Isotropic volumetric MRI for displaying cranial perineural spread of cranial nerve in nasopharyngeal carcinoma

Objective To observe the value of isotropic volumetric MRI for displaying perineural spread(PNS)of cranial nerve(CN)in nasopharyngeal carcinoma.Methods Eighty-seven patients with pathologically proven nasopharyngeal carcinoma were prospectively enrolled.MR scanning,including three-dimensional liver acquisition with volume acceleration-flexible(3D LAVA_Flex)image,T2WI with fat suppression(T2WI-FS),T1WI,contrast enhancement(CE)T1WI-FS of nasopharynx and neck region were performed.The displaying rates of CN PNS were evaluated and compared between 3D LAVA_Flex and T2WI-FS,T1WI,CE-T1WI-FS at patient level,CN group level and neural level,respectively.Results The displaying rate of CN PNS in all 87 nasopharyngeal carcinoma patients by 3D LAVA_Flex sequence was 49.43%(43/87),higher than that of conventional MRI(30/87,34.48%,P=0.001).Among 59 patients with advanced nasopharyngeal carcinoma diagnosed with conventional sequences,the displaying rate of CN PNS was 71.19%(42/59)by 3D LAVA-Flex sequence,higher than that of conventional MRI(30/59,50.85%,P=0.001).At both patient level and posterior CN level,significant differences of the displaying rate of CN PNS were found between 3D LAVA-Flex sequence and T2WI-FS,T1WI,CE-T1WI-FS,while at CN level,the displaying rates of mandibular nerve PNS,CNⅨ—ⅪPNS in jugular foramen(P<0.05)and CNⅨ—ⅫPNS in carotid space of 3D LAVA_Flex sequence were all significantly higher than that of T2WI-FS,T1WI and CE-T1WI-FS(all P<0.05),of PNS of CNⅢ—Ⅴin cavernous sinus were higher than that of T2WI-FS(P<0.05),while of PNS of hypoglossal nerve were significantly higher than that of T2WI-FS and T1WI(both P<0.05).Conclusion 3D LAVA_Flex sequence could be used to effectively display CN PNS of nasopharyngeal carcinoma.

Comparative study on the efficacy of transoral robotic surgery and non-robotic surgery for tongue base tumors

Objective:To compare the efficacy of transoral robotic surgery(TORS)and non-robotic surgery(NRS)in the treatment of tongue base tumors.Methods:A total of 45 patients with tongue base tumors treated in our hospital were selected,and they were divided into the TORS group and NRS group according to different surgical methods.The surgical indicators and postoperative complications of patients in the two groups were compared and analyzed.Results:Compared with the NRS group,the operative time,bleeding volume and length of hospital stay were less in the TORS group,and the postoperative recurrence rate was less in the TORS group than that in the NRS group.The incidence rate of dysphagia and restricted mouth opening in the TORS group was lower than that in the NRS group within 30 d after surgery,and the difference was statistically significant(P<0.05).Conclusion:TORS has better minimally invasive advantages in the treatment of tongue base tumors,including less intraoperative bleeding,smaller trauma,shorter length of hospital stay and faster recovery.

麻风联合化疗后的复发

麻风联合化疗(MDT)的主要目的在于治疗和防止耐药。1982年以来,全世界登记的病人已有50％以上采用MDT。复发率(RR)是考核MDT效果的一个重要指标。对麻风复发的标准目前尚有不同意见。

Clinical Experience of Primary Retroperitoneal Tumor: Report of 600 Cases

Objective： To summarize the experience of management for primary retroperitoneal tumor （PRPT） and to analyze the factors influencing the outcome after operation. Methods： The data of 600 cases of PRPT in General Hospital of PLA were reviewed retrospectively. Results： Of 600 cases of PRPT, 546 were surgically treated. Among theme 369 were malignant and 177 benign. 366 cases were followed up for 1 month to 15 years. The 1-years 3-year, and 5-year survival rate in the patients subject to complete resection was 90.5%, 73.2% and 53.6%, respectively, and that in incomplete resection patients was 70.6%, 32.0%, 5.7% respectively （P〈0.01）. The Cox multi-various regression analysis revealed showed completeness of tumor resection, sex and histologic type were associated closely with local recurrence. Conclusion： Sufficient preoperative preparation and complete tumor resection play important roles for reducing recurrence and improving survival.

Clinico-pathologic significance of neuroendocrine cells in gastric carcer tissue

AIMS To elucidate the biological and clinicopathological signifi- cance of neuroendocrine(NE)cells in gastric carcinoma(GC). METHODS One hundred and eighty-nine cases of various histo- logical types of GC were observed using light microscopy, histochemistry,immunohistochemistry and electron microscopy. Of them 127 patients were followed up. RESULTS Chromogranin A(CgA)positive GC was demonstrat- ed in 85 cases(45.0%).The typos of NE cells in GC were probed using 9 kinds of hormone antibodies 49 cases(67.2%) contained more than one hormone.NE cells were found more often in poorly differentiated GC than in well differentiated ones(P<0. 01).Expression of some kinds of hormone Was relative to the dif- ferentiation and histological types of GC.BOM,CT(P<0.01) GAST and 5-HT(P<0.05)were more expressed in poorly differ- entiated cases than in well defferentiated ones.Nineteen cases of the matastatic foci in regional lymph nodes were found to have CgA positive cancer cells.The presence of HCG in matastatic lymph nodes was more often observed than that of other hormone (P<0.01).The survival rate of patients with NE positive GC was 38.9% and negative GC 52.7%.Five of 7 patients(71. 4%)with somatostatin positive GC still survived at follow up of 33-66 months,but 4 patients with HCG positive GC died in 12-29 months. CONCLUSIONS The NE cells occur more frequently in poorly differentiated GC.Certain hormones appear to be related to the metastasis and prognosis.

多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值

目的探讨多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值。方法 9例颅底肿瘤术前均行DynaCTA检查及MRI薄层(2 mm)增强扫描检查,将多组影像数据输入工作站,采用"双容积重建"技术进行脑血管及MRI的影像融合,通过静态及动态融合影像观察肿瘤与脑结构、血管及颅骨的毗邻关系,并对肿瘤的诊断、手术治疗及预防血管并发症进行分析。结果 9例均获得满意的影像融合、具有很好的空间一致性,在一张影像上可以清晰显示病变及其周围脑结构、血管及颅骨解剖关系,提高精准性诊断,并应用于指导治疗策略、设计手术划及预防并发症。9例均恢复满意出院。结论多模态影像融合对提高颅底肿瘤的诊断精准性、提高肿瘤全切除率、降低病死率和残疾率效果肯定,对血管损伤并发症治疗疗效肯定。

Results of percutaneous sclerotherapy and surgical treatment in patients with symptomatic simple liver cysts and polycystic liver disease

AIM: To evaluate the results of the treatment of simple liver cysts (solitary and multiple) and polycystic liver disease (PLD) using percutaneous sclerotherapy and/or surgical procedures in a single tertiary referral centre. METHODS: Retrospective analysis of 54 patients referred for evaluation and possible treatment of simple liver cysts (solitary and multiple) and PLD, from January 1997 to July 2006. RESULTS: Simple liver cysts were treated in 41 pts (76/) with a mean size of 12.6 cm. The most common reason for referral was abdominal pain or discomfort (85/). Percutaneous sclerotherapy was performed as initial treatment in 30 pts, showing cyst recurrence in 6 pts (20/). Surgical treatment was initially performed in 11 pts with cyst recurrence in 3 pts (27/). PLD was treated in 13 pts (24/) with a mean size of the dominant cyst of 13 cm. Percutaneous sclerotherapy for PLD was performed in 9 pts with recurrence in 7 pts (77.8/). Surgical treatment for PLD was undertaken in 4 pts (30.8/) with recurrence in all. Eventually, 2 pts with PLD in the presence of polycystic kidney disease underwent liver-and kidney transplantation because of deterioration of liver and kidney function. CONCLUSION: The majority of patients with simple liver cysts and PLD are referred for progressive abdominal pain. As initial treatment, percutaneous sclerotherapy is appropriate. Surgical deroofing is indicated in caseof cyst recurrence after percutaneous sclerotherapy. However, the results of percutaneous sclerotherapy and surgical treatment for PLD are disappointing. Partial liver resection is indicated when there is suspicion of a pre-malignant lesion.

Gastrointestinal autonomic nerve tumors:A surgical point of view

AIM: Gastrointestinal autonomic nerve tumors are uncommon stromal tumors of the intestinal tract. Their histological appearance is similar to that of other gastrointestinal stromal tumors. We report two cases and performed an analysis of the literature by comparing our findings with the available case reports in the medical literature.METHODS: Two patients were admitted with abdominal tumor masses. One occurred in the stomach with large multiple liver metastases and the second originated in Meckel's diverticulum. The latter site has never been reported previously. Both patients underwent surgery. In one patient gastrectomy, right liver resection and colon transversum resection were performed to achieve aggressive tumor debulking. In the other patient the tumor bearing diverticulum was removed.RESULTS: Postoperative recovery of both patients was uneventful. Histological examination, immunohistochemical analysis and electron microscopy revealed the diagnosis of a gastrointestinal autonomic nerve tumor. The patient with the tumor in Meckel's diverticulum died 6 mo after surgery because of pneumonia. The patient with liver metastases have been alive 13 years after initial tumor diagnosis and 7 years after surgery with no evidence of tumor progression. In light of our results, we performed athorough comparison with available literature reports.CONCLUSION: Radical surgical resection of gastrointestinal autonomic nerve tumors seems to be the only available curative approach to date, and long term survival is possibleeven in large metastasized tumors.

A case of an intussuscepted neuroendocrine carcinoma of the appendix

We have described a previously unreported entity of an intussuscepted neuroendocrine carcinoma of the appendix. Our patient was a 70-year-old man whose only complaint was insipient weight loss. Colonoscopy showed a malignant cecal ＂polyp＇; and an extended right hemicolectomy was performed. We have reviewed the literature on the causes of appendiceal intussusception and their appropriate treatment options, and clarified the classification of neuroendocrine tumors of the gastrointestinal tract.

PROGNOSTIC FACTORS FOR DEEP SITUATED MALIGNANT GLIOMAS TREATED WITH LINAC RADIOSURGERY

Objective To study the function of radiosurgery on malignant glioma by analyzing prognostic factors affecting malignant gliomas treated with linac radiosurgery. Method Fifty-eight patients with deep situated malignant gliomas, aged 7 to 70 years, 28 anaplastic astrocytomas and 30 glioblastomas multiforme were analyzed. The median volume of tumor was 10.67 cm3, and median prescription dose for linac radiosurgery was 20 Gy. Results were analyzed with Kaplan-Meier curve and Cox regression. Result In follow-up 44.8 percent tumors (26 patients) decreased in size. Median tumor local control interval was 10 months, 15 months for anaplastic astrocytomas, and 9 months for glioblastoma multiforme. Tumor local control probability was 37.9 percent for 1 year and 10.3 percent for 2 years. Median survival was 22.5 months for anaplastic astrocytoma, 13 months for glioblastoma multiforme, and 15 months for all patients. The survival probability was 79.3 percent at 1 year and 20.6 per-cent at 2 years. Isocenter numbers and tumor volume were the prognostic factors for tumor control, but conformity index was the prognostic factor for survival by Cox regression analysis. Considering pathology, only isocenter number and target volume significantly affected tumor control interval. Complications appeared in 44.8 percent patients and the median interval of com-plication onset was 8 months. Symptomatic cerebral edema was observed in 31.0 percent patients. Conclusion Linac radiosurgery can effectively improve tumor local control and prolong survival for deep situated mali-gnant gliomas.

Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation

Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.

Liver transplantation for metastatic neuroendocrine tumor: A case report and review of the literature

Neuroendocrine tumors are divided into gastrointestinal carcinoids and pancreatic neuroendocrine tumors. The WHO has updated the classification of these lesions and has abandoned the term ＂carcinoid＂. Both types of tumors are divided into functional and non-functional tumors. They are characterized by slow growth and frequent metastasis to the liver and may be limited to the liver for long periods. The therapeutic approach to hepatic metastases should consider the number and distribution of the liver metastases as well as the severity of symptoms related to hormone production and tumor bulk. Surgery is generally considered as the first line therapy. In patients with unresectable liver metastases, alternative treatments are dependent on the type and the growth rate. Initial treatments consist of long acting somatostatin analogs and/or interferon. Streptozocin-based chemotherapy is usually reserved for symptomatic patients with rapidly advancing disease, but generally the therapy is poorly tolerated and its effects are short-lived. Locoregional therapy directed such as hepatic-artery embolization and chemoembolization, radiofrequency thermal ablation and cryosurgery, is often used instead of systemic therapy, if the disease is limited to the liver. However, liver transplantation should be considered in patients with neuroendocrine metastases to the liver that are not accessible to curative or cytoreductive surgery and if medical or Iocoregional treatment has failed and if there are life threatening hormonal symptoms. We report a case of liver transplantation for metastatic neuroendocrine tumor of unknown primary source and provide a detailed review of the world literature on this controversial topic.

COMBINATION OF γ-INTERFERON WITH TRAIL AND CISPLATIN OR ETOPOSIDE INDUCES APOPTOSIS IN HUMAN NEUROBLASTOMA CELL LINE SH-SY5Y

Objective To study the effect of γ-interferon （IFNγ）, tumor necrosis factor related apoptosis inducing ligand （TRAIL）, and cisplatin or etoposide induced apoptosis in human neuroblastoma cell line SH-SY5Y and its possible molecular mechanisms. Methods The expressions of Caspase 8 mRNA and protein were detected with RT-PCR and Western blot analysis. The effects of IFNγ, TRAIL, IFNγ ＋ TRAIL, IFNγ ＋ Caspase 8 inhibitor ＋ TRAIL, IFNγ ＋ cisplatin ＋ TRAIL, and IFNγ ＋ etoposide ＋ TRAIL on the growth and apoptosis of SH-SY5Y cells were detected with the methods of MTT and flow cytometry. The relative Caspase 8 activity was measured with colorimetric assay. Results Caspase 8 was undetectable in SH-SY5Y cells but an increased expression of Caspase 8 mRNA and protein was found after treatment with IFNγ. SH-SY5Y ceils themselves were not sensitive to TRAIL, but those expressing Caspase 8 after treatment with IFNγ were. The killing effect of TRAIL on SH-SY5Y cells expressing Caspase 8 was depressed by Caspase 8 inhibitor. Cisplatin and etoposide could enhance the sensitivity of TRAIL on SH-SY5Y cells. The relative Caspase 8 activity of SH-SY5Y cells in IFNγ ＋ TRAIL group was significantly higher than those of control group, IFNγ group, TRAIL group, and inhibitor group （ P 〈 0. 01 ）. There was no significant difference among IFNγ ＋ TRAIL group, IFNγ ＋ cisplatin ＋ TRAIL group, and IFNγ ＋ etoposide ＋ TRAIL group. Conclusions IFNγ could sensitize SH-SY5Y cells to TRAIL-induced apoptosis and this may be realized by the up-regulation of Caspase 8. Cisplatin and etoposide could enhance the killing effect of TRAIL on SH-SY5Y cells.

Management of Hinchey Ⅱ diverticulitis

Colonic diverticulosis can either be asymptomatic or present with complications resulting in significant morbidity and mortality.A key presentation of complicated disease is abscess formation(Hinchey type Ⅱ).The natural course of this is unclear and therefore treatments range from conservative approach with antibiotics and percutaneous guided drainage(PCD) to surgery.There is no clear consensus on the exact management strategy.A Medline based literature search specifically looking at studies dealing with Hinchey type Ⅱ diverticulitis and its management was carried out.For comparison,five-year retrospective data of diverticular abscesses from our institution was collected and the outcome analysed.Various studies have looked into this aspect of the disease,elaborating on the significance of the size and location of the abscesses,the role of PCD,recurrence rates and the controversies regarding the need for elective surgery.Conservative treatment with antibiotics alone is effective in a majority of cases with a role for PCD in large safely accessible abscesses.Variable recurrence rates have been reported in literature and elective surgery should be planned for selected groups of patients.

Long-term outcomes of hepatectomy vs percutaneous ablation for treatment of hepatocellular carcinoma≤4 cm

AIM： To determine which treatment modality - hepatectomy or percutaneous ablation - is more beneficial for patients with small hepatocellular carcinoma （HCC） （≤4 cm） in terms of long-term outcomes. METHODS： A retrospective analysis of 149 patients with HCC ≤ 4 cm was conducted. Eighty-five patients underwent partial hepatectomy （anatomic in 47 and nonanatomic in 38） and 64 underwent percutaneous ablation （percutaneous ethanol injection in 37, radiofrequency ablation in 21, and microwave coagulation in 6）. The median follow-up period was 69 mo. RESULTS： Hepatectomy was associated with larger tumor size （P〈0.001）, whereas percutaneous ablation was significantly associated with impaired hepatic functional reserve. Local recurrence was less frequent following hepatectomy （P〈0.0001）. Survival was better following hepatectomy （median survival time： 122 mo） than following percutaneous ablation （median survival time： 66 mo; P= 0.0123）. When tumor size was divided into ≤ 2 cm vs 〉 2 cm, the favorable effects of hepatectomy on long-term survival was seen only in patients with tumors 〉2 cm （P= 0.0001）. The Cox proportional hazards regression model revealed that hepatoctomy （P= 0.006） and tumors ≤ 2 cm （P=0.017） were independently associated with better survival. CONCLUSION： Hepatectomy provides both better local control and better long-term survival for patients with HCC ≤4 cm compared with percutaneous ablation. Of the patients with HCC ≤4 cm, those with tumors 〉 2 cm are good candidates for hepatectomy, provided that the hepatic functional reserve of the patient permits resection.

Endoscopic submucosal dissection for foregut neuroendocrine tumors:An initial study

AIM： To evaluate the feasibility and efficacy of endo- scopic submucosal dissection （ESD） for foregut neuro- endocrine tumors （NETs）. METHODS： From April 2008 to December 2010, pa- tients with confirmed histological diagnosis of foregut NETs were included. None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography （EUS）. ESD was attempted under general anesthesia. After making several mark-ing dots around the lesion, a mixture solution was injected into the submucosa. The mucosa was incised outside the marking dots. Dissection of the submu- cosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen. Tumor features, clinicopathological char- acteristics, complete resection rate, and complications were evaluated. Foregut NETs were graded as G1, G2, or G3 on the basis of proliferative activity by mitotic count or Ki-67 index. All patients underwent regular follow-up to evaluate for any local recurrence or dis- tant metastasis. RESULTS： Those treated by ESD included 24 patients with 29 foregut NETs. The locations of the 29 lesions are as follows： esophagus （n = 1）, cardia （n = 1）, stomach （n = 23）, and duodenal bulb （n = 4）. All le- sions were found incidentally during routine upper gastrointestinal endoscopy for other indications, and none had symptoms of carcinoid syndrome. Preop- erative EUS showed that all tumors were confined to the submucosa. Among the 24 gastric lesions, 16 le- sions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia, while the other 8 solitary lesions were type Ⅲ because of absence of atrophic gastritis in these cases. All of the tumors were removed in an en bloc fashion. The av- erage maximum diameter of the lesions was 9.4 mm （range： 2-30 ram）, and the procedure time was 20.3 rain （range： 10-45 rain）. According to the World Health Organization 2010 classification, histological evaluation determined that 26 lesions were NET-G1, 2 gastric le- sions were NET-G2, and 1 esophageal lesion was neu- roendocrine carcinoma （NEC）. Complete resection was achieved in 28 lesions （28/29, 96.6%）, and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion. The re- maining patient with NEC underwent additional surgery because the resected specimens revealed angiolym- phatic and muscularis invasion, as well as incomplete resection. Delayed bleeding occurred in 1 case 3 d af- ter ESD, which was managed by endoscopic treatment. There were no procedure-related perforations. During a mean follow-up period of 24.4 mo （range： 12-48 too）, local recurrence occurred in only 1 patient 7 mo after initial ESD. This patient successfully underwent repeat ESD. Metastasis to lymph nodes or distal organs was not observed in any patient. No patients died dur- ing the study period. CONCLUSION： ESD appears to be a safe, feasible, and effective procedure for providing accurate histo- pathological evaluations and curative treatment for eligible foregut NETs.

