Cancers of the papilla of vater: mutator phenotype is associated with good prognosis

Cancer of the papilla (ampulla) of Vater is an uncommon disease that kills 60% of affected patients. There is general agreement that local spread of the tumor (T stage) is the only significant and independent prognostic factor for this cancer, whereas the predictive value of tumor grade and lymph node metastases is controversial. The genetic anomalies involved in this process have the potential to serve as additional prognostic markers. We explored 25 ampullary cancers for the occurrence of instability at simple repeat DNA sequences (microsatellites) of the type seen in replication error phenotype (RER-positive) cancers. Ten microsatellites from five different chromosomes were amplified by PCR from both normal and cancer tissue DNA of the same patients. A tumor was defined as RER-positive when microsatellite instability was found in the majority (>/=6) of the loci analyzed. Five cancers (20%) showed a RER phenotype and were associated with long survival of patients (32-96 months), whereas RER-negative cancers had a significantly poorer prognosis (Mantel-Cox test; P = 0.0084), with a median actuarial survival of 17 months. We also report that three (12%) patients belonged to cancer-prone families and four (16%) were cancer-prone individuals.

[Reconstruction technique after pancreaticoduodenectomy]

The many techniques proposed for the reconstruction of the digestive path after pancreaticoduodenectomy show the continuous research of the most anatomical and safest way to achieve the best results. Most of the technical variations concern the treatment of the pancreatic stump and are directed to prevent the pancreatic fistula that is the most frequent cause of postoperative mortality and morbidity. None of the pancreatico-digestive reconstruction ways is absolutely better than the others and we think neither the total obstruction of the Wirsung duct is the solution of the problem of the pancreatic fistula. The accuracy and technical precision, the availability to modify the technique in relationship to different anatomy and functional conditions of the pancreatic stump are essential to improve the results. To achieve this goal is decisive the experience and patients volume of the surgeon and of the institutional team.

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800+/-490 ml vs. 700+/-586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16+/-8.1 days vs. 17+/-13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360+/-68.9 minutes vs. 330=66.9 minutes, P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study.

[Complete congenital atrioventricular block: a case report and review of the literature]

The description of a clinical case of a newborn with congenital complete atrioventricular block, due to maternal connective-tissue disease, is the occasion for a review of the literature. The clinical elements allowing an early diagnosis and treatment of these patients, who often need a permanent pacemaker, are described.

[Laparoscopic cholecystectomy after myocardial revascularization using the gastro-epiploic artery]

The authors report the case of a man operated by coronary artery bypass graft using the right gastro-epiploic artery. Laparoscopic cholecystectomy had to be performed postoperatively because of cholecystitis. Surgeons must be aware of the possibility of coeliotomy in the context of coronary artery surgery: this is a small incision, the sternotomy incision is only slightly lengthened towards the epigastrium. A history of such surgery requires certain precautions during subsequent abdominal incisions, particularly laparoscopic, and during dissection of the porta hepatis.

Endocrine tumors of the pancreas: Ki-67 immunoreactivity on paraffin sections is an independent predictor for malignancy: a comparative study with proliferating-cell nuclear antigen and progesterone receptor protein immunostaining, mitotic index, and other clinicopathologic variables

Prediction for malignancy of pancreatic endocrine tumors (PET) is often a formidable challenge for the pathologist. The authors evaluated the role of the proliferative activity and progesterone receptor protein (PgRP) in predicting prognosis and survival of PET. Twenty-three functioning (FT) and 31 nonfunctioning tumors (NFT) were evaluated for mitotic activity and immunostaining for Ki-67 antigen, proliferating cell nuclear antigen (PCNA), and progesterone receptor protein (PgRP) on paraffin sections. The results were expressed as a percentage (index) of immunoreactive or mitosing cells. All 54 cases showed immunostaining for Ki-67 and PCNA, and valuable mitotic index, whereas only a fraction of tumors (25 of 54 cases) exhibited PgRP expression. Ki-67 and PCNA indexes correlated strongly between themselves and to mitotic index, whereas an inverse relationship was observed between cell proliferation and PgRP status in both FT and NFT. Although univariate analysis showed that Ki-67, PCNA, mitotic and PgRP indexes, stage, immunoreactivity for hormones other than insulin, diameter, and nonfunctioning type of tumor were statistically correlated to survival, Cox's regression method let only Ki-67 index emerge as an independent predictor of survival using a cutoff value of 5% in both FT and NFT.

