Surgery for oligometastasis of pancreatic cancer

The incidence of pancreatic adenocarcinoma（PDAC） has steadily increased over the past several decades. The majority of PDAC patients will present with distant metastases, limiting surgical management in this population. Hepatectomy and pulmonary metastasectomy（PM） has been well established for colorectal cancer patients with isolated, resectable hepatic or pulmonary metastatic disease. Recent advancements in effective systemic therapy for PDAC have led to the selection of certain patients where metastectomy may be potentially indicated. However, the indication for resection of oligometastases in PDAC is not well defined. This review will discuss the current literature on the surgical management of metastatic disease for PDAC with a specific focus on surgical resection for isolated hepatic and pulmonary metastases.

Impact and clinical usefulness of genetic data in the surgical management of colorectal cancer liver metastasis: a narrative review

Importance:In patients who undergo surgery for colorectal cancer liver metastases(CRLM),a number of somatic mutations have been associated with worse overall(OS)and recurrence-free survival(RFS).Although useful,an association with prognosis does not necessarily equate to an impact on surgical management.Objective:The aim of this review was to investigate whether the best-studied somatic mutations impact surgical management of CRLM by informing:(I)post-hepatectomy surveillance;(II)selection of surgical technique;(III)selection of optimal margin width;and(IV)selection of patients for surgery.Lastly,we discuss the refinement of genetic data from overall mutation status to specific variants,as well as lesser studied somatic mutations.Evidence Review:We conducted a computerized search using PubMed and Google Scholar for reports published so far,using mesh headings and keywords related to genetic data and CRLM.Findings:Genetic data may impact surgical management of CRLM in three ways.Firstly,KRAS mutations can predict lung recurrences.Secondly,KRAS mutations may help tailor margin width.Thirdly,KRAS mutations may help tailor surgical technique.Conclusions:Although genetic data may impact post-hepatectomy surveillance,selection of surgical technique and optimal margin width,their use to guide surgical selection remains elusive,as the data cannot support denying surgery to patients according to their somatic mutation profile.

肝切除术治疗结直肠癌肝转移的患者选择

1简介 结直肠癌最常见的血行转移器官为肝脏。大约有一半的患者在结直肠癌病程中发展为肝转移癌[1]。针对肝转移病灶,肝切除术仍是唯一可能的根治性治疗,其5年生存率约50%[2],10年治愈率接近20%[3]。此外,有效的系统和局部化疗结合手术切除可以达到在未治愈的情况下使患者长期存活[4]。因此,

Lessons learned from hepatocellular carcinoma may cause a paradigm shift in intraductal papillary mucinous neoplasms:a narrative review and discussion of conceptual similarities in tumor progression and recurrence

Although the natural history of recurrence/progression in patients with intraductal papillary mucinous neoplasms (IPMN) of the pancreas has not been studied thoroughly, the three principal mechanisms have been identified: (a) presence of residual disease at the transection margin, (b) presence of intraductal/intraparenchymal metastases and (c) development of new primary lesions. Mechanisms (a) and (b) result in metastatic lesions that are genetically related to the primary, while new primary lesions (mechanism c) are genetically distinct. Interestingly, recurrence/progression in IPMN displays conceptual parallels with the well-established paradigm of disease recurrence in patients with hepatocellular carcinoma (HCC). Specifically, patients with HCC may also develop recurrent tumors due to microscopic residual disease/intrahepatic metastasis which are genetically similar to the primary while the development of genetically unrelated, de novo HCC after curative-intent resection is also common. The latter has been attributed to the presence of a widespread genetic abnormality ( "field defect" ) in the liver (ie, cirrhosis). Given the conceptual similarities between IPMN and HCC, a pancreatic "field defect" may also be hypothesized to exist. This review does not suggest that HCC and IPMN have identical pathogeneses, but rather that they have conceptual similarities in tumor recurrence/progression;thus, lessons learned from HCC could be applied to IPMN research and subsequent management. Conceptual similarities in tumor progression and recurrence may also be observed between IPMN and other malignancies. However, HCC was selected because it is well studied and can serve as a paradigm.

Clinicopathological features and surgical outcomes of resected functional pancreatic neuroendocrine tumors: a single institution experience

Background:Functional pancreatic neuroendocrine tumors(f-PanNETs)are rare tumors of the pancreas that are associated with excess hormone production.A majority of literature available on these tumors is limited to case reports and small series and discusses a particular subtype.Here,we report the clinicopathological features and outcomes of all f-PanNETs from a high-volume pancreatectomy center.Methods:A prospectively maintained database was used to identify patients who underwent resection for f-PanNETs between January 1995 and December 2015.Patients were stratified by the type of f-PanNET,and their clinicopathological features and outcomes were analyzed and reported.Results:We identified 69 patients with a mean age of 52±16 years,and the majority were female(62%).The most common type of f-PanNET were insulinomas(70%)followed by gastrinomas(15%),and vasoactive intestinal peptidomas(VIPomas)(10%).There was considerable heterogeneity in the presenting symptoms.Patients with insulinomas presented with smaller tumors compared to the other subtypes.Nodal disease was most frequent in patients with VIPomas(71%),and gastrinomas(50%).The median overall survival(OS)was 7.4 years.Elevated Ki-67 and age>65 years were associated with poorer OS.Recurrence was observed in 8 patients(12%)and was most frequent in patients with VIPomas.Recurrence was associated with a poorer OS(P=.012).Conclusion:f-PanNETs are exceedingly rare and present with a wide variety of symptoms,histopathological findings,and outcomes.Surgical resection can help achieve good long-term survival.