Prognostic Factors and Survival Rate of Ampulla of Vater Cancer after Curative Surgery

PURPOSE: Ampulla of Vater cancer has a more favorable prognosis than other malignant tumors of the periampullary region, but prognostic factors have not been identified. The aim of this study was to evaluate the prognostic factors of ampulla of Vater cancer from a single hospital experience. METHODS: The medical records of the 102 patients with ampulla of Vater cancer which underwent curative surgery between 1992 and 2002, were reviewed. All specimens were critically reviewed by an expert pathologist. The relationships between survival and the clinicopathological variables were assessed. RESULTS: In 120 patients that presented with ampulla of Vater cancer, 102 (85%) were resected. The 5 year survival rate was 69.1%. A univariate analysis showed the survival was closely related to gender, the tumor gross morphology, invasion depth and lymph node metastasis. A multivariate analysis identified two significant factors; the depth of invasion and gender. Twenty nine of the 102 patients suffered a recurrence. CONCLUSION: The depth of invasion and gender were independent significant prognostic factors of resectable ampulla of Vater cancer. Careful observation is essential for liver metastasis after surgery, especially in patients that have these factors.

Clinical & Pathological Characteristics of Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: Intraductal papillary mucinous tumors of the pancreas (IPMT) are becoming increasingly recognized. Despite a better understanding of these conditions, IPMT still present difficulty relating to the predictive factors and the risk of relapse after surgery. The aim of this study was to investigate the clinical, and pathological characteristics of IPMT. METHODS: Between October 1998 and July 2002, 22 patients with IPMT underwent surgery. We retrospectively examined the clinicopathological features and surgical outcomes of these patients. RESULTS: The types of IPMT were as follows: dysplasia (1); adenoma (4); borderline malignancy (9); carcinoma in situ (3); and carcinoma, both non-invasive (3) and invasive (2). Lymph node metastasis was not found, but stromal invasion was found in the 2 cases of invasive carcinoma. The locations of the IPMT were as follows: head (6); uncinate process (11); body (4); and tail (1). There were 11 main duct types, 10 branched duct types and 1 combined. All patients underwent surgical resection, including 3 pancreaticoduodenectomies, 12 pylorus-preserving pancreaticoduodenectomies, 4 distal pancreatectomies with splenectomies, 2 near-total pancreatectomies with splenectomies, and 1 enucleation. There were no operative or hospital deaths. A recurrence of the IPMT following surgery occurred in 2 cases. Their pathological features were a carcinoma in situ and a borderline malignancy, but not the invasive type. However, one case of recurrence expired 7 month after surgery. A combination of other malignancies in these patients was found in 2 cases. CONCLUSION: IPMT has a favorable prognosis, when compared with pancreatic duct carcinoma. However, long-term follow-up after surgery is necessary, even for a curative resection due to a recurrence or a combination of other malignancies. Because combination of other malignancies exist infrequently, surgeons should be aware of the possibility of co-existing other malignancies.

Laparoscopic Surgery for benign Gastric Tumor

PURPOSE: Laparoscopic surgery of the abdomen has grown rapidly in popularity due to the benefits, including a low level of post operative pain, early recovery, short hospitalization and excellent cosmetic results. Concerning tumor resection, most benign gastric tumors are ideal for the use of the non invasive method of a laparoscopic procedure. To evaluate the feasibility of laparoscopic surgery for benign gastric tumors, we analysed the clinicopathological findings, post operative course and prognosis. METHODS: Between January 1995 and August 2001, laparoscopic surgery was performed on 18 patients with benign gastric tumors at the Department of Surgery at Yonsei University Hospital. To evaluate the feasibility of laparoscopic surgery for these lesions, the sex, age, pathologic diagnosis, operative methods, tumor location, tumor size, operative time, recurrence, gas passing time and diet recovery time were analyzed. RESULTS: The patients group consisted of 3 men (16.7%) and 15 women (83.3%), with a mean age of 51.9+/-15.0 years (range, 23~80). The histopathological examinations showed 12 mesenchymal tumors (5 leiomyomas, 4 stromal tumors, 3 Schwannomas), 2 mucosa origin tumors (1 retention polyp, 1 villous adenoma), 2 ectopic pancreata, 1 carcinoid tumor and 1 lipoma. The operation methods were 14 laparoscopic wedge resections of stomach, 1 laparoscopic assisted partial gastrectomy and 1 gastrotomy and polypectomy. In 2 patients, a laparotomy was required following the laparoscopy due to difficulties in detecting the tumors. In one of the 2 converted cases, preoperative endoscopic marking of the tumor site was performed, but the dye was spread very widely from the mid body to the prepylorus. The other tumor was located on the lesser curvature of the upper third, around the esophagogastric junction, but it was not exactly identified. The tumors were located in the upper, middle, and lower third of the stomach in 7, 9 and 2 cases, respectively. As a circumferential location, 7 tumors were mainly situated on the anterior wall, 6 on the posterior wall, 3 on the greater curvature and 2 on the lesser curvature. All tumors, even those on the lesser curvature and posterior wall, were able to be resected with laparoscopy. The size of the resected tumors averaged 2.2+/-0.9 cm (range, 0.8~4.3). The resection margins were all negative. The operation time averaged 145.8+/-57.0 min (range 70~280). The time to passing gas averaged 2.2+/-0.9 days (range 1~4). The recovery time to a soft diet averaged 5.9+/-1.9 days (range, 2~9). The postoperative course of all the patients was uneventful, and there were no postoperative complications with the exception of one case of diet intolerance. During the follow up there have been no recurrences to date. CONCLUSION: With its proper application in benign gastric tumors, laparoscopic surgery needs to identify the exact site of a tumor, can contribute significantly to an improved patient outcome because it is less complicated and safer compared to conventional gastrectomy methods.

