Combined resection of lung cancer and thoracic aortic wall with simultaneous thoracic aortic endografting: a case report

BACKGROUND

Combined resection of lung cancer and the thoracic aortic wall with thoracic aortic endografting has been reported. However, whether the resection and endografting should be performed simultaneously or in two steps remains controversial.

CASE PRESENTATION

A 68-year-old man was referred to our hospital because of left chest pain. Chest contrast-enhanced computed tomography revealed a huge tumor of the left lower lung lobe, and invasion to the aortic wall was suspected. Bronchoscopic examination was performed, revealing squamous cell carcinoma with a programmed death ligand 1 expression level of 90%. The clinical stage was T4N0M0 stage 3A. After neoadjuvant chemotherapy and radiotherapy, we performed one-stage surgery with the patient in the right lateral decubitus position and the left inguinal region exposed for femoral vessel isolation. Posterolateral thoracotomy was performed with making a latissimus dorsi muscle flap. The pulmonary artery, vein, and left lower bronchus were cut with a stapler. After hilar isolation, we evaluated the involvement of the descending aorta and marked the area of the involved aortic wall by a surgical clip. Using the left femoral artery approach, a GORE TAG conformable thoracic stent graft was delivered to the descending aorta. After thoracic aortic endografting, the involved aortic wall was resected and the left lower lobe of the lung and resected aortic wall were resected en bloc. The adventitial defect was covered by the latissimus dorsi muscle flap. The operating time was 474 min, and the blood loss volume was 330 mL. The postoperative pathological diagnosis was adenocarcinoma with an epidermal growth factor receptor mutation of exon 19 deletion. The residual viable tumor was 7 mm in diameter and close to the resected aortic wall. The patient's postoperative course was uneventful. Five days after surgery, chest contrast-enhanced computed tomography revealed no endoleak or stent migration. Three months after surgery, he was alive with neither recurrence nor stent graft-related complications.

CONCLUSIONS

One-stage surgery involving combined resection of lung cancer and the thoracic aortic wall with simultaneous thoracic aortic endografting in the right lateral decubitus position with the left inguinal region exposed is safe and acceptable.

Rare resected eight cases of duodenal adenocarcinomas

INTRODUCTION

Duodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications.

METHODS

Nine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found.

OUTCOMES

One case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12 months. With additional strong chemotherapy, eight patients survived up to 84 months, and one died of liver metastasis at 43 months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown.

CONCLUSION

In the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important.

Simultaneous approach for patients with synchronous colon and rectal liver metastases: Impact of site of primary on postoperative and oncological outcomes

BACKGROUND AND AIMS

We aimed to investigate the impact of the site of the primary on postoperative and oncological outcomes in patients undergone simultaneous approach for colon (CC) and rectal cancer (RC) with synchronous liver metastases (SCRLM).

PATIENTS AND METHODS

Of the 220 patients with SCRLM operated on between Mar 2006 and Dec 2017, 169 patients (76.8%) were treated by a simultaneous approach and were included in the study. Two groups were considered according to the location of primary tumor RC-Group (n = 47) and CC-group (n = 122).

RESULTS

Multiple liver metastases were observed in 70.2% in RC-Group and 77.0% in CC-Group (p = 0.233), whilst median Tumor Burden Score (TBS) was 4.7 in RC-Group and 5.4 CC-Group (p = 0.276). Severe morbidity (p = 0.315) and mortality at 90 days (p = 0.520) were comparable between RC-Group and CC-Group. The 5-year overall survival (OS) rate was similar comparing RC-Group and CC-Group (48.2% vs. 45.3%; p = 0.709), but it was significantly different when considering left-CC, right-CC and RC separately (54.5% vs. 35.2% vs. 48.2%; p = 0.041). Primary tumor location (right-CC, p = 0.001; RC, p = 0.002), microscopic residual (R1) disease at the primary (p < 0.001), TBS ≥6 (p = 0.012), bilobar metastases (p = 0.004), and chemotherapy strategy (preoperative ChT, p = 0.253; postoperative ChT, p = 0.012; and perioperative ChT, p < 0.001) resulted to be independent prognostic factors at multivariable analysis.

CONCLUSION

In patients with SCRLM, simultaneous resection of the primary tumor and liver metastases seems feasible and safe and allows satisfactory oncological outcomes both in CC and RC. Right-CC shows a worse prognosis when compared to left-CC and RC.

Complete resection of local advanced thymic carcinoma with total aortic arch replacement after chemotherapy: a case report

Background

Although complete surgical resection of thymic carcinoma is a prognostic factor, it is not always an option for advanced tumors because of locoregional invasion. Extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality.

Case presentation

Chest computed tomography (CT) uncovered an abnormal shadow in the mediastinum of a 74-year-old man. An irregularly shaped tumor obstructed the left innominate vein, and invasion of the aortic arch was suspected. A CT-guided percutaneous needle biopsy revealed squamous cell carcinoma of the thymus, which was considered unresectable. The patient underwent chemotherapy elsewhere, then was referred to us for surgical resection. We combined extended surgery with total aortic arch replacement under a cardiopulmonary bypass. Complete resection was achieved, and the patient remains alive without recurrence at 3 years after surgery

Conclusion

Resection including aortic arch replacement might be an option that can achieve complete resection of local advanced thymic carcinoma.

Long-term outcomes after an aggressive resection of adenosquamous carcinoma of the pancreas

PURPOSE

Adenosquamous carcinoma (ASC) of the pancreas is a rare malignancy, associated with a poor prognosis after surgical resection, with reported median survival times (MSTs) ranging from 4.4 to 13.1 months. We conducted this study to investigate the long-term outcomes of patients after the resection for ASC.

METHODS

Between 2002 and 2016, a total of 456 patients underwent resection for ASC or adenocarcinoma (AC) of the pancreas. ASC was confirmed in 17 (3.7%) of these patients. We analyzed the clinicopathological characteristics and survival of these 17 patients in comparison with those of patients with AC of the pancreas.

RESULTS

The operative procedures performed were pancreaticoduodenectomy (n = 6) and distal pancreatectomy (n = 11). Seven (41.2%) of the 17 patients underwent combined organ resection. R0 resection was achieved in 16 (94