Current perspectives on pancreatic serous cystic neoplasms:Diagnosis, management and beyond

Pancreatic cystic neoplasms have been increasingly recognized recently. Comprising about 16% of all resected pancreatic cystic neoplasms, serous cystic neoplasms are uncommon benign lesions that are usually asymptomatic and found incidentally. Despite overall low risk of malignancy, these pancreatic cysts still generate anxiety, leading to intensive medical investigations with considerable financial cost to health care systems. This review discusses the general background of serous cystic neoplasms, including epidemiology and clinical characteristics, and provides an updated overview of diagnostic approaches based on clinical features, relevant imaging studies and new findings that are being discovered pertaining to diagnostic evaluation. We also concisely discuss and propose management strategies for better quality of life.

THE DIAGNOSIS AND TREATMENT FOR RECURRENT DYSPHAGIA OF ESOPHAGEAL CARCINOMA AFTER RADICAL RADIOTHERAPY

Objective: To investigate the diagnosis and treatment for recurrent dysphagia of esophageal carcinoma after radical radiotherapy. Methods: The experince of 41 cases with recurrent dysphagia of esophageal carcinoma after radical radiotherapy were retrospectively summerized. Results: All of the cases were surgically treated form July, 1989 to May, 1997 with resectability rate in 97%, operative mortality in 4.8%, postoperative morbidity in 29%. Pathological examination showed squemous cell carcinoma in 82.8%, and serious radiation reaction in 13.2% after operation. The 1, 3, 5year survival rates after operation were 72.7%, 36.3%, 18.1% respectively, and those after radiation in 100%, 60%, and 35.5% respectively. Conclusion: Most of recurrent dysphagia for these cases were due to uncontrolled/recurrent cancer, and minority of them were due to constriction after radiotherapy. It is difficult to distinguish cancer with benigh constriction before operation. Some cases have lymphatic metastasis without local cancer recurrence. For those patients with recurrent disphagia should be treated with operation as early as possible.

Effect of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

AIM:To investigate the role of neoadjuvant chemoradiotherapy in prognosis and surgery for esophageal carcinoma by a meta-analysis.METHODS:PubMed and manual searches were done to identify all published randomized controlled trials(RCTs) that compared neoadjuvant chemoradiotherapy plus surgery(CRTS) with surgery alone(S) for esophageal cancer.According to the test of heterogeneity,a fi xed-effect model or a random effect model was used and the odds ratio(OR) was the principal measure of effects.RESULTS:Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C(Cochrane Reviewers' Handbook 4.2.2).OR(95% CI,P value),expressed as CRTS vs S(values>1 favor CRTS arm),was 1.19(0.94-1.48,P=0.28) for 1-year survival,1.33(1.07-1.65,P=0.69) for 2-year survival,1.76(1.42-2.19,P=0.11) for 3-year survival,1.41(1.06-1.87,P=0.11) for 4-year survival,1.64(1.28-2.12,P=0.40) for 5-year survival,0.82(0.39-1.73,P<0.0001) for rate of resection,1.53(1.33-2.84,P=0.007) for rate of complete resection,1.78(1.14-2.78,P=0.79) for operative mortality,1.12(0.89-2.48,P=0.503) for all treatment mortality,1.33(0.94-1.88,P=0.04) for the rate of adverse treatment,1.38(1.23-1.63,P=0.0002) for local-regional cancer recurrence,1.28(0.85-1.58,P=0.60) for distant cancer recurrence,and 1.27(0.86-1.65,P=0.19) for all cancer recurrence.A complete pathological response to chemoradiotherapy occurred in 10%-45.5% of patients.The 5-year survival benefi t was most pronounced when chemotherapy and radiotherapy were given concurrently(OR:1.45,95% CI:1.26-1.79,P=0.015) instead of sequentially(OR:0.85,95% CI:0.64-1.35,P=0.26).CONCLUSION:Compared with surgery alone,neoadjuvant chemoradiotherapy can improve the long-term survival and reduce local-regional cancer recurrence.Concurrent administration of neoadjuvant chemoradiotherapy was superior to sequential chemoradiotherapy.

Oesophageal surgery

INTRODUCTIONThe origins of oesophageal surgery ,like most surgical treatments ,are based in the treatment of traumatic injury .The Smith Surgical Papyrus describes the examination, diagnosis and treatment of 'a gaping wound of throat, penetrating the gullet' [1].