Papillary cystic neoplasm of the pancreas: radiological findings

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Lymphoepithelial cyst of the pancreas. Report of two cases and review of the literature

CONCLUSION

Lymphoepithelial cyst of the pancreas (LC) is a very rare benign lesion and preoperative diagnosis is difficult. Conservative surgery seems to be the appropriate therapy in symptomatic patients or when a precise preoperative diagnosis is not achieved. The benign behavior of all reported cases suggests that the asymptomatic patients with a certain morphological preoperative diagnosis might be clinically followed up. The histogenesis of LC remains to be elucidated.

BACKGROUND

LC of the pancreas is a cyst that is histologically characterized by a fibrous tissue, a lymphoid component and a lining squamous epithelium.

METHODS

Clinical and pathological findings of two personal cases are reported with review of the literature.

RESULTS

A 56-yr-old man, complaining of epigastric pain, and a 47-yr-old man, with a history of alcohol abuse, were admitted to hospital. In both cases the lesion was detected with abdominal ultrasound but a certain diagnosis was obtained only after histological examination of the resected cysts.

Papillary cystic neoplasm of the pancreas: radiological findings

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Solid and cystic papillary neoplasm of the pancreas: a clinico-cytopathologic and immunocytochemical study of five new cases diagnosed by fine-needle aspiration cytology and a review of the literature

We report here on five new cases of solid and cystic papillary neoplasm (SCPN) of the pancreas diagnosed by fine-needle aspiration cytology (FNAC). All cytologic samples were obtained by ultrasonography, and the smears were conventionally fixed and stained. Special histochemical and immunocytochemical stains were also performed in some samples. Cytology revealed in all but one case numerous pseudopapillary structures composed of fibrovascular stalks lined with one or more layers of bland-appearing, uniform tumor cells. The tumor cells had round-to-oval euchromatic nuclei with frequently folded smooth contours and one or two small nucleoli. Their cytoplasm often contained eosinophilic, PAS-positive, and diastase-resistant inclusions. Foamy cells, psammoma bodies, blood, and cellular debris were found in the background. The criteria for the differential diagnosis versus other pancreatic lesions are discussed in some detail, as is the role of immunocytochemistry (ICC). In the literature, only 28 cases of cytologically investigated SCPN have been reported to the best of our knowledge. The most helpful criteria for the conclusive identification of SCPN by FNAC include the pseudopapillary arrangement with bland-appearing tumor cells, and, especially, the finding of acidophilic, PAS-positive, and diastase-resistant cytoplasmic granules.

[Role of transesophageal echocardiography in aortic dissection]

Aortic dissection, especially type A, is a life-threatening condition, that requires a prompt and accurate diagnosis to ensure a rapid and precise therapeutic approach. Transesophageal echocardiography (TEE) is a highly reliable technique because of its sensitivity and specificity (near 100%; almost similar to nuclear magnetic resonance), and because it is a very low risk, rapid and easy diagnostic tool. Two hundred sixty-one patients were admitted at our institution in a 6-year period (1988-1994), because of a suspicion of aortic dissection. Two hundred forty-seven of them were submitted to TEE and the diagnosis was compared with surgical data in 124. There was only one false positive by TEE. Sensitivity of TEE vs surgery was 100%, specificity 93.7%, diagnostic accuracy 99%. Agreement between TEE and surgery in the setting of intimal tear was 69.2%. These data confirm the usefulness of TEE in the diagnostic approach to aortic dissection and the therapeutic decision, without using other methods.

