Franz Robert Apodaca-Torrez

Insulinoma de páncreas

Resumen El insulinoma es la neoplasia mas frecuente del grupo de tumores neuroendocrinos de pancreas. En el presente estudio se evaluaron los resultados clinicos e inmunohistoquimicos de 20 casos de pacientes tratados quirurgicamente desde enero de 1986 hasta diciembre de 2004. Se describio el cuadro clinico, los examenes de laboratorio e imageneologicos, y se hizo enfasis en los aspectos quirurgicos, las complicaciones y el seguimiento a medio y largo plazo. La cirugia se indico sobre la base de las evidencias clinicas y analiticas de hipoglucemia e hiperinsulinemia. En 15 pacientes se logro la localizacion previa de la lesion, en 5, su localizacion fue identificada durante la cirugia mediante la palpacion y a traves del ultrasonido intraoperatorio. Los procedimientos quirurgicos realizados con mas frecuencia fueron la reseccion pancreatica en la mitad de los pacientes y la enucleacion por laparotomia en la otra mitad. En 2 pacientes se utilizo la via laparoscopica. Dos presentaron tardiamente diabetes mellitus. La complicacion quirurgica mas frecuente fue la fistula pancreatica en 13 de los casos. No hubo mortalidad en la presente serie. En la totalidad de los pacientes se obtuvo la reversion clinica de los sintomas, caracterizada por la desaparicion de la triada de Whipple, ademas de la normalizacion o el aumento de los valores de glucemia, comparados con los valores del preoperatorio.

Insulinomas do pâncreas: diagnóstico e tratamento

BACKGROUND Despite its rarity, the insulinoma is the most common pancreatic neuroendocrine tumor. OBJECTIVE Analyze clinical and immunohistochemical data from surgical resection of the pancreas insulinoma. METHOD Twelve cases are described, concerning surgical aspects, complications and medium-long term outcome of patients. They underwent surgical treatment due to clinical suspicion and biochemical diagnosis of hypoglycemia and hyperinsulinism. RESULTS The insulinoma was identified preoperatively in seven patients, while intraoperative ultrasonography and palpation were necessary for diagnosis in the other cases. Eight patients underwent pancreatic resection and pancreatic leak was observed in seven cases. Two patients developed diabetes mellitus and no mortality occurred in the current series. CONCLUSION All patients presented satisfactory outcome and remained asymptomatic with normal glicemia levels.

Castleman’s Disease Mimetizing Pancreatic Tumor

CONTEXT Angiofollicular lymph node hyperplasia or Castlemans disease is a rare clinical condition. Knowledge about etiology and physiopathology; and treatment management as well are yet to be defined. Unicentric presentation of this disease affecting single lymph nodes in the mediastinum seems to be the most common presentation. Castlemans disease localized in the pancreas topographic area that mimics a pancreatic neoplasm is an even more uncommon event, with available published data of less than 15 cases until now. CASE REPORT We present a 64-year-old male patient with a six-month past history of asthenia, adynamia, and lack of general clinical conditions. Imaging studies showed a nodular hypoechoic mass in the pancreatic head. Enucleation of the lesion was performed. Histopathological study revealed unicentric form of Castlemans Disease. CONCLUSIONS Castlemans disease mimetizing pancreatic tumor is uncommon and it also curses with a difficult preoperative diagnosis. Surgery seems to be the best therapeutic alternative for this disease.

Extra-pancreatic vipoma

Neuroendocrine tumors of the pancreas are rare neoplasms representing approximately 2% of all pancreatic tumors9. Due to the progress of diagnostic imaging and radioimmunoassay, its diagnosis has become more frequent. Recent epidemiological studies suggest increased frequency12. Among the functioning tumors, vipoma (tumor cells producing vasoactive intestinal polypeptide) is also known as WDHA syndrome (watery diarrhea, hypokalaemia, and achlorhydria), Werner Morrison ́s syndrome and pancreatic cholera; it is still rare neoplasia, mainly characterized by profuse diarrhea with hydroelectrolytic disorders. It has an estimated incidence of 0,2 to 0,5 per million inhabitants per year3. Approximately 90% of these tumors originate in the pancreas; however, there are descriptions located in other segments of the gastrointestinal tract, bronchus, adrenal, sympathetic ganglia and liver. There are few cases described in the medical literature of extrapancreatic location in adults8. Due to its low incidence, it is unknown the true epidemiological data of this unique neoplasm. The objective of this report is to present another case of extra-pancreatic vipoma.

