Optimal Region of Lymph Node Dissection in Distal Pancreatectomy for Left-Sided Pancreatic Cancer Based on Tumor Location.

BACKGROUND: The optimal lymph node (LN) dissection for left-sided pancreatic cancer based on tumor location has remained unknown. In particular, the efficacy of LN dissection around the common hepatic artery and the celiac axis for distal tumors has not been established. This study was designed to elucidate the frequency and prognostic impact of LN metastasis, focusing on tumor location. METHODS: Data from 110 patients with invasive pancreatic cancer who underwent distal pancreatectomy between 2007 and 2020 were collected. We used a quantitative value-the distance between the left side of the portal vein and the right side of tumor (DPT)-to define the tumor location. LN stations were divided into two groups: peripancreatic lymph nodes (PLN) and non-PLN. We then analyzed the frequency of LN metastasis based on the tumor location and prognostic factors. RESULTS: Non-PLN metastasis was observed in 7.3% of patients. Non-PLN metastasis was found only in patients with a DPT < 20 mm. Patients with non-PLN metastasis exhibited a significantly worse prognosis than those with only-PLN metastasis (median survival time: 20.3 vs. 42.5 months, p = 0.048). Multivariate analysis for survival indicated that tumor size > 4 cm (hazard ratio [HR]: 2.23, p = 0.012) and metastasis in the non-PLN region (HR: 3.02, p = 0.015), and inability to undergo adjuvant chemotherapy (HR: 2.81, p = 0.0018) were also associated with poor prognosis. CONCLUSIONS: Dissection of the non-PLN region can be avoided in selected patients with DPT ≥ 20 mm.

Strategy of Pancreatectomies for Pancreatic Ductal Adenocarcinoma in Patients with a History of Gastrectomy.

Recently, the incidence of pancreatectomy for patients with a history of upper abdominal surgery has been increasing. The clinical courses of 307 patients who underwent the pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) were retrospectively reviewed to clarify the impact of a history of gastrectomy in patients undergoing a pancreatectomy for PDAC. Among 307 patients, 28 (9.1%) had a history of gastrectomy, while 279 did not. We compared the difference in clinical course and prognostic outcomes between the groups. In patients with a history of gastrectomy, the 5-year survival rate was 17.6%, which was relatively poorer than that of patients without it (33.4%, P = 0.1329). A multivariate analysis of factors associated with the overall survival rate identified the low preoperative body mass index [BMI < 20.3 kg/m2, hazard ratio (HR) 1.646, P = 0.0190] and adjuvant chemotherapy (not-completed, HR 1.652, P = 0.0170) as independent prognostic factors. In patients with a history of gastrectomy, there were significantly more patients with poor prognostic factors, including a low preoperative BMI (P = 0.0009) and low completion rate of adjuvant chemotherapy (P = 0.0294) as compared with those without a history of gastrectomy. A low preoperative BMI significantly reduced the completion rate of adjuvant chemotherapy (P = 0.0186), which may lead to poor prognostic outcomes. In conclusion, perioperative nutritional management is important to reduce postoperative BMI loss and obtain a better prognosis after a pancreatectomy for PDAC in patients with a history of gastrectomy.

Six autoantibodies as potential serum biomarkers of hepatocellular carcinoma: A prospective multicenter study.

Serum autoantibodies have been reported to react with tumor-associated antigen (TAA) in various cancers. This multicenter study evaluated the diagnostic and prognostic value of six autoantibodies against a panel of six hepatocellular carcinoma (HCC)-associated antigens, including Sui1, p62, RalA, p53, NY-ESO-1 and c-myc. A total of 160 patients with HCC and 74 healthy controls were prospectively enrolled from six institutions. Serum antibody titers were determined by enzyme-linked immunosorbent assays. The sensitivities were 19% for Sui1, 18% for p62, 17% for RalA, 11% for p53, 10% for NY-ESO-1 and 9% for c-myc. Overall sensitivity of the TAA panel (56%) was higher than that of α-fetoprotein (41%, P < .05). The combined sensitivity of the TAA panel and α-fetoprotein was significantly higher than that of α-fetoprotein alone (P < .001). The difference in overall survival of TAA panel-positive and panel-negative patients was significant when the Stage I/II patients were combined (P = .023). Overall survival was worse in NY-ESO-1 antibody-positive than in NY-ESO-1 antibody-negative patients (P = .002). Multivariate analysis found that positivity for the TAA panel was independently associated with poor prognosis (P = .030). This TAA panel may have diagnostic and prognostic value in the patients with HCC.

