Locally advanced carcinosarcoma of the pancreas.

Carcinosarcoma is a rare subtype of pancreatic neoplasm including both carcinomatous and sarcomatous components. Fewer than 30 cases have been reported to the Surveillance, Epidemiology, and End Results Program database. Given such rarity, definitive treatment guidelines are not well defined. We report a case of pancreatic carcinosarcoma diagnosed in our institution, review tumor clinicopathological characteristics, and describe our medical and surgical management strategy.

Liver Resection and Transplantation for Patients With Hepatocellular Carcinoma Beyond Milan Criteria.

OBJECTIVES: To assess survival after liver resection and transplantation in patients with hepatocellular carcinoma (HCC) beyond Milan criteria. BACKGROUND: The role of liver resection and transplantation remains controversial for patients with HCC beyond Milan criteria. Resection of advanced tumors and transplantation using extended-criteria are pursued at select high-volume center. METHODS: Patients from 5 liver cancer centers in the United States who had liver resection or transplantation for HCC beyond Milan criteria between 1990 and 2011 were included in the study. Multivariable and propensity-matching analyses estimated the effects of clinical factors and operative selection on survival. RESULTS: Of 608 patients beyond Milan without vascular invasion, 480 (79%) patients underwent resection and 128 (21%) underwent transplantation. Clinicopathologic profiles between resection and transplant patients differed significantly. Hepatitis C and cirrhosis were more prevalent in transplantation group (P < 0.001). Resection patients had larger tumors [median 9 cm, interquartile range (IQR): 6.5-12.9 cm vs. median 4.1, IQR: 3.4-5.3 cm, P < 0.001]; transplant patients were more likely to have multiple tumors (78% vs 28%, P < 0.001).Overall (OS) and disease-free survival (DFS) were both greater after tumor downstaging and transplantation than resection (all P < 0.001). OS did not differ between liver transplant recipients who were not pretreated or pretreated and failed to downstage compared with propensity-matched liver resection patients (P ≥ 0.176); DFS in this propensity matched cohort was greater after liver transplantation (P ≤ 0.017). CONCLUSIONS: Liver resection and transplantation provide curative options for patients with HCC beyond Milan criteria. Further treatment strategies aimed at the efficiency and durability of tumor downstaging and expansion of the role of transplantation among suitable candidates could improve outcomes in patients with large or multifocal HCC.

The extraperitoneal laparoscopic TRAM flap delay procedure: an alternative approach.

INTRODUCTION: Ligation of the deep inferior epigastric vessels prior to transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction (delay procedure) was introduced to augment vascularity to the island flap through improved superior epigastric flow, thus decreasing flap morbidity. There are various surgical approaches described, including open and laparoscopic approaches, for ligation of inferior epigastric arteries. We describe an extraperitoneal laparoscopic technique (EPLT) and the outcomes of the procedure. METHODS: All patients who underwent EPLT prior to TRAM flap construction between July 2006 and December 2008 were included in the study. Data were analyzed retrospectively from a prospectively collected database. RESULTS: The study group included 11 female patients with mean age of 55 years and mean body mass index (BMI) of 34.4 kg/m(2). There were no conversions to open procedure. Ten patients had bilateral ligation of inferior epigastric arteries, and one patient had it only on one side. There were no complications related to the procedure. CONCLUSION: Extraperitoneal laparoscopic technique as a delay procedure for TRAM flap reconstruction is safe and feasible with no morbidity related to surgery.