Chang Moo Kang

Solid pseudopapillary tumor of the pancreas suggesting malignant potential

Objectives: It has been suggested that the histopathologic features associated with malignant potential in solid pseudopapillary tumors (SPTs) of the pancreas include cellular polymorphism, mitotic activity, peripancreatic tissue invasion, neural invasion, lymphovascular invasion, and lymph node metastasis. This study aimed to delineate the features predicting SPTs with malignant potential, which can be easily assessed in the clinical setting, and long-term results of patients who underwent resection of SPT. Methods: A retrospective review and analysis were done of 33 patients who had SPTs that were surgically treated. Results: Eleven patients (33.3%) had SPTs suggesting malignant potential among surgically treated patients with SPTs. The local invasion to the peripancreatic tissue was the most frequent malignant pathological feature (7/11 patients, 63.7%). Using univariate analysis, tumor size greater than 5 cm was a significant clinical factor to predict SPTs with malignant potential (P = 0.022). The prognosis was excellent. No statistically significant survival difference was noted between groups of malignant potential and benign pathology (P = 0.1904). Conclusions: Malignant SPTs are low-grade tumors with good prognosis. Adequate surgical intervention is necessary. Especially, SPTs over 5 cm in diameter need to be treated carefully because of the chance of malignant pathology. Careful long-term follow-up is necessary in those patients in case of possible tumor recurrences.

Prognostic value of metabolic tumor volume and total lesion glycolysis on preoperative18f-fdg pet/ct in patients with pancreatic cancer

In this study, we aimed to assess the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) measured on 18F-FDG PET/CT in pancreatic cancer patients who underwent resection with curative intent. Methods: Eighty-seven patients with pancreatic ductal adenocarcinoma who underwent 18F-FDG PET/CT and subsequent surgical resection with curative intent with (30 patients) or without (57 patients) neoadjuvant therapy were retrospectively enrolled. The maximum standardized uptake value (SUVmax), MTV, and TLG were measured on 18F-FDG PET/CT in all patients. The prognostic significances of PET/CT parameters and tumor factors for recurrence-free survival (RFS) and overall survival (OS) were evaluated by univariate and multivariate analyses. Results: Of the 87 patients, 57 (64%) experienced recurrence during the follow-up period. The tumor size, pathologic T (pT) stage, SUVmax, MTV, and TLG were significant prognostic factors for both RFS and OS (P < 0.05) on univariate analyses, and the presence of lymph node metastasis showed significance only for predicting RFS (P < 0.05). On multivariate analyses, the tumor size, MTV, and TLG were independent prognostic factors for RFS, and pT stage, MTV, and TLG were independent prognostic factors for OS. For the 57 patients who did not undergo neoadjuvant treatment, MTV and TLG remained significant predictive factors for tumor recurrence, along with tumor size and SUVmax. Conclusion: MTV and TLG are independent prognostic factors for predicting RFS and OS in patients with pancreatic cancer. Thus, 18F-FDG PET/CT can provide useful prognostic information for patients undergoing resection of pancreatic cancer with curative intent irrespective of neoadjuvant treatment.

Prognostic Factors and Optimal Treatment Strategy for Intrahepatic Nodular Recurrence After Curative Resection of Hepatocellular Carcinoma

BackgroundIntrahepatic recurrence is a major problem after curative resection of hepatocellular carcinoma. However, the most effective treatments for patients with intrahepatic recurrence still remain unclear. In addition, the selection of various treatment modalities such as repeat resection, local ablation therapy, and transarterial chemoembolization is only applicable to patients with intrahepatic nodular recurrence.MethodsOf 353 patients who underwent curative resection, 97 patients with intrahepatic nodular recurrence were retrospectively studied. The prognostic factors for survival after recurrence and treatment modalities were analyzed. The patients were divided into two groups, a control group and a progression group, according to their response to initial treatment for recurrent tumors.ResultsThe 1-, 3-, and 5-year overall survival rates after recurrence in patients with intrahepatic nodular recurrence were 91.0%, 71.0%, and 37.5%, respectively. Multivariate analysis revealed that early recurrence (≤12 months), Child-Pugh class B or C at diagnosis of recurrence, and serum albumin level of ≤3.5 g/dL at diagnosis of recurrence were poor prognostic factors for survival after recurrence. With regard to the response to the initial treatment, time to recurrence of ≤12 months was found to be the only statistically significant risk factor for progression of disease in multivariate analysis.ConclusionsTime to recurrence, which usually corresponds with the cellular origin of recurrence, seems to be more important when determining the prognosis of patients with recurrent disease and treatment response than treatment modality. Therefore, different treatment methods should be selected according to the time to recurrence of intrahepatic nodular recurrence.

Effects of neoadjuvant combined chemotherapy and radiation therapy on the CT evaluation of resectability and staging in patients with pancreatic head cancer.