The Risk of Developing Multiple Primary Cancers among Long-Term Survivors Five Years or More after Stomach Carcinoma Resection.

Recently, the number of long-term survivors of ≥ 5 years after stomach carcinoma resection is increasing in Japan. The clinical courses of 4,883 patients who underwent stomach carcinoma resection were retrospectively reviewed to investigate the cause of death including multiple primary cancers (MPC) and delayed stomach carcinoma recurrence among long-term survivors of ≥ 5 years. Of 3,061 patients who survived for ≥ 5 years, 1,203 patients (39.3%) were dead after 5 years survival, including 299 patients (24.9%) who died of MPC. Of 84 patients (7.0%) who died of recurrent stomach carcinoma, 25 patients were newly diagnosed ≥ 5 years postoperative. The most common site of MPC was lung in 124 patients, and 347 patients (44.7%) had a smoking-related MPC, including 124 lung, 63 esophagus, 62 head and neck, and 98 other cancers. We examined the prognostic differences in 527 patients with MPC according to the diagnosis time. In 325 patients of long-term survivors in whom MPC was diagnosed ≥ 5 years postoperative, 5-year survival rate and the median survival time after diagnosis were 35.1% and 17.7 months, respectively. This outcome was significantly poorer than that of 160 patients in whom MPC was diagnosed within 5 years postoperative (58.5% and 62.7 months, P < 0.0001). In conclusion, MPC accounted for approximately a quarter of the cause of death in long-term survivors. Lifestyle instructions including smoking cessation are important. Periodical cancer screening allows the early asymptomatic diagnosis and may contribute to a decrease in cancer mortality of MPC in long-term cancer survivors.

Albumin-Indocyanine Green Evaluation Grading System Predicts Post-Hepatectomy Liver Failure for Biliary Tract Cancer.

BACKGROUND: In biliary tract cancer treatment, a precise preoperative evaluation of the patient's liver function is essential to avoid post-hepatectomy liver failure (PHLF) and mortality. The present study aimed to evaluate the role of the Albumin-Indocyanine Green Evaluation (ALICE) grading system in predicting PHLF in biliary tract cancer patients. METHODS: Data from 166 patients who underwent hepatectomy for biliary tract cancer between 2000 and 2016 were retrospectively analyzed. Univariate and multivariate analyses were performed to identify the risk factors for PHLF. RESULTS: Among the 166 patients, major hepatectomy was performed in 101 (61%) and bile duct resection was performed in 99 (60%) patients. Thirteen (8%) patients developed PHLF. Furthermore, PHLF, major complications, and mortality were significantly higher in patients with high ALICE grades (≥2b) than in those with low ALICE grades (<2b) (PHLF, 42 vs. 18%, p = 0.002; major complications, 35 vs. 19%, p = 0.036; mortality, 9.3 vs. 0%, p = 0.001). In multivariate analysis, high ALICE grade (p = 0.016) and blood loss ≥1,500 mL (p = 0.009) were identified as independent risk factors for PHLF. CONCLUSIONS: The ALICE grading system effectively stratified the risks for PHLF for biliary tract cancer.

The RAS mutation status predicts survival in patients undergoing hepatic resection for colorectal liver metastases: The results from a genetic analysis of all-RAS.

INTRODUCTION: We investigated the impact of mutations in KRAS exons 3-4 and NRAS exons 2-3 in addition to KRAS exon 2, so-called all-RAS mutations, in patients with colorectal liver metastasis (CLM) undergoing hepatic resection. METHODS: We analyzed 421 samples from CLM patients for their all-RAS mutation status to compare the overall survival rate (OS), recurrence-free survival rate (RFS), and the pattern of recurrence between the patients with and without RAS mutations. RESULTS: RAS mutations were detected in 191 (43.8%). Thirty-two rare mutations (12.2%) were detected in 262 patients with KRAS exon 2 wild-type. After excluding 79 patients who received anti-EGFR antibody therapy, 168 were classified as all-RAS wild-type, and 174 as RAS mutant-type. A multivariate analysis of factors associated with OS and RFS identified the RAS status as an independent factor (OS; hazard ratio [HR] = 1.672, P = 0.0031, RFS; HR = 1.703, P = 0.0024). Recurrence with lung metastasis was observed significantly more frequent in patients with RAS mutations than in patients with RAS wild-type (P = 0.0005). CONCLUSIONS: Approximately half of CLM patients may have a RAS mutation. CLM patients with RAS mutations had a significantly worse survival rate in comparison to patients with RAS wild-type, regardless of the administration of anti-EGFR antibody therapy.

