rendered after examining forceps-biopsies of and totally excised colonic polyps. Nevertheless, it is advisable to procure biopsies prior to the excision of the growths, because on those occasions in which patients' growths cannot be removed or have not been retrieved for one reason or another, a small forceps-captured tissue sample correctly reflects the characteristics of the polyp in 81.4% of the cases. Finally, the biopsies may be discarded in the event that total removal was successful.     

后腹腔镜肾上腺肿瘤切除术78例报告

目的探讨后腹腔镜肾上腺肿瘤切除术的价值。方法2003年3月～2008年5月对78例肾上腺肿瘤行后腹腔镜肾上腺切除术。腰部3个trocar穿刺入路,观察镜直接推移法建立后腹膜腔,用超声刀将肿瘤切除。结果78例手术均取得成功,未输血。手术时间45～180min,平均90min。术后24h拔除引流管,术后3～5d出院。1例有局部皮下气肿,术后自行吸收,未出现其他并发症。72例术后随访3～24个月,平均10个月,36例术后3个月内血压恢复正常,7例仍需口服降压药物,肿瘤局部无复发。结论后腹腔镜肾上腺切除术具有安全、有效、创伤小、术后恢复快、住院时间短等优点,是治疗肾上腺良性肿瘤的首选方法。     

Adenoid Cystic Carcinoma ex Pleomorphic Adenoma of the Parotid Gland

There is a considerable variation in the histologic subtype of epithelial malignancies among carcinoma ex pleomorphic adenomas (CXPA) and virtually any known carcinoma entity can develop. To our knowledge, adenoid cystic carcinoma (AdCC) ex PA is quite rare despite the fact that de novo AdCC is the fourth most common salivary gland malignancy. We describe a new case of AdCC ex PA in the parotid gland of a 62 year-old woman. In our patient, there was a short interval of time between parotidectomy and local recurrence and rapid development of distant metastases. Although most of the reported cases are considered low-grade, evidence is presented here that AdCC can take the form of a high-grade malignancy in PA.     

An Update on Grading of Salivary Gland Carcinomas

Histologic grade is a significant predictor of outcome in salivary gland carcinomas. However, the sheer variety of tumor type and the rarity of these tumors pose challenges to devising highly predictive grading schemes. As our knowledge base has evolved, it is clear that carcinoma ex pleomorphic adenoma is not automatically a high grade tumor as is traditionally suggested. These tumors should be further qualified as to type/grade of carcinoma and extent, since intracapsular and minimally invasive carcinomas ex pleomorphic adenoma behave favorably. The two carcinoma types for which grading schemes are common include adenoid cystic carcinoma and mucoepidermoid carcinoma. Adenoid cystic carcinomas are graded based solely on pattern with solid components portending a worse prognosis. Occasionally, adenoid cystic carcinomas may undergo transformation to pleomorphic high grade carcinomas. This feature confers a high propensity for lymph node metastasis and should thus be reported to alert the clinical team. Mucoepidermoid carcinomas are graded in a three tier fashion based on a constellation of features including cystic component, border, mitoses, anaplasia, and perineural invasion among others. All grading schemes are somewhat cumbersome, intimidating and occasionally ambiguous, but evidence suggests that using a scheme consistently shows greater reproducibility than using an intuitive approach. The intermediate grade category demonstrates the most variability between grading systems and thus the most controversy in management. In the AFIP system intermediate grade tumors cluster with high grade tumors, while in the Brandwein system, they cluster with low grade tumors.     

巨大垂体腺瘤的治疗策略

目的通过回顾性分析32例巨大垂体腺瘤病例的临床资料，探讨其治疗策略。方法男性17例，女性15例，平均年龄46．7岁，平均病程4．7年。其中垂体生长激素(GH)腺瘤1例，泌乳素(PRL)腺瘤6例，无功能腺瘤25例。采用经口鼻蝶窦入路手术24例，经额下人路手术1例，经蝶窦和经颅分期手术6例，药物治疗1例。结果手术显微镜下肿瘤全部切除20例，7欠全切除9例，部分切除2例；手术后放疗10例，药物治疗5例。术后死亡1例。随访6个月～4年，影像学检查显示肿瘤全部切除15例，次全切除14例，部分切除2例；肿瘤无复发。结论对巨大垂体腺瘤，应根据患者的临床表现、内分泌学检查和肿瘤的生长方式决定治疗方案；大多数巨大垂体腺瘤可以首选经蝶窦入路手术，并发症较少，死亡率低；对侵袭性生长的肿瘤，应采用手术、放疗和药物综合治疗。     

乳管内窥镜在合并甲状腺功能低下或垂体瘤的双侧乳头溢液中的应用

目的 探讨合并甲状腺功能低下或垂体瘤的双侧乳头溢液与乳腺导管内病变的关系.方法 对222例临床确诊的甲状腺功能低下(94例)和垂体瘤(128例)患者行乳管镜检查.结果 222例患者中有64例乳管镜诊断为乳腺导管内乳头状瘤,158例诊断为导管扩张炎症.64例均行手术治疗,术后病理证实59例为导管内乳头状瘤,5例为导管扩张性炎症,病理符合率为92.18%(59/64),未见乳腺癌.合并甲状腺功能低下或垂体瘤的双侧乳头溢液患者各民族之间分布差异无统计学意义(P>0.05);绝经前的合并垂体瘤的患者发生导管病变的概率高于甲状腺功能低下患者,而绝经后甲状腺功能低下患者发生导管病变的概率高于垂体瘤患者(P<0.05);合并垂体瘤的乳头溢液多为乳汁样,而合并甲状腺功能低下的乳头溢液多为清水样.本组乳管内乳头状瘤约71.19%发生在主导管以下的分支导管.结论 合并甲状腺功能低下或垂体瘤的双侧乳头溢液患者要考虑到发生导管内病变的可能.乳管镜是较为适宜的检查方法.     

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report

Objective  This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma. Method  A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 × 3.5 × 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. Results  Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. Conclusions  This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.