ras-family gene mutations in neoplasia of the ampulla of Vater

Mutations in the first and second exons of Ha-, Ki- and N-ras oncogenes were investigated in 17 epithelial tumors of the ampulla of Vater by single-strand conformation polymorphism analysis and direct sequencing of DNA fragments amplified by polymerase chain reaction. The panel included 12 intestinal-type adenocarcinomas, 3 villous adenomas, 1 papillary carcinoma and 1 neuroendocrine carcinoma. Six cases (35%) contained ras mutations, affecting codon 12 of Ki-ras in 2 adenomas and 3 carcinomas, and of N-ras in 1 adenoma. All mutations were found in adenomas and among cancers with adenomatous areas, whereas none of the cases lacking adenomatous areas contained mutations. This suggested that ampullary cancers represent heterogeneous diseases with respect to the presence or absence of adenomatous areas and, among those with adenomatous areas, with respect to the presence of activated ras genes. Ki-ras mutated cases included 3 of 4 tumors which mainly involved the intraduodenal bile duct, thus suggesting that a proportion of Ki-ras-mutated ampullary cancers might correspond to those originating from the epithelium of the bile duct component of the ampulla.

Retroperitoneal paragangliomas: role of immunohistochemistry in the diagnosis of malignancy and in assessment of prognosis

OBJECTIVE

To present our experience of 10 patients with extra-adrenal retroperitoneal paragangliomas, and assess prognostic tests.

DESIGN

Retrospective study of casenotes.

SETTING

University hospital, Italy.

SUBJECTS

10 Patients who presented with paragangliomas between 1970 and 1991.

MAIN OUTCOME MEASURES

Histological and immunohistochemical results, and outcome.

RESULTS

All tumours were completely resected and there was no operative mortality. Of the 8 patients who had no metastases at presentation 3 died of recurrence 3, 5, and 10 years later, respectively; 4 were alive and free of disease 2-7 years after diagnosis. The 2 patients with synchronous bone metastases at presentation died 1 and 4 years later. Immunohistochemical analysis of type I cells (chromogranin A and neurone-specific enolase) showed little correlation with progression of disease, but there was a correlation between the presence of type II cells (S100 protein) and good prognosis.

CONCLUSIONS

Excision is the treatment of choice for paraganglioma. Immunohistochemical techniques may provide useful information about prognosis, in particular about those patients who are at increased risk of recurrence. Long term follow up is essential, because successful management of recurrence is dependent on early recognition.

[Surgical resection for pancreatic neoplasms in the past 20 years]

Over the last 20 years there has been substantial progress in histopathological and biological understanding of pancreatic tumours. This has allowed surgical removal to be planned according to the aggressiveness and natural history of the tumours with benign (cystoadenomas, insulinomas) or low grade tumours (borderline mucin producing tumours, cystic papillary tumours), the trend towards cost effective surgery (conservative pancreatectomy) may be linked to the neighbouring organs (spleen, stomach, duodenum) in an attempt to bring about more rapid functional recovery for the patient and an improvement in the quality of life. On the other hand, the drastic reduction in operative mortality, which is currently less than 5% of cases following duodeno-pancreatectomy, has encouraged a more aggressive surgical technique in order to increase radical resectability for malignant tumours. Moreover, for highly malignant tumours such as ductal adenocarcinoma, the role of pancreatic resection for palliative purposes, in order to improve the quality of life with an acceptable operative risk, has been confirmed. It is foreseeable that as a result of a more accurate selection and grading of patients for surgery, there may in the future be improvements in survival even in those patients operated on for ductal adenocarcinoma. Until now, these patients have received no significant benefit from the undoubted progress achieved in diagnostic and operative techniques.

Dermoid cyst of the head of the pancreas area

We report a case of dermoid cyst of the head of the pancreas area in a 26-yr-old woman radically treated with pancreatoduodenectomy and alive with no recurrence at 6-yr follow-up. The diagnostic and surgical procedures are described, and the literature is reviewed.