Survival of surgery for recurrent biliary tract cancer: a single-center experience and systematic review of literature.

BACKGROUND: For recurrent biliary tract cancer, chemotherapy is the standard treatment. However, the efficacy of surgery is unknown. Here, the prognostic benefit of surgery for recurrent biliary tract cancer was investigated. METHODS: Data of 206 patients who underwent surgery for biliary tract cancer between 2005 and 2015 were retrospectively analyzed. Of these, 107 recurrent patients were divided into two groups, surgery (n = 14) and non-surgery (n = 93) groups. In the latter group, 45 patients received chemotherapy and 48 received best supportive care. RESULTS: Of the total 121 sites of recurrence, the liver was the most common (n = 41), followed by locoregional recurrence (n = 32) and lymph nodes (n = 18). Surgery was performed in the 14 patients with recurrence, comprising nine patients with intrahepatic cholangiocarcinoma, three with perihilar cholangiocarcinoma, one with distal cholangiocarcinoma and one with gallbladder carcinoma. Survival after recurrence was significantly better after surgery than after chemotherapy or best supportive care (38% vs. 5.3% vs. 0% at 3 years and 19% vs. 5.3% vs. 0% at 5 years; P < 0.0001). Multivariate analysis identified the residual status of the primary tumor (hazard ratio = 1.58, 95% confidence interval = 1.00-2.44; P = 0.047), time to recurrence ≥1 year (hazard ratio = 0.62, 95% confidence interval = 0.39-0.97; P = 0.037) and surgery for recurrence (hazard ratio = 0.32, 95% confidence interval = 0.14-0.62; P < 0.001) as independent prognostic factors. CONCLUSIONS: Surgery for recurrent biliary tract cancer may prolong survival in patients with time to recurrence ≥1 year.

[A Case of a Patient with Distal Bile Duct Carcinoma Who Underwent Surgical Resection Three Times for Pulmonary Metastases].

A 63-year-old woman attended our hospital after diagnosis of a solitary pulmonary metastasis from a distal bile duct carcinoma. She had undergone a subtotal stomach-preserving pancreaticoduodenectomy 1 year 9 months prior to the current presentation. She was treated with right thoracoscopic pulmonary partial resection. The specimen was a solitary nodule 5 mm in diameter. In addition, she was treated with adjuvant chemotherapy involving GEM for 6 months. One year 5 months later, she was diagnosed with a second pulmonary metastasis and was treated with a left thoracoscopic partial resection. Four months later, she experienced recurrence in the right lung stump and was treated with right thoracoscopic partial resection. The specimen was a solitary nodule 21 mm in diameter. Cytopathologic examination of the pleural fluid resulted in a diagnosis of Class Ⅴ. She was treated with adjuvant chemotherapy involving TS-1 for 6 months. Seven months later, she was experienced recurrence with multiple pulmonary metastases and an affected hilar lymph node. GEM/CDDP chemotherapy was started, but bone multiple metastases developed. After she received 30 Gy of radiotherapy, her pain improved. She died of cancer 5 years and 4 months after her initial pancreaticoduodenectomy, which was 3 years and 4 months after her initial pulmonary resection. We identified 14 other case reports of long-term survivors of distal bile duct carcinoma.

[Recurrence of Rectal Cancer with Submucosal Invasion in the Bone and Lymph Nodes 89 Months after Surgery--A Case Report].

