Endometriosis peritoneal masiva asociada a gran elevación de CA-125: discrepancia entre hallazgos y clínica / Massive peritoneal endometriosis associated with high elevation of CA-125: discrepancy between findings and symptoms

ANTECEDENTES: Frecuentemente, las pacientes con endometriosis presentan una elevación de marcadores tumorales Ca 125 y Ca 19.9. No obstante, no existe correlación clara con la expresión clínica ni con el grado de afectación. En algunos casos, es necesario un diagnóstico diferencial con patologías malignas. CASO CLÍNICO: Mujer de 29 años con clínica aislada de dismenorrea moderada y hallazgo de masas ováricas bilaterales con elevación intensa de marcadores tumorales: Ca-125: 7.716 U/mL y Ca-19.9: 995 U/mL. Se decide intervención quirúrgica laparoscópica evidenciándose endometriosis ovárica y extensión peritoneal masiva con afectación de peritoneo parietal abdominal, superficie uterina, fondo de Douglas, parametrios, vejiga, hemidiafragma derecho, hígado y serosa intestinal. Se realiza adhesiolisis cuidadosa, quistectomía y extirpación de múltiples implantes endometriósicos en cavidad abdominal. Se observó un descenso de los marcadores a las 48 horas: Ca-125 de 253 U/mL y Ca 19.9 de 4,9 U/mL, ambos negativos al mes de la cirugía. CONCLUSIÓN: Una elevación intensa de los marcadores tumorales precisa de diagnóstico diferencial en el contexto de la endometriosis. Existe una gran discrepancia entre los valores de los marcadores tumorales con la clínica y severidad de la endometriosis. Los hallazgos quirúrgicos son fundamentales, evidenciando una afectación masiva subdiagnosticada hasta la cirugía.

BACKGROUND: Frequently, patients with endometriosis present elevated tumor marker Ca 125 and Ca 19.9. However, there is no clear correlation with the clinical expression or the degree of involvement. In some cases, differential diagnosis is necessary with malignancies. CASE REPORT: A 29 year old woman with moderate dysmenorrhea and finding of bilateral ovarian masses with intense elevation of tumor markers, CA125: 7,716 U/mL and Ca-19.9: 995 U/mL. Laparoscopic surgery is decided evidenced massive ovarian endometriosis and peritoneal extension with involvement of abdominal peritoneum, uterine surface, Douglas, parametrium, bladder, right hemidiaphragm, liver and intestinal serosa. Careful liberation of adherences, ovarian cystectomy and removal of multiple endometriosic implants. A decrease of tumor markers was observed at 48 hours (Ca-125: 253 U/mL and Ca-19.9: 4.9 U/mL), and negative one month after surgery. CONCLUSION: An intense elevated tumor markers accurate differential diagnosis in the context of endometriosis. There is a large discrepancy between the values of tumor markers with clinical and severity of endometriosis.

Primary Adenocarcinoma with Focal Choriocarcinomatous Differentiation in the Sigmoid Colon / 대한소화기학회지

Primary colorectal choriocarcinoma is a rare neoplasm. Only 19 cases have been reported worldwide, most of which involved adenocarcinomas. The prognosis is usually poor, and the standard therapy for this tumor has not been established. A 61-year-old woman presented with constipation and lower abdominal discomfort. She was diagnosed with primary adenocarcinoma with focal choriocarcinomatous differentiation in the sigmoid colon and liver metastasis. Because the serum beta-human chorionic gonadotropin level was not significantly elevated, and because only focal choriocarcinomatous differentiation was diagnosed, we selected the chemotherapy regimen that is used for the treatment of metastatic colorectal adenocarcinoma. The patient survived for 13 months after the initial diagnosis. This is the first case in Korea to assess the suppressive effects of the standard chemotherapy for colorectal adenocarcinoma against coexisting colorectal choriocarcinoma and adenocarcinoma.