A new model to evaluate the hypertensive response to noxious stimuli in the anesthetized, spontaneously hypertensive rat

We have developed a method to evaluate the hypertensive response after noxious stimuli in anesthetized rats. Anesthetic level, stimuli, and responses were standardized by using an etomidate infusion, a series of stimuli of increasing intensity applied to the tail, and measuring maximal changes in systolic blood pressure (delta SBP) after each stimulus. Normotensive Sprague Dawley rats (SD) (n = 7) were studied using an etomidate infusion of 4.2 mg.kg-1 x h-1. This method was then applied to spontaneously hypertensive rats (SHR) anesthetized with three rats of etomidate infusion: Group 1 (n = 8), 7.0 mg.kg-1 x h-1; Group 2 (n = 8), 5.6 mg.kg-1 x h-1; and Group 3 (n = 11), 4.2 mg.kg-1 x h-1. Under anesthesia, three types of noxious stimuli were applied to the tail at 1-min intervals (13 total): (a) Type 1:11 2-s electrical stimuli of increasing intensity (0.4-12 mA, to produce threshold to maximal responses); (b) Type 2: one intense, prolonged electrical stimulus (10 mA, 5 s); and (c) Type 3: tail-clamping. After each stimulus, delta SBP was measured. In the SHR, comparing single delta SBP responses to single noxious stimuli after each of the three most intense stimuli showed no statistically significant differences among the three anesthetic groups. In contrast, comparison of dose-response curves of multiple delta SBP responses to multiple Type 1 (2-s) stimuli demonstrated a significant difference among the three anesthetic groups of SHR.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic adenocarcinomas frequently show p53 gene mutations

Thirty-four pancreatic adenocarcinomas were studied for the presence of p53 gene mutations by the single-strand conformation polymorphism method and by direct sequencing of PCR-amplified fragments. p53 protein expression was immunohistochemically evaluated using monoclonal PAb1801 and polyclonal CM1 antibodies. Mutations were detected in 14 cases. The transitions were six G to A and two A to G; the transversions were one C to G and two A to C; the remaining three were frameshift mutations. Immunostaining results were identical with both antibodies. Nuclear immunohistochemical p53-positive cells were found in nine p53 mutated cases and in 12 cases in which no mutation was detected. In most of these latter cases only a minority of cancer cells showed immunohistochemical positivity. Twenty-nine cases, including all p53 mutated cancers, were known to contain codon 12 Ki-ras gene mutations. Also in the light of the demonstrated cooperation of ras and p53 gene alterations in the transformation of cultured cells, our data suggest that p53 mutation is one of the genetic defects that may have a role in the pathogenesis of a proportion of pancreatic cancers.

Neoplasia of the ampulla of Vater. Ki-ras and p53 mutations

Eleven tumors of the ampulla of Vater (5 stage IV and 2 stage II adenocarcinomas, 1 stage II papillary carcinoma, 1 neuroendocrine carcinoma, and 2 adenomas, one with foci of carcinoma) were examined for Ki-ras and p53 gene mutations by single-strand conformation polymorphism analysis and direct sequencing of polymerase chain reaction-amplified DNA fragments. Ki-ras mutations were found in one adenocarcinoma and in the adenoma with foci of carcinoma, both involving mainly the intraduodenal bile duct component of the ampulla. Seven cases showed p53 gene mutations: four advanced-stage adenocarcinomas, the papillary carcinoma, the neuroendocrine carcinoma, and the adenoma with foci of carcinoma. Nuclear accumulation of p53 protein was immunohistochemically detected in the morphologically high-grade areas of the five cancers harboring a p53 gene missense point mutation. The adenomas, the two frame shift-mutated cancers, and the adenomatous and low-grade cancer areas of mutated carcinomas were immunohistochemically negative. Our data suggest that in ampullary neoplasia 1) p53 mutations are common abnormalities associated with the transformation of adenomas and low-grade cancers into morphologically high-grade carcinomas, and 2) Ki-ras mutations are relatively less frequent and might be restricted to tumors originating from the bile duct component of the ampulla.