Non-cirrhotic Portal Hypertension in Idiopathic Myelofibrosis: A case report

We report a case of non-cirrhotic portal hypertension in a 73 year-old woman, who had 19-year history of idiopathic myelofibrosis. There were esophageal varix, splenomegaly, and ascites. The biopsied liver showed irregular sinusoidal/ perisinusoidal fibrosis and occasional central-to-central fibrous connection. In areas with extensive fibrosis, coarse collagen fibers filled the sinusoidal spaces and compressed hepatocytes. However, nodular regeneration was absent. Double immunohistochemical stain for smooth muscle actin and proliferation cell nuclear antigen (PCNA) revealed diffusely activated stellate cells, some of which showed nuclear PCNA staining. There was also extramedullary hematopoiesis with bizarre megakaryocytes. The portal vein and its branches were patent. Idiopathic myelofibrosis is a rare cause of non-cirrhotic portal hypertension: the portal hypertension was considered to be the result of sinusoidal/perisinusoidal fibrosis in this case.

Two Cases of Arachnoid Cyst of the Middle Cranial Fossa with Chronic Subdural Hematoma

Diagnosis of arachnoid cyst has often been delayed and uncertain in the past, but development of computerized tomography has greatly improved the ease and accuracy of their identification, helping to provide for earlier surgical treatment and better care of patients. Arachnoid cysts of the middle cranial fossa may be associated with a unique complication, namely subdural hematoma. The hematoma with its membrane may be located either superficial to the cyst or within the cyst. Recently we have experienced two cases of arachnoid cyst of the middle cranial fossa with chronic subdural hematoma. We present the cases and their pathogenesis will be reviewed.

Atypical C-T Features of Intracranial Meningiomas and Pathological Correlation

Most intracranial meningiomas present on the C-T as typical features with homogeneous, occasionally lobulated mass of density equal or greater than of surrounding brain tissue. After contrast injection, there is uniform and homogeneous enhancement in the density. Infrequently a significant number present as atypical features which are regional inhomogenecity of tumor mass on C-T and common source of error in the diagnosis of meningioma. The authors reviewed 25 consecutive meningiomas, all confirmed pathologically. 7 cases have been encountered as atypical features on the C-T. Among them, 2 cases of peritumoral low density were diagnosed as meningioma with C-T only. 5 cases(2 cases of peritumoral cyst, 2 cases of intratumoral cyst, 1 case of peritumoral bleeding) were misdiagnosed initially as malignant lesion based on C-T findings. Those C-T patterns have been found to correlate with certain histologic and morphologic alternation in tumor anatomy. Close correlation with pathological findings of tumor necrosis, cystic changes and hemorrhage was noted.

Therapeutic Results of Chemonucleolysis in Patients with Herniated Lumbar Discs

We had experienced 60 cases of chemonucleolysis with Discase(R)(chymopapain for injection) under careful patient selection of herniated lumbar discs and had followed up thereafter at least 3 months since July, 1984. Therapeutic results were generally favorable, with 90% of patients achieving either excellent or good(satisfactory) results. Three patients only had poor or failure results. There was no major anaphylatic reaction and no serious neurologic complications. Back spasm and stiffness/soreness were the most frequently encountered complications.