PURPOSE To evaluate the effect of neoadjuvant combined chemotherapy and radiation therapy (CCRT) on preoperative accuracy of multidetector computed tomography (CT) for resectability and tumor staging in patients with pancreatic head cancer. MATERIALS AND METHODS This retrospective study received institutional review board approval and was exempted from informed consent requirements. From May 2002 to March 2007, 38 patients with pancreatic head adenocarcinoma underwent multidetector CT before surgery. Of these, 12 patients received neoadjuvant CCRT. Imaging findings were evaluated for tumor resectability and tumor staging. Surgical and pathologic results were used as the reference standard. The accuracy of resectability and individual components of each T category were compared between the patients with neoadjuvant CCRT and without it by using the chi(2) test or Fisher exact test. A P of less than .05 was considered as significant. RESULTS The accuracy in determining resectability was 83% (10 of 12) in patients who had received neoadjuvant CCRT and 81% (21 of 26) in patients who had not, without significant difference (P > .05). Of 32 patients who underwent pancreaticoduodenectomy, histopathologic tumor staging was reported for T1 (n = 2), T2 (n = 1), and T3 (n = 9) lesions in patents with neoadjuvant CCRT (n = 12), and for T3 in all patients without neoadjuvant CCRT (n = 20). T-staging accuracy was 67% (eight of 12) with neoadjuvant CCRT and 95% (19 of 20) without it, with a significant difference (P = .0185). CONCLUSION Neoadjuvant CCRT reduces the accuracy of tumor restaging after treatment of pancreatic head cancer, but this effect is not so great as to affect the determination of resectability.

Laparoscopic cholecystectomy only could be an appropriate treatment for selected clinical R0 gallbladder carcinoma.

BackgroundLaparoscopic cholecystectomy (LC) for gallbladder carcinoma still is controversial except for the early stages of gallbladder carcinoma (Tis). This study was designed to evaluate and revisit the role of LC in treating gallbladder carcinoma.MethodsAvailable medical records of patients with surgeries for gallbladder carcinoma were retrospectively investigated from August 1992 to February 2005.ResultsAmong 219 patients treated for gallbladder carcinoma, 57 (26%) underwent LC. A total of 16 patients (28.1%) underwent subsequent radical cholecystectomy (LC–RC), and 41 (71.9%) were only followed up without radical surgery (LC). Tis was found in 11 patients (19.3%), T1a in 3 patients (5.3%), T1b in 8 patients (14%), T2 in 19 patients (33.3%), and T3 in 16 patients (28.1%). The findings showed R0 in 14 cases of the radical cholecystectomy group, and clinical R0 was noted in 30 cases of the LC-only group. No survival differences were noted between LC and LC–RC (p = 0.2575), especially in the case of T2 lesions (p = 0.6274), nor between the R0 and clinical R0 (p = 0.5839). However, significant survival differences were noted between the R2 and R0 groups, and between R2 and clinical R0, respectively (p < 0.001).ConclusionsThe findings show that LC could be appropriate treatment for gallbladder carcinoma only in selected cases of clinical R0 lesions.

Gallbladder carcinoma associated with anomalous pancreaticobiliary duct junction

BACKGROUND Anomalous pancreaticobiliary ductal junction (APBDJ) is believed to be one of the risk factors for gallbladder carcinoma. The present study aims to delineate the gallbladder carcinoma characteristics associated with APBDJ. PATIENTS AND METHODS Patients with gallbladder carcinoma associated with APBDJ between August 1992 and February 2005 were retrospectively reviewed. Two types of APBDJ classifications were considered: right-angle type (C-P) and acute-angle type (P-C). RESULTS Ten of 218 patients (4.6%) with gallbladder carcinomas were associated with APBDJ. All patients were female with a mean age of 55.4 years (range 41 to 72 years). Gallstones were absent in nine patients. Seven patients (70%) had the P-C type and three patients (30%) had the C-P type. Survival differences between the P-C type and the C-P type of gallbladder carcinomas were noted (P=0.0269). Patients with incidentally detected gallbladder carcinoma had superior survival (P=0.0316). CONCLUSION Gallbladder carcinomas associated with APBDJ were significantly related to relatively young female patients without gallbladder stones. Survival outcomes in these patients were not different from those of gallbladder carcinoma without APBDJ. In particular, the P-C type of APBDJ seemed to be more associated with relatively advanced gallbladder carcinomas, and patients with incidentally detected gallbladder carcinomas with APBDJ had superior survival.

Predicting recurrence of pancreatic solid pseudopapillary tumors after surgical resection: a multicenter analysis in Korea.

