Lucia Moletta

Metastatic tumors to the pancreas: The role of surgery

Pancreatic metastases from other primary malignancies are a rare entity. By far, the most common primary cancer site resulting in an isolated pancreatic metastasis is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. Only few data on the surgical outcome of pancreatic resections performed for metastases from other primary tumor have been published, and there are no guidelines to address the surgical treatment for these patients. In this study, we performed a review of the published literature, focusing on the early and long-term results of surgery for the most frequent primary tumors metastasizing to the pancreas. Results for the Literatures analysis show that in last years an increasing number of surgical resections have been performed in selected patients with limited pancreatic disease. Pancreatic resection for metastatic disease can be performed with acceptable mortality and morbidity rates. The usefulness of pancreatic resection is mainly linked to the biology of the primary tumor metastasizing to the pancreas. The benefit of metastasectomy in terms of patient survival has been observed for metastases from renal cell cancer, while for other primary tumors, such as lung and breast cancers, the role of surgery is mainly palliative.

Acinar cell carcinoma of the pancreas associated with subcutaneous panniculitis.

CONTEXT Acinar cell carcinoma is a rare pancreatic malignant tumor, which can be associated with a particular manifestation: pancreatic panniculitis. It presents with erythematous subcutaneous nodules located mainly on the legs. The skin lesions can precede, be concurrent with or follow the pancreatic illness. The pathogenesis is not fully understood, but it is believed to be associated with high levels of serum lipase produced by the neoplasm, causing fat necrosis in tissues. The treatment of pancreatic panniculitis is directed at the underlying pancreatic disease, which may result in regression of the skin lesions. We report a case of pancreatic acinar cell carcinoma associated with subcutaneous panniculitis together with a review of the English literature. CASE REPORT A 79-year-old woman, with a 13-month history of acute pancreatitis, asthenia, weight loss, and the CT finding of a mass in the pancreatic head, presented complaining of multiple, migrant and painful subcutaneous nodules on her lower extremities. High serum lipase levels were also present. She underwent a pancreaticoduodenectomy, with subsequent regression of the skin lesions and normalization of her serum lipase levels. Histology revealed an acinar cell carcinoma of the pancreas. Liver metastases occurred six months after surgery, and the patient underwent chemotherapy with gemcitabine. She is still alive 14 months after the initial surgery. CONCLUSIONS Although rare, the association between acinar cell carcinoma and pancreatic panniculitis has been described in the literature. In a patient with subcutaneous nodules, the presence of acinar cell carcinoma should be considered in order to prevent long delays in the diagnosis and treatment of this pancreatic malignancy.

Leiomyosarcoma of the Pancreas with Liver Metastases as a Paradigm of Multimodality Treatment: Case Report and Review of the Literature

Primary leiomyosarcoma is a rare malignant neoplasm, although it is the most common primary pancreatic sarcoma [1]. It accounts for 0.1 % of malignant pancreatic neoplasms [2], and it seems to arise from smooth muscle cells of ducts or blood vessels within the pancreas [3] Pancreatic leiomyosarcoma is a highly aggressive neoplasm in which widespread metastases occur frequently and the liver is typically affected [4], so the prognosis is generally bad [5]. Radical resection of the primary lesion seems to offer the best possibility for cure [6]. We report a case of primary leiomyosarcoma of the pancreas with synchronous hepatic metastases occurring in a 54-year-old female who was treated with repeated surgical excision together with different chemotherapeutic regimens.

Pancreatic resection in very elderly patients: A critical analysis of existing evidence

The aging of the population results in a rise of number of elderly patients (aged 80 years and older) with pancreatic or periampullary cancer, and more pancreatectomies could eventually be performed in such complex patients. However, early and long-term results after pancreatic resection in octogenarians are still controversial, and may trouble the surgeon when approaching this type of population. Evaluation of reported experiences shows that for almost all Authors, pancreatectomy can be performed safely in elderly population, although overall morbidity and mortality rates were 34.9% and 13.2% respectively, with a mean length of hospital stay of 18 d. These features appear higher in older patients compared to the younger counterpart. Less than 50% of patients underwent adjuvant therapy after operation. Long-term survival is reported not significantly different in aged 80 years and older patients, with a median overall survival time of 17.6 mo. The quality of life after pancreatic resection is only sporadically evaluated but, when considered, it highlights the need of health facility service after operation for these “frail” patients. Prospective studies on the quality of life of pancreatectomized octogenarians are welcome. Proper selection of patients, geriatric assessment with multidisciplinary approach, centralization of pancreatic surgery in high-volume centres and rehabilitation programs after surgery appear to be crucial points in order to improve surgical treatments of pancreatic tumors in very elderly patients.

Multimodality treatment of recurrent pancreatic cancer: Mith or reality?

