Standard pancreatoduodenectomy versus extended pancreatoduodenectomy with modified retroperitoneal nerve resection in patients with pancreatic head cancer:a multicenter randomized controlled trial

Background:The extent of pancreatoduodenectomy for pancreatic head cancer remains controversial,and more high-level clinical evidence is needed.This study aimed to evaluate the outcome of extended pancreatoduodenectomy(EPD)with retroperitoneal nerve resection in pancreatic head cancer.Methods:This multicenter randomized trial was performed at 6 Chinese highvolume hospitals that enrolled patients between October 3,2012,and September 21,2017.Four hundred patients with stage I or II pancreatic head cancer and without specific pancreatic cancer treatments(preoperative chemotherapy or chemoradiation)within three months were randomly assigned to undergo standard pancreatoduodenectomy(SPD)or EPD,with the latter followed by dissection of additional lymph nodes(LNs),nerves and soft tissues 270◦on the right side surrounding the superior mesenteric artery and celiac axis.The primary endpoint was overall survival(OS)by intention-to-treat(ITT).The secondary endpoints were disease-free survival(DFS),mortality,morbidity,and postoperative pain intensity.Results:TheR1 ratewas slightly lower with EPD(8.46%)thanwith SPD(12.56%).The morbidity and mortality rates were similar between the two groups.The median OS was similar in the EPD and SPD groups by ITT in the whole study cohort(23.0 vs.20.2 months,P=0.100),while the median DFS was superior in the EPD group(16.1 vs.13.2 months,P=0.031).Patients with preoperative CA19–9<200.0 U/mL had significantly improved OS and DFS with EPD(EPD vs.SPD,30.8 vs.20.9 months,P=0.009;23.4 vs.13.5 months,P<0.001).The EPD group exhibited significantly lower locoregional(16.48%vs.35.20%,P<0.001)andmesenteric LNrecurrence rates(3.98%vs.10.06%,P=0.022).The EPD group exhibited less back pain 6 months postoperation than the SPD group.Conclusions:EPD for pancreatic head cancer did not significantly improve OS,but patients with EPD treatment had significantly improved DFS.In the subgroup analysis,improvements in bothOS and DFS in the EPD armwere observed in patients with preoperative CA19–9<200.0 U/mL.EPD could be used as an effective surgical procedure for patients with pancreatic head cancer,especially those with preoperative CA19–9<200.0 U/mL.

An alpha-fetoprotein-negative hepatoid adenocarcinoma of the gallbladder with squamous differentiation

During a routine health examination, a 61-year-old male was incidentally found to have a neoplasm spreading beyond the gallbladder and into the liver on abdominal ultrasound. The ultrasound demonstrated a mixed-echo mass, measuring 7.6 cm × 4.8 cm in diameter, within the capsuled wall of the gallbladder and adhering to the liver. The patient was subsequently admitted to our hospital. His medical, family, and personal history were unremarkable, and serology tests for hepatitis B and C were both negative. Laboratory tumor marker investigations revealed increases in carcinoembryonic antigen (104.7 ng/mL;normal: 0-5 ng/mL), carbohydrate antigen (CA) 125 (421.3 U/mL;normal:0-37 U/mL), CA 242 (220.4 U/mL;normal: 0-20 U/mL), and CA19-9 (2,118.4 U/mL;normal: 0-27 U/mL) levels. Plasma alpha-fetoprotein (AFP) was within the normal range. An enhanced computed tomography (CT) scan revealed a mass in the gallbladder bed with enlarged hilar lymph nodes (Figure 1A,B,C). A cholecystectomy was subsequently performed, along with a liver and lymph node dissection. Histological findings revealed poorly differentiated cells with abundant eosinophilic cytoplasm ( Figure 1D,E ), and positive staining for cytokeratin-7 (CK7) and hepatocyte specific protein (HepPar-1) by immunohistochemistry (Figure 1F,G), suggesting that these cells were hepatoid adenocarcinoma (HAC).

Metastatic solitary fibrous tumor of the pancreas in a patient with Doege-Potter syndrome

A 46-year-old man was admitted to our hospital with a 6-month history of recurrent hypoglycemia with an unknown cause. Four months back, he was diagnosed with a complex ulcer in the stomach and duodenum in a local hospital. Physical examination revealed that the liver was swollen with a hard texture and located 5 cm below the costal margin of the abdomen. On admission, his random blood glucose level was 1.6 mmol/L, and routine laboratory tests, including those for liver enzymes, showed normal findings. The levels of tumor markers, including carcinoembryonic antigen, alpha-fetoprotein, carbohydrate antigen 19-9, and neuron-specific enolase, were normal. Magnetic resonance imaging (MRI) of the brain and pituitary gland showed no abnormalities. However, abdominal MRI revealed solid components in the pancreas and multiple masses on the liver (Figure 1A,B,C). We first considered functional neuroendocrine cancer of the pancreas with multiple liver metastases. For blood glucose control, the patient first received multiple transarterial chemoembolization (TACE) sessions to reduce the tumor burden. This resulted in amelioration of the symptoms of hypoglycemia, although they occasionally manifested. Whole-body fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) revealed a slightly hypodense lesion measuring 7.0×6.1 cm2 in diameter in the body of the pancreas. The lesion exhibited significantly different degrees of FDG uptake [ Figure 1D;maximum standardized uptake (SUVmax): 4.74].