Background:Solid pseudopapillary tumors (SPTs) of the pancreas are still considered a surgical enigma. Many clinical research trials have failed to identify prognostic factors that predict the malignant behavior of SPTs. Materials and Methods:This work was a retrospective multicenter study that included a total of 17 medical institutions. Data from 351 patients who underwent surgical resection from January 1990 to December 2008 were retrospectively collected using standardized case report forms requesting clinicopathologic features. Results:Thirty-four patients (9.7%) were male, and 317 (90.3%) were female, with a mean age of 36.8 ± 12.4 years. Recently, minimally invasive (P < 0.001) and parenchyma or function-preserving limited surgeries (P = 0.016) have been more frequently applied for the treatment of pancreatic SPTs. Ninety-eight patients (27.9%) had microscopic malignant features. Only 9 patients (2.6%) experienced tumor recurrence after the initial pancreatic SPT resection. Multivariate analysis showed that a tumor size larger than 8 cm [Exp (&bgr;) = 7.385, P = 0.018], microscopic malignant features [Exp (&bgr;) = 10.009, P = 0.011], and stage IV [Exp (&bgr;) = 42.003, P = 0.002] were significant prognostic factors for tumor recurrence. When combined with stage IV, the microscopic malignant features and 2010 World Health Organization definition of solid pseudopapillary carcinoma more successfully differentiated future recurrence risk groups (P < 0.001). Conclusions:More specific pathologic descriptions need to be employed in pathologic report forms to provide proper information to predict SPT recurrence after resection. Future studies emphasizing the standardized pathologic evaluation of pancreatic SPTs may unveil the enigmatic nature of pancreatic SPTs.

Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results

BackgroundLaparoscopic distal pancreatectomy with splenectomy is regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions [1, 2]. However, its application for left-sided pancreatic cancer is still debatable [3, 4]. No general consensus, no standardized technique, and no surgical indication exist in applying the laparoscopic approach to left-sided pancreatic cancer.MethodsAccording to our institutional experiences of treating left-sided pancreatic cancer, bloodless and margin-negative resection was found to be important. Bloodless and margin-negative laparoscopic distal pancreatosplenectomy would be technically possible in suspicious pancreatic cancers with these tentative conditions: (1) pancreas-confined suspicious pancreatic cancer on preoperative image study (cT2), (2) intact fascia layer between the pancreas and left adrenal gland/left kidney, and (3) tumor more than 1 cm from the celiac axis. A 59-year-old female patient was found to have suspicious left-sided pancreatic cancer. Therefore, we performed laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) [5, 6] with a curative intent based on selection criteria.ResultsThe margin-negative (resectional and tangential) curative resection could be obtained by applying laparoscopic anterior RAMPS in well-selected left-sided pancreatic cancer. The operation time was 180 min and estimated blood loss was 100 ml. The diagnosis from pathology was that the tumor was ductal adenocarcinoma of the pancreas (pT3) with lymph node metastasis (pN1, 2 of 23 lymph nodes). The patient went home on the 7th postoperative day. Adjuvant chemotherapy began within 2 weeks after surgery. From June 2007 to August 2010, nine patients underwent minimally invasive (5 laparoscopic and 4 robot-assisted) anterior RAMPS based on the selection criteria. The perioperative outcomes and short-term oncologic results are summarized.ConclusionLaparoscopic modified anterior RAMPS is thought to be technically feasible for curative resection in well-selected pancreatic cancer. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. More careful study is necessary.

The first experience of robot assisted spleen-preserving laparoscopic distal pancreatectomy in Korea.

Spleen-preservation has recently been emphasized in benign and borderline malignant pancreatic diseases requiring distal pancreatectomy. Reports to suggest that laparoscopic distal pancreatectomy is feasible and safe have been increasingly published. Robotic surgical system has been introduced and is expected to provide unique advantages in laparoscopic surgery. However, robot-assisted pancreatic surgery has not yet been performed by many surgeons. A 45-year-old female patient with abdominal discomfort was found to have pancreatic cyst in the body of the pancreas. Mucinous cystic tumor of the pancreas was the most favourable preoperative diagnosis. She underwent spleen-preserving laparoscopic distal pancreatectomy by using da Vinci surgical robot system. Splenic artery and vein were so tightly adherent to the pancreatic cyst that segmental resection of splenic vessels was required. Postoperative course was uneventful. She was able to come home in 5 days after surgery. Postoperative follow up color doppler ultrasound scan, taken on 2 weeks after surgery, showed minimal fluid collection around surgical field and no evidence of splenic infarction with good preservation of splenic perfusion. Robot-assisted spleen preserving distal pancreatectomy is thought to be feasible and safe. Several unique advantages of robotic system are expected to enhance safer and more precise surgical performance in near future. More experiences are mandatory to confirm real benefit of robot surgery in pancreatic disease.

Robotic anterior RAMPS in well-selected left-sided pancreatic cancer.

A relatively pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney is thought to be a potential indication for a minimally invasive approach in treating left-sided pancreatic cancer. Usually four or five trocars are needed for conventional laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) and the surgeon is able to perform all procedures aided by two assistants who help with camera control and counter traction. However, five ports are required for the robotic approach: one for the robotic camera, three for the working robotic arms, and one for the assistant surgeon for vessel clipping, suction, and endo-linear stapling. Four patients with pancreatic cancer were selected for robotic RAMPS. Four robotic arms were used while the patient was in a supine position with the patients head and left side elevated. Pancreatic dissection was performed from right to left after division of the pancreatic neck portion. Lymph nodes around the common hepatic artery and celiac axis were dissected during this procedure. Clinicopathologic characteristics and perioperative surgical outcomes, including interim oncologic outcomes, were analyzed.