[The clinicopathologic features and prognostic analysis of pancreatic metastasis from clear cell renal cell carcinoma].

Objective: To investigate the clinicopathologic features and prognosis of the patients who had clear cell renal cell carcinoma (CCRCC) with metastasis to the pancreas. Methods: From Jan, 2000 to Dec, 2018, 18 patients with clear cell renal cell carcinoma (CCRCC) and had pathologically diagnosed metastasis to the pancreas were enrolled at Peking Union Medical College Hospital. The clinical and pathological data were retrospectively analyzed. Results: 11 out of 18 patients were male, and the other 7 were female. The average age of onset of CCRCC was 51.4 years. 8 cases (44.4%) occurred in the left kidney, and the other 10 cases (55.6%) with right kidney tumor. Three patients had synchronous pancreatic metastasis, and the other 15 patients had metachronous pancreatic metastasis. The median time from CCRCC onset to pancreas metastasis was 156 months. The main complaints of pancreas metastasis were abdominal pain, jaundice, gastrointestinal bleeding, nausea, weakness, loss of weight and so on. Seven patients (38.9%) had single lesion of pancreas, while 11 patients (66.1%) had multiple lesions of pancreas. Nine patients (50%) had other organs metastasis besides pancreatic metastasis at the same time. Five patients underwent pancreatic metastasis resection, while 15 patients received oral tyrosine kinase inhibitor(TKI). The mean follow-up was 171.7 months(1~361.5 months) and 5 patients died. The median overall survival (mOS) was 122 months, and the 5 year-survival rate was 81.4%. In univariate analysis, synchronous metastasis to the pancreas, relapse after 10 years, Memorial Sloan Kettering Cancer Center prognostic index, International Metastatic Renal Cell Carcinoma Database Consortium index were all significant parameters for patients'survival. Conclusions: Metastasis to the pancreas from clear cell renal cell carcinoma were rare. These patients had better survival outcomes, especially those relapsing after ten years. Pancreatic metastasis resection had no significant benefit on patient's survival.

[Sequential parathyroidectomy under cervical plexus anesthesia for secondary hyperparathyroidism with renal function failure].

Objective: To summarize the strategy of sequential parathyroidectomy for secondary hyperparathyroidism. Methods: Between January 2009 and December 2017, 32 patients with secondary hyperparathyroidism underwent parathyroidectomy in Department of General Surgery, Peking Union Medical College Hospital. There were 11 male and 21 female patients with a mean age of 51.3 years. Eleven of them underwent bilateral neck exploration under general anesthesia, while the rest of them underwent sequential parathyroidectomy. For the patients with sequential parathyroidectomy, a unilateral neck exploration was performed in the initial operation under cervical plexus blocking anesthesia. Second operation for contralateral parathyroid lesions was performed if the serum intact parathyroid hormone (iPTH) was still higher than 1 000 ng/L or related symptoms were not relieved significantly 6 months later after initial surgery. Fisher exact test was used to compare the date between the 2 groups. Results: In the bilateral exploration group, the serum iPTH level gradually exceeded above 1 000 ng/L in 5 patients during follow-up, and reoperation were performed in 3 patients of them. In the group with sequential parathyroidectomy, the serum iPTH level after initial operation exceeded above 1 000 ng/L in 15 patients. Eleven of them underwent contralateral parathyroidectomy, which decreases the serum iPTH levels to less than 1 000 ng/L in 10 patients. Compared with the sequential parathyroidectomy group (1/11), more patients needed to be treated in the intensive care unit after operation in bilateral exploration group (6/11), although the difference was statistically insignificant (P=0.063). Conclusions: Sequential parathyroidectomy strategy is feasible for the secondary hyperparathyroidism with severe complications. Prospective controlled observation with large sample size is needed to confirm its effect.

[The clinical analysis of preventable reoperation for primary hyperparathyroidism].

Objective: To discuss the diagnosis, preoperative imaging and surgical technique of patients who underwent reoperation for persistent hyperparathyroidism. Methods: A prospective database about primary hyperparathyroidism in Department of General Surgery, Peking Union Medical College Hospital was searched for the patients who underwent reoperation for persistent hyperparathyroidism from January 2009 to December 2016. The information about the initial operation, preoperative imaging study and result of reoperations were collected and reviewed. A total of 58 patients underwent reoperation for hyperparathyroidism. Eleven of these patients were referred to this institute for reoperation after missing single parathyroid lesion in the initial parathyroidectomy. Nine patients were female, and the mean patient age at reoperation was 54.9 years. Results: For this group, the accuracy of ultrasound neck scan and sestamibi scintigraphy was 10/11 in identifying diseased parathyroid gland before reoperation. Combined with enhanced CT and SPECT, all parathyroid lesions were localized before reoperations. With general anesthesia or cervical plexus block, all diseased parathyroid glands were removed in the reoperations. No signs of hyperparathyroidism appeared during follow-up. Conclusions: The initial surgery for primary hyperparathyroidism should be performed in experienced center to avoid reoperations. Combining preoperative localization and cervical exploration will help to increase the success rate of reoperation.