Identification of patients at high risk for recurrence in carcinoma of the ampulla of Vater: Analysis in 460 patients.

Aim: Carcinoma of the ampulla of Vater (CAV) shows a favorable prognosis compared to that with the other periampullary tumors, while some cases have a poor prognosis. The aims of the present study are to clarify the clinicopathological factors associated with poor recurrence-free survival (RFS) in patients with CAV after curative resection and to validate the usefulness of adjuvant chemotherapy (AC). Patients: The study design is a multicenter retrospective cohort study. Patients with CAV who underwent pancreaticoduodenectomy between January 2008 and December 2020 at 26 hospitals were analyzed. The 30 clinicopathological factors were evaluated. A propensity score matching (PSM) was used to compare between patients with and without AC. Results: Finally, 460 patients were analyzed. Median duration of follow-up was 47.2 months. Twenty-one prognostic factors associated with poor RFS were identified by univariate analysis. In multivariate analysis, aged ≥71, tumor diameter ≥12 mm, pT2 or higher stage (pT≥2), portal vein invasion (PV+), venous invasion(V+), and node positive disease (pN+) were independent prognostic factors for poor RFS. Out of 80 patients who received AC, 63 patients were assigned to analysis for PSM. The results showed no beneficial effect of AC on RFS. The preoperative factors potentially predicting pT≥2, V+, and/or N+ were at least one of following; (1) CA19-9 > 37 IU/mL, (2) ulcerative or mixed type appearance, (3) except for well-differentiated tumor, or (4) except for intestinal subtype of histology. Conclusions: Aged ≥71, tumor diameter ≥12 mm, pT≥2, PV+, V+, and pN+ were independent prognostic factors for poor RFS in patients with CAV. An additional therapeutic strategy may be desirable in CAV patients at high risk for recurrence.

Impact of anatomical liver resection on patient survival in KRAS-wild-type colorectal liver metastasis: A multicenter retrospective study.

BACKGROUND: Liver resection is a standard therapy for colorectal liver metastasis. However, the impact of anatomical resection and nonanatomical resection on the survival in patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated colorectal liver metastasis remain unclear. We investigated whether anatomical resection versus nonanatomical resection improves survival in colorectal liver metastasis stratified by Kirsten rat sarcoma mutational status. METHODS: Among 639 consecutive patients with colorectal liver metastasis who underwent primary liver resection between January 2008 and December 2017, 349 patients were excluded due to their unknown Kirsten rat sarcoma mutational status, or due to receiving anatomical resection with concomitant non-anatomical resection, radiofrequency, or R2 resection. Accordingly, 290 patients with colorectal liver metastasis were retrospectively assessed. The relationships between resection types and survival were investigated in Kirsten rat sarcoma-wild-type and -mutated groups. RESULTS: Anatomical resection was performed in 77/186 (41%) and 44/104 (42%) patients with Kirsten rat sarcoma-wild-type and Kirsten rat sarcoma-mutated genetic statuses, respectively. For both, the clinical-pathologic factors were comparable, except a larger maximum tumor size and surgical margin were observed in anatomical resection cases. Anatomical resection patients had significantly longer recurrence-free survival and overall survival than nonanatomical resection cases in the Kirsten rat sarcoma-wild-type group (recurrence-free survival, P < .001; overall survival, P = .005). No significant recurrence-free survival or overall survival differences were observed between Kirsten rat sarcoma-mutated anatomical resection and non-anatomical resection (recurrence-free survival, P = .132; overall survival, P = .563). Although, intrahepatic recurrence in Kirsten rat sarcoma-wild-type and -mutated colorectal liver metastasis was comparable (P = .973), extrahepatic recurrence was increased in Kirsten rat sarcoma-mutated versus -wild-type colorectal liver metastasis (P < .001). CONCLUSION: In contrast to Kirsten rat sarcoma-mutated colorectal liver metastasis with higher extrahepatic recurrence after liver resection, local liver control via anatomical resection improved the postoperative survival in patients with Kirsten rat sarcoma-wild-type colorectal liver metastasis.

Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy.

