Aaron Lewis

Diagnosis and Management of Malignant Salivary Gland Tumors of the Parotid Gland

Malignant parotid tumors are heterogeneous and diverse. Accurate diagnosis requires a pathologist familiar with the various histologic subtypes, immunohistochemistry stains, and common translocations. Clinical course varies according to tumor subtype, ranging from indolent, slow-growing adenoid cystic carcinoma to rapidly progressive, possibly fatal, salivary ductal carcinoma. Histologic grade is important in prognosis and therapy. Surgery remains the mainstay of treatment when negative margins can be achieved. Radiation improves locoregional control of tumors with high-risk features. Chemotherapy for parotid tumors can be disappointing. Studies of new targeted therapies have not offered significant benefits.

The Modified Appleby Procedure for Locally Advanced Pancreatic Body/Tail Cancer: How I Do It

Tumors of the body and tail account for approximately one-third of pancreatic cancers, and up to three-quarters of body and tail tumors are deemed unresectable on presentation. Unresectability is a result of liver metastases, carcinomatosis, or local invasion of major vascular structures. Although pancreatectomy in the presence of metastatic disease has not proven beneficial, resection of locally advanced pancreatic cancer to negative margins may improve survival. Treatment of locally advanced pancreatic adenocarcinoma with arterial involvement remains controversial; however, 30% of patients with locally advanced, Stage III pancreatic cancer will die without evidence of metastatic spread. As such, this group of patients is most likely to benefit from an aggressive surgical approach. Neoadjuvant therapy has allowed for more careful selection of patients that may benefit from pancreatectomy with arterial resection. In this chapter, we discuss how we perform the modified Appleby procedure and review the literature.

Hybrid Robot-Assisted Surgery

Hybrid robot-assisted surgery is a planned operative approach that integrates multiple access methods for various specific portions of a procedure. Initially used as a bridge for the transition from other approaches (open or laparoscopic) to a totally robotic procedure, hybrid approaches still retain patient benefits of minimally invasive surgery. While surgeons have reported diverse operative procedures using only the robotic surgical instruments, many of the more complex procedures are taking advantage of hybrid methods, conceived to address the two main concerns associated with robotic operations in certain circumstances: safety and speed. In this chapter we will discuss factors that play a role in the selection of a hybrid robot-assisted approach, and the many ways in which hybrid surgery has allowed minimally invasive, complex surgery not otherwise considered feasible. Both the novice and the expert robotic surgeon can benefit from concepts and operations developed in hybrid surgery. Hybrid approaches capitalize on the philosophy that the robot is just another surgical instrument, to be integrated with open and laparoscopic instruments, for the optimal care of patients.