Multidisciplinary approach and multimodal therapy in resected pancreatic cancer. Observational study.

OBJECTIVE: Analysis and evaluation of a multidisciplinary approach, postoperative results and survival of a group of patients with resected pancreatic cancer after a multimodal therapy. DESIGN: DESCRIPTIVE, prospective and observational study. PATIENTS: Between January 2004 and December 2004, 124 patients with pancreatic cancer were evaluated. In 30 patients pancreatic resection was performed, and they are the object of this study. Results of preoperative evaluation, postoperative morbidity and mortality, and long term survival were studied. RESULTS: Diagnostic evaluation was completed in ambulatory basis in 20% of the patients. In 63% of cases, admission was done in the same day of surgery. In 3 patients (9%), tumor resection was not achieved, therefore, concordance between radiological and surgical resectability rate was 91%. Resectability rate was 24.1%. Surgical Mortality was 3.3%, with a global morbidity rate of 56.6%. Survival at one, two, three and, four years was 76.2%, 56.3%, 43%, y 27.3% respectively. CONCLUSIONS: Technological development and coordination of efforts in multidisciplinary teams offer an accurate evaluation of tumor involvement, and may reduce the number of laparotomies without tumor resection. The application of a systematic and generalized multimodal treatment in pancreatic cancer is progressively showing a tendency of progressive increase in resectability and survival rates in pancreatic cancer.

Evaluación multidisciplinaria y tratamiento multimodal del cáncer de páncreas resecado. Estudio observacional / No disponible

Objetivo: analizar la evaluación del abordaje multidisciplinario de un grupo de pacientes con cáncer de páncreas resecado, los resultados postoperatorios y la supervivencia tras la aplicación de un tratamiento multimodal. Diseño: estudio descriptivo prospectivo observacional. Pacientes: entre enero de 2004 y diciembre 2009 se evaluaron 124 pacientes con cáncer de páncreas. De ellos, se realizó la resección pancreática con intención curativa en 30 casos que constituyen el objeto del estudio. Se analizaron los resultados del estudio preoperatorio de extensión tumoral, la morbi-mortalidad postoperatoria, y la supervivencia. Resultados: la evaluación diagnóstica se hizo en régimen ambulatorio en el 20% de los pacientes. En el 63% de los casos, el ingreso fue el mismo día de la intervención. En 3 pacientes intervenidos no se consiguió realizar la resección del tumor (9%), por lo que la tasa de concordancia entre la resecabilidad radiológica y la quirúrgica fue del 91%. La tasa de resecabilidad quirúrgica fue del 24,1%. La mortalidad quirúrgica de la serie fue de un 3,3%, con una morbilidad global del 56,6%. La supervivencia al año, dos, tres y cuatro años fue del 76,2%, 56,3%, 43%, y 27,3% respectivamente. Conclusiones: el desarrollo tecnológico y la evaluación multidisciplinar coordinada, permite realizar una evaluación precisa de la extensión tumoral, y puede reducir el número de laparotomías sin resección del tumor. Con la aplicación de una terapia multimodal sistemática combinada, la resecabilidad quirúrgica y la supervivencia a medio y largo plazo parece que están aumentando de forma progresiva(AU)

Objective: analysis and evaluation of a multidisciplinary approach, postoperative results and survival of a group of patients with resected pancreatic cancer after a multimodal therapy. Design: descriptive, prospective and observational study. Patients: between January 2004 and December 2004, 124 patients with pancreatic cancer were evaluated. In 30 patients pancreatic resection was performed, and they are the object of this study. Results of preoperative evaluation, postoperative morbidity and mortality, and long term survival were studied. Results: diagnostic evaluation was completed in ambulatory basis in 20% of the patients. In 63% of cases, admission was done in the same day of surgery. In 3 patients (9%), tumor resection was not achieved, therefore, concordance between radiological and surgical resectability rate was 91%. Resectability rate was 24.1%. Surgical Mortality was 3.3%, with a global morbidity rate of 56.6%. Survival at one, two, three and, four years was 76.2%, 56.3%, 43%, y 27.3% respectively. Conclusions: technological development and coordination of efforts in multidisciplinary teams offer an accurate evaluation of tumor involvement, and may reduce the number of laparotomies without tumor resection. The application of a systematic and generalized multimodal treatment in pancreatic cancer is progressively showing a tendency of progressive increase in resectability and survival rates in pancreatic cancer(AU)

Image analysis of dermal collagen changes during skin aging.