PURPOSE: Pancreas-sparing duodenectomy (PSD) represents an alternative procedure to pancreatoduodenectomy (PD) for patients with duodenal neoplasms. METHODS: The postoperative early and late complications of 21 patients who underwent PSD between 1992 and 2014 were compared with those of 44 patients with soft pancreatic parenchyma who underwent PD between 2009 and 2014. RESULTS: The median operation time and blood loss were less in the PSD group than in the PD group (P < 0.001). The overall incidence of early complications was less in the PSD group than in the PD group (PSD with ampullectomy vs. PSD without ampullectomy vs. PD; 45.5 vs. 20.0 vs. 56.8 %). The incidence of pancreatic fistula formation and overall incidence of late complications were also less in the PSD group than in the PD group (P = 0.031, 0.020). There were no complications related to the pancreatic endocrine or exocrine functions in the PSD group. CONCLUSION: PSD is a less-invasive procedure and has the advantage over PD of preserving the pancreas.

Preoperative Sarcopenia Strongly Influences the Risk of Postoperative Pancreatic Fistula Formation After Pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy (PD). Sarcopenia is a newly identified marker of frailty. We performed this study to assess whether preoperative sarcopenia has an impact on clinically relevant POPF formation. METHODS: A total of 266 consecutive patients who underwent a PD between 2010 and 2014 were enrolled in this retrospective study. Skeletal muscle mass was measured using preoperative computed tomography images. The impact of preoperative sarcopenia on clinically relevant POPF formation was analyzed using univariate and multivariate analyses. RESULTS: Of the 266 patients, 132 (49.6 %) were classified as having preoperative sarcopenia. The rate of clinically relevant POPF formation was significantly higher in the sarcopenia group (22.0 vs. 10.4 %; P = 0.011). A multivariate logistic regression analysis showed that sarcopenia (odds ratio, 2.869; P = 0.007) was an independent risk factor for the development of clinically relevant POPF, along with a soft pancreas and a parenchymal thickness at the pancreatic resection site of ≥8 mm. CONCLUSIONS: Preoperative sarcopenia was identified as a strong and independent risk factor for clinically relevant POPF formation after PD. Perioperative rehabilitation and nutrition therapy may contribute to the prevention of POPF formation and a safer PD.

A resected case of intraductal tubulopapillary neoplasm of the pancreas: report of a case.

The patient was a 61-year-old male who was referred to our hospital after dilatation of the main pancreatic duct was detected by screening ultrasonography. Computed tomography revealed a protruding lesion measuring 15 mm in diameter within the main pancreatic duct in the head of the pancreas, and magnetic resonance cholangiopancreatography revealed interruption of the duct at the tumor site. We performed pancreaticoduodenectomy under a suspected diagnosis of invasive ductal carcinoma. Gross examination of the resected specimen showed that the tumor invaginated into the main pancreatic duct, and no mucin was found. Histological examination revealed proliferation of high-grade dysplastic cells in a tubulopapillary growth pattern. Immunohistochemically, cytokeratin 7 expression was detected, but not trypsin expression. Based on these morphological features, we diagnosed the tumor as intraductal tubulopapillary neoplasm (ITPN). We report the case with bibliographic consideration, together with a review of intraductal neoplasms of the pancreas encountered at our institution.

A case of mucinous cystic neoplasm of the liver: a case report.

A 71-year-old woman was referred to our institution for further investigation of epigastric pain. The patient had been detected to have a multilocular cyst in the medial segment of the liver measuring 69 mm in diameter at another hospital 2 years ago, and the diameter of the cyst had increased to 90 mm. Although the cyst had gradually increased in size, there was no evidence of mural nodules. As we were concerned about the malignant potential of the lesion, a left hepatic segmentectomy was performed. Pathologically, the cyst was lined by columnar and cuboidal epithelium with low-grade atypia. The epithelium covered an ovarian-like stroma, and the diagnosis was mucinous cystic neoplasm of the liver (MCN-L) with low-grade intraepithelial neoplasia. MCN-L is a rare disease and its characteristics are still poorly understood. MCN-L occurs at a lower frequency as compared to the counterpart of MCN of the pancreas, further investigations are necessary to clarify the biological malignancy of MCN-L.

Intraoperative circulatory management using the FloTrac™ system in laparoscopic liver resection.

INTRODUCTION: Several studies have shown that maintenance of the central venous pressure at a low level during liver surgery is effective for intraoperative management. However, others have suggested that stroke volume variation (SVV) may be a better predictor of fluid responsiveness than central venous pressure. The purpose of this study is to conduct a new type of circulatory management using the FloTrac(TM) system in laparoscopic liver resection and to evaluate specific fluctuations in SVV. METHODS: Of the laparoscopic liver resections that we performed between March 2012 and December 2013, we used the FloTrac system for intraoperative circulatory management in 21 cases. We analyzed the data, mainly the average value of SVV. RESULTS: The average SVV value during liver transection was 5.2%-24.6% (mean, 17.0%), and 18 cases (86%) exceeded the conventional cut-off value (13%). The average SVV value was 4.3%-18.2% (mean, 9.7%) when pneumoperitoneum was not in effect, whereas it was 7.3% greater on average during liver transection (mean, 17.0%). No perioperative complications developed. CONCLUSION: The average SVV value during laparoscopic liver transection (mean, 17.0%) exceeded the conventional cut-off value, but in this study, no perioperative complications developed, which enabled safe management. We might be able to manage appropriate fluid control using FloTrac system in patients with laparoscopic liver resection. Therefore, it is necessary to set the target SVV and conduct prospective trials to verify the safety margin for intraoperative management in the future.

Mesenteric leiomyosarcoma in a 13-year-old boy.

Mesenteric leiomyosarcoma occurs most commonly in middle-aged individuals. Primary tumors of the mesentery are uncommon in pediatric and adolescent patients, and primary mesenteric leiomyosarcoma is particularly rare. Accurate preoperative diagnosis of mesenteric soft tumor is generally difficult. We describe a case of leiomyosarcoma arising from the ileal mesentery in a 13-year-old boy. The diagnosis was based on histopathologic evaluation using immunohistochemical staining and gene analysis.

[A case of interstitial pneumonitis induced by FOLFIRI+bevacizumab combination therapy for liver and lung metastasis of colon cancer].

A 64 -year-old female received oral S-1 chemotherapy followed by mFOLFOX6 chemotherapy for postoperative liver and lung metastasis of sigmoid colon cancer. The tumor progression was observed after twelve courses of mFOLFOX6 chemotherapy, and then FOLFIRI+bevacizumab chemotherapy was performed. After two courses of FOLFIRI+bevacizumab chemotherapy, leucopenia was observed. The chemotherapy was then discontinued and G-CSF was administered. Two days later she complained of high fever and dry cough, and was admitted to the hospital. A diffuse ground-glass appearance of bilateral lung was observed on chest X-ray and CT. Drug-induced interstitial pneumonitis was suspected, and Pneumocystis carini pneumonia was considered in the differential diagnosis. Oral administration of prednisolone and sulfamethoxazole/trimethoprim did not improve the symptoms, so steroid pulse therapy was performed. Steroid pulse therapy improved respiratory symptoms, but CT findings did not change remarkably. After nine weeks in the hospital, she was discharged with home oxygen therapy. Interstitial pneumonitis induced by FOLFIRI+bevacizumab chemotherapy is rare, but the number of cases may increase with increased use of this regimen. The possibility of interstitial pneumonitis should always be considered when the patient presents with a respiratory disorder while receiving systemic chemotherapy.

[A successfully resected case of liver metastasis of gastrointestinal stromal tumor responding to neoadjuvant chemotherapy with imatinib mesylate and interventional radiology].

A 75-year-old woman underwent resection of gastrointestinal stromal tumor (GIST) of small intestine in 1999. In January 2006, she suffered liver dysfunction and abdominal CT revealed she had a large liver metastasis. At first the tumor in the right lobe progressed to the medial segment and seemed unresectable. She twice underwent transarterial embolization and treatment with 400mg/day of imatinib mesylate. Then percutaneous transhepatic portal embolization was performed. As a result, liver metastasis markedly decreased in size, and extended right lobectomy of the liver was performed in June 2006. A large portion of the liver metastasis showed necrosis, but histopathological examination revealed focal remnants of viable tumor cells. In March 2007, radiofrequency ablation was performed for recurrence of remnant liver. The patient has been treated by imatinib mesylate and is alive with no evidence of tumor recurrence.