Vascular resections in minimally invasive surgery for pancreatic cancer

Pancreatic ductal adenocarcinoma(PDAC)is characterised by poor oncological outcome and is the seventh cause of cancer-related deaths worldwide.With the advances in surgical technology,oncological treatment,and critical care,extended pancreatic resections including vascular resections have become more frequently performed in specialised centres.Furthermore,the boundaries of resectability continue to be pushed in order to achieve a potentially curative approach in selected patients in combination with neoadjuvant and adjuvant treatment strategies.This review gives an overview on the current state of venous and arterial resections in PDAC surgery with particular attention given to the minimally invasive approach.

Paratesticular liposarcoma: Two case reports

BACKGROUND Paratesticular liposarcoma accounts for approximately 7%of scrotal tumors.They are rare lesions of the reproductive system with approximately 90%of the lesions originating from the spermatic cord.Surgery,with the goal of complete resection,is the mainstay for treatment of this disease.However,treatment consisting of extended resection to decrease local recurrence remains controversial.CASE SUMMARY We report the cases of two patients with paratesticular liposarcomas who were treated with radical testicular tumor resection without adjuvant therapy.Followup investigations at 9 mo showed no sign of recurrence.CONCLUSION Surgery is the first-line treatment,regardless of whether it is a recurrent or primary tumor.Extended resection carries a higher risk of complications and should not be performed routinely.Preoperative radiotherapy can reduce the local recurrence rate without affecting the overall survival.

Malignant peripheral nerve sheath tumor in an elderly patient with superficial spreading melanoma:A case report

BACKGROUND Malignant peripheral nerve sheath tumor(MPNST)is a type of spindle cell sarcoma originating from the peripheral nerve,which usually results in the corresponding nerve sign on magnetic resonance imaging(MRI).Patients with MPNST may also have neurofibromatosis type 1.CASE SUMMARY A 78-year-old male was admitted to the hospital due to a tumor in his left knee.He had a previous history of superficial spreading melanoma on the left thigh.Color Doppler ultrasonography showed a hypoechoic mass in the subcutaneous soft tissues of the medial left knee with an abundant rich blood flow.Computed tomography scanning did not show obvious signs of bone destruction,but the skin adjacent to the tumor was slightly thickened.MRI examination revealed that the hypervascular lesion was well-circumscribed,lobulated,invaded the surrounding soft tissues and demonstrated heterogeneous enhancement but lacked an entering and exiting nerve sign.The MRI result indicated the invasiveness of the tumor.The patient underwent a left knee joint mass expanded resection and the first histopathological examination showed a MPNST with positive surgical margins.Therefore,the second extended resection was performed,and the patient had a good outcome in the short term.CONCLUSION MRI is a useful technique for revealing the biological characteristics of MPNST and provides clinical support for evaluation of the surgical area before operation.

Retrospective analysis of surgically treated pT4b gastric cancer with pancreatic head invasion

BACKGROUND For advanced gastric cancer patients with pancreatic head invasion,some studies have suggested that extended multiorgan resections(EMR)improves survival.However,other reports have shown high rates of morbidity and mortality after EMR.EMR for T4b gastric cancer remains controversial.AIM To evaluate the surgical approach for pT4b gastric cancer with pancreatic head invasion.METHODS A total of 144 consecutive patients with gastric cancer with pancreatic head invasion were surgically treated between 2006 and 2016 at the China National Cancer Center.Gastric cancer was confirmed in 76 patients by postoperative pathology and retrospectively analyzed.The patients were divided into the gastrectomy plus en bloc pancreaticoduodenectomy group(GP group)and gastrectomy alone group(GA group)by comparing the clinicopathological features,surgical outcomes,and prognostic factors of these patients.RESULTS There were 24 patients(16.8%)in the GP group who had significantly larger lesions(P<0.001),a higher incidence of advanced N stage(P=0.030),and less neoadjuvant chemotherapy(P<0.001)than the GA group had.Postoperative morbidity(33.3%vs 15.3%,P=0.128)and mortality(4.2%vs 4.8%,P=1.000)were not significantly different in the GP and GA groups.The overall 3-year survival rate of the patients in the GP group was significantly longer than that in the GA group(47.6%,median 30.3 mo vs 20.4%,median 22.8 mo,P=0.010).Multivariate analysis identified neoadjuvant chemotherapy[hazard ratio(HR)0.290,95%confidence interval(CI):0.103–0.821,P=0.020],linitis plastic(HR 2.614,95%CI:1.024–6.675,P=0.033),surgical margin(HR 0.274,95%CI:0.102–0.738,P=0.010),N stage(HR 3.489,95%CI:1.334–9.120,P=0.011),and postoperative chemoradiotherapy(HR 0.369,95%CI:0.163–0.836,P=0.017)as independent predictors of survival in patients with pT4b gastric cancer and pancreatic head invasion.CONCLUSION Curative resection of the invaded pancreas should be performed to improve survival in selected patients.Invasion of the pancreatic head is not a contraindication for surgery.

放疗后直肠癌手术近端肠管应切除多少:病理角度的思考

背景:新辅助化放疗(nCRT)会增加直肠癌患者术后吻合口并发症的发生概率。有报道显示,吻合时至少保证有一端是未被放射损伤的肠管,可降低术后吻合口并发症的发生风险。然而,放疗对残留乙状结肠确切的损伤范围目前尚不明确。方法:我们对44例直肠癌手术标本中近端肠管的放射性损伤情况进行评估,其中21例在nCRT后接受了传统切除术(nCRT-C组),23例在nCRT后接受了近端扩大切除术(nCRT-E组)。另取13例仅接受新辅助化疗(nCT)的直肠癌手术标本作为对照。每隔2 cm对手术标本进行取材。采用放射性损伤评分(RIS)和血管抑素水平及其分布模式,对切除的近端肠管进行放射性损伤评估。结果:与nCT组相比,nCRT组近端肠管的RIS评分更高,血管抑素水平更高,血管抑素呈弥散分布的比例更高。随着距肿瘤距离的增加,上述指标逐渐下降;当距离肿瘤20 cm以远时,上述指标与nCT组肠管的差异已无统计学意义。与nCRT-C组相比,nCRT-E组近切缘中位RIS评分更低(2 vs 4,P=0.002),血管抑素呈非弥散分布的比例更高(87%vs 55%,P=0.039)。结论:直肠癌近切缘的放射性损伤程度与近端肠管切除长度负相关;当近端切除长度超过20 cm时,近切缘基本没有放射性损伤。建议nCRT后直肠癌手术近端肠管至少切除20 cm。