A woman in her 60s showed positive results on a fecal occult blood test and consulted her doctor. Early-stage cancer of the lower rectum was diagnosed, and a transanal local excision was performed. Histopathological examination revealed that the depth of submucosal invasion was ≧1,000 mm, and the submucosal invasive part of the tumor was a poorly differentiated adenocarcinoma. Therefore, she was referred to our hospital for additional resection. Intersphincteric resection was performed 11 months after the initial operation. The cancer stage was T1N0M0, Stage Ⅰ(UICC 7th edition), and the cancer did not recur. The patient visited our hospital again, 78 months after the additional resection, because of left hip-joint pain. Positron-emission tomography revealed fluorodeoxyglucose uptake in the left acetabulum, para-aortic lymph nodes, and left external iliac lymph nodes; these findings indicated recurrence of the rectal cancer. The patient received radiation therapy (57 Gy) and FOLFIRI; bevacizumab was added from the third course onward. The therapy reduced the size of the tumor recurrence in the bone. This was a rare case of rectal cancer with submucosal invasion that showed recurrence in the bone and lymph nodes 78 months after the additional resection.

Hepatectomy As A First Choice Treatment For Liver Metastasis From Gastric Cancer: A Single Center Experience.

BACKGROUND/AIMS: Indication of hepatectomy for liver metastases from gastric cancer (LMGC) is still controversial despite many papers favoring surgery. The aim of this study is to claim that we should accept hepatectomy as first choice treatment for LMGC. It is important to have a consensus on this matter for surgeons to treat LMGC properly. METHODOLOGY: Fifty three patients undergoing hepatectomy for LMGC from 1990 through 2010 were retrospectively analysed for survival and prognostic factors. Analyses were made on size, multiplicity, synchronicity and positive surgical margin as liver metastasis factors. Serosal invasion, node metastasis, histological differentiation and UICC stage were analysed as primary site factors. Multivariate analysis was performed for those positive for univariate analysis. RESULTS: Cumulative 5 year survival rate was 27%. Multiplicity, positive margin and node metastasis (N > 2) yielded significant difference on univariate analysis. On multivariate analysis multiplicity and node metastasis (N > 2) were significant. CONCLUSION: Hepatectomy for LMGC is potentially curative and should be regarded as first choice. Solitary and N < 3 are good prognostic factors.

[Useful device for hepatectomy in patients with a surgical history of bile duct-GI tract anastomosis at the porta hepatis].

We experienced three hepatectomies in patients with a history of bile duct-gastrointestinal (GI) tract anastomosis at the porta hepatis. Patient 1 had a history of pancreaticoduodenectomy for bile duct cancer. Because the third liver metastasis of cecal cancer postoperatively invaded the right kidney, after 5 courses of FOLFOX we performed partial resection of the liver (S6) and the right kidney using microwave pre-coagulation and a cavitron ultrasonic surgical aspirator (CUSA) without the Pringle method. Patient 2 had a history of splenectomy for congenital spherocytosis, cholecystectomy, choledocholithotomy, and bile duct duodenal anastomosis for hepatolithiasis. Partial (S5) liver resection was performed to treat hepatocellular carcinoma. Patient 3 had a history of bile duct resection and choledochojejunostomy for congenital cystic dilatation of the common bile duct. She had repeated episodes of cholangitis in the year following surgery. Extended liver segmental (S4) resection was performed to treat intrahepatic bile duct carcinoma. Bile duct jejunum anastomosis was performed, and the portal vein and the hepatic artery in the porta hepatis were exfoliated. Hepatectomy was performed using the Pringle method and a CUSA. Surgical procedures using various devices are necessary for hepatectomy in patients with a history of bile duct-GI tract anastomosis at the porta hepatis.

[A case of adenosquamous carcinoma of the ascending colon].

A 6 8-year-old man was admitted to our hospital with lower abdominal pain. Lower gastrointestinal endoscopy showed type 2 advanced cancer in the ascending colon. Histopathological examination after endoscopical biopsy revealed both moderately differentiated adenocarcinoma and well-differentiated squamous carcinoma. Subsequently, right hemicolectomy was performed. The tumor was 55 × 40 mm in size and was diagnosed as an adenosquamous carcinoma A, type 2, pSS, pN0, sH0, sP0, sM0, fStageII. Adenosquamous carcinoma is extremely rare, represents about 0.1% of all colorectal cancer, and usually has a poor prognosis. Thirty-one months after surgery, the patient is still in good health and displays no signs of recurrence.