Ethyl-pyruvate reduces lung injury matrix metalloproteinases and cytokines and improves survival in experimental model of severe acute pancreatitis

PURPOSE To investigate if the ethyl-pyruvate solution could reduce mortality in AP and/or diminish the acute lung injury. METHODS Forty male rats, weighing between 270 to 330 grams were operated. An experimental model of severe AP by injection of 0.1 ml/100g of 2.5% sodium taurocholate into the bilio-pancreatic duct was utilized. The rats were divided into two groups of ten animals each: CT - control (treatment with 50 ml/kg of Ringers solution, intraperitoneal) and EP (treatment with 50 ml/kg of Ringer ethyl-pyruvate solution, intra-peritoneal), three hours following AP induction. After six hours, a new infusion of the treatment solution was performed in each group. Two hours later, the animals were killed and the pulmonary parenchyma was resected for biomolecular analysis, consisting of: interleukin, myeloperoxidase, MDA, nitric oxide, metalloproteinases and heat shock protein. In the second part of the experiment, another, 20 rats were randomly divided into EP and CT groups, in order to evaluate a survival comparison between the two groups. RESULTS There were no significant differences in IL-1B,IL-10, MMP-9, HSP70, nitric oxide, MPO, MDA (lipidic peroxidation) concerning both groups. The levels of IL-6 were significantly diminished in the EP group. Furthermore, the MMP-2 levels were also reduced in the EP group (p<0.05). The animals from the EP treatment groups had improved survival, when compared to control group (p<0.05). CONCLUSION The ethyl-pyruvate diminishes acute lung injury inflammatory response in acute pancreatitis and ameliorates survival when compared to control group, in the experimental model of necrotizing acute pancreatitis.

Tumor neuroendocrino quístico no funcionante del páncreas. Una presentación poco usual

Pancreatic endocrine neoplasms are a group of tumors that sporadically affect this gland, although their etiopathogenesis, diagnosis and treatment are still object of debate. The approximate incidence of these neoplasms is from 1 to 2% of all pancreatic tumors and their clinical symptoms depend on the production of hormones or biologically active amines. The cystic presentation of these tumors is a much rarer situation (approximately 4.5%), which usually makes their preoperative diagnosis difficult. Therefore, they are frequently confused with other cystic neoplasms of the pancreas with different therapeutic approaches, such as serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and epithelial cysts, among others. The aim of this letter is to present 3 new cases of nonfunctioning pancreatic neuroendocrine tumors with predominantly cystic characteristics. The patients are two females, aged 53 and 63, and one male, aged 25. The first two patients presented no specific symptoms. The male patient was in follow-up for a diagnosis of multiple endocrine neoplasia type 1 (MEN-1) and Cushing’s disease. The diagnosis of the pancreatic lesions was incidental. Computed tomography showed evidence of a cystic formation with hypodense areas measuring 3.5 cm in the body of the pancreas in the first case (Fig. 1A). In the second case, a solid cystic lesion was detected in the uncinate process measuring 1.7 cm (Fig. 2A), which was confirmed by endoscopic ultrasound. And, in the third case, magnetic resonance showed a predominantly cystic lesion with cell thickening in the tail of the pancreas measuring 6.2 cm. Surgery was indicated in all cases: in the first, pancreatectomy of the body and tail of the pancreas with splenectomy (Fig. 1B); in the second, pylorus-preserving pancreaticoduodenectomy (Fig. 2B); and, laparoscopic distal splenopancreatectomy in the third case. This last patient presented a type Ipancreatic fistula in the postoperative period. Hematoxylin-eosin confirmed the diagnosis of well-differentiated pancreatic endocrine neoplasm, with mitotic index inferior to 10 fields in the 3 cases. Immunohistochemistry showed positivity for chromogranin A, cytoplasmic neuroendocrine marker and neuron-specific enolase in the first case. The second case was positive for chromogranin A, synaptophysin, progesterone receptor 1A6, Mib-1, AE1, AE3 and the proliferation rate (Ki-67) was 5%. In the third patient, this method was positive for somatostatin, enolase monoclonal, chromogranin A, synaptophysin and glucagon, with Ki-67 less than 1%. The first 2 patients had no symptoms in follow-up, and the third patient continues in clinical and endocrinological follow-up. The development of diagnostic imaging methods in recent decades has undoubtedly resulted in the diagnosis of a series of asymptomatic pancreatic neoplasms, which before would probably have gone undetected with traditional methods. This has also led to controversial situations in the diagnosis and especially the treatment of certain diseases. Among these incidental diagnoses, pancreatic endocrine neoplasms are the most frequent. Their low incidence causes great diagnostic difficulties due to the absence of characteristic disease symptoms. This diagnostic difficulty can increase when these endocrine tumors adopt a cystic form,

Pancreatectomía central: Relato de casos y descripción de la técnica

Central pancreatectomy. Cases report and technique description The conventional techniques of pancreatic resections, most of the time imply in the withdrawal of ex- tensive segments of pancreatic parenchyma, having as possible complications at the long time, the appearance of endocrine or exocrine insufficience. The central pancreatectomy consists in an alternative of pancreatic resection to resect benign or low grade malignant tumours located in the pancreatic isthmus. We present the clinical characteristics, image, and the surgical technique used, for withdraw of pancreatic isthmus nonfunctio- ning pancreatic neuroendocrine neoplasm and pancreatic serous cystic adenoma.

