Surgical resection of metastasis to the pancreas / 대한외과학회지

PURPOSE: Metastasis to the pancreas is rare, and the benefit of resection for pancreatic metastasis is poorly defined. The aim of this study was to review our experiences of the operative management of metastasis to the pancreas. METHODS: Between 1995 and 2009, 11 patients (8 men and 3 women; median age, 54 years) were admitted to our institution with a metachronously metastatic lesion to the pancreas and later underwent pancreatic resection. The clinical features and outcomes of treatments were examined. RESULTS: The primary cancers were renal cell carcinoma (RCC, n = 7), carcinoid tumor (n = 2), rectal cancer and leiomyosarcoma. Six patients underwent distal pancreatectosplenectomy, 3 pancreaticoduodenectomy and 2 patients underwent enucleation for small RCC. One patient died of metastatic RCC at 53 months after surgery and ten patients remain alive; four patients without disease at 7 to 69 months postoperatively, and the other six with disease at 11 to 68 months. Median postoperative survival of all patients was 34 months. CONCLUSION: Patients with a low surgical risk should be considered for pancreatic metastasectomy if curative resection is possible. Primary cancer type, which is associated with survival benefit, would be the best candidate for surgical resection of metastases to the pancreas.

A Case of Primary Hepatic Malignant Paraganglioma without Hypertension

Paraganglioma is an unusual neoplasm that is embryologically derived from neural crest cells. The most common location of this neoplasm is the adrenal medulla, where these tumors are known as pheochromocytoma. It is extremely rare that paragangliomas occur in the liver. There are only 7 reports of primary hepatic paraganglioma. A 56-year-old man was referred to XX Medical Center. Hypertension was not found. He had suffered from jaundice, headache and weight loss for the 4 previous weeks, but hypertension was not present. The total bilirubin was 7.7 mg/dl and the CA19-9 level was 56.3 U/dl. The tumor was diagnosed as intrahepatic cholangiocarcinoma on the computed tomography image. After biliary drainage via endoscopic nasobiliary drainage, surgical exploration was carried out; right trisectionectomy with caudate lobectomy, portal vein resection and anastomosis were then done. The final pathological diagnosis was primary hepatic malignant paraganglioma of the intrahepatic duct. There has been no evidence of recurrence on the follow up CT images during the 24 month follow up period.

Comparative Analysis of Limited Resection and Conventional Resection for Pancreatic Benign Lesions Focused on Perioperative Diabetes and Pancreatic Fistula

PURPOSE: Pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) are treatments used for pancreatic benign neoplasms even though both of these treatments result in significant loss of normal pancreatic parenchyma; this leads to subsequent impairment of exocrine and endocrine pancreatic function. The purpose of this study is to provide short-and long-term result of limited resection (LR) in a single center. METHODS: Two-hundred thirty patients who had undergone pancreatic resection between April 1998 and September 2008 for benign neoplasms were reviewed retrospectively. DP was performed in 102 patients, LR in 77, PD in 51 patients. The definitions of the International Study Group of Pancreatic Fistula (ISGPF) were applied to postoperative pancreatic fistulas (POPF), perioperative endocrine function was evaluated through oral glucose tolerance test. RESULTS: LR includes 42 enucleation, 24 central pancreatectomy, and 11 uncinate process resection. No deaths occurred to patients during the study review period; POPF was detected in 50 patients (65%), 37 patients with grade A and 13 patients with grade B or C. POPF occurred 65% of the time after LR, more frequently compared to the occurrance after PD or DP (58%), but this was not statistically significant (P =.322). After LR, there were 2 patients with new onset diabetes (3%), while 26 (17%) patients developed diabetes after DP or PD (P = .002). CONCLUSION: LR may preserve endocrine and exocrine function. While mortality is low with the use of LR, it is associated with a higher pancreatic-leakage rate. The precise management of benign pancreatic lesions remains in evolution.