Pancreatic adenocarcinoma is the fourth cause of cancer-related death in the United States. Surgery is the only potentially curative treatment, but most patients present at diagnosis with unresectable or metastatic disease. Moreover, even with an R0 resection, the majority of patients will die of disease recurrence. Most recurrences occur in the first 2-year after pancreatic resection, and are commonly located in the abdomen, even if distant metastases can occur. Recurrent pancreatic adenocarcinoma remains a significant therapeutic challenge, due to the limited role of surgery and radio-chemotherapy. Surgical management of recurrence is usually unreliable because tumor relapse typically presents as a technically unresectable, or as multifocal disease with an aggressive growth. Therefore, treatment of patients with recurrent pancreatic adenocarcinoma has historically been limited to palliative chemotherapy or supportive care. Only few data are available in the Literature about this issue, even if in recent years more studies have been published to determine whether treatment after recurrence have any effect on patients outcome. Recent therapeutic advances have demonstrated the potential to improve survival in selected patients who had undergone resection for pancreatic cancer. Multimodality management of recurrent pancreatic carcinoma may lead to better survival and quality of life in a small but significant percentage of patients; however, more and larger studies are needed to clarify the role of the different therapeutic options and the optimal way to combine them.

Endoscopic Tumor Length Should Be Reincluded in the Esophageal Cancer Staging System: Analyses of 662 Consecutive Patients

Esophageal cancer represents the 6th cause of cancer mortality in the World. New treatments led to outcome improvements, but patient selection and prognostic stratification is a critical aspect to gain maximum benefit from therapies. Today, patients are stratified into 9 prognostic groups, according to a staging system developed by the American Joint Committee on Cancer. Recently, trying to better select patients with curing possibilities several authors are reconsidering tumor length as a valuable prognostic parameter. Specifically, endoscopic tumor length can be easily measured with an esophageal endoscopy and, if its utility in esophageal cancer staging is demonstrated, it may represent a simple method to identify high risk patients and an easy-to-obtain variable in prognostic stratification. In this study we retrospectively analyzed 662 patients treated for esophageal cancer, stratified according to cancer histology and current staging system, to assess the possible role of endoscopic tumor length. We found a significant correlation between endoscopic tumor length, current staging parameters and 5-year survival, proving that endoscopic tumor length may be used as a simple risk stratification tool. Our results suggest a possible indication for preoperative therapy in early stage squamocellular carcinoma patients without lymph nodes involvement, who are currently treated with surgery alone.

Cervical Esophageal Cancer Treatment Strategies: A Cohort Study Appraising the Debated Role of Surgery

BackgroundFew studies have examined optimal treatment specifically for cervical esophageal carcinoma. This study evaluated the outcome of three common treatment strategies with a focus on the debated role of surgery.MethodsAll patients with cervical esophageal cancer treated at a single center were identified and their outcomes analyzed in terms of morbidity, mortality, and recurrence according to the treatment they received, i.e. surgery alone, definitive platinum-based chemoradiation (CRT), or CRT followed by surgery.ResultsThe study population included 148 patients with cervical esophageal cancer from a prospective database of 3445 patients. Primary surgery was the treatment of choice for 56 (37.83%) patients, definitive CRT was the treatment of choice for 52 (35.13%) patients, and CRT followed by surgery was the treatment of choice for 40 (27.02%) patients. CRT-treated patients obtained 36.96% complete clinical response, with overall morbidity and mortality rates of 36.95 and 2.17%, respectively. Surgical complete resection was achieved in 71.88% of surgically treated cases, with morbidity and mortality rates of 52.17 and 6.25%, respectively. No significant survival difference existed among the three treatments, but patients who underwent surgery alone had a significantly lower stage of disease (p = 0.031). Compared with patients with complete response after CRT, surgery did not confer any significant survival benefit, and overall 5-year survival was lower than definitive CRT alone. In contrast, surgery improved survival significantly in patients with non-complete response after definitive CRT (p = 0.023).ConclusionsDefinitive platinum-based CRT should be the treatment of choice for cervical esophageal cancer. Surgery has a role for patients with non-complete response as it adds significant survival benefit, with acceptable morbidity and mortality.

Staging chronic pancreatitis with exocrine function tests: Are we better?

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas evolving in progressive fibrotic disruption of the gland with exocrine and endocrine pancreatic insufficiency. Although imaging features of CP are well known, their correlation with exocrine pancreatic function tests are not obvious, particularly in the early stage of the disease. There are many clinical classification of CP, all suggested for better distinguish and manage different forms based on etiological and clinical factors, and severity of the disease. Recently, a new classification of CP has been suggested: the M-ANNHEIM multiple risk factor classification that includes etiology, stage classification and degree of clinical severity. However, more accurate determination of clinical severity of CP requires a correct determination of exocrine function of the pancreas and fecal fat excretion. Recently, Kamath et al demonstrated that the evaluation of exocrine pancreatic function by acid steatocrit and fecal elastase-1 (EF-1) was helpful, but EF-1 was able to detect exocrine pancreatic insufficiency in more patients, upgrading some patients in higher stage of disease according to M-ANNHEIM classification. So, EF-1 is a more accurate test to determine exocrine pancreatic insufficiency and to stage chronic pancreatitis in the M-ANNHEIM classification. On the contrary, EF-1 determination shows low sensitivity in detecting exocrine pancreatic insufficiency in early stage of the disease.

Su1778 Recurrence After Resection for Pancreatic Cancer: Is There a Place for Surgery?

increased by more than

Pancreatic Metastasis from Carcinoid Midgut Tumor. A Case Report

10,000 with each severity grade of ISGPS DGE (p<0.001). Conclusions: DGE is a morbid complication after PD and it is associated with a substantial increase in hospital cost. In many instances, DGE is likely secondary to abdominal infection or other non-gastric complications, and interventions aimed at preventing these complications may be the most effective strategy towards preventing DGE. Risk Factors for DGE (Multivariate)