Medical expenditure for esophageal cancer in China:a 10-year multicenter retrospective survey(2002-2011)

Background: Esophageal cancer is associated with substantial disease burden in China, and data on the economic burden are fundamental for setting priorities in cancer interventions. The medical expenditure for the diagnosis and treatment of esophageal cancer in China has not been fully quantified. This study aimed to examine the medical expenditure of Chinese patients with esophageal cancer and the associated trends.Methods: From 2012 to 2014, a hospital-based multicenter retrospective survey was conducted in 37 hospitals in 13 provinces/municipalities across China as a part of the Cancer Screening Program of Urban China. For each esophageal cancer patient diagnosed between 2002 and 2011, clinical information and expense data were extracted by using structured questionnaires. All expense data were reported in Chinese Yuan(CNY; 1 CNY = 0.155 USD) based on the2011 value and inflated using the year-specific health care consumer price index for China.Results: A total of 14,967 esophageal cancer patients were included in the analysis. It was estimated that the overall average expenditure per patient was 38,666 CNY, and an average annual increase of 6.27% was observed from 2002(25,111 CNY) to 2011(46,124 CNY). The average expenditures were 34,460 CNY for stage Ⅰ,39,302 CNY for stage Ⅱ,40,353 CNY for stage Ⅲ, and 37,432 CNY for stage IV diseases(P < 0.01). The expenditure also differed by the therapy type, which was 38,492 CNY for surgery, 27,933 CNY for radiotherapy, and 27,805 CNY for chemotherapy(P < 0.05).Drugs contributed to 45.02% of the overall expenditure.Conclusions: These conservative estimates suggested that medical expenditures for esophageal cancer in China substantially increased in the last 10 years, treatment for early-stage esophageal cancer costs less than that for advanced cases, and spending on drugs continued to account for a considerable proportion of the overall expenditure.

Aggressive surgical resection does not improve survival in operable esophageal squamous cell carcinoma with N2-3 status

AIM:To investigate the influence of nodal status on response and clarify the optimal treatment for operable esophageal squamous cell carcinoma(OSCC).METHODS:We retrospectively analyzed 1490 OSCC patients who underwent transthoracic esophagectomy and lymphadenectomy between December 1996 and December 2009 at the Sun Yat-sen University Cancer Center.The surgical approach and the number of resected lymph nodes(LNs) were considered in the assessment of surgery.Patients were classified according to their nodal statuses(NO vs N1 vs N2-3).Overall survival was defined as the time from the date of death or final follow-up.Survival analysis was performed using the Kaplan-Meier method and differences between curves were assessed by the logrank test.Univariate and multivariate Cox regression analyses were used to identify factors associated with prognosis.Statistical significance was assumed at a P<0.05.RESULTS:With a median time from surgery to the last censoring date for the entire cohort of 72.2 mo,a total of 631 patients were still alive at the last follow-up and the median survival time was 35.5 mo.The surgical approach(left transthoracic vs Ivor-Lewis/tri-incisional)was verified as independent prognostic significance in patients with NO or N1 status,but not in those with N2-3 status.Similar results were also observed with the number of resected LNs(≤14 vs ≥15).Compared with surgery alone,combined therapy achieved better outcomes in patients with N1 or N2-3 status,but not in those with NO status.For those with N2-3status,neither the surgical approach nor the number of resected LNs reached significance by univariate analysis,with unadjusted HRs of 0.826(95%CI:0.644-1.058) and 0.849(95%CI:0.668-1.078),respectively,and aggressiveness of surgery did not influence the outcome;the longest survival was observed in those patients who received the combined therapy.CONCLUSION:Combined therapy has a positive role in OSCC with LN metastasis,and aggressive surgical resection does not improve survival in patients with N2-3 status.

Narrow-band imaging without magnification for detecting early esophageal squamous cell carcinoma

AIM：To compare narrow-band imaging（NBI）without image magnification,and chromoendoscopy with Lugol＇s solution for detecting high-grade dysplasia and intramu-cosal esophageal squamous cell carcinoma（SCC）in patients with head and neck cancer.METHODS：This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas,Sao Paulo University Medical School,Brazil,between August 2006 and Feb-ruary 2007.Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed,and the discovered lesions were mapped,recorded and sent for biopsy.The results of the three methods were compared regarding sensitivity,specificity,accuracy,positive predictive value,negative predictive value,positive likelihood value and negative likelihood value.RESULTS：Of the 129 patients,nine（7%）were diag-nosed with SCC,5 of which were in situ and 4 which were intramucosal.All carcinomas were detected through NBI and Lugol chromoendoscopy.Only 4 le-sions were diagnosed through conventional examination,all of which were larger than 10 mm.CONCLUSION：NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC,and produces results comparable to those obtained with 2.5%Lugol chromoendoscopy.

