Annals of Surgical Oncology最新文献

Background: Locally advanced pancreatic adenocarcinomas (LA-PDAC) are more frequently operated now than in the past because of new regimen chemotherapy and improvement in surgical technique.¹ Resection of the coeliac trunk (CT) during pancreatoduodenectomy (PD) or total pancreatectomy (TP) is not routinely done owing to the risk of liver and gastric ischaemia.² In this video, a patient with LA-PDAC underwent TP with CT resection and retrograde gastric revascularization through the distal splenic artery.

Patients and methods: A 57-year-old male with LA-PDAC at the head-neck junction with circumferential invasion of the CT and the mesentericoportal axis showed excellent response to chemotherapy (FOLFIRINOX, 12 cycles) and radiotherapy (54 Gy) with normalization of tumour markers. One year later, TP instead of PD was decided to avoid postoperative pancreatic fistula.³ An allograft (en Y) from bank vessels was anastomosed between the aorta and the propre hepatic artery. For gastric revascularization and to avoid the small left gastric artery, the arterial anastomosis was done on the distal part of the splenic artery, allowing retrograde vascularization through short gastric vessels. Segmental venous resection was done.

Results: Venous and arterial liver ischaemia times were 11 min and 31 min, respectively. The postoperative outcome showed asymptomatic pseudoaneurysm on the hepatic anastomosis. Pathology confirmed T1cN1R0. Nine months after surgery, no recurrence was observed.

Conclusion: CT resection may be needed during PD. If the right gastric pedicle cannot be preserved, retrograde gastric revascularization through the splenic artery is an important technical modification. The availability of allografts from bank vessels is very useful, and the outcome is mitigated by TP.

Background: Flat epithelial atypia (FEA), a rare breast proliferative lesion, is often diagnosed following core biopsy (CB) of mammographic microcalcifications. In the prospective multi-institution TBCRC 034 trial, we investigate the upgrade rate to ductal carcinoma in situ (DCIS) or invasive cancer following excision for patients diagnosed with FEA on CB.

Patients and methods: Patients with a breast imaging reporting and data system (BI-RADS) ≤ 4 imaging abnormality and a concordant CB diagnosis of FEA were identified for excision. Upgrade rates were determined on the basis of local and central pathology review. The prespecified threshold to omit excision of FEA on CB was an upgrade rate of ≤ 3%. Sample size and confidence intervals were based on exact binomial calculation.

Results: Overall, 129 patients underwent excision (median age 50 years, range 30-84 years). After local pathology review, 6/129 patients (4.7%; 95% CI 1.7-9.8%) were upgraded to invasive carcinoma (n = 3) or DCIS (n = 3) at excision. Among 116 patients with CB available for central pathology review, FEA was confirmed in 78 (67.2%, 95% CI 57.9-75.7%). Of these, only one patient was upgraded to DCIS (1.3%; 95% CI 0.03-6.9%), which was also one of the locally upgraded cases. Among the other five local upgrades, two did not have CB available for central review, two CB had ADH, and one CB had normal tissue on central review.

Conclusions: Among patients with FEA on CB, the upgrade rate was 4.7% based on local pathology review and 1.3% based on central pathology review. These findings highlight the importance of shared decision-making in the management of FEA.

Introduction: Children and young adults diagnosed with sarcoma often present with pulmonary metastases requiring wedge resection. It is important to balance the risk of pulmonary recurrence against the desire to limit resection of benign parenchyma. This study aims to determine the impact of resection margins on survival and recurrence among pediatric and young adult sarcoma patients.

Patients and methods: We conducted a retrospective cohort study of patients ages 25 years and younger with primary or recurrent osteogenic, Ewing's, or soft tissue sarcoma who underwent pulmonary metastasectomy (2006-2022). Margins were categorized as > 1 mm, ≥ 5 mm, or ≥ 10 mm length. Two-year overall survival (OS), disease-free survival (DFS), and regional disease-free survival, consisting of pulmonary recurrence following metastasectomy, were analyzed using the Kaplan-Meier method. Cox analysis utilized patient, tumor, and treatment factors to predict risk of death and/or recurrence.

Results: In total, 122 patients were identified for analysis. The median number of wedge resections was 3.5, median nodule size was 12.5 mm, and median margin length was 3 mm. A 5-mm margin was associated with improvements in DFS and regional-DFS (10.6% vs. 29.7%, p = 0.01 and 10.7% versus 31.1%, p = 0.005, respectively). On Cox analysis, margin length was not associated with OS (p > 0.05); however, 5 mm (HR 0.46, p = 0.005) and 10-mm margins (HR 0.39, p = 0.04) were associated with improvements in regional DFS. Margin length was not associated with development of postoperative complications (p = 0.20).

Conclusions: Among pediatric and young adult sarcoma patients with pulmonary metastases, increased margin length was associated with decreasing risk of local recurrence but not the development of postoperative complications.