Synchronous Malignant Intraductal Papillary Mucinous Neoplasms of the Bile Duct and Pancreas Requiring Left Hepatectomy and Total Pancreatectomy / 대한소화기학회지

Intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) and intraductal papillary mucinous neoplasm of the pancreas (IPMN-P) have striking similarities and are recognized as counterparts. However, simultaneous occurrence of IPMN-B and IPMN-P is extremely rare. A 66 year-old female presented with recurrent epigastric pain and fever. During the past 9 years, she had three clinical episodes related to intrahepatic duct stones and IPMN-P in the pancreas head and was managed by medical treatment. Laboratory test results at admission revealed leukocytosis (12,600/mm3) and elevated CA 19-9 level (1,200 U/mL). Imaging study demonstrated liver abscess in the Couinaud's segment 4, IPMN-B in the left lobe, and IPMN-P in the whole pancreas with suspicious malignant change. Liver abscess was drained preoperatively, followed by left lobectomy with bile duct resection and total pancreatectomy with splenectomy. On histologic examination, non-invasive intraductal papillary mucinous carcinoma arising from various degree of dysplastic mucosa of the liver and pancreas could be observed. However, there was no continuity between the hepatic and pancreatic lesions. This finding in our case supports the theory that double primary lesions are more likely explained by a diffuse IPMN leading to synchronous tumors arising from both biliary and pancreatic ducts rather than by a metastatic process. Herein we present a case of simultaneous IPMN of the bile duct and pancreas which was successfully treated by surgical management.

An Experience of Cyberknife Treatment in Patients with Advanced Pancreaticobilliary Malignancy / 대한소화기학회지

BACKGROUND/AIMS: CyberKnife(TM) stereotactic body radiotherapy (SBRT) has been thought as a promising treatment modality for inoperable or recurred pancreaticobiliary malignancies. But, clinical course of CyberKnife(TM) treatment have not been established yet, so we report the experience of CyberKnife(TM) treatment in 19 patients with recurred or advanced pancreaticobilliary malignancies. METHODS: Between July 2008 and May 2009, 19 patients (gallbladder cancer 4, common bile duct cancer 5, and pancreatic cancer 10) with recurred (12) and advanced pancreaticobiliary cancer (7) underwent CyberKnife(TM) treatment in Soonchunhyang University Hospital. Tumor size was evaluated at 1, 3, 6, 8 and every 3 months after SBRT. RESULTS: The mean age was 60.2 years, and the mean size of target lesions was 28.1+/-1.30 mm. After CyberKnife(TM) treatment, the average size of target lesions was decreased; 2.53+/-4.18 mm from months 0-1 in 19 patients, 2.47+/-4.7 mm from months 1-3 in 15 patients, 0.08+/-5.11 mm from months 3-6 in 12 patients. However, the average size of target lesions was increased 3.67+/-8.98 mm from months 6-8 in 6 patients. There were 2 cases of massive duodenal ulcer bleeding after CyberKnife(TM) treatment, one of them expired due to ulcer bleeding. Also, other minor complications appeared such as 1 case of abdominal pain and 1 case of diarrhea. CONCLUSIONS: CyberKnife(TM) treatment seems to be effective in local control of pancreaticobiliary cancer, but we experienced serious complications. Further prospective studies will be needed for the proper evaluation of role of Cyberknife(TM) treatment in patients with advanced pancreaticobiliary malignancies.

Diagnostic Usefulness of PET/CT for Pancreatic Malignancy / 대한소화기학회지

BACKGROUND/AIMS: The purpose of this study was to evaluate the diagnostic usefulness of PET/CT for pancreatic malignancy. METHODS: We retrospectively analyzed medical records of 115 patients with pathologically diagnosed pancreatic cancer between January 2003 to August 2008 who underwent abdominal CT and PET/CT examination before histological confirmation. CT and PET/CT images were reviewed in single-blinded status and diagnostic ability on primary pancreatic lesion, regional lymph node metastasis, and distant metastasis was evaluated. RESULTS: 99 patients (86%) had malignant diseases including 91 cases of adenocarcinoma, and 16 patients (14%) benign diseases. Only CA 19-9 value and SUV were significantly different between PET/CT positive and negative groups (p=0.001, p<0.001). Sensitivity, specificity and positive predictive values (PPV) of both modality for pancreatic lesion were same (94%, 62%, and 95%, respectively), and negative predictive values (NPV) were 67% on CT and 57% on PET/CT. PET/CT correctly diagnosed 8 cases (6.9%) of falsely diagnosed pancreatic lesion on CT. Nine cases (15.7%) of misdiagnosed lymph node metastasis on CT were correctly diagnosed on PET/CT. But, there was no significant difference in the diagnosis of regional lymph node metastasis. 3 out of 29 cases of distant metastasis, except 2 cases of supraclavicular lymph node metastasis, were additionally diagnosed by PET/CT. But, overall sensitivity of distant metastasis was significantly higher in CT (83% vs 69%, p=0.045). CONCLUSIONS: Although PET/CT provided additional correct diagnoses in many cases, it showed fair diagnostic power for primary pancreatic lesion and lymph node metastasis, and lower sensitivity for distant metastasis. Therefore, PET/CT should be used as an supplementary modality of CT in diagnosing pancreatic malignancy.

The Prognostic Factors of Pancreatic Cancer Can be Different according to Clinical Stages / 대한소화기학회지

BACKGROUND/AIMS: The prognosis of patients with pancreatic cancer remains very poor. Although many studies have evaluated the prognostic factors of pancreatic cancer, their results are inconclusive because of different inclusion criteria, tumor stages, and treatment modalities. This large scale retrospective analysis was performed to assess whether active treatment of pancreatic cancer, even in its advanced stage, could improve patients' survival. In addition, we sought to identify factors associated with favorable prognosis of pancreatic cancer. METHODS: Between 1994 and 2004, a total of 971 patients with pancreatic cancer were treated at Asan Medical Center. The patients were classified into three groups according to clinical stages: resectable (RE, n=226), locally advanced (LA, n=409), and far advanced (FA, n=336). Treatment response and prognostic factors for survival were analyzed in each group. RESULTS: Compared to supportive care, active treatment significantly increased the median survival time in all groups (RE: 18.0 vs. 9.0 months; LA: 10.0 vs. 7.0 months; FA: 5.0 vs. 3.0 months). Multivariate analysis showed that prognostic factors for survival differed according to clinical stages. In the RE group, unfavorable prognostic factors were high CA 19-9, poor histologic differentiation, large tumor size, and regional lymph node involvement. In the FA group, however, poor outcomes were associated with old age, poor performance status, and hypoalbuminemia. CONCLUSIONS: More active treatment of pancreatic cancer, even in advanced stage, can make a significant difference in terms of patient's survival. The prognosis of resectable pancreatic cancer is dependent on tumor-related factors, while the prognosis of patients with far advanced pancreatic cancer is dependent on patient-related factors.

Significances of Serum Level and Immunohistochemical Stain of CA19-9 in Simple Hepatic Cysts and Intrahepatic Biliary Cystic Neoplasms / 대한소화기학회지

BACKGROUND/AIMS: In spite of various diagnostic modalites, biliary cystic neoplasms (biliary cystadenoma and cystadenocarcinoma) remain to be difficult to diagnose preoperatively. Recently, there are some reports that elevated CA19-9 level in serum and/or cystic fluid could be a useful finding in the differential diagnosis of biliary cystic neoplasm. This study aimed to evaluate the expression of CA19-9 and to elucidate its significances in intrahepatic biliary cystic neoplasms and simple hepatic cysts. METHODS: In 8 patients with biliary cystic neoplasms and 6 simple hepatic cysts, symptoms, radiologic and laboratory findings were reviewed retrospectively. In 5 biliary cystic neoplasms (4 bililary cystadenomas, 1 biliary cystadenocarcinoma) and 5 simple hepatic cysts, immunohistochemical stainings for CA19-9 were performed with formalin-fixed, paraffin-embedded tissues. RESULTS: In 8 biliary cystic neoplasms, two cases were suspected as biliary cystadenoma preoperatively and 6 cases could not be distinguished from simple cysts or cholangiocarcinoma preoperatively. In 6 simple hepatic cysts, 3 cases were diagnosed preoperatively and 3 cases could not be distinguished from biliary cystadenoma or pancreatic pseudocyst preoperatively. Expression of CA19-9 in simple hepatic cysts and biliary cystic neoplasms were 80% in both groups. Expression of CA19-9 is not related to the elevated level of CA19-9 in serum. CONCLUSINOS: Our data suggests that the elevated level of CA19-9 in serum may not be helpful in the preoprative diagnosis of biliary cystic neoplasm.