OBJECTIVE: To determine progressive quantitative, directional and textural changes in dermal collagen as a function of age and sex and to estimate their evolutive trend with appropriate regression models. STUDY DESIGN: Ninety-six samples of abdominal skin from autopsy cases were analyzed. The ages ranged from 3.5 months to 86 years. Picro-Sirius-stained slides were examined by polarizing microscopy, and spatial density, directional features and texture of collagen were measured by computerized image analysis. Nonlinear regression models were built to estimate evolutive changes with respect to age. The relationship between spatial orientation of collagen bundles and age was best modeled by linear regression. RESULTS: The evolutive patterns of dermal thickness and spatial density of collagen bundles correspond to a second-order polynomial model with a progressive increase from childhood to middle age and a relatively sharp decrease after the seventh decade. The evolution of textural pattern of dermal collagen, defined by gradient analysis, depicts a sort of inverted U. Its complexity is maximum in the first year of life, decreases until the period 25-50 years and increases progressively after the sixth decade. The horizontal orientation of collagen bundles with intermingled fascicles oriented in other directions, shown by young individuals, is progressively simplified with aging. In elderly subjects, collagen bundles have a horizontal orientation. No significant sex-related differences were found. CONCLUSION: Dermal collagen changes related to aging are apparently independent of sex, at least in abdominal skin, and show characteristic curvilinear evolutive trends defined by decreased dermal thickness in the elderly, decrease in the spatial density of collagen bundles and increase in textural heterogeneity of the dermis. Progressive simplification in the orientation of collagen bundles leading to a predominant horizontal disposition followed a linear trend. These changes could contribute to providing a substantial morphologic basis to age-associated biomechanical alterations in the skin.

Cytologic diagnosis of salivary duct carcinoma: a review of seven cases.

The cytomorphologic findings in fine-needle aspirates from 7 cases of salivary duct carcinoma (SDC) are reviewed and correlated with the histologic features. Malignant cytologic characteristics are clear in this tumor, and no false-negative results were obtained. But the absence of cribriform or papillary groups suggests an inconclusive diagnosis and sometimes the need to establish a differential diagnosis with other salivary tumors, and in particular with adenocarcinoma not otherwise specified (ADC-NOS) and high-grade mucoepidermoid carcinoma (h-g MEC). The pitfalls in the cytologic diagnosis of this tumor are discussed. In addition, the literature on the subject is reviewed.

Fine needle aspiration cytology of undifferentiated (embryonal) sarcoma of the liver. A case report.

BACKGROUND: Undifferentiated (embryonal) sarcoma of the liver (UESL) is a rare malignant mesenchymal hepatic tumor with an incidence among liver tumors of 27.7%. It occurs predominantly in children under the age of 15. CASE: The cytologic findings in a case of UESL in fine needle aspiration biopsy material in a 12-year-old girl are described. The patient presented clinically with upper abdominal pain and a palpable mass in the right hepatic lobe. Cytologic features included a combination of polygonal and spindle cells. The polygonal cells were large, with round or lobulated nuclei, and occasionally multinucleated, with one or several nucleoli and variable cytoplasm with poorly defined borders. A few intracytoplasmic and extracytoplasmic eosinophil globules were observed. Histologic and immunohistochemical studies were performed, and staining for vimentin and alpha-1 antichemotrypsin was positive. CONCLUSION: It is important to recognize the cytologic features of this type of liver tumor since rapid diagnosis and initiation of early treatment may improve the poor prognosis of these neoplasms.

Differential diagnosis of malignant and reactive cells from serous effusions: image and texture analysis study.

The interrelationship of textural primitives which define morphological texture can be estimated by quite different descriptors; the discriminant value of which varies considerably. In the present study three different approaches to the texture analysis of nuclear chromatin were assayed to correctly allocate 332 cells from a pool obtained from serous effusions (six malignant mesotheliomas, six reactive mesothelial proliferations and five pleural metastases of lung adenocarcinoma). In all cases, initial cytological diagnosis posed considerable problems and final diagnosis was established by histologic examination of surgical specimens. The three approaches were based on binarization of the image obtained by edge detection, gradient analysis and pattern spectrum by morphological opening-closing, respectively. Characteristics afforded by each method were: (a) spatial distribution of heterochromatin, besides geometric features, (b) features related to transitions and contrast between dark and light chromatin primitives, and (c) granulometric characteristics of the theoretically biphasic heterochromatin-euchromatin image defined by mathematical morphology. The three methods were applied to the raw grey-tone image and did not require interactive handling. Although each of the three approaches yielded relatively satisfactory results, with percentages of well-classified cells in the test set ranging from 61.45 to 67.47, the best results (78.31% of well-classified cells) were obtained taking into consideration the three types of variables (area, 2nd opening, 5th closing, and S.D. of the amplitude image). A point to be stressed is the considerably high proportion of correctly-allocated reactive mesothelial cells (82.0%) in a field where subjective assessment commonly yields rather poor results. Nevertheless, classification yielded 14.8% and 3.3% false positives as adenocarcinomatous and malignant mesothelioma cells, respectively. In the theorectical situation devised in the study, results on a cell-by-cell basis encouraging and suggest that a textural approach might be useful in a dedicated expert system or on a more real case-by-case basis.

Nuclear texture in poorly differentiated small round cell tumors. Image analysis study of fine needle aspiration material.

Gradient analysis and pattern spectrum decomposition based on mathematical morphology concepts were used to explore nuclear texture patterns in a pool of 108 cells obtained by fine needle aspiration of five undifferentiated small round cell tumors of childhood, including one case each of Wilms' tumor, neuroblastoma, lymphoblastic lymphoma, Ewing's sarcoma and rhabdomyosarcoma. The aim of the study was to determine the presumptive value of nuclear pattern to correctly allocate each isolated cell to each of the five patients. The cells were examples of five histogenetically different tumors, all undifferentiated and with a close microscopic resemblance to one another. High gradient structures (heterochromatin-euchromatin and nuclear membrane edges) were estimated by a difference-of-boxes filter, and pattern spectrum decomposition was obtained by successive openings and closings performed on the input gray tone image. One important feature of these procedures was that no prior selection by thresholding of the structures to be studied was required, thus obviating subjective bias. Percentages of correctly allocated cells by canonical analysis ranged from 70.0% (rhabdomyosarcoma) to 92.9% (Ewing's sarcoma). Although the five cases could be distinguished using seven texture variables, this does not imply generalization of the results for the differential diagnosis of these tumors. Nonetheless, the possibility that undifferentiated small round cells present distinctive nuclear patterns when studied by sensitive image analysis techniques is suggested by our results.

Image analysis of hemosiderin-laden macrophages in bronchoalveolar lavage fluid.

The aim of this study was to assess quantitatively the relationship between the number of iron-laden macrophages, extent of hemosiderin content and amount of dark-stained hemosiderin clumps in bronchoalveolar lavage (BAL) fluids. The series included specimens from 20 subjects whose BAL had yielded iron-laden macrophages. Six had developed hemoptysis 3-15 days prior to BAL. Quantitative studies were performed on smears stained by the ferrocyanide reaction, using true color image analysis for image segmentation. A top-hat function based on mathematical morphologic concepts was used for extraction of dark clumps of hemosiderin. The results demonstrated the presence of iron-laden macrophages three days after hemoptysis. There was a moderate correlation between the percentage of macrophages and amount of hemosiderin content, but the extent of dark-stained clumps did not increase in parallel to the increase in hemosiderin content and probably represented an advanced stage in the phagocytic processing of hemosiderin formed from engulfed red blood cells. The main difference between subjects with and without previous hemoptysis was higher values for dark clumps of hemosiderin in the former.

Textural analysis of lymphoid cells in serous effusions. A mathematical morphologic approach.

Nuclear texture of reactive and well-differentiated neoplastic lymphocytes from serous effusions was studied by an approach based on principles of mathematical morphology. Density features were obtained before and after gray level nuclear image transformation by morphologic closing (dilation followed by erosion) and application of a top-hat function, which detects light or dense spots with a determined width and contrast. Five cases of benign reactive lymphocytic serous effusions and 11 cases of effusions in well-differentiated lymphocytic lymphomas were analyzed retrospectively. Each lymphoid cell was characterized by 24 densitometric features. Rank-order transformation was used for linear discriminant analysis given non-normal distributions of variables. In a first model formed by pooling all cells, discriminant function distinguished between 110 reactive and 216 malignant lymphocytes in the learning set and between 111 reactive and 226 malignant lymphocytes in the test set with better than 81% accuracy in both. In a second model, correct classification of cases as reactive or malignant was achieved in 5/5 reactive and 11/11 malignant lymphoid effusions. The results indicate that mathematical morphologic transformations of the gray level image may be an effective adjunct to other textural descriptors of cellular atypia, especially in the differential diagnosis of lymphoid serous effusions.

Fine needle aspiration diagnosis of renal oncocytoma. A mathematical morphologic approach.

Differentiation between renal oncocytomas and well-differentiated oxyphilic cell renal carcinomas from fine needle aspiration cytology smears may present considerable difficulties. To better define diagnostic criteria, we used high-resolution architectural characteristics of nucleus and cytoplasm based on mathematical morphologic concepts. Particulate structural elements were selected for their size and optical density by the so-called top-hat function. Spatial density, size distribution and a function of distance between particles were computed. We quantitated cellular samples from fine needle aspirates obtained from 10 renal oncocytomas and 5 well-differentiated oxyphilic cell renal carcinomas. In two of the former, cytologic diagnosis was doubtful. Subsequent removal of the tumor and its histologic examination established the final diagnosis in all cases. Stepwise discriminant analysis correctly classified all cases as oncocytomas or renal carcinomas, although the results need to be considered with caution due to the necessarily limited number of observations. Multivariate graphic representation by star glyphs clearly depicted the differences between oncocytoma and oxyphilic cell renal carcinomas and the abnormal characteristics of two oncocytoma cases misclassified initially.

Mathematical morphologic analysis of liver cirrhosis. Correlation with etiology, clinical score and hepatocellular carcinoma.

Remodeling of the cirrhotic liver was studied retrospectively by mathematical morphologic methods in 75 autopsy cases (40 alcoholic, 17 hepatitis B virus (HBV)-related and 18 cryptogenetic cirrhosis), including 28 hepatocellular carcinomas. The aim was to obtain objective measurements of cirrhotic patterns that could be correlated with liver function evaluated by the Pugh-Child score, establish the relationship among different morphogenetic features and evaluate the implications of an objective classification of cases by numerical taxonomy in terms of their etiology, liver function and malignant transformation. The results indicate that the Pugh-Child score was closely related to the global amount of fibrosis or to the percentage of regenerative nodules < 0.8 mm in diameter. In contrast, the higher the percentage of lobular-sized regenerative nodules (0.8-1.6 mm), the better the functional score, suggesting that they are probably residual lobules, albeit completely surrounded by fibrous tissue, rather than true regenerative pseudolobules. The four groups of cases obtained by numerical taxonomy (cluster analysis) showed different distributions for alcoholic and HBV-related cirrhosis. The pattern of the latter was practically analogous to that in classically labeled cryptogenetic cirrhosis, suggesting its viral etiology. Taxonomic classification had functional implications. The Pugh-Child score showed a definite relationship with the different clusters obtained. The incidence of malignant transformation gradually decreased from group G1 to G4, with a steeper descent between G2 and G3. These results might contribute to a more dynamic concept of morphologic changes in liver biopsies from patients with cirrhosis.

Cirrhotic changes in livers from children undergoing transplantation. Image analysis.

The pattern and extent of disorganization of the liver architecture were studied in 25 children undergoing orthotopic liver transplantation for cirrhosis. Image analysis techniques based on mathematical morphology were used to define seven parameters for each case, including fibrosis index (percentage of Sirius-red-stained areas), three categories of regenerative nodules (< 0.8, 0.8-1.6 and > 1.6 mm in diameter) and three categories of fibrous septa (< 0.4, 0.4-1.2 and > 1.2 mm in width). Fibrosis index ranged from 10.2% to 51.9%. Percentage of small nodules of infralobular size (< 0.8 mm in diameter) varied from 31.4% to 98.2%. Percentage of large nodules, > 1.6 mm in diameter, in only four cases was > 15%. Multivariate clustering analysis classified the cases into three main groups. One of them included only cases of cirrhosis secondary to parenchymal disease or to inborn errors of metabolism. In their pattern, tiny nodules predominated, and the percentage of slender septa, < 0.4 mm in diameter, was very high, although the overall fibrosis index was relatively low. Patients with biliary cirrhosis were classified into two groups. In one the fibrosis index was low and the size of the nodules variable, with 12% large nodules. In the other the fibrosis index was high, and small nodules, < 0.8 mm in diameter, predominated. No relationship was found with age at transplantation or previous portoenterostomy. A presumptive explanation for this divergent evolution might be the occurrence of cholangitic episodes. Overall fibrosis that the liver can sustain without failure is apparently limited.(ABSTRACT TRUNCATED AT 250 WORDS)

Lobar emphysema associated with patient ductus arteriosus and pulmonary obstructive vascular disease.

Three cases of respiratory distress with patent ductus arteriosus are presented. The left-to-right shunt across the ductus arteriosus produced dilated pulmonary arteries and secondary bronchial compression, leading to lobar emphysema. The increase of blood flow across the ductus arteriosus causes structural changes of the wall of the preacinar and intra-acinar arteries. All three patients died, most probably from the association of parenchymatous pulmonary disease and pulmonary obstructive vascular disease.

Functioning metastases of a nonfunctioning paraganglioma.

A case of nonfunctioning paraganglioma, initially qualified as benign, is described. Two years following extirpation, functioning bone and lung metastases were manifested by hypertensive crises and increased levels of vanilmandelic acid and catecholamines in urine. The criteria for benign and malignant paragangliomas are discussed with regard to functional transformation of the tumor described in this case. It is concluded that the phenotypic heterogeneity of the primary tumor cells could explain the difference in biological behavior of the primary tumor and its metastases.