Oncologic Reappraisal of Bile Duct Resection for Middle-Third Cholangiocarcinoma.

BACKGROUND: Although bile duct resection (BDR) in addition to pancreaticoduodenectomy (PD) is considered a surgical approach in patients with middle-third cholangiocarcinoma (MCC), available prognostic information after BDR remains very limited. The aim of this study was to reappraise BDR from the viewpoint of surgical oncology. METHODS: Patients who underwent BDR or PD for MCC between 2001 and 2010 at 32 Japanese hospitals were included. Clinicopathological factors were retrospectively compared according to surgical procedure to identify a subset cohort who benefited most from BDR. RESULTS: During the study, 92 patients underwent BDR (n = 38) or PD (n = 54). BDR was characterized by a shorter operation time, less blood loss, less frequent complications, and lower mortality, than PD. The incidence of positive surgical margins was 26.3% versus 5.6% (P = 0.007). The survival rate after BDR was significantly worse than that after PD: 38.8% versus 54.8% at 5 years (P = 0.035), and BDR was independently associated with deteriorated survival [hazard ratio (HR), 1.76; P = 0.023] by multivariable analysis. In the BDR group, tumor length < 15 mm (HR, 3.38; P = 0.017) and ductal margin length ≥ 10 mm (HR, 2.54; P = 0.018) were independent positive prognostic factors. Stratified by these two favorable factors, the 5-year survival rate was 63.0% in patients with 1/2 factors and 6.7% in those with 0 factors (P < 0.001). CONCLUSION: In patients with MCC, BDR provided a better short-term and a worse long-term outcome than PD. However, patient selection using tumor length and ductal margin length may allow a favorable survival probability even after BDR.

The Utility of Diagnostic Laparoscopic Biopsy for Mesenteric and Retroperitoneal Lymph Nodes.

BACKGROUND Ultrasound (US) or computed tomography (CT)-guided biopsy of intra-abdominal lymph nodes is minimally invasive; however, percutaneous procedures are often difficult to perform because of the location and size of the lymph nodes. In many cases, this approach may result in insufficient specimens necessary to evaluate histopathology. In such cases, laparoscopic biopsy is useful to obtain adequate specimens, regardless of the location and size of the lymph nodes. Additionally, laparoscopic biopsy is an approach that can avoid the possible complications associated with a laparotomy. CASE REPORT Between 2013 and 2016, a series of 11 patients underwent laparoscopic biopsy of mesenteric and retroperitoneal lymph nodes. All patients received a definitive histopathological diagnosis via laparoscopic biopsy. The median postoperative hospital stay was four days (range 3-13 days), and all patients were able to resume oral intake on postoperative day 1. No case was converted to laparotomy, and no major perioperative complication occurred, except for wound infection in one patient. CONCLUSIONS Diagnostic laparoscopic biopsy for mesenteric and retroperitoneal lymph nodes is safe and reliable.

Angiosarcoma arising in the non-operated, sclerosing breast after primary irradiation, surviving 6 years post-resection: A case report and review of the Japanese literature.

INTRODUCTION: Angiosarcoma consists only 0.04% of all breast malignancies and has a poor prognosis. This is the first reported case of an angiosarcoma arising in the non-operated breast after primary irradiation for occult breast cancer. The patient underwent mastectomy, surviving disease free for 6 years. PRESENTATION OF CASE: A 73-year-old woman with a past history of irradiation of the non-operated left breast complained of skin thickening and crust formation on the left nipple 8 years post-irradiation. Considering the clinical history and radiological studies, recurrent cancer was suspected and biopsy was performed. However, no proof of malignancy was obtained. As clinical symptoms continued to advance, informed consent was obtained and mastectomy was performed. Histological examination of the surgical specimen revealed angiosarcoma. DISCUSSION: In this case, angiosarcoma occurred after radiation on a non-operated breast. Preoperative diagnosis was not achieved even with two cytology specimen and one biopsy. Each showed only fibrosis and inflammatory changes. The background breast tissue inflammation should have been caused by radiation. Marked fibrosis and the rather small number of sarcoma cells in the breast tumor in this case may be why bioptic diagnosis was difficult. Kaplan-Meier analysis of 60 Japanese breast angiosarcoma patients showed significantly better prognosis in patients with a tumor 2cm or smaller. CONCLUSION: Angiosarcoma may occur in the non-operated breast, post irradiation. The potential difficulties of diagnosing angiosarcoma against background fibrosis should be kept in mind. Initial radical surgery currently represents the only effective treatment for improving survival in these patients.

Ruptured hepatic epithelioid angiomyolipoma: a case report and literature review.

A 38-year-old male was admitted to our hospital due to upper abdominal pain. Computed tomography revealed a hepatic angiomyolipoma (AML; 10.5 × 9.5 × 7.0 cm in size), which had ruptured into the space between the liver and the diaphragm. Following transcatheter arterial embolization, surgical resection was performed. The tumor consisted of epithelioid cells (50-60%), mature fat (40-50%), and thickened-wall blood vessels. Considering the amount of epithelioid cells and their positivity for E-cadherin and ß-catenin, the tumor was diagnosed as hepatic epithelioid AML. Cases of ruptured hepatic AML are rare. To the best of our knowledge, this is the sixth case reported in the English literature.

Six-year survival following left hepatic trisectionectomy with simultaneous resection of the portal vein and right hepatic artery for advanced perihilar cholangiocarcinoma without lymph node metastases: report of a case.

We report a case of survival for more than 6 years following left hepatic trisectionectomy and caudate lobectomy with simultaneous resection of the portal vein and right hepatic artery. The patient was a 65-year-old woman admitted to a local hospital with obstructive jaundice. The patient was diagnosed with perihilar cholangiocarcinoma and referred to our hospital. The tumor was located mainly in the left hilar region and occluded the left portal vein; furthermore, it involved the right portal vein and the right hepatic artery. The patient underwent left hepatic trisectionectomy and caudate lobectomy with simultaneous resection of the portal vein and right hepatic artery. The histological findings revealed that the tumor had invaded the portal vein and surrounded the right hepatic artery without any lymph node metastases. Microscopic curative (R0) resection was achieved. The patient is now healthy and still alive 6 years and 6 months after the surgery without any recurrence. Precise preoperative evaluation of the tumor and R0 resection by extended surgery contributed to a satisfactory outcome.