[Transurethral resection of a intravesical recurrence of a tumor after resection of sigmoid colon cancer].

A 66-year-old man presented to the urology clinic with hematuria. Cystoscopy with biopsy was performed for suspected bladder cancer, and a pathological diagnosis of adenocarcinoma was made. Colonoscopy revealed sigmoid colon cancer, and he was referred to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) showed sigmoid colon cancer with urinary bladder invasion. Sigmoidectomy with lymph node dissection and partial cystectomy were performed under laparotomy. The pathological diagnosis was moderately differentiated adenocarcinoma: T4b (bladder), N1, M0, and the bladder margin was negative. Four months after surgery, CT revealed a small mass in the bladder. Cystoscopy showed a papillary pedunculated tumor at the bladder trigone, and a transurethral resection was performed. Pathological examination revealed a moderately differentiated adenocarcinoma, similar to the prior sigmoid colon cancer, which was diagnosed as an intravesical recurrence of the tumor. More than 8 years after the transurethral resection, the patient has shown no signs of recurrence.

Staging laparoscopy in advanced gastric cancer: usefulness and issues requiring improvement.

BACKGROUND/AIMS: We performed staging laparoscopy (SL) for advanced gastric cancer with suspicion of positive peritoneal cytology (CY) or peritoneal metastasis (P). This study was designed to show SL's utility in advanced gastric cancer. METHODOLOGY: This was a retrospective study of 124 patients with primary gastric cancer who underwent SL between October 2001 and March 2009. RESULTS: There were no perioperative complications without a case of bleeding. The patient breakdown was P0CY0, 67; P0CY1, 19; P1CY0, 6; and P1CY1, 32. Chemotherapy was administered as the initial treatment in 33 patients and the period from SL to chemotherapy was 19.5 days. In 7 patients undergoing laparotomy as the initial treatment but later requiring exploratory laparotomy or palliative surgery followed by chemotherapy, the period from laparotomy to chemotherapy was 36.8 days. The difference was significant (p<0.0001). P1 was confirmed in 10 (14.5%) of 69 patients undergoing laparotomy as the initial treatment. CY was re-examined in 53 of these 69 patients and CY1 was confirmed in 6 (13.3%) of 45 patients who were CY0 according to SL. CONCLUSION: With SL, early initiation of chemotherapy was possible for P1 patients. Although improved accuracy is required, SL, which can be carried out safely with minimal invasiveness, was suggested to be useful.

[Surgical management for more than 10 liver metastases from colorectal cancer].

We examined the clinical course of patients with multiple liver metastases (≥10) from colorectal cancer after hepatectomy. Of 455 patients, 336 patients had 1-4 metastases, 71 had 5-9 metastases, and 48 had ≥10 metastases (31 patients had undergone chemotherapy along with hepatectomy and 17 had not undergone chemotherapy). Chemotherapy was effective in improving the 5-year survival rate of patients with 5 or more metastases. The 5-year survival rate in patients who underwent hepatectomy along with chemotherapy (52.7%[1-4 metastases], 49.9%[5-9 metastases], and 42.3% [≥10; n=5]) was better than that in patients who did not undergo chemotherapy( 56.1%[not significant: ns], 13.1% [p=0.0003], and 0%[p<0.0001], respectively). Five patients with ≥10 liver metastases survived for 5 years after hepatectomy, of which, 1 received FOLFOX (Leucovorin plus 5-FU plus oxaliplatin) adjuvant chemotherapy, 2 received preoperative FOLFOX, and 2 received LV5FU2 (5-FU plus Leucovorin) hepatic arterial infusion chemotherapy. Our results suggest that long-term improvement in prognosis could be possible with aggressive repeat hepatectomy along with effective chemotherapy.

[A case of laparoscopic partial hepatectomy and splenectomy for hepatocellular carcinoma and pancytopenia].

A 69-year-old woman with chronic hepatitis B and esophageal varices was admitted to our hospital because of a hepatocellular carcinoma( HCC) measuring 3 cm in segment S3. Computed tomography( CT) scan revealed splenomegaly, and the platelet count was 6.0×104/µL. Partial hepatectomy and splenectomy were performed sequentially under laparoscopic guidance in a right half-lateral decubitus position, using 7 working ports. The operation time was 237 min, and the amount of bleeding was 26 mL. Her postoperative course was uneventful, and she was discharged on the 10th day after the operation.