Expressão das proteínas p53, p16 e ki67 no adenocarcinoma da cabeça do pâncreas e sua relação com a sobrevida e diferenciação celular

Objective: To determine the expression of p53, p16 and Ki-67 and its relevance in survival and cell differentiation. Methods: Fifteen duodenopancreatectomized patients were included. Immunohistochemical expression of p53, p16 and Ki-67 was determined in paraffin embedded tumor blocks. The relation of these expressions with different variables was studied. Results: Ninetythree per cent of tumors showed expression of p53 and p16. Ki- 67 was expressed in 86.66% of tumors (labeling index plus or minus LI 11.91 ± 9.47). The presence of combined alterations was not related to significant differences in tumor type, stage or survival; similar results were obtained analyzing isolated expressions. When groups of p16 and Ki-67 expressions where created, the median survival was not significant. However, there was a slightly better survival in patientswith focal expression of p16 (median survival 20.75 versus 14.34), when compared to patients with diffuse expression. Conclusion: The overexpression of p53, p16 and Ki-67 was not related to survival or tumor grade, when comparing isolated or combined expressions. Objetivo: Determinar a expressao de p53, p16 e Ki-67 e sua relevância na sobrevida e diferenciacao celular. Metodos: Foram incluidos 15 pacientes submetidos a duodenopancreatectomia. A expressao imunohistoquimica de p53, p16 e Ki-67 foi determinada em blocos tumorais embebidos em parafina. Foi estudada a relacao dessas expressoes com as variaveis. Resultados: Noventa e tres por cento dos tumores apresentaram expressao de p53 e p16. Ki-67 estava expresso em 86,66% dos tumores (indice proliferativo mais ou menos IP 11,91 ± 9,47). A presenca de alteracoes combinadas nao estava relacionada a diferencas significativas no tipo tumoral, no estagio ou na sobrevida; resultados semelhantes foram obtidos com a analise de expressoes isoladas. Quando foram criados os grupos de expressoes de p16 e Ki-67, a sobrevida mediana nao era significativa. Entretanto, havia uma sobrevida discretamente melhor nos pacientes com expressao focal do p16 (sobrevida mediana 20,75 versus 14,34) em comparacao com pacientes com expressao difusa. Conclusao: A superexpressao das proteinas p53, p16 e Ki-67 nao estava relacionada a sobrevida ou ao grau tumoral quando se compararam as expressoes isoladas ou combinadas.

Expression of p53, p16 and Ki67 proteins in ductal adenocarcinoma of the pancreatic head and their relation with survival and cell differentiation

OBJECTIVE To determine the expression of p53, p16 and Ki-67 and its relevance in survival and cell differentiation. METHODS Fifteen duodenopancreatectomized patients were included. Immunohistochemical expression of p53, p16 and Ki-67 was determined in paraffin embedded tumor blocks. The relation of these expressions with different variables was studied. RESULTS Ninety-three per cent of tumors showed expression of p53 and p16. Ki-67 was expressed in 86.66% of tumors (labeling index - LI 11.91 ± 9.47). The presence of combined alterations was not related to significant differences in tumor type, stage or survival; similar results were obtained analyzing isolated expressions. When groups of p16 and Ki-67 expressions where created, the median survival was not significant. However, there was a slightly better survival in patients with focal expression of p16 (median survival 20.75 versus 14.34), when compared to patients with diffuse expression. CONCLUSION The overexpression of p53, p16 and Ki-67 was not related to survival or tumor grade, when comparing isolated or combined expressions.

Acidose metabólica por hiperglicemia transitória pós enucleação de insulinoma pancreático

INTRODUCAO: Insulinoma e a neoplasia endocrina mais frequente dos tumores funcionantes do pâncreas. Origina-se a partir das celulas beta das ilhotas de Langerhans e caracteriza-se pela producao excessiva de insulina, com consequente hipoglicemia. O tratamento de escolha e a remocao cirurgica da neoplasia. O presente relato tem como objetivo apresentar uma complicacao metabolica pouco observada. RELATO DO CASO: Homem de 41 anos de idade ha dois anos com tonturas, visao turva e convulsoes. Os sintomas estavam bem relacionados com periodos prolongados de jejum e melhoravam com as refeicoes, e durante um dos episodios foi constatada a presenca de hipoglicemia, melhorando os sintomas imediatamente apos administracao de glicose endovenosa. A pesquisa glicemica revelou intensa hipoglicemia. Ultrassonografia, tomografia computadorizada e ressonância magnetica de abdome nao revelaram nenhum tipo de alteracoes no pâncreas. Com a hipotese diagnostica de hiperglicemia orgânica por provavel insulinoma, o paciente foi submetido a enucleacao da lesao. No 5o dia do pos-operatorio surgiu fistula pancreatica e acidose metabolica com resolucao satisfatoria. O laudo histopatologico mostrou tumor endocrino de pâncreas de 1,5 cm. CONCLUSAO: Todo paciente submetido a resseccao de insulinoma pancreatico deve realizar o pos-operatorio imediato em unidades de terapia intensiva, monitorando de forma rigorosa os niveis de glicemia como prevencao de acidose metabolica.