Pancreatic cystadenocarcinoma

Introduction to pancreatic cystadenocarcinoma Pancreatic cystatic adenocarcinoma (Pancreatic cystadenocarcinoma) is also a proliferative cyst of the pancreas, which can be malignant from pancreatic cystadenoma. The disease is very rare in the clinic, accounting for only 1% of pancreatic malignancies. The earliest literature reports on pancreatic cystadenocarcinoma were reported in the 1911 Kaufman and 1834 Lichenstem in the German and American journals. In 1963, Cullen found a total of 17 cases of pancreatic cystadenocarcinoma with complete data and can be diagnosed in the hospitalized medical records of Mayo Hospital. As of 1984, Segessen reported pancreatic cystadenocarcinoma reported in medical literature around the world. In just over 100 cases, China is a scattered case or a small number of case reports. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: non-infectious Complications: abdominal pain, indigestion

The cause of pancreatic cystadenocarcinoma

The etiology of pancreatic cystadenocarcinoma is unclear. A number of recent studies have shown that the occurrence of pancreatic cystadenocarcinoma may be related to the following factors.

Smoking (30%):

A large number of studies support a close relationship between pancreatic cystadenocarcinoma and smoking, and the possible mechanisms by which smoking causes pancreatic cystadenocarcinoma:

1 smoking promotes the secretion of tobacco-specific N-nitrite to the bile duct, and then reverses into the pancreatic duct; 2 the specific effect of tobacco-specific N-nitrite on organs can flow into the pancreas with blood; 3 smoking increases blood lipid levels To promote pancreatic cancer, smokers may be carcinogenic due to low levels of cellular methylation. Stolzenberg et al. demonstrated that maintaining adequate concentrations of folic acid and pyridoxal reduces the risk of smoking-related pancreatic cystadenocarcinoma.

Chronic pancreatitis (18%):

Epidemiological and molecular epidemiological studies mostly support the development of chronic pancreatitis as pancreatic cystadenocarcinoma. The Friess study at the molecular level demonstrates that there may be some association between chronic pancreatitis and pancreatic cystadenocarcinoma.

Drug factors (15%):

Studies have shown that women taking aspirin have a lower incidence of pancreatic cystadenocarcinoma, but studies have shown that routine use of aspirin does not reduce the incidence of pancreatic cystadenocarcinoma, and the risk of pancreatic cystadenocarcinoma may increase.

Drinking alcohol (15%):

The incidence of pancreatic cystadenocarcinoma varies after drinking from different races.

Diabetes (8%):

Experimental studies have shown that insulin can promote the growth of pancreatic cystadenocarcinoma cells in vitro or in vivo.

Helicobacter pylori (Hp) (5%):

Studies have shown that patients with pancreatic cystadenocarcinoma have Hp seropositive results, which are significantly different from the control group, suggesting that Hp infection is associated with pancreatic cystadenocarcinoma.

The coffee survey found that coffee can increase the risk of pancreatic cystadenocarcinoma by a factor of four. Studies have shown that coffee can inhibit DNA repair and induce mitosis before DNA replication is complete, which is the main cause of cancer.

Pancreatic cystadenocarcinoma prevention

It is necessary to prevent the occurrence of pancreatic cystadenocarcinoma or reduce the incidence of pancreatic cystadenocarcinoma for the prevention of cause, smoking cessation and alcohol control, less coffee, and eating more fresh vegetables and fruits.

Pancreatic cystadenocarcinoma Complications, abdominal pain, indigestion

Concurrent abdominal pain, indigestion and other diseases.

Pancreatic cystadenocarcinoma Common symptoms Low back pain, abdominal pain, back pain, nausea, dyspepsia, loss of appetite, abdominal mass, jaundice, internal hemorrhage

The main symptoms of pancreatic cystadenocarcinoma are upper, middle and lower abdominal pain or low back pain, and upper abdominal mass, abdominal pain is not severe, some patients only have full discomfort; other symptoms may have loss of appetite, nausea, indigestion, Weight loss, jaundice, etc., a small number of patients may have gastrointestinal bleeding; some patients usually do not have any complaints, only found in the laparotomy or autopsy.

The abdominal mass is like its size. The small one can just touch the upper abdomen. The larger one can fill the entire abdominal cavity and even extend into the pelvic cavity. The abdominal mass is generally not tender. It can be sexy or hard and sexy. The block can suddenly increase, the abdominal pain is intensified, and the tenderness is obvious. Six cases of pancreatic cystic tumors were reported in the country, and all of them were treated with upper abdominal mass and abdominal pain or low back pain. Three of them had unbearable low back pain. For cystic adenocarcinoma, obstructive jaundice may occur when the tumor infiltrates or compresses the common bile duct.

Because of the lack of specificity in the symptoms and signs of pancreatic cystadenocarcinoma, especially in the small stage of the mass, it often causes difficulties in clinical diagnosis, which makes many patients have symptoms for several months or years at the time of treatment, even for up to 15 years. Becker et al reported that the symptoms occurred between 7 months and 11 years before the final diagnosis of pancreatic cystadenocarcinoma, with an average of 22 months.

Examination of pancreatic cystadenocarcinoma

1. Laboratory tests:

If the patient's urine sugar and blood sugar increase, glucose tolerance decreased, which helps to establish the value of pancreatic lesions. Among the 62 patients with pancreatic cystadenocarcinoma reported by Strodel, 11% were associated with diabetes.

2. X-ray inspection:

In the abdominal plain film, the calcification of the cyst wall is seen, and its shape is round or crescent. Warshaw reported 67 patients with pancreatic cyst. Among them, 7 patients with calcification were pancreatic cystadenocarcinoma, and pancreatic pseudocyst, retention. Patients with cysts and cystadenomas have no calcifications.

Upper digestive tract barium meal examination, generally no specific diagnostic value, but if there is a duodenal ring enlargement, the stomach or transverse colon is displaced, can help to guess the location and size of the mass.

Intravenous pyelography has no specific diagnostic value. The location, size and growth direction of the mass can be understood by the direction and compression of the left kidney.

3. B-type ultrasound examination:

It can show the location, size and relationship between the tumor and its surrounding organs, and help to define the structure and morphology of the cyst, solidity, size and size of the cyst, cyst contents, cyst wall and its interval. The characteristics provide an important basis for diagnosis and differential diagnosis.

4. Abdominal CT:

It can clearly show the location of the abdominal mass, the relationship between the size and the surrounding organs; CT can show that the cyst is isolated or multi-atrial, the latter is often a reliable sign of pancreatic cystadenoma or cystadenocarcinoma; CT can also indicate whether there is liver or abdominal lymph node metastasis in the cancer, and if there is metastatic disease, it supports the diagnosis of pancreatic cystadenocarcinoma.

5. Selective celiac artery or superior mesenteric artery angiography:

Can determine the shape, size and organs of the tumor, because pancreatic cystic carcinoma has a rich blood supply, can be distinguished from the bloodless pancreatic pseudocyst and the less abundant pancreatic cancer, pancreatic cystic adenocarcinoma The main signs of angiography are: 1 compression, displacement, distortion, stretch and irregularity around the large blood vessels in the lesion area, 2 blood supply is abundant, tumor area is congested, and the contrast agent is deposited in the capillaries, 3 The blood vessel is embedded in the tumor tissue and is affected by the invasiveness of the lesion, suggesting that the tumor is malignant, 4 arteriovenous shunt, 5 venous return obstruction, 6 lesions without blood vessels or hypovascularization, can not completely rule out the cyst gland Tumor, Warshaw et al. performed an angiographic examination of 11 patients with pancreatic cystic carcinoma. Only 2 patients had abundant blood supply, and only 10 patients with cystadenomas had only 4 patients with blood supply. Another 19 patients with cystic adenocarcinoma Arterial angiography is less blood supply.

6. Retrograde cholangiopancreatography (ERCP) examination:

In the diagnosis of difficulty, the application of ERCP examination can help to exclude chronic pancreatitis, pancreatic pseudocyst and intraductal carcinoma, but does not help the identification of cystadenocarcinoma and cystadenoma, about 70% of pancreatic pseudocysts The pancreatic duct is connected to the cyst; the pancreatic cancer can be characterized as pancreatic duct stenosis or obstruction. Warshaw et al reported that 50% of patients with pancreatic cystadenocarcinoma have normal pancreatic angiography, and 33% of patients have main pancreatic ducts that bend around the tumor. shape.

Mucinous ductal ectasia is a newly recognized sign of precancerous lesions. When papillary hyperplasia occurs on the pancreatic duct and a large amount of mucus is produced, obstruction can be induced by mucus filling the main pancreatic duct. Pancreatitis, this damage involves part or all of the pancreas, and the lesions may be aggravated to cause dilatation of the duct. In retrograde pancreatic duct intubation, mucus outflow can be seen at the opening of the pancreatic duct, while in the retrograde pancreatic duct These enlarged and expanded pancreatic ducts can be shown on the film.

7. Percutaneous pancreatic cyst fine needle puncture drainage test:

Fine needle aspiration through percutaneous pancreatic cysts, extraction of intracapsular fluid to determine amylase, carcinoembryonic antigen, CA19-9 and cytological examination, can help identify the nature of cysts, radiology, B-mode ultrasound and CT Guided, can also be used for intraoperative direct puncture, pancreatic pseudocyst and retention cysts, cystic fluid amylase content is extremely high, while cystic tumors do not increase amylase, and pancreatic mucinous cysts (cyst adenoma) Or cystic adenocarcinoma) The bladder carcinoembryonic antigen value is significantly higher than that of pseudocyst and serous cyst. Ferrer reported a case of pancreatic cystadenocarcinoma. The plasma carcinoembryonic antigen was 200 g/ml during laparotomy. The antigen is reduced to normal, and the carcinoembryonic antigen in the cyst fluid is 100,000 times higher than the normal plasma level. Since the carcinoembryonic antigen is derived from the columnar epithelium which secretes mucus, a large number of carcinoembryonic antigens can be produced regardless of the cystadenoma or cystadenocarcinoma. Therefore, it is not helpful for the identification of good and malignant.

Recently, Rubin reported that CA15-3 protein expression in cyst contents can be used to identify benign, malignant pancreatic mucinous cystic tumors. CA15-3 is a mucin of 400 KDa or more present in the milk fat globule membrane and including the pancreas. In multiple adenocarcinomas, the authors obtained the intracapsular fluid of pancreatic cysts by percutaneous puncture, and the concentration of CA15-3 was determined by monoclonal antibody 115-D8 and DF-3 radioimmunoassay. The normal value was 0-30 IU/ml; The cystic fluid CA15-3 value of pancreatic cystadenocarcinoma is 40-392 IU/ml; the mean value of 3 cases of mucinous cystadenoma is 4.7 IU/ml (0-14 IU/ml), and 5 cases of serous cystadenoma The mean value was 9.2 IU/ml (0-32 IU/ml), the mean value of 6 pseudocysts was 15.3 IU/ml (0-66 IU/ml), and the average value of CA15-3 in the latter 3 groups of benign cystic cysts was 10.6 IU/ml, which was significantly lower than the average value of CA15-3 in pancreatic sac cancer. The sensitivity of cystic fluid CA15-3 in differential diagnosis of benign and malignant cystic lesions of pancreas was 100%, and the specificity was also 100% (P<0.01). ).

Diagnosis and differentiation of pancreatic cystadenocarcinoma

1. Retention cyst: generally single-atrial, no capsule, its volume is generally small, and the cyst is sometimes large and small, the wall is covered by a single layer of cubic flat epithelium, often outside the cyst wall for chronic pancreatitis There are catheter obstruction, and often accompanied by pancreatic stone disease, etc., there are not many inflammatory exudative components in the cyst fluid, and pancreatic amylase is often strongly positive.

2. Cyst adenoma: fibrous tissue interval and capsule, glassy degeneration and calcium salt deposition, pancreatic tissue adjacent to the capsule shrinks due to compression; catheter and acinar can be expanded due to obstruction, the size of the capsule is larger Small, no inflammatory cell infiltration in the wall; cystic wall covered epithelium is a single layer of flat cells, cubic cells or high columnar cells; single layer of squamous epithelium should be differentiated from lymphangioma or capillary hemangioma, the former is silver staining Positive, and the latter two are positive for silver staining. The cystic adenoma of the columnar epithelium is more likely to be malignant, and the papillary cystadenoma can be regarded as a precancerous lesion. When the cystadenoma is malignant, there is obvious hyperplasia of the nipple. The cells showed obvious heteromorphism, which showed nuclear enlargement, deep nuclear staining, increased mitotic phase, pathological mitosis, common wall of glandular duct, back to back and other malignant features.

3. Pancreatic cancer: When the pancreatic cancer obstructs the pancreatic duct, the distal pancreatic duct can be expanded into a saclike shape, but the cyst is generally small, the cystic cavity communicates with the duct, and the capsule contains bloody liquid or clear thin liquid, and Contains trypsin.

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