Robotic resection of a single adenoid cystic tumor liver metastasis using ICG fluorescence. A case report and literature review.

Adenoid cystic carcinoma (AdCC) is a rare tumor that typically develops in the salivary glands and less frequently in other sites of the head and neck region. Only a few cases of resected metachronous liver metastases have been reported. Minimally invasive surgery is currently the gold standard of care for liver resections; furthermore, the use of Indocyanine Green (ICG) is continuously increasing in surgical practice, especially in cases of primary liver tumors and colorectal liver metastases, due to its capacity to enhance liver nodules. We report the case of a 54-year-old male with a single liver metastasis of AdCC, located in SIII, who presented in our center 9 months after resection of a primary tumor of the laryngotracheal junction and adjuvant proton therapy. A 25-mg injection of ICG (0.3 mg/kg) was administered 48 h before surgery in order to highlight the tumor and perform an ICG-guided resection. The lesion was clearly visible during surgery, and, given its position and the proximity to the main lobar vessels of the left lobe, we opted for a left lateral sectionectomy. The outcome was unremarkable, with no major postoperative complications. The administration of ICG 48 h before surgery seems to be a valid tool even in cases of AdCC liver metastases, providing surgeons with better visualization of the lesion and improving the precision of the resection.

The role of robotic surgery for the treatment of hilar cholangiocarcinoma: A systematic review.

Background: The role of robotic surgery (RS) for hilar cholangiocarcinoma (HC) is under investigation. Surgical resection is the only curative modality of treatment but extremely complex and high risk of morbidity and mortality may occur. The aim of this study is to perform a systematic review of perioperative and oncological outcomes of RS for HC, across a comprehensive range of outcomes reported in recent literature. Materials and Methods: PRISMA checklist was used as a basis for writing the systematic review and studies' selection. Literature documenting RS for HC was analyzed by searching PubMed and Cochrane Library from 2009 to May 2022. The search terms, either independently or in combination, were used according to PICOT framework. The target population are patients treated with robotic surgical approach for HC. Results: 12 studies with 109 patients were included after screening process. The Bismuth classification in all series except one was: 21 type I, 7 type II, 12 type IIIa, 26 type IIIb and 4 type IV. Mean operative time for a total of 21 patients was 644 minutes. Other two case series reported a median operative time of 375 with a console time of 276 minutes. Mean blood loss for case reports and two case series was 662 milliliters. Blood transfusion rate for all operation was 33.3%. Overall Conversion rate was 2.8%. Pooled post operative morbidity and mortality was 39.8% and 1.8% respectively. Mean LOS for case reports and one case series for a total of 17 patients was 16 days. R0 resection rate for the 11 papers was 74.3%. Seven out of 12 studies reported on the oncological follow up: median observation time ranged from 5 to 60 months, recurrence rate was 52.6% (range 0-90%) reported only in 19 patients (10/19). Conclusions: RS for HC was feasible and safe. However, although this systematic review could not be conclusive in most of the analyzed items, RS for the treatment of HC could represent the best tool for a future meticulous and precision surgery. The review's results certainly indicate that further research in urgently is required on this field.

Impact of Positive Radial Margin on Recurrence and Survival in Perihilar Cholangiocarcinoma.

In resected perihilar cholangiocarcinoma (PHC), positive ductal margin (DM) is associated with poor survival. There is currently little knowledge about the impact of positive radial margin (RM) when DM is negative. The aim of this study was to evaluate the incidence and the role of positive RM. Patients who underwent surgery between 2005 and 2017 where retrospectively reviewed and stratified according to margin positivity: an isolated RM-positive group and DM ± RM group. Of the 75 patients identified; 34 (45.3%) had R1 resection and 17 had positive RM alone. Survival was poorer in patients with R1 resection compared to R0 (p = 0.019). After stratification according to margin positivity; R0 patients showed better survival than DM ± RM-positive patients (p = 0.004; MST 43.9 vs. 23.6 months), but comparable to RM-positive patients (p = 0.361; MST 43.9 vs. 39.5 months). Recurrence was higher in DM ± RM group compared to R0 (p = 0.0017; median disease-free survival (DFS) 15 vs. 30 months); but comparable between RM and R0 group (p = 0.39; DFS 20 vs. 30 months). In univariate and multivariate analysis, DM positivity resulted as a negative prognostic factor both for survival and recurrence. In conclusion, positive RM resections appear to have different recurrence patterns and survival rates than positive DM resections.

Microwave Thermal Ablation in an Unusual Case of Malignant and Locally Advanced Rare Tumor of Pancreas in ASA IV Old Male Patient and Literature Review.

Pancreatic intraductal papillary-mucinous neoplasm is a rare primary neoplasm of unknown pathogenesis. This kind of tumor represents 0.2-2.7% of all pancreatic cancers and they may proceed to malignant lesions. In this study, we describe a case of pancreatic intraductal papillary-mucinous tumor (4.3 cm) with normal tumoral markers and nuclear atypia. We perform also a systematic review of the literature on MEDLINE and find only one relevant study that used microwave ablation for the palliative treatment of pancreatic tumor. We describe the case of a 70-year-old Caucasian male who was diagnosed with a pancreatic tumor with biliary tree dilatation. The patient underwent computed tomography (CT), percutaneous biopsy, and an endoscopic positioning of prosthesis in the biliary tree. Due to the worsening of jaundice and cholestasis, and considering the severe systemic disease status, palliative surgery with microwave thermoablation in the head of pancreas was performed. No complications were observed. The hospitalization lasted for 11 days after surgery, with normal liver and pancreatic lab tests at discharge. The patient followed a line of chemotherapy for 6 months with a complete response for 8 months. One month after the treatment, a staging CT scan was performed showing the size of the cephalopancreatic lesion had decreased from 43 to 35 mm with signs of complete ablation. The patient had a total response at the imaging of 10 months. One year later, a CT scan follow-up showed progression of the pancreatic disease. The disease remained stable for 18 months. The patient died due to cardiovascular complications with an overall survival of 30 months. Microwave ablation in our case report has been demonstrated to be feasible and safe without complications. It can be used as a phase of multimodality treatment in patients with severe systemic disease status and advanced intraductal papillary-mucinous neoplasm.