Advances in early diagnosis and therapy of pancreatic cancer

BACKGROUND: Pancreatic cancer remains a devastating disease with a 5-year survival rate of less than 5%. Recent advances in diagnostic methods and therapeutic approaches have increased the possibility of improving the existing poor prognosis. DATA SOURCES: English-language articles reporting early diagnosis and therapy of pancreatic cancer were searched from the MEDLINE and PubMed databases, Chinese-language articles were from CHKD (China Hospital Knowledge Database) RESULT: The current literature about pancreatic cancer was reviewed from three aspects: statistics, screening and early detection, and therapy. CONCLUSIONS: Early detection and screening of pancreatic cancer currently should be limited to high risk patients Surgical resection is the only curative approach available, with some recent improvement in outcomes. Gemcitabine has been a standard treatment during the last decade. Gemcitabine based combination treatment, especially combined with newer molecular targeted agents, is promising. The rationale for radiotherapy is controversial, but with the recent development of modern radiation delivery techniques, radiotherapy should be intensified. Patients with borderline pancreatic cancer could benefit from neoadjuvant therapy but more evidence is needed and the best neoadjuvant regimen is still to be determined.

Clinical diagnosis and management of pancreatic mucinous cystadenoma and cystadenocarcinoma:Single-center experience with 82 patients

BACKGROUND Mucinous cystic neoplasm(MCN)of the pancreas is characterized by mucinproducing columnar epithelium and dense ovarian-type stroma and at risk for malignant transformation.Early diagnosis and treatment of MCN are particularly important.AIM To investigate the clinical characteristics of and management strategies for pancreatic mucinous cystadenoma(MCA)and mucinous cystadenocarcinoma(MCC).METHODS The clinical and pathological data of 82 patients with pancreatic MCA and MCC who underwent surgical resection at our department between April 2015 and March 2019 were retrospectively analyzed.RESULTS Of the 82 patients included in this study,70 had MCA and 12 had MCC.Tumor size of MCC was larger than that of MCA(P=0.049).Age and serum levels of tumor markers carcinoembryonic antigen(CEA),carbohydrate antigen(CA)19-9,and CA12-5 were significantly higher in MCC than in MCA patients(P=0.005,0.026,and 0.037,respectively).MCA tumor size was positively correlated with serum CA19-9 levels(r=0.389,P=0.001).Compared with MCC,MCA had a higher minimally invasive surgery rate(P=0.014).In the MCA group,the rate of major complications was 5.7%and that of clinically relevant pancreatic fistula was 8.6%;the corresponding rates in the MCC group were 16.7%and 16.7%,respectively.CONCLUSION Tumor size,age,and serum CEA,CA19-9,and CA12-5 levels may contribute to management of patients with MCN.Surgical resection is the primary treatment modality for MCC and MCA.

Radiotherapy of 180 cases of operable esophageal carcinoma

AIM To compare the validity of radiotherapy and surgery for operable esophageal carcinoma in 180 patients with pathologically proved esophageal carcinoma who had been accepted for surgery, but for various reasons, were given radical radiation therapy. METHODS The reasons of abandoning surgery in the patients were: poor cardiac function (21), poor pulmonary function (36), poor general condition (9), senility (aged 69～81 years), 32 and refusal by the patient (82). They were treated either by the isocenter technic alone or anteroposterior plus isocenter irradiation to a total dose of 50～70 Gy/5～7wk. RESULTS The 1 , 3 and 5 year survival rates were 64%, 34% and 23%. The 3 and 5 year survival rates showed that lesions in the upper third did better than those in the middle and lower thirds ( P <0 05). The 5 year survival rate by radiation alone (44 5%) of the upper third lesions was slightly better than by surgery. The effect for lesions in the middle third was slightly inferior, and that for the lower third was even poorer than that of surgery. CONCLUSION The result of radiation alone for the operable esophageal carcinoma was similar to that of surgery.

Prognostic value of preoperative weight loss-adjusted body mass index on survival after esophagectomy for esophageal squamous cell carcinoma

BACKGROUND The impact of body mass index(BMI)on survival in patients with esophageal squamous cell carcinoma(ESCC)undergoing surgery remains unclear.Therefore,a definition of clinically significant BMI in patients with ESCC is needed.AIM To explore the impact of preoperative weight loss(PWL)-adjusted BMI on overall survival(OS)in patients undergoing surgery for ESCC.METHODS This retrospective study consisted of 1545 patients who underwent curative resection for ESCC at West China Hospital of Sichuan University between August 2005 and December 2011.The relationship between PWL-adjusted BMI and OS was examined,and a multivariate analysis was performed and adjusted for age,sex,TNM stage and adjuvant therapy.RESULTS Trends of poor survival were observed for patients with increasing PWL and decreasing BMI.Patients with BMI≥20.0 kg/m2 and PWL<8.8%were classified into Group 1 with the longest median OS(45.3 mo).Patients with BMI<20.0 kg/m2 and PWL<8.8%were classified into Group 2 with a median OS of 29.5 mo.Patients with BMI≥20.0 kg/m2 and PWL≥8.8%(HR=1.9,95%CI:1.5-2.5),were combined into Group 3 with a median OS of 20.1 mo.Patients in the three groups were associated with significantly different OS(P<0.05).In multivariate analysis,PWL-adjusted BMI,TNM stage and adjuvant therapy were identified as independent prognostic factors.CONCLUSION PWL-adjusted BMI has an independent prognostic impact on OS in patients with ESCC undergoing surgery.BMI might be an indicator for patients with PWL<8.8%rather than≥8.8%.

Intensify standardized therapy for esophageal and stomach cancer in tumor hospitals

INTRODUCTIONCancer treatment situation in tumor hospitals inChina has its own unique characteristics which arenot found in other parts of the world. Because ofthe huge population and high incidence rates ofesophageal and stomach cancer[1-5], the number ofcancer patients waiting for admission isinconceivably large.

SURGICAL TREATMENT OF PRIMARY ESOPHAGEALADENOCARCINOMA

Objective: To study the biocharacteristics of primary esophageal adenocarcinoma (PEAC) and factors influencing patients’ prognosis and to find rational surgical indications and combined therapy. Methods: To analyze the clinical material of 106 patients with PEAC and compared with that of patients with esophageal squamous-cell carcinoma (ESCC). Results: The overall resectability, morbidity and 30-day mortality rates of PEAC were 92.5%, 23.5% and 2.8% respectively, similar to those of ESCC. The TNM staging, lymph node metastasis, extraesophageal invasion and the nature of operation were major determinants influencing long-term prognosis. The 5-year survival rate of PEAC was 21.0%, which was lower than that of ESCC (P<0.01). Metastasis or recurrence remained to be the cause of death in 82.4% of patients who lived longer than 5 years, which was higher than that of ESCC (P<0.01). Adjuvant radiation did not influence survival of the patients with lymph node metastasis, but appeared helpful to the patients with no lymph node metastasis. Conclusion: compared with ESCC, PEAC is a malignant disease with poor prognosis. Surgical resection is the first and chief choice of treatment. Surgical indications include patients in stage 0, I, II and some in stage III and even in stage IV of PEAC. Early detection, early diagnosis and early treatment as well as radical operation could improve prognosis. Adjuvant radiotherapy appears helpful only to the patients without lymph node metastasis.

Successful endoscopic removal of a giant upper esophageal inflammatory fi brous polyp

Giant esophageal inflammatory fibrous polyp （espedally 〉 17 cm in size） is seen rarely. Endoscopic removal has been reported rarely because the procedure is technically demanding and the hemostasis is difficult to ascertain. Here, we describe a case of a giant upper esophageal inflammatory fibrous polyp that was resected successfully by endoscopy.

Surgical Treatment of Perforation with Esophageal Carcinoma

OBJECTIVE To determine the ideal method of surgical preoperative treatment for perforation with esophageal carcinoma.METHODS 36 cases of perforation with esophageal carcinoma were treated surgically in this series.Perforations occurred into the right lung in 14 cases.the mediastinum in 17 cases and treachea in 5 cases.Open thoracic surgery was performed in 34 cases.in which the right thoracic approach using a 3-incision method was applied in 16 cases,and operation by stages in 15 cases.Of the 34 cases.retrosternal substitution of the esophagus with stomach or colon was performed in 26 cases.RESULTS Surgery was successful in 31 cases and operative death occurred in 3 cases.The postoperative follow up study was from 3-72 months.Of these cases 15 were alive 15 7-12 months,2 at 24 months.and 1 at 72 months.The results can be considered satisfactory.CONCLUSION The therapeutic results of surgical treatment of perforation with esophageeal carcinoma were markedly superior to that of conventional conservative treatment.The authors suggest that surgical interventionwithout delay should be undertaken for patients having a perforation with carcinoma of the esophagus.A right thoracic approach with a 3-incision method（retrosternal replacement of esophagus with stomach or colon0or operation by stages is preferable.

