June S. Peng

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

BackgroundThere is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC.MethodsSequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL.ResultsOf 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62–1.37), oncologic treatment (CR 0.66, 95% CI 0.32–1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77–1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16–0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens.ConclusionsSDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Multiloculated mesothelial cyst presenting as a malignant mimic

A 46-year-old woman was referred for a second opinion regarding an intra-abdominal mass discovered on imaging performed for abdominal pain and distension. The tumour appeared to involve the small bowel, left colon and mesentery and was initially thought to be consistent with an infiltrative tumour or loculated mucinous ascites. Due to the unusual appearance of the tumour and suspicion for an omental-based mass, a laparoscopic resection was recommended to the patient. Intraoperatively, the tumour was found to be a multiloculated, benign appearing, omental cyst without involvement of the bowel and was completely resected laparoscopically. Pathology demonstrated a multiloculated peritoneal mesothelial cyst.