The paper focuses on Toni Morrison＇s latest novel God Help the Child （2015）. By presenting a skillful though somewhat perverse merger of binary oppositions at different levels （racial, social, moral, and psycholog...The paper focuses on Toni Morrison＇s latest novel God Help the Child （2015）. By presenting a skillful though somewhat perverse merger of binary oppositions at different levels （racial, social, moral, and psychological）, the writer makes borderlines of all sorts appear artificial and therefore invalidates them. Thus, childhood merges with adulthood through sexual traumas that live on; touch with no touch as the evil touch of a parent equals an abhorrence of touching the child Other; truth with a lie as it proves as destructive as lying in good faith; passing blackness with blue blackness as the former conceives the latter; and appearances with reality in the ironic title of the book, where it is both the mother and the child that in fact need God＇s help. Thus, as Toni Morrison demonstrates, a thoroughly surreptitious, because natural, process of dissolution of all barriers makes them appear to be arbitrary constructs responsible for the equally arbitrary notion of the Other. Taking an utterly holistic view of the nature of things, Morrison seems to suggest that borderlines are a consequence and a manifestation of a lack of balance, which therefore needs to be redressed through love, mutual understanding, and maturation.展开更多
This case study describes the care provided to a female patient with borderline personality disorder (BPD) who presented to the emergency department (ED). While people with borderline personality disorder use emergenc...This case study describes the care provided to a female patient with borderline personality disorder (BPD) who presented to the emergency department (ED). While people with borderline personality disorder use emergency services frequently, clinicians often face difficulties when providing medical and behavioral services to these patients. It may be difficult for nurse practitioners to determine if a patient with BPD who presents to the ED in crisis should be admitted, medicated, observed, or discharged. Self-harm is frequently confused with suicide attempts, which can result in unnecessary hospitalizations. This case study seeks to examine the proper management and difficulties encountered by healthcare providers in managing crises involving individuals with BPD in ED settings. The case study underscores the significance of thorough evaluation, recognition of BPD characteristics, active engagement in treatment, the therapeutic alliance, and the emphasis on interpersonal connections and stressors alongside the utilization of psychopharmacology.展开更多
Since its inception,localized pancreatic cancer has been identified as a systemic illness.Hence,to increase its survival rates,surgical resection followed by ad-juvant chemotherapy is used as a treatment option.A sign...Since its inception,localized pancreatic cancer has been identified as a systemic illness.Hence,to increase its survival rates,surgical resection followed by ad-juvant chemotherapy is used as a treatment option.A significant barrier,though,is the high morbidity and drawn-out recovery after extensive surgical resection,which may postpone or prohibit the prompt administration of adjuvant therapy.Thereby,acknowledging the efficacy of neoadjuvant therapy in various digestive tract malignancies like rectal,gastric,and oesophagal cancers in en-hancing long-term survival and the likelihood of successful resection,researchers have turned their attention to exploring its potential benefits in the context of both resectable and borderline resectable pancreatic cancer(RPC).According to recent data,neoadjuvant chemoradiation has major advantages for both resectable and borderline RPC.These advantages include increased surgical resection rates,longer survival times,decreased recurrence rates,and better overall disease control with a manageable toxicity profile.Despite its benefits,research is still being done to determine the best way to sequence and combine chemotherapy and radiation.Furthermore,studies have demonstrated the potential for cus-tomized therapy regimens based on the patient’s general health status and the tumor’s biological behavior to maximize the neoadjuvant approach.As progress continues,neoadjuvant chemoradiation is set to become a key component of treatment for both resectable and borderline RPC,providing a more efficient way to manage this deadly condition.While further development is required to fully grasp its potential in enhancing long-term patient outcomes,evidence supports its increasing usage in clinical practice.展开更多
BACKGROUND Fibroadenomas(FA)and phyllodes tumors(PT)are fibroepithelial neoplasms and are difficult to differentiate radiographically and histologically.We present a partially infarcted borderline PT in an adolescent ...BACKGROUND Fibroadenomas(FA)and phyllodes tumors(PT)are fibroepithelial neoplasms and are difficult to differentiate radiographically and histologically.We present a partially infarcted borderline PT in an adolescent with rapid tumor enlargement within 24 hours.Tumor infarction made the diagnostic work-up difficult.Com-plete surgical excision is the standard of care for PTs.There is controversy regar-ding margin re-excision for borderline PTs.In this report,we discuss the diagno-stic challenges of PT and the evolving concept of margin status on PT recurrence rate.CASE SUMMARY A 14-year-old healthy female with no medical history presented with a painful right breast mass with no nipple discharge,trauma,or skin findings.The mass showed rapid enlargement over 24 hours,prompting a workup with ultrasound and core needle biopsy.The initial biopsy was limited due to