Annals of Surgical Oncology最新文献

Background: Pancreatic neuroendocrine tumor liver metastases (PanNET LMs) are traditionally classified into three types based on their distribution. Surgery is generally considered for patients with type I/II LMs, while those with type III LMs are typically regarded as unresectable; however, type III LMs encompass a wide range of clinical scenarios, some of which may allow surgical resection.

Objective: The aim of this study was to identify preoperative predictors of early progression following surgery (≤6 months) in patients with PanNETs and LMs.

Methods: Consecutive patients with PanNETs and LMs who underwent surgery at San Raffaele Hospital (2010-2023) were included.

Results: After a median follow-up of 56 months, 18/54 patients (34%) experienced early disease progression. Female gender was identified as a protective factor (hazard ratio [HR] 0.373, p = 0.049), while age ≥ 70 years emerged as a significant risk factor (HR 2.744, p = 0.042) for early postoperative progression. When overall disease progression was considered as an outcome, female gender was confirmed as protective (HR 0.426, p = 0.010), while type III LMs significantly increased the risk of progression (HR 2.500, p = 0.012). In the subgroup of patients with type III LMs (n = 37), female gender was confirmed as the only predictor of longer progression-free survival (HR 0.332, p = 0.006).

Conclusions: This study highlights the potential role of surgery for patients with resectable or potentially resectable PanNETs and LMs. For patients with type III LMs, the role of surgery remains controversial. Nevertheless, surgery may still be an option in selected cases, particularly in younger patients and females, as part of a multidisciplinary treatment strategy.

Background: Locally advanced pancreatic cancer (LAPC) that involves more than 180° of contact with the superior mesenteric artery (SMA) is defined as unresectable. With advances in multimodal therapies, some cases with a favorable response to induction treatment have become candidates for resection.¹ Although divestment of the SMA is now widely adopted,^2,3 a standardized surgical technique for resecting tumors that encircle the SMA has yet to be established.

Patients and methods: Three patients with LAPC received a median of 8 months of chemotherapy and a total radiation dose of 50.4 gray (Gy) in 28 fractions (preoperative chemoradiotherapy, CRT) with oral S-1, followed by conversion pancreaticoduodenectomy with SMA divestment. The chemotherapy regimen and timing of radiation therapy varied by case: the first case received gemcitabine monotherapy after CRT, the second case received CRT after gemcitabine plus nab-paclitaxel (GnP), and the third case received CRT after GnP, followed by a switch to modified fluorouracil, irinotecan, and oxaliplatin (mFOLFIRINOX) before surgery.

Results: All patients satisfied the ABCD criteria, which included (A) tumor shrinkage, (B) normalization of cancer antigen (CA)19-9 levels, (C) a modified Glasgow Prognostic Score of 0, and (D) a minimum of 6 months of chemotherapy.⁴ Each patient underwent circumferential SMA adventitia divestment and portal vein resection. Postoperative courses were favorable, with a median hospital stay of 17 days, although one patient required readmission owing to delayed pancreatic fistula. The resection margins were measured at 0.9 mm, 1.4 mm, and 4.0 mm, respectively.

Conclusions: Circumferential divestment of the SMA for LAPC can be safely performed following chemoradiotherapy, yielding favorable short-term outcomes.

Background: A radiomics model constructed from the intratumoral region of computed tomography (CT) can predict the pathologic T stage of clear cell renal cell carcinoma (ccRCC). However, the predictive capability of the radiomics model that incorporates both intra- and peritumoral regions of CT for the pathologic T stage in ccRCC patients has not been reported to date.

Methods: This study enrolled 250 patients with ccRCC who underwent laparoscopic surgery. Three radiomics models were developed based on the intra- and peritumoral regions. The sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curves of each model were analyzed. Decision curve analysis (DCA) and calibration curves were used to assess the net benefit and calibration ability of the models. Additionally, the diagnostic performance of the different models were compared with that of radiologists.

Results: The radiomics model based on the intra- and peritumoral regions at 5 mm exhibited the strongest performance, with area under curve values of 0.91 (95 % confidence interval [CI], 0.8551-0.9650), 0.85 (95 % CI, 0.7490-0.9517), and 0.873 (95 % CI, 0.7612-0.9839) in distinguishing high and low T stages of ccRCC across the training, validation, and test sets, respectively. The model's accuracy in the training, validation, and test sets was 0.798, 0.732, and 0.769, with corresponding sensitivity values of 0.921, 0.857, and 0.882, and specificity values of 0.747, 0.690, and 0.729. The calibration curve demonstrated a high level of agreement between the predicted and actual outcomes, whereas the DCA showed that the model provided a meaningful net benefit.

Conclusions: The radiomics model based on the intra- and peritumoral regions of CT has certain value in distinguishing between high and low T stages of ccRCC.

Background: Total vascular exclusion (TVE) of the liver preserving the caval flow with portal hypothermic perfusion and temporary portacaval shunt (PCS) is a validated technique for tumors invading the hepatic veins (HV) close to their confluence with the inferior vena cava (IVC). It prevents the risk of haemorrhage, gas embolism and avoids the haemodynamic consequences of clamping the IVC and veno-venous bypass. No published cases have reported using hypothermic oxygenated perfusion machine.

Patients and methods: The patient was a 58-year-old woman presenting a recurrent metastatic pleural chondrosarcoma, with a pleural metastasis and several intra-abdominal metastases, including a lesion localized in segment 1 close to the hilar plate and invading the left HV near its abutment in the IVC. A left hepatectomy enlarged to segment 1 was performed under TVE preserving the caval flow with in situ hypothermic portal perfusion of the liver using perfusion machine.

Results: PV clamping lasted 57 min, and 2 l of preservative solution were perfused. The maximum pressure in the PV was 10 mmHg and oxygen flow was regulated at 2 L/min. The resection was complete and margins were negative. Liver temperature was monitored at 5-6 °C. Postoperative follow-up was favourable, with hospital discharge at 16 days after surgery.

Discussion: The use of hypothermic oxygenated perfusion machine is therefore possible in this technique. In parallel with the results obtained in liver transplantation on marginal grafts, it could probably reduce ischemia-reperfusion injury of the remnant parenchyma compared with static cold storage and improve post-operative outcome.