Transient small bowel angioedema due to intravenous iodinated contrast media

Three cases of transient proximal small bowel angioedema induced by intravenous administration of nonionic iodinated contrast media (CM) are presented.Computed tomography (CT) images in the venous phase displayed the proximal small bowel with circumferential thickening of the wall including the duodenum and proximal segment of the jejunum.The bowel wall was normal in non-enhanced images,and normal or inconspicuous in arterial phase enhanced images.In one of the three cases,the bowel wall was thickened in venous phase but disappeared in the 40 s delayed phase images.No filling defect was seen in the lumen of the superior mesenteric artery and vein.No peritoneal effusion or mesentery abnormality was found.Each of these patients reported only mild abdominal discomfort and recovered without specific treatment within a short time.Only one patient suffered mild diarrhea after scanning which had resolved by the following day.The transient anaphylactic small bowel angioedema due to intravenous iodinated contrast media was easily diagnosed based on its characteristic CT findings and clinical symptoms.Differential diagnosis may include inflammatory and ischemic bowel disease,as well as neoplasms.A three-phase CT protocol and good under-standing of this disorder are fundamentally important in the diagnosis of this condition.The supposed etiology behind the transient anaphylactic reaction to intravenous administration of iodinated CM in small bowel is similar to other CM-induced hypersensitive immediate reactions.The predilection location of transient anaphylactic bowel angioedema is the small intestine,particularly the proximal segment.A speculated cause may be the richer supply of vessels in the small intestine,ample mucous folds and loose connective tissue in the duodenum and the jejunum.

Total intravenous general anesthesia with laryngeal mask airway for transurethral resection of bladder tumor

Objective： To observe the advantage of total intravenous anesthesia for transurethral resection of bladder tumor （TURBT）. Methods.. Sixty ASA Ⅰ-Ⅱ patients undergoing TURBT were randomly assigned to 2 groups. Spinal anesthesia with 0. 75% pure bupivacaine （8-12 rag） was applied to patients in Group Ⅰ （n= 30）. Patients in Group Ⅱ （n=30） received total intravenous anesthesia with continuous infusion of Propofol and Remifentanil ; and a laryngeal mask was used to ensure the airway and ventilation. BP, HR, SPO2 and pertinent side effects were monitored and recorded. Results ： The patients in group Ⅱ experienced more stable hemodynamics than those in group Ⅰ . Obturator nerve reflex was observed in 15 （50. 0%） patients in Group Ⅰ , but none （0%） in Group Ⅱ （P〈0. 01）. Conclusion.. Total intravenous anesthesia with laryngeal mask is a safe, reliable, controllable and simple manual for patient undergoing TURBT.

Neuroendocrine tumors of the gastro-entero-pancreatic system

Gastro-entero-pancreatic (GEP) neuroendocrine tumors (NETs) are rare neoplasms, although their prevalence has increased substantially over the past three decades. Moreover, there has been an increased clinical recognition and characterization of these neoplasms. They show extremely variable biological behavior and clinical course. Most NETs have endocrine function and secrete peptides and neuroamines that cause distinct clinical syndromes, including carcinoid syndrome; however, many are clinically silent until late presentation with mass effects. Investigation and management should be individualized for each patient, taking into account the likely natural history of the tumor and general health of the patient. Management strategies include surgery for cure or palliation, and a variety of other cytoreductive techniques, and medical treatment including chemotherapy, and biotherapy to control symptoms due to hormone release and tumor growth, with somatostatin analogues (SSAs) and alphainterferon. New biological agents and somatostatintagged radionuclides are under investigation. Advances in the therapy and development of centers of excellence which coordinate multicenter studies, are needed to improve diagnosis, treatment and therefore survival of patients with GEP NETs.