Clinical study of simultaneous lung volume reduction surgery during resection of pulmonary or esophageal neoplasms

Background If the emphysema lesions are not symmetrical, unilateral lung volume reduction surgery （LVRS） can be carried out on the more severe side. The aim of this research was to evaluate the feasibility and effects of LVRS performed simultaneously with resection of pulmonary and esophageal neoplasms. Methods Forty-five patients with pulmonary neoplasm and 37 patients with esophageal neoplasm were randomly assigned to group A or group B. In group A, LVRS was performed simultaneously on the same side as thoracotomy. In group B, only tumor resection was performed. The nonfunctional lung area was determined by preoperative chest computed tomography and lung ventilation/perfusion scan. The lung volume removed was about 20% to 30% of the lobes on one side. Preoperative and postoperative indexes including pulmonary function testing variables, arterial blood gas analysis variables, dyspnea scale, 6-minute walk distance, etc., were compared between the groups. Results There were no surgical deaths in this study. The postoperative forced vital capacity in 1 second, PaO2, PaCO2, dyspnea scale, and 6-minute walk distance were improved significantly in group A, whereas these indexes did not change or decreased slightly in group B. Conclusions For tumor patients who have associated emphysema, simultaneous LVRS not only increases the chance of receiving surgical therapy, but also improves the postoperative quality of life of the patient. LVRS has expanded the surgical indication for tumor patients.

胸腺肿瘤外科诊治的研究进展

胸腺肿瘤是一种胸腺上皮细胞来源的肿瘤,包括胸腺瘤及胸腺癌。临床上发病率较低,目前均认为是一种恶性肿瘤,其主要的治疗方法是以手术为主的外科治疗。随着检查技术与治疗技术的发展,胸腺肿瘤的外科诊治有了一定的进展。本文对胸腺肿瘤的辅助检查、分型与分期、术前准备、手术方式、手术入路、复发与转移、预后等方面进行综述。

胰腺体部神经鞘瘤1例

胰腺神经鞘瘤是一种极为罕见的神经源性肿瘤,缺乏特征性临床表现和影像学征象,术前明确诊断存在较大困难,常与其他胰腺良恶性肿瘤难以鉴别。文章报道1例胰腺体部神经鞘瘤患者的诊治经过,患者为44岁女性,因体检发现胰腺肿物5 d入院,行腹部增强CT提示胰腺体部肿物,约6.4 cm×5.4 cm,予行胰腺中段切除+远端胰腺残端空肠Roux-en-Y吻合术,术后病理回报符合胰腺上皮样神经鞘瘤。术后随访2年余,未见肿瘤复发或转移。该例为临床医师诊治胰腺神经鞘瘤提供了临床参考。

食管胃结合部腺癌外科治疗中国专家共识(2024年版)

《食管胃结合部腺癌外科治疗中国专家共识(2018版)》自颁布以来,很大程度上促进了我国食管胃结合部腺癌(AEG)的规范化、同质化诊疗,提升了我国AEG的外科治疗水平。经过5年的临床实践,该共识普适性和可行性已得到广泛证实。鉴于AEG发病率持续上升的趋势及其解剖部位、临床病理特征和分子生物学特征的特殊性,AEG成为近5年来外科临床研究的热点之一,并不断有新的临床研究证据发表。但是,对于AEG的定义、分型、分期、手术路径、切除范围、淋巴结清扫规范和消化道重建等外科问题,仍旧存在争议。鉴于此,有必要对2018版的共识进行更新。《食管胃结合部腺癌外科治疗中国专家共识(2024版)》在前一版的基础上,整合并分析5年来新的最佳临床证据,参考最新国际指南与共识,结合我国外科专家组意见,针对AEG外科治疗关键环节,包括AEG的定义和分型、手术径路、手术方式、淋巴结清扫范围、消化道重建方式及外科围手术期治疗等存在争议的问题,提出相关推荐建议,以期更好地规范AEG的外科治疗方式。在本共识中未解决的相关问题,尚需积极开展高质量的临床研究,以逐步探索和解决。

Progress in research of liver surgery in China

INTRODUCTIONLiver surgery,was started in the late 1950s in Chinaand has developed rapidly in the past 40 years.The study on the diagnosis and treatment of primaryliver cancer in China underwent four stages:①Inthe 1950s,the anatomical study of the liver lay asolid foundation for liver resection.①In