[A case of superficial carcinoma in a diverticulum of the thoracic esophagus].

An upper gastrointestina(l GI) series revealed a diverticulum in the anterior wall of the middle thoracic esophagus of a 72-year-old man. Endoscopy revealed a type 0-IIc lesion in the esophageal diverticulum. The margin of the lesion was unclear. Biopsy proved that it was squamous cell carcinoma. Endoscopic ultrasonography showed that the deepest layer of the tumor was the lamina propria mucosae (cT1a-LPM) and that the underlying muscularis propria was thinning. No distant metastasis or regional lymph node metastasis was detected. Diverticulectomy or endoscopic submucosal dissection (ESD) was out of indication due to the unclear margin and thin muscularis propria. We conducted mediastinoscopy-assisted esophagectomy. The pathological diagnosis of the resected specimen was moderately differentiated squamous cell carcinoma with invasion to the lamina propria mucosae (pT1a-LPM). Pathological examination proved the thinning of the underlying muscularis propria in the diverticulum. The patient is alive without recurrence at 6 months after surgery.

[A case study of pulmonary and pancreatic metastasis from primary renal cell carcinoma more than ten years after nephrectomy].

A 73-year-old man, who had a left nephrectomy for renal cell carcinoma at the age of 58, visited our hospital for the treatment of 2 right lung tumors. Both tumors were resected. Immunopathology showed that one of these was a metastatic tumor from renal cell carcinoma, and the other was a primary lung adenocarcinoma. Four years later, a follows-up computed tomography showed a hypervascular nodule in the body of the pancreas. Distal pancreatectomy and spleenectomy were performed, and histopathological analysis revealed that the tumor was a metastasis from renal cell carcinoma. Three months after surgery, multiple liver metastases were discovered, and molecular-targeted therapy was started. If a distant metastasis from renal cell carcinoma can be resected completely, it has been reported that a good long-term prognosis can be expected. Therefore, postoperative long-term follow-up after resection of the renal cell carcinoma is essential, and if possible, the resection of metastasis should be considered.

[A case report of surgical treatment for axillary lymph node metastasis from descending colon cancer].

We report a rare case of a 78-year-old woman with metachronous axillary lymph node metastasis originating from descending colon cancer. Her past medical history included right mastectomy for breast cancer at age 53 and distal gastrectomy for gastric cancer at age 70. She underwent a left hemicolectomy for descending colon adenocarcinoma in April 2011. Four months after that operation, 3 enlarging nodules in the left lung and a swollen left axillary lymph node were detected by computed tomography. No tumor was detected in the left breast by ultrasonography and mammography. The lung tumors were resected thoracoscopically, and the left axillary lymph node was excised. These specimens were histologically diagnosed as moderately differentiated adenocarcinoma, which had metastasized from colon cancer, not from the previous breast or gastric cancer. She received adjuvant chemotherapy with uracil and tegafur (UFT) plus Leucovorin for 6 months and is still alive after 12 months without recurrence.

Conversion surgery for initially unresectable advanced biliary tract cancer treated with gemcitabine plus cisplatin combination chemotherapy: a case report and literature review.

Recently, the number of reports describing patients with initially unresectable biliary tract cancer (BTC) who underwent resection in the form of conversion surgery is increasing. Gemcitabine plus cisplatin (GC) combination therapy has been reported to significantly prolong the median survival time from 8.1 to 11.7 months compared with conventional gemcitabine therapy in patients with unresectable BTC. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy. A 78-year-old woman was diagnosed with unresectable BTC with invasion of the right hepatic artery by lymph node metastasis and liver metastases. The patient received GC combination therapy. After 6 cycles of chemotherapy, the patient achieved a partial response. The radiological findings revealed a marked shrinkage in the primary lesion and the disappearance of lymph node and liver metastases. Therefore, the patient underwent conversion surgery, including biliary tract resection and regional lymph node dissection. For postoperative follow-up, the patient was monitored without receiving adjuvant chemotherapy. The patient had not exhibited recurrence during the 12-month follow-up period. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy.