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Non-ampullary-duodenal carcinomas: clinicopathologic analysis of 47 cases and comparison with ampullary and pancreatic adenocarcinomas.

十二指肠非壶腹癌:47例临床病理分析以及与壶腹和胰腺腺癌的比较

Xue Y,Vanoli A,Balci S,Reid MM,Saka B,Bagci P,Memis B,Choi H,Ohike N,Tajiri T,Muraki T,Quigley B,El-Rayes BF,Shaib W,Kooby D,Sarmiento J,Maithel SK,Knight JH,Goodman M,Krasinskas AM,Adsay V
阅读:1109 Modern PathologyFeb 2017; 30 (2): 158 - 313:255-266 

Abstract

Literature on non-ampullary-duodenal carcinomas is limited. We analyzed 47 resected non-ampullary-duodenal carcinomas. Histologically, 78% were tubular-type adenocarcinomas mostly gastro-pancreatobiliary type and only 19% pure intestinal. Immunohistochemistry (n=38) revealed commonness of 'gastro-pancreatobiliary markers' (CK7 55, MUC1 50, MUC5AC 50, and MUC6 34%), whereas 'intestinal markers' were relatively less common (MUC2 36, CK20 42, and CDX2 44%). Squamous and mucinous differentiation were rare (in five each); previously, unrecognized adenocarcinoma patterns were noted (three microcystic/vacuolated, two cribriform, one of comedo-like, oncocytic papillary, and goblet-cell-carcinoid-like). An adenoma component common in ampullary-duodenal cancers was noted in only about a third. Most had plaque-like or ulcerating growth. Mismatch repair protein alterations were detected in 13% (all with plaque-like growth and pushing-border infiltration). When compared with ampullary (n=355) and pancreatic ductal (n=227) carcinomas, non-ampullary-duodenal carcinomas had intermediary pathologic features with mean invasive size of 2.9 cm (vs 1.9, and 3.3) and 59% nodal metastasis (vs 45, and 77%). Its survival (3-, 5-year rates of 57 and 57%) was similar to that of ampullary-duodenal carcinomas (59 and 52%; P=0.78), but was significantly better than the ampullary ductal (41 and 29%, P<0.001) and pancreatic (28 and 18%, P<0.001) carcinomas. In conclusion, non-ampullary-duodenal carcinomas are more histologically heterogeneous than previously appreciated. Their morphologic versatility (commonly showing gastro-pancreatobiliary lineage and hitherto unrecognized patterns), frequent plaque-like growth minus an adenoma component, and frequent expression of gastro-pancreatobiliary markers suggest that many non-ampullary-duodenal carcinomas may arise from Brunner glands or gastric metaplasia or heterotopic pancreatobiliary epithelium. The clinical behavior of non-ampullary-duodenal carcinoma is closer to that of ampullary-duodenal subset of ampullary carcinomas, but is significantly better than that of ampullary ductal and pancreatic cancers. The frequency of mismatch repair protein alterations suggest that routine testing should be considered, especially in the non-ampullary-duodenal carcinomas with plaque-like growth and pushing-border infiltration.

摘要

关于十二指肠非壶腹部癌的文献很少。我们分析了47例切除的十二指肠非壶腹部癌。就组织学而言,78%是管状型腺癌,大部分是胃肠胰胆管型,只有19%是单纯的肠型。免疫组化(n=38)显示“胃肠胰胆管标记物”(CK7为55%,MUC1为50%, MUC5AC为50,MUC6为34%)常见,而“肠标记物”相对少见(MUC2为36%,CK20为42,CDX2为44%)。鳞状上皮化生和粘液化生罕见(每个5例)。以前不能被识别的腺癌类型也被标记出来(3例微囊型/泡状型,2例筛状形,1例粉刺样/嗜酸性乳头以及杯状细胞类癌样型)。在十二指肠壶腹部癌常见的腺瘤成分仅出现在1/3的病例中。大多数呈斑块样或溃疡型生长。13%的病例中检测到错配修复蛋白(全部呈斑块样及推挤样生长方式)。和壶腹部癌(n=355)以及胰腺导管癌(n=227)相比,十二指肠非壶腹部癌病理特征介于两者之间:平均大小2.9cm(前两者1.9cm,3.3cm);59%发现淋巴结转移(前两者为45%和77%);3年和5年生存率均为57%,和十二指肠壶腹部癌类似(59%和52%;P=0.78),但是远好于十二指肠壶腹部导管癌(41%和29%;P<0.001)和胰腺癌(28%和18%;P<0.001)。

总之,十二指肠非壶腹部癌的组织形态比以前认为的更具有异质性。它们形态的多样性(大部分呈胃肠胰导管型和迄今尚不能识别的类型),多见斑块样生长(除去一种腺瘤成分),多表达胃肠胰导管标记物(这表明许多十二指肠非壶腹部癌可能起源于Brunner腺或胃肠道腺体化生或异位的胰导管上皮)。十二指肠非壶腹部癌的临床行为更接近十二指肠壶腹部癌,但是预后明显比十二指肠导管癌和胰腺癌好。由于错配修复蛋白改变的频率很高,这提示应该考虑把它作为常规检测,特别是在十二指肠非壶腹部癌呈斑块样和推挤样生长方式的时候。



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