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.

Oncological problems in pancreatic cancer surgery

Despite the development of more sophisticated diagnostic techniques, pancreatic carcinoma has not yet been detected in the early stage. Surgical resection provides the only chance for cure or long-term survival. The resection rate has increased due to recent advances in surgical techniques and the application of extensive surgery. However, the postoperative prognosis has been poor due to commonly occurring liver metastasis, local recurrence and peritoneal dissemination. Recent molecular-biological studies have clarified occult metastasis, micrometastasis and systemic disease in pancreatic cancer. Several oncological problems in pancreatic cancer surgery are discussed in the present review.

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.

To what extent should the intestinal be resected proximally after radiotherapy:hint from a pathological view

Background:Neoadjuvant chemoradiotherapy(nCRT)is associated with post-operative anastomotic complications in rectal-cancer patients.Anastomosis involving at least one non-irradiated margin reportedly significantly reduces the risk of post-operative anastomotic complications in radiation enteritis.However,the exact scope of radiotherapy on the remaining sigmoid colon remains unknown.Methods:We evaluated the radiation damage of proximally resected colorectal segments in 44 patients with rectal cancer,who received nCRT followed by conventional resection(nCRT-C,n=21)or proximally extended resection(nCRT-E,n=23).The segments from another 13 patients undergoing neoadjuvant chemotherapy(nCT)were used as control.We dissected these samples at a distance of 2 cmbetween the two adjacent sections.Radiation damage in proximally resected colorectal segments was evaluated using the radiation injury score(RIS)and the concentration and distribution patterns of angiostatin.Results:Compared to those in the nCT group,the nCRT group showed higher RIS,levels of angiostatin,and proportion of diffuse pattern of angiostatin.With increasing distance from the tumor site,these parameters all gradually decreased;and the differences came to be not significant at the site that is over 20cm from the tumor.The nCRT-E group showed lower RIS(median:2 vs 4,P=0.002)and a greater proportion of non-diffuse angiostatin(87%vs 55%,P=0.039)at the proximal margins compared with the nCRT-C group.Conclusions:The severity of the radiation damage of the proximal colon is inversely proportional to the proximal-resection margin length.Little damage was left on the proximal margin that was over 20cm from the tumor.Removal of an initial length of20cm from the tumor may be beneficial for rectal-cancer patients after nCRT.