Management of a Bleeding Pseudoaneurysm after Pancreaticoduodenectomy: 27 cases experience in single-center

PURPOSE: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding pseudoaneurysms after pancreaticoduodenectomy. METHOD: The medical records of 905 consecutive patients who underwent pancreaticoduodenectomies between October 1994 and February 2007 were reviewed retrospectively. In 27 cases with hemorrhagic complications, pseudoaneurysms were diagnosed as the main cause of bleeding. The clinical characteristics, course, management, and outcomes were reviewed. RESULT: In 27 cases (3.0%) of the 905, the bleeding pseudoaneurysms were diagnosed by angiography, during surgery or clinically. In 11 cases, the hemorrhage was from the pseudoaneurysm on the ligated gastroduodenal artery-stump, in five it was from the right hepatic artery, in four from the proper hepatic artery or common hepatic artery, and two from the right gastric artery. Twelve cases had pancreatic leakage. Sentinel bleedings were observed in 21 cases, there were 11 cases of bleeding from the surgical drains, eight cases from the GI tract, and in two cases from both. In 23 cases, arterial embolization was attempted and 18 cases were successful. Four cases had secondary pseudoaneurysmal bleeding. After embolization at the common or proper hepatic artery, six cases had liver abscess or infarction and there was one case of hepatic failure. CONCLUSION: Delayed massive hemorrhage after pancreaticoduodenectomy should be ruled out to determine whether it is associated with an arterial pseudoaneurysm rupture. Transcatheter arterial embolization is an effective modality for control of the bleeding from an arterial pseudoaneurysm.

Clinical Usefulness of Preoperative and Postoperative CA-19-9 Antigen in Pancreatic and Bile Duct Neoplasms

PURPOSE: The CA-19-9 antigen is a commonly used tumor marker for pancreatic and bile duct neoplasms. It is well known that the CA-19-9 antigen is a good predictor of resectability, prognosis and recurrence. The aim of this study was to evaluate the efficacy of the CA-19-9 antigen as preoperative resectability and postoperative recurrence markers in pancreatic and bile duct neoplasms. METHODS: Between February 1995 and June 2001, 234 patients, with pancreatic and bile duct neoplasms, at the Department of Surgery, Samsung Medical Center, were followed up with the CA-19-9 antigen, both preoperatively and postoperatively. The ROC curve was used to analyze the relationship between a radical resection and the preoperative CA-19-9 antigen. During the postoperative follow- up, 124 patients that had radical resections, and postoperative follow-up for the CA-19-9 antigen, were studied for this relationship using Chi-square tests. RESULTS: The cut-off values in the pancreatic (P=0.527) and bile duct (P=0.688) neoplasms were 325.50 U/ml and 58.35 U/ml, respectively, using the ROC curve for the relationship between a radical resection and the preoperative CA-19-9 antigen, although the result was statistically insignificant. From the 124 patients used for the statistical analysis, 64 had a recurrence, of which 57 showed an increase in the CA-19-9 antigen, with the 7 showing no elevation. 60 patients had no recurrence, of which 28 showed an increase in the CA-19-9 antigen. The elevation of the CA-19-9 antigen was analyzed between the recurrence and no recurrence groups using Chi-square tests, which revealed a statistical significance (P<0.001). CONCLUSION: In patients with pancreatic and bile duct neoplasms, the CA-19-9 antigen could not predict the preoperatie resectability, but was a clinically effective follow-up marker for a recurrence.

Expression of alpha-smooth muscle actin and collagenIV in villous stroma of placental terminal villi and congestion fetal capillary in growth restricted pregnancies with severe preeclampsia / 대한산부인과학회잡지

OBJECTIVE: Preeclampsia is the major cause of prenatal mortality and morbidity. The functional disorder of uteroplacental insufficiecy is caused by the impaired uteroplacental blood flow and diffusion barrier in the villi. Functional disorders like placental circulating disorders results in morphological changes of terminal. villi as functional unit of placenta. We studied to investigate the differences in villous stoma of placental terminal villi and fetal capillary between growth restricted pregnancies with severe preeclampsia and normal preterm pregnancies. METHOD: Terminal villi was examined using light microscopy and by immunohistochemical localization of matrix molecule (alpha-smooth muscle actin and collagenIV) and the immunoreactivity of alpha-smooth muscle actin and collagenIV were evaluated in 17 cases of severe preeclampsia with intrauterine growth restriction as a study group and in 17 cases of gestational age matched normotensive preterm pregnancies as a control group. Fetal capillary congestion in terminal villi was also evaluated by Hematoxylin-Eosin staining. The patterns of immunohistochemical staining were all determinated in a visual qualitative manner (0-25%: -, 25-50%: +, 50-75%: ++, 75-100%: +++) by one pathologist. Congestion was considered to be present in a failed where the majority (>90%) of the capillaries demonstrated densely packed erythrocyte. RESULT: Expression of alpha-smooth muscle actin in the terminal villous stroma was significantly increased in study group compared with control group (P=0.0001). Expression of collagen IV in the terminal villous stroma was significantly increased in study group compared with control group (P=0.0001). Fetal capillary congestion was also significantly increased in study group compared with control group (P=0.049). CONCLUSION: The result suggests that there be the structural or biochemical difference in the villous stroma between normotensive preterm pregnancies and severe preeclampsia with intrauterine growth restriction and that the extravascular contractile system might be in the villous stroma in the severe preeclampsia intrauterine growth restriction.