[Treatment of pain in advanced-stage intra-abdominal neoplasms]

Different types of pain are present in far advanced intra-abdominal cancer, sometimes in the same site too. An accurate semeiological analysis of pain is important because different types of pain often differently respond to the available therapeutical tools. In this paper the results and the complications of the most important methods of pain management in far advanced intra-abdominal cancer are examined. Analysis of the data reveals that the association of more methods, pharmacological and non, should be a rule rather than the exception.

Immunodetection of proliferating cell nuclear antigen assesses the growth fraction and predicts malignancy in endocrine tumors of the pancreas

Thirty-five endocrine tumors of the pancreas, 17 functioning and 18 nonfunctioning, were immunohistochemically studied for the expression of proliferating cell nuclear antigen (PCNA) using 19A2 and PC10 monoclonal antibodies. The proportion of PCNA-reactive cells (PCNA index) ranged from 0.2 to 27% in functioning tumors and from 0.1% to 55% in nonfunctioning tumors. PCNA index showed a statistically significant correlation with mitotic and Ki67 indexes. The median values of PCNA index identified three groups of patients: group A (PCNA < or = 2%), including 13 functioning and six nonfunctioning tumors; group B (PCNA between 2 and 5%), including three functioning and three nonfunctioning tumors; group C (PCNA > 5%), including one functioning and nine nonfunctioning tumors. All group A tumors were confined to the pancreas. In group B, the functioning tumors were limited to the pancreas, and the nonfunctioning tumors extended to extrapancreatic tissues. All group C patients had extrapancreatic extension of the disease. At follow-up, a PCNA index higher than 5% correlated to a decreased mean survival. Our data suggest that PCNA index is a reliable tool to assess the growth fraction, discern local from advanced diseases, and predict malignancy in pancreatic endocrine tumors.

[Pneumothorax in multiple trauma. Radiologic and CT study]

This study was aimed at evaluating the necessity to perform chest Computerized Tomography (CT) in multiple traumatized patients to diagnose pleuropulmonary lesions and, particularly, pneumothorax: the correct identification of this condition, although minimal, is important especially in prevision of long anesthesias and/or positive end-expiratory pressure (PEEP) therapy. This assisted respiratory technique improves arterial oxygenation but causes a barotrauma which may cause some complications; particularly, a small undetected pneumothorax can suddenly increase so as to cause pulmonary collapse with sometimes dramatic symptoms. Chest X-ray films and CT scans, performed in rapid succession on patient's admission in Emergency Ward, were compared in 21 subjects. CT is indispensable in case of severe chest parietal lesions which can mask the radiological evidence of pulmonary or pleural conditions, as it occurred in 3 of our cases. Moreover, CT resulted more reliable than chest X-rays (18 versus 10 correct diagnoses) especially in the detection of small antero-inferior pneumothorax flaps, in which direct radiological signs cannot be identified, in default of radio-geometrical assumptions. Indirect radiological signs of pneumothorax must be recognized but critically considered in order to avoid over-staging.

Cystic islet cell tumors of the pancreas. A clinico-pathological report of two nonfunctioning cases and review of the literature

Cystic islet cell tumors of the pancreas are extremely rare. The authors report their personal experience with two cases of nonfunctioning cystic endocrine neoplasms. The tumor was diagnosed preoperatively in one case by ultrasonography (US)-guided fine-needle aspiration cytology, while in the other it was identified only in the surgical specimen after a clinical-radiologic diagnosis of pancreatic mucinous cystic tumor. Immunohistochemical assay showed positivity for the generic neuroendocrine markers (neuron specific enolase, or NSE, synaptophysin, and chromogranin A) in both cases and also for glucagon in one case. The neoplasms were resected by distal pancreatectomy with splenectomy and intermediate pancreatectomy respectively. Both patients are alive and recurrence-free 6 mo and 2.5 yr, respectively, after surgery. The authors also review the existing literature, discussing the pathogenesis of such tumors and the imaging techniques and surgical strategies adopted in their management.