large areas of in-farction.Based on the scant viable tissue and considering the patient’s age,the mass was favored to be a juvenile FA.The patient underwent excision of the mass.Final pathology confirmed a borderline PT with positive surgical margins.The patient underwent margin re-excision,which did not show any residual tumor.At the 6-month post-op visit,there was a mass-forming lesion on the breast ultrasound.Subsequent core needle biopsy showed benign breast parenchyma with scar formation.The primary goal of evaluation in pediatric breast masses is to do no harm.However,rapidly growing and symptomatic masses require a more extensive work-up including biopsy and surgical excision.We present a rapidly growing breast mass in a 14-year-old female which was diagnosed as a borderline PT on her excision specimen.The mass rapidly enlarged over 24 hours.The initial biopsy pathology was limited due to a large area of infarction.The patient underwent excision of the mass.Final pathology confirmed a borderline PT that extended into the surgical margin,resulting in an additional re-excision procedure.Accurate diagnosis prior to surgical intervention is crucial to avoid additional procedures.Although histological morphology remains the gold standard for diagnosis,immunohistochemistry and molecular studies have recently shown to improve the accuracy of diagnosis of PTs.Long-term clinical and pathologic follow-up of PTs in adolescent patients should be collectively studied to examine whether our current diagnostic criteria for PT can reliably predict tumor behavior in this age group.CONCLUSION Accurate diagnosis of PTs requires surgical excision.Tumor infarction may lead to rapid tumor enlargement,hindering the correct diagnosis.More research is needed on margin status and recurrence rate,especially in adolescent patients,to help establish the best possible care for this age group.展开更多
Pancreatic cancer is the fourth leading cause of cancer death in the United States. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease. Unfortunately...Pancreatic cancer is the fourth leading cause of cancer death in the United States. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease. Unfortunately, even among those who undergo resection, the reported median survival is 15-23 mo, with a 5-year survival of approximately 20%. Disappointingly, over the past several decades, despite improvements in diagnostic imaging, surgical technique and chemotherapeutic options, only modest improvements in survival have been realized. Nevertheless, it remains clear that surgical resection is a prerequisite for achieving longterm survival and cure. There is now emerging consensus that a subgroup of patients, previously considered poor candidates for resection because of the relationship of their primary tumor to surrounding vasculature, may benefit from resection, particularly when preceded by neoadjuvant therapy. This stage of disease, termed borderline resectable pancreatic cancer, has become of increasing interest and is now the focus of a multiinstitutional clinical trial. Here we outline the history, progress, current treatment recommendations, and future directions for research in borderline resectable pancreatic cancer.展开更多
Pancreatic ductal adenocarcinoma(PDAC) is one of the most aggressive human neoplastic entities,with a very poor prognosis characterized by a high mortality rate and short survival.This is due both to its aggressive bi...Pancreatic ductal adenocarcinoma(PDAC) is one of the most aggressive human neoplastic entities,with a very poor prognosis characterized by a high mortality rate and short survival.This is due both to its aggressive biological behaviour and the high incidence of locally advanced stages at the time of the initial diagnosis.The limits of resectability and the role of neoadjuvant(radio) chemotherapy for PDAC management are still unclear.A recently published article by Kats et al compared the radiological,surgical and histopathological results of 129 patients with borderline resectable tumors undergoing neoadjuvant treatment followed by surgery.Although post-neoadjuvant treatment imaging implied a low response rate,a high rate of complete resections was achieved.This seems to confirm that,though radiology has made a significant progress in defining locally advanced PDAC,there is place for further improvement.In particular,the differentiation between radiotherapy-induced scarring/fibrosis and cancer-associated desmoplasia remains a clinical/radiological challenge.Though selection of patients with occult systemic disease is possible with neoadjuvant treatment,downstaging does not seem to occur frequently.Thus,development of novel,more aggressive(radio) chemotherapy regimens is required to improve prognosis of patients with locally unresectable but not systemically micro-metastasized tumors.展开更多
BACKGROUND: Pancreatic cancer remains a devastating disease with a 5-year survival rate of less than 5%. Recent advances in diagnostic methods and therapeutic approaches have increased the possibility of improving the...BACKGROUND: Pancreatic cancer remains a devastating disease with a 5-year survival rate of less than 5%. Recent advances in diagnostic methods and therapeutic approaches have increased the possibility of improving the existing poor prognosis. DATA SOURCES: English-language articles reporting early diagnosis and therapy of pancreatic cancer were searched from the MEDLINE and PubMed databases, Chinese-language articles were from CHKD (China Hospital Knowledge Database) RESULT: The current literature about pancreatic cancer was reviewed from three aspects: statistics, screening and early detection, and therapy. CONCLUSIONS: Early detection and screening of pancreatic cancer currently should be limited to high risk patients Surgical resection is the only curative approach available, with some recent improvement in outcomes. Gemcitabine has been a standard treatment during the last decade. Gemcitabine based combination treatment, especially combined with newer molecular targeted agents, is promising. The rationale for radiotherapy is controversial, but with the recent development of modern radiation delivery techniques, radiotherapy should be intensified. Patients with borderline pancreatic cancer could benefit from neoadjuvant therapy but more evidence is needed and the best neoadjuvant regimen is still to be determined.展开更多
BACKGROUND： The treatment of borderline resectable pancreatic head cancer（BRPHC） is still controversial and challenging. The artery-first approaches are described to be the important options for the early determina...BACKGROUND： The treatment of borderline resectable pancreatic head cancer（BRPHC） is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach（MAFA）, with conventional techniques for the surgical treatment of BRPHC.METHODS： A total of 117 patients with BRPHC undergone pancreaticoduodenectomy（PD） from January 2013 to June 2015 were included. They were divided into an MAFA group（n=78） and a conventional-technique group（n=39）. Background characteristics, operative data and complications were compared between the two groups.RESULTS： Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group（313 vs 384 min; P=0.014）; mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group（534 vs 756 m L; P=0.043）; and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group（61.5% vs 35.9%; P=0.014）. Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS： MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.展开更多
Pseudomyxoma peritonei (PMP) is an uncommon "bor-derline malignancy" generally arising from a perforated appendiceal epithelial tumour. Optimal treatment involves a combination of cytoreductive surgery (CRS)...Pseudomyxoma peritonei (PMP) is an uncommon "bor-derline malignancy" generally arising from a perforated appendiceal epithelial tumour. Optimal treatment involves a combination of cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC). Controversy persists regarding the pathological classification and its prognostic value. Computed tomography scanning is the optimal preoperative staging technique. Tumour marker elevations correlate with worse prognosis and increased recurrence rates. Following CRS with HIPEC, 5-year survival ranges from 62.5% to 100% for low grade, and 0%-65% for high grade disease. Treat-ment related morbidity and mortality ranges from 12 to 67.6%, and 0 to 9%, respectively. Surgery and HIPEC are the optimal treatment for PMP which is at best a "borderline" peritoneal malignancy.展开更多
Pancreatic adenocarcinoma remains the fourth leading cause of cancer-related death and is one of the most aggressive malignant tumors with an overall 5-year survival rate of less than 4%.Surgical resection remains the...Pancreatic adenocarcinoma remains the fourth leading cause of cancer-related death and is one of the most aggressive malignant tumors with an overall 5-year survival rate of less than 4%.Surgical resection remains the only potentially curative treatment but is only possible for 15%-20% of patients with pancreatic adenocarcinoma.About 40% of patients have locally advanced nonresectable disease.In the past,determination of pancreatic cancer resectability was made at surgical exploration.The development of modern imaging techniques has allowed preoperative staging of patients.Institutions disagree about the criteria used to classify patients.Vascular invasion in pancreatic cancers plays a very important role in determining treatment and prognosis.There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer and a unified definition ofborderline resectable pancreatic cancer is also lacking.Thus,there is much room for improvement in all aspects of treatment for pancreatic cancer.Multi-detector computed tomography has been widely accepted as the imaging technique of choice for diagnosing and staging pancreatic cancer.With improved surgical techniques and advanced perioperative management,vascular resection and reconstruction are performed more frequently;patients thought once to be unresectable are undergoing radical surgery.However,when attempting heroic surgery,a realistic approach concerning the patient's age and health status,probability of recovery after surgery,perioperative morbidity and mortality and life quality after tumor resection is necessary.展开更多
Laparoscopy-related tumor implantations of gynecological malignancies into the subcutaneous tissue are rarely diagnosed.We report an interesting case of a 46-year-old female who presented with an abdominal subcutaneou...Laparoscopy-related tumor implantations of gynecological malignancies into the subcutaneous tissue are rarely diagnosed.We report an interesting case of a 46-year-old female who presented with an abdominal subcutaneous metastasis of a borderline ovarian tumor.The patient received a laparoscopic unilateral adnexectomy for a solid-cystic tumor of the right ovary.Histopathological workup showed a papillary borderline tumor of mucinous type.Nine days later she underwent a hysterectomy,left adnexectomy,appendectomy and omentectomy.Exploration of the peritoneum revealed no intraperitoneal implants.Further exploration showed a non-invasive implant of a borderline tumor in the subcutaneous tissue above the fascia that had no contact to the peritoneum.It is hypothesized that tumor cells may have been implanted during a previous laparoscopy,the most recent of which had been fourteen years prior to her current presentation.Various risk factors for port-site malignancies have been identified.Tumor manipulation and extraction of tumor tissue without a protective bag may contribute to development of trocarsite metastasis.展开更多
Background:Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy(NAT).The aim of this study was to determine the inciden...Background:Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy(NAT).The aim of this study was to determine the incidence of significant pathologic response to NAT in borderline resectable pancreatic cancer(BRPC),and association of NAT regimen and other clinico-pathologic characteristics with pathologic response.Methods:Patients with BRPC who underwent NAT and pancreatic resection between January 2012 and June 2017 were included.Pathologic response was assessed on a qualitative scale based on the College of American Pathologists grading system.Demographics and baseline characteristics,oncologic treatment,pathology,and survival outcomes were compared.Results:Seventy-one patients were included for analysis.Four patients had complete pathologic responses(tumor regression score 0),12 patients had marked responses(score 1),42 had moderate responses(score 2),and 13 had minimal responses(score 3).Patients with complete or marked responses were more likely to have received neoadjuvant gemcitabine chemoradiation(62.5%,38.1%,and 23.1%of the complete/marked,moderate,and minimal response groups,respectively;P=0.04).Of the complete/marked,moderate,and minimal response groups,margins were negative in 75.0%,78.6%,and 46.2%(P=0.16);node negative disease was observed in 87.5%,54.8%,and 15.4%(P<0.01);and median overall survival was 50.0 months,31.7 months,and 23.2 months(P=0.563).Of the four patients with pathologic complete responses,three were disease-free at 66.1,41.7 and 31.4 months,and one was deceased with metastatic liver disease at 16.9 months.Conclusions:A more pronounced pathologic tumor response to NAT in BRPC is correlated with node negative disease,but was not associated with a statistically significant survival benefit in this study.展开更多
Pancreatic carcinoma(PC)is one of the leading causes of cancer-related deaths worldwide.Despite early detection and advances in therapeutics,the prognosis remains dismal.The outcome and therapeutic approach are depend...Pancreatic carcinoma(PC)is one of the leading causes of cancer-related deaths worldwide.Despite early detection and advances in therapeutics,the prognosis remains dismal.The outcome and therapeutic approach are dependent on the stage of PC at the time of diagnosis.The standard of care is surgery,followed by adjuvant chemotherapy.The advent of newer drugs has changed the landscape of adjuvant therapy.Moreover,recent trials have highlighted the role of neoadjuvant therapy and chemoradiotherapy for resectable and borderline resectable PC.As we progress towards a better understanding of tumor biology,genetics,and microenvironment,novel therapeutic strategies and targeted agents are now on the horizon.We have described the current and emerging therapeutic strategies in PC.展开更多
The use of neoadjuvant therapies has played a major role for borderline resectable and locally advanced pancreatic cancers(PCs). For this group of patients, preoperative chemotherapy or chemoradiation has increased th...The use of neoadjuvant therapies has played a major role for borderline resectable and locally advanced pancreatic cancers(PCs). For this group of patients, preoperative chemotherapy or chemoradiation has increased the likelihood of surgery with negative resection margins and overall survival. On the other hand, for patients with resectable PC, the main rationale for neoadjuvant therapy is that the overall survival with current strategies is unsatisfactory. There is a consensus that we need new treatments to improve the overall survival and quality of life of patients with PC. However, without strong scientific evidence supporting the theoretical advantages of neoadjuvant therapies, these potential benefits might turn out not to be worth the risk of tumors progression while waiting for surgery. The focus of this paper is to provide the readers an overview of the most recent evidence on this subject.展开更多
AIM To evaluate the usefulness of frozen section diagnosis(FSD) of bile duct margins during surgery for extrahepatic cholangiocarcinoma(CCA). METHODS We retrospectively analyzed 74 consecutive patients who underwent s...AIM To evaluate the usefulness of frozen section diagnosis(FSD) of bile duct margins during surgery for extrahepatic cholangiocarcinoma(CCA). METHODS We retrospectively analyzed 74 consecutive patients who underwent surgery for extrahepatic CCA from 2012 to 2017, during which FSD of bile duct margins was performed. They consisted of 40 distant and 34 perihilar CCAs(45 and 55 bile duct margins, respectively). The diagnosis was classified into three categories: negative, borderline(biliary intraepithelial neoplasia-1 and 2, and indefinite for neoplasia), or positive. FSD in the epithelial layer, subepithelial layer, and total layer was compared with corresponding permanent section diagnosis(PSD) postoperatively.Then, association between FSD and local recurrence was analyzed with special reference to borderline.RESULTS Analysis of 100 duct margins revealed that concordance rate between FSD and PSD was 68.0% in the total layer, 69.0% in the epithelial layer, and 98.0% in the subepithelial layer. The extent of remaining biliary epithelium was comparable between FSD and PSD, and more than half of the margins lost > 50% of the entire epithelium, suggesting low quality of the samples. In FSD, the rate of negative margins decreased and that of borderline and positive margins increased according to the extent of the remaining epithelium. Diagnostic discordance between FSD and PSD was observed in 31 epithelial layers and two subepithelial layers. Alteration from borderline to negative was the most frequent(20 of the 31 epithelial layers). Patients with positive margin in the total and epithelial layers by FSD demonstrated a significantly worse local recurrence-free survival(RFS) compared with patients with borderline and negative margins, which revealed comparable local RFS. Patients with borderline and negative margins in the epithelial layer by PSD also revealed comparable local RFS. These results suggested that epithelial borderline might be regarded substantially as negative. When classifying the status of the epithelial layer either as negative or positive, concordance rates between FSD and PSD in the total, epithelial, and subepithelial layers were 95.0%, 93.0%, and 98.0%, respectively.CONCLUSION During intraoperative assessment of bile duct margin, borderline in the epithelial layer can be substantially regarded as negative, under which condition FSD is comparable to PSD.展开更多
Borderline resectable pancreatic cancer(BRPC)is a complex clinical entity with specific biological features.Criteria for resectability need to be assessed in combination with tumor anatomy and oncology.Neoadjuvant the...Borderline resectable pancreatic cancer(BRPC)is a complex clinical entity with specific biological features.Criteria for resectability need to be assessed in combination with tumor anatomy and oncology.Neoadjuvant therapy(NAT)for BRPC patients is associated with additional survival benefits.Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT.More attention to management standards during NAT,including biliary drainage and nutritional support,is needed.Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period,including NAT responsiveness and the selection of surgical timing.展开更多
文摘The paper focuses on Toni Morrison＇s latest novel God Help the Child （2015）. By presenting a skillful though somewhat perverse merger of binary oppositions at different levels （racial, social, moral, and psychological）, the writer makes borderlines of all sorts appear artificial and therefore invalidates them. Thus, childhood merges with adulthood through sexual traumas that live on; touch with no touch as the evil touch of a parent equals an abhorrence of touching the child Other; truth with a lie as it proves as destructive as lying in good faith; passing blackness with blue blackness as the former conceives the latter; and appearances with reality in the ironic title of the book, where it is both the mother and the child that in fact need God＇s help. Thus, as Toni Morrison demonstrates, a thoroughly surreptitious, because natural, process of dissolution of all barriers makes them appear to be arbitrary constructs responsible for the equally arbitrary notion of the Other. Taking an utterly holistic view of the nature of things, Morrison seems to suggest that borderlines are a consequence and a manifestation of a lack of balance, which therefore needs to be redressed through love, mutual understanding, and maturation.
文摘This case study describes the care provided to a female patient with borderline personality disorder (BPD) who presented to the emergency department (ED). While people with borderline personality disorder use emergency services frequently, clinicians often face difficulties when providing medical and behavioral services to these patients. It may be difficult for nurse practitioners to determine if a patient with BPD who presents to the ED in crisis should be admitted, medicated, observed, or discharged. Self-harm is frequently confused with suicide attempts, which can result in unnecessary hospitalizations. This case study seeks to examine the proper management and difficulties encountered by healthcare providers in managing crises involving individuals with BPD in ED settings. The case study underscores the significance of thorough evaluation, recognition of BPD characteristics, active engagement in treatment, the therapeutic alliance, and the emphasis on interpersonal connections and stressors alongside the utilization of psychopharmacology.
文摘Since its inception,localized pancreatic cancer has been identified as a systemic illness.Hence,to increase its survival rates,surgical resection followed by ad-juvant chemotherapy is used as a treatment option.A significant barrier,though,is the high morbidity and drawn-out recovery after extensive surgical resection,which may postpone or prohibit the prompt administration of adjuvant therapy.Thereby,acknowledging the efficacy of neoadjuvant therapy in various digestive tract malignancies like rectal,gastric,and oesophagal cancers in en-hancing long-term survival and the likelihood of successful resection,researchers have turned their attention to exploring its potential benefits in the context of both resectable and borderline resectable pancreatic cancer(RPC).According to recent data,neoadjuvant chemoradiation has major advantages for both resectable and borderline RPC.These advantages include increased surgical resection rates,longer survival times,decreased recurrence rates,and better overall disease control with a manageable toxicity profile.Despite its benefits,research is still being done to determine the best way to sequence and combine chemotherapy and radiation.Furthermore,studies have demonstrated the potential for cus-tomized therapy regimens based on the patient’s general health status and the tumor’s biological behavior to maximize the neoadjuvant approach.As progress continues,neoadjuvant chemoradiation is set to become a key component of treatment for both resectable and borderline RPC,providing a more efficient way to manage this deadly condition.While further development is required to fully grasp its potential in enhancing long-term patient outcomes,evidence supports its increasing usage in clinical practice.
文摘BACKGROUND Fibroadenomas(FA)and phyllodes tumors(PT)are fibroepithelial neoplasms and are difficult to differentiate radiographically and histologically.We present a partially infarcted borderline PT in an adolescent with rapid tumor enlargement within 24 hours.Tumor infarction made the diagnostic work-up difficult.Com-plete surgical excision is the standard of care for PTs.There is controversy regar-ding margin re-excision for borderline PTs.In this report,we discuss the diagno-stic challenges of PT and the evolving concept of margin status on PT recurrence rate.CASE SUMMARY A 14-year-old healthy female with no medical history presented with a painful right breast mass with no nipple discharge,trauma,or skin findings.The mass showed rapid enlargement over 24 hours,prompting a workup with ultrasound and core needle biopsy.The initial biopsy was limited due to large areas of in-farction.Based on the scant viable tissue and considering the patient’s age,the mass was favored to be a juvenile FA.The patient underwent excision of the mass.Final pathology confirmed a borderline PT with positive surgical margins.The patient underwent margin re-excision,which did not show any residual tumor.At the 6-month post-op visit,there was a mass-forming lesion on the breast ultrasound.Subsequent core needle biopsy showed benign breast parenchyma with scar formation.The primary goal of evaluation in pediatric breast masses is to do no harm.However,rapidly growing and symptomatic masses require a more extensive work-up including biopsy and surgical excision.We present a rapidly growing breast mass in a 14-year-old female which was diagnosed as a borderline PT on her excision specimen.The mass rapidly enlarged over 24 hours.The initial biopsy pathology was limited due to a large area of infarction.The patient underwent excision of the mass.Final pathology confirmed a borderline PT that extended into the surgical margin,resulting in an additional re-excision procedure.Accurate diagnosis prior to surgical intervention is crucial to avoid additional procedures.Although histological morphology remains the gold standard for diagnosis,immunohistochemistry and molecular studies have recently shown to improve the accuracy of diagnosis of PTs.Long-term clinical and pathologic follow-up of PTs in adolescent patients should be collectively studied to examine whether our current diagnostic criteria for PT can reliably predict tumor behavior in this age group.CONCLUSION Accurate diagnosis of PTs requires surgical excision.Tumor infarction may lead to rapid tumor enlargement,hindering the correct diagnosis.More research is needed on margin status and recurrence rate,especially in adolescent patients,to help establish the best possible care for this age group.
文摘Pancreatic cancer is the fourth leading cause of cancer death in the United States. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease. Unfortunately, even among those who undergo resection, the reported median survival is 15-23 mo, with a 5-year survival of approximately 20%. Disappointingly, over the past several decades, despite improvements in diagnostic imaging, surgical technique and chemotherapeutic options, only modest improvements in survival have been realized. Nevertheless, it remains clear that surgical resection is a prerequisite for achieving longterm survival and cure. There is now emerging consensus that a subgroup of patients, previously considered poor candidates for resection because of the relationship of their primary tumor to surrounding vasculature, may benefit from resection, particularly when preceded by neoadjuvant therapy. This stage of disease, termed borderline resectable pancreatic cancer, has become of increasing interest and is now the focus of a multiinstitutional clinical trial. Here we outline the history, progress, current treatment recommendations, and future directions for research in borderline resectable pancreatic cancer.
文摘Pancreatic ductal adenocarcinoma(PDAC) is one of the most aggressive human neoplastic entities,with a very poor prognosis characterized by a high mortality rate and short survival.This is due both to its aggressive biological behaviour and the high incidence of locally advanced stages at the time of the initial diagnosis.The limits of resectability and the role of neoadjuvant(radio) chemotherapy for PDAC management are still unclear.A recently published article by Kats et al compared the radiological,surgical and histopathological results of 129 patients with borderline resectable tumors undergoing neoadjuvant treatment followed by surgery.Although post-neoadjuvant treatment imaging implied a low response rate,a high rate of complete resections was achieved.This seems to confirm that,though radiology has made a significant progress in defining locally advanced PDAC,there is place for further improvement.In particular,the differentiation between radiotherapy-induced scarring/fibrosis and cancer-associated desmoplasia remains a clinical/radiological challenge.Though selection of patients with occult systemic disease is possible with neoadjuvant treatment,downstaging does not seem to occur frequently.Thus,development of novel,more aggressive(radio) chemotherapy regimens is required to improve prognosis of patients with locally unresectable but not systemically micro-metastasized tumors.
文摘BACKGROUND: Pancreatic cancer remains a devastating disease with a 5-year survival rate of less than 5%. Recent advances in diagnostic methods and therapeutic approaches have increased the possibility of improving the existing poor prognosis. DATA SOURCES: English-language articles reporting early diagnosis and therapy of pancreatic cancer were searched from the MEDLINE and PubMed databases, Chinese-language articles were from CHKD (China Hospital Knowledge Database) RESULT: The current literature about pancreatic cancer was reviewed from three aspects: statistics, screening and early detection, and therapy. CONCLUSIONS: Early detection and screening of pancreatic cancer currently should be limited to high risk patients Surgical resection is the only curative approach available, with some recent improvement in outcomes. Gemcitabine has been a standard treatment during the last decade. Gemcitabine based combination treatment, especially combined with newer molecular targeted agents, is promising. The rationale for radiotherapy is controversial, but with the recent development of modern radiation delivery techniques, radiotherapy should be intensified. Patients with borderline pancreatic cancer could benefit from neoadjuvant therapy but more evidence is needed and the best neoadjuvant regimen is still to be determined.
基金supported by grants from The National Natural Science Foundation of China(81071775,81272659,81101621,81172064,81001068 and 81272425)Key Projects of Science Foundation of Hubei Province(2011CDA030)Research Fund of Young Scholars for the Doctoral Program of Higher Education of China(20110142120014)
文摘BACKGROUND： The treatment of borderline resectable pancreatic head cancer（BRPHC） is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach（MAFA）, with conventional techniques for the surgical treatment of BRPHC.METHODS： A total of 117 patients with BRPHC undergone pancreaticoduodenectomy（PD） from January 2013 to June 2015 were included. They were divided into an MAFA group（n=78） and a conventional-technique group（n=39）. Background characteristics, operative data and complications were compared between the two groups.RESULTS： Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group（313 vs 384 min; P=0.014）; mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group（534 vs 756 m L; P=0.043）; and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group（61.5% vs 35.9%; P=0.014）. Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS： MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.
文摘Pseudomyxoma peritonei (PMP) is an uncommon "bor-derline malignancy" generally arising from a perforated appendiceal epithelial tumour. Optimal treatment involves a combination of cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC). Controversy persists regarding the pathological classification and its prognostic value. Computed tomography scanning is the optimal preoperative staging technique. Tumour marker elevations correlate with worse prognosis and increased recurrence rates. Following CRS with HIPEC, 5-year survival ranges from 62.5% to 100% for low grade, and 0%-65% for high grade disease. Treat-ment related morbidity and mortality ranges from 12 to 67.6%, and 0 to 9%, respectively. Surgery and HIPEC are the optimal treatment for PMP which is at best a "borderline" peritoneal malignancy.
文摘Pancreatic adenocarcinoma remains the fourth leading cause of cancer-related death and is one of the most aggressive malignant tumors with an overall 5-year survival rate of less than 4%.Surgical resection remains the only potentially curative treatment but is only possible for 15%-20% of patients with pancreatic adenocarcinoma.About 40% of patients have locally advanced nonresectable disease.In the past,determination of pancreatic cancer resectability was made at surgical exploration.The development of modern imaging techniques has allowed preoperative staging of patients.Institutions disagree about the criteria used to classify patients.Vascular invasion in pancreatic cancers plays a very important role in determining treatment and prognosis.There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer and a unified definition ofborderline resectable pancreatic cancer is also lacking.Thus,there is much room for improvement in all aspects of treatment for pancreatic cancer.Multi-detector computed tomography has been widely accepted as the imaging technique of choice for diagnosing and staging pancreatic cancer.With improved surgical techniques and advanced perioperative management,vascular resection and reconstruction are performed more frequently;patients thought once to be unresectable are undergoing radical surgery.However,when attempting heroic surgery,a realistic approach concerning the patient's age and health status,probability of recovery after surgery,perioperative morbidity and mortality and life quality after tumor resection is necessary.
文摘Laparoscopy-related tumor implantations of gynecological malignancies into the subcutaneous tissue are rarely diagnosed.We report an interesting case of a 46-year-old female who presented with an abdominal subcutaneous metastasis of a borderline ovarian tumor.The patient received a laparoscopic unilateral adnexectomy for a solid-cystic tumor of the right ovary.Histopathological workup showed a papillary borderline tumor of mucinous type.Nine days later she underwent a hysterectomy,left adnexectomy,appendectomy and omentectomy.Exploration of the peritoneum revealed no intraperitoneal implants.Further exploration showed a non-invasive implant of a borderline tumor in the subcutaneous tissue above the fascia that had no contact to the peritoneum.It is hypothesized that tumor cells may have been implanted during a previous laparoscopy,the most recent of which had been fourteen years prior to her current presentation.Various risk factors for port-site malignancies have been identified.Tumor manipulation and extraction of tumor tissue without a protective bag may contribute to development of trocarsite metastasis.
文摘Background:Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy(NAT).The aim of this study was to determine the incidence of significant pathologic response to NAT in borderline resectable pancreatic cancer(BRPC),and association of NAT regimen and other clinico-pathologic characteristics with pathologic response.Methods:Patients with BRPC who underwent NAT and pancreatic resection between January 2012 and June 2017 were included.Pathologic response was assessed on a qualitative scale based on the College of American Pathologists grading system.Demographics and baseline characteristics,oncologic treatment,pathology,and survival outcomes were compared.Results:Seventy-one patients were included for analysis.Four patients had complete pathologic responses(tumor regression score 0),12 patients had marked responses(score 1),42 had moderate responses(score 2),and 13 had minimal responses(score 3).Patients with complete or marked responses were more likely to have received neoadjuvant gemcitabine chemoradiation(62.5%,38.1%,and 23.1%of the complete/marked,moderate,and minimal response groups,respectively;P=0.04).Of the complete/marked,moderate,and minimal response groups,margins were negative in 75.0%,78.6%,and 46.2%(P=0.16);node negative disease was observed in 87.5%,54.8%,and 15.4%(P<0.01);and median overall survival was 50.0 months,31.7 months,and 23.2 months(P=0.563).Of the four patients with pathologic complete responses,three were disease-free at 66.1,41.7 and 31.4 months,and one was deceased with metastatic liver disease at 16.9 months.Conclusions:A more pronounced pathologic tumor response to NAT in BRPC is correlated with node negative disease,but was not associated with a statistically significant survival benefit in this study.
文摘Pancreatic carcinoma(PC)is one of the leading causes of cancer-related deaths worldwide.Despite early detection and advances in therapeutics,the prognosis remains dismal.The outcome and therapeutic approach are dependent on the stage of PC at the time of diagnosis.The standard of care is surgery,followed by adjuvant chemotherapy.The advent of newer drugs has changed the landscape of adjuvant therapy.Moreover,recent trials have highlighted the role of neoadjuvant therapy and chemoradiotherapy for resectable and borderline resectable PC.As we progress towards a better understanding of tumor biology,genetics,and microenvironment,novel therapeutic strategies and targeted agents are now on the horizon.We have described the current and emerging therapeutic strategies in PC.
基金Stefanie Condon-Oldreive founder and director of Craig’s Cause Pancreatic Cancer Society (www.craigscause.ca) for the research scholarship that supported Dr. Sheikh Hasibur Raman while working on this project
文摘The use of neoadjuvant therapies has played a major role for borderline resectable and locally advanced pancreatic cancers(PCs). For this group of patients, preoperative chemotherapy or chemoradiation has increased the likelihood of surgery with negative resection margins and overall survival. On the other hand, for patients with resectable PC, the main rationale for neoadjuvant therapy is that the overall survival with current strategies is unsatisfactory. There is a consensus that we need new treatments to improve the overall survival and quality of life of patients with PC. However, without strong scientific evidence supporting the theoretical advantages of neoadjuvant therapies, these potential benefits might turn out not to be worth the risk of tumors progression while waiting for surgery. The focus of this paper is to provide the readers an overview of the most recent evidence on this subject.
基金JSPS KAKENHI(No.JP16K08695)from the Ministry of Education,Culture,Sports,Science and Technology of Japan
文摘AIM To evaluate the usefulness of frozen section diagnosis(FSD) of bile duct margins during surgery for extrahepatic cholangiocarcinoma(CCA). METHODS We retrospectively analyzed 74 consecutive patients who underwent surgery for extrahepatic CCA from 2012 to 2017, during which FSD of bile duct margins was performed. They consisted of 40 distant and 34 perihilar CCAs(45 and 55 bile duct margins, respectively). The diagnosis was classified into three categories: negative, borderline(biliary intraepithelial neoplasia-1 and 2, and indefinite for neoplasia), or positive. FSD in the epithelial layer, subepithelial layer, and total layer was compared with corresponding permanent section diagnosis(PSD) postoperatively.Then, association between FSD and local recurrence was analyzed with special reference to borderline.RESULTS Analysis of 100 duct margins revealed that concordance rate between FSD and PSD was 68.0% in the total layer, 69.0% in the epithelial layer, and 98.0% in the subepithelial layer. The extent of remaining biliary epithelium was comparable between FSD and PSD, and more than half of the margins lost > 50% of the entire epithelium, suggesting low quality of the samples. In FSD, the rate of negative margins decreased and that of borderline and positive margins increased according to the extent of the remaining epithelium. Diagnostic discordance between FSD and PSD was observed in 31 epithelial layers and two subepithelial layers. Alteration from borderline to negative was the most frequent(20 of the 31 epithelial layers). Patients with positive margin in the total and epithelial layers by FSD demonstrated a significantly worse local recurrence-free survival(RFS) compared with patients with borderline and negative margins, which revealed comparable local RFS. Patients with borderline and negative margins in the epithelial layer by PSD also revealed comparable local RFS. These results suggested that epithelial borderline might be regarded substantially as negative. When classifying the status of the epithelial layer either as negative or positive, concordance rates between FSD and PSD in the total, epithelial, and subepithelial layers were 95.0%, 93.0%, and 98.0%, respectively.CONCLUSION During intraoperative assessment of bile duct margin, borderline in the epithelial layer can be substantially regarded as negative, under which condition FSD is comparable to PSD.
文摘Borderline resectable pancreatic cancer(BRPC)is a complex clinical entity with specific biological features.Criteria for resectability need to be assessed in combination with tumor anatomy and oncology.Neoadjuvant therapy(NAT)for BRPC patients is associated with additional survival benefits.Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT.More attention to management standards during NAT,including biliary drainage and nutritional support,is needed.Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period,including NAT responsiveness and the selection of surgical timing.