The Utility of Matrix Metalloproteinase-2 as a tumor marker in cervical cancer / 대한산부인과학회잡지

OBJECTIVE: Degradation of the extracellular matrix and the basement membrane is believed to be associated with tumor invasion and metastasis. To evaluate the roles of Matrix metalloproteinase-2 (MMP-2) in cervical cancer and its utility as a potential diagnostic tumor biomarker, we investigated the expression of MMP-2 in cervical cancer tissue and sera. METHODS: Through the zymography of MMP-2 in cervical cancer tissues from 35 patients, we investigated the extent and distribution of MMP-2. Also, up-regulation of its gene expression was examined by reverse transcription-polymerase chain reaction (RT-PCR) analysis. Then, we attempted to investigate by ELISA serologic responses in the sera obtained from 35 cervical cancer patients, and examined its utility as diagnostic and prognostic tumor marker in cervical cancer by comparing it with conventional tumor markers SCCA and CEA. RESULTS: In zymography, the active form of MMP-2 was detected in 66kDa. In cervical cancer the active form of MMP-2 is more strongly reacted with the substrates than those in normal tissues. Also, the mRNA of MMP-2 was more up-regulated in cervical cancer tissue than in normal one. MMP-2 was detected in the sera of cervical cancer patients, and its amount differed according to clinical situations. While it was not more effective than previous tumor markers SCCA and CEA in diagnosis, it was more useful in monitoring of the cancer. The effect was especially remarkable when it was combined with any other conventional tumor markers. CONCLUSIONS: The results suggest that the expressions of MMP-2 correlate with cervical cancer invasion and metastasis. Also, it may be useful in the monitoring of the cervical cancer lesion.

A Case of Nonimmune Hydrops Fetalis with neuroblastoma / 대한산부인과학회잡지

Hydrops fetalis is diagnosed when abnormal fluid collections are manifest in two or more fetal compartmnets including abdominal ascite, pleural effusion, percardial effusion, skin edema, polyhydroamniosis and placental edema. Although fetal hydrops was historically most commonly associated with Rh blood group isoimmunization, the availability of Rh immunoglobulin has increased the proportion of fetuses affected due to nonimmune etiologies. Neuroblastoma is a malignant tumor which originates in the autonomous nervous system. Congenital neuroblastoma is the most common solid malignant tumor of the neonatal period, incidence ranges 1:10,000 of all live births, retroperitoneal space being the most frequent localization. We have experienced a case of nonimmune hydrops fetalis with neuroblastoma at 32 weeks of gestation in 39 year old woman and reported that with brief review of related literatures.

Cytogenetic Analysis in 1,565 Cases of Midtrimester Amniocentesis: CUMC Experience(I) / 대한산부인과학회잡지

OBJECTIVES: To analyze chromosomal abnormalities according to patient's age and indications of patients in midtrimester amniocentesis for prenatal genetic diagnosis. METHODS: We retrospectively analyzed 1,565 cases of midtrimester prenatal genetic amniocentesis cases which were done in the cytogenetics laboratory at Kangnam St. Hospital, Catholic University Medical College from November1997 to May 2000. RESULTS: In 1,565 cases, the most common maternal and gestational age distributions were 35 to 39 years old and 17 to 17+6 weeks (32.78% and 21.47%, respectively). Abnormal maternal serum markers were the most common indication for amniocentesis (43.64%), and followed by advanced maternal age (40.45%) and abnormal ultrasonographic findings (3.64%). The overall incidence of chromosomal abnormalities was 4.47% (70 cases), of which numerical abnormalities and structural abnormalities were 1.86% (29 cases) and 2.61% (41 cases), respectively. Among the autosomal abnormalities, Down syndrome was most common (10 cases, 0.65%), and followed by Edward syndrome (9 cases, 0.59%). Among the sex chromosomal abnormalities, both of 47,XXX and 47,XXY were most common (3 cases, 0.20%, respectively). Chromosomal abnormalities were most frequently noted in the maternal age of 25 to 29 years old (5.10%), 30 to 34 years old (4.82%), 40 to 44 years old (4.31%), and followed by 35 to 39 years old (3.90%). On the other hand, chromosomal abnormalities were most frequently noted in abnormal ultrasonographic findings (7.02%), previous history of aneuploidy (5.88%), and followed by advanced maternal age (3.95%). CONCLUSION: This study suggested that although advanced maternal age is still important indication in midtrimester amniocentesis for prenatal diagnosis, abnormal maternal serum markers and ultrasonographic findings might be also important as indications. Therefore, they should be considered in prenatal genetic counseling.

Involvement of Oxidative Stress in Sodium Taurocholate-Induced Acute Necrotizing Pancreatitis in Rats

Oxidative radicals are regarded as a major factor in the pathogenesis of both acute and chronic pancreatitis. Because oxygen radicals react most readily with polyunsaturated fatty acids, resulting in peroxidation of lipids, several studies have been performed to determine the development of lipid peroxidation in pancreatitis. The purpose of this study was to evaluate the effects of free radicals and decision of the experimental model in acute necrotizing pancreatitis. Acute necrotizing pancreatitis was induced in 18 rats by retrograde injection into the bilopancreatic duct of 2%, 3%, and 5% sodium taurocholate. After a 12-hour observation time, the pancreas / the body weight, the serum amylase and the malondialdehyde content in tissue, as well as the reduced glutathione were measured in resected tissue samples. In addition, to determine the pathologic damage grade, tissue samples were examined by light microscopy. According to the amount of sodium taurocholate injected, the serum amylase and tissue malondialdehyde concentration were significantly increased. The reduced glutathione was significantly decreased, suggesting glutathione depletion due to oxidative stress. During the 12 hours after injection the pancreatic lesions were immediate and were characterized by interstitial edema, atrophy and extensive necrotic changes of the acinar cells, and hemorrhage. The pathologic damage grade increased according to the amount of sodium taurocholate injected. This study created an experimental model for studying the pathogenesis of acute necrotizing pancreatitis by using bile acid. In acute necrotizing pancreatitis, the increased levels of lipid peroxidation products in tissues and the change in glutathione metabolism suggest ongoing peroxidation of lipids due to an enhanced generation of oxygen radicals. Therefore, antioxidant treatment can reduce tissue damage, biochemical alterations, and extrapancreatic complications, thus improving the final outcome.

In vivo Assessment for the Antioxidant Activity of the Calcium Channel Blocker Nicardipine in 3% Sodium-Taurocholate-induced Acute Pancreatitis

BACKGROUND: Although several pathophysiological sequences, such as protease activation, free radical generation, and inflammatory mediator release, have been described in acute pancreatitis, the precise mechanism by which acute pancreatitis is initiated is unkown. Cellular calcium, a key function and also a crucial pathological intracellular messenger in cell injury, appears to be involved in the initiation and development of acute pancreatitis. The aim of this study is to evaluate the role of cellular calcium and therapeutic effect of administering the Ca++ channel blocker nicadipine as an antioxidant. METHOD:Nicardipine, known to be a calcium channel blocker and a most potent antioxidant, was wed as a pretreatment 1 hour before induction of pancreatitis by intraductal infusion of 3% sodium taurocholate or as a post-treatment 1 hour after induction of aucte pancreatitis by retrograde infusion of sodium taurocholate. The net weight of the pancrease, the amounts of s-amylse, GSH and MDA in the pancreatic tissue, and the histologic damage were examined 12 hours after the induction of pancreatitis. RESULTS: Nicardipine administration ameliorated pancreatic edema and reduced the amount of s-amylase compare to untreated necrotizing pancreatitis group. Also, pre- or post-treatment with nicardipine had beneficial protective effect with respect to free radical-induced injury; in particular, pre-treatment with nicardipine was much better. With respect to the histologic findings, pancreatic necrosis, hemorrhage, and neutrophil infiltration were prominent in the necrotizing group, however, in the group treated with nicardipine, the necrosis and hemorrhage were ameliorated remarkably. CONCLUSION:The free oxygen radicals and the intracellular calcium influx were major elements in the pathogenesis of acute pancreatitis, and nicardipine ameliorated pancreatic necrosis and hemorrage and exerted an antioxidant effect. The administration of nicardipine should be considered in the early stage of pancreatitis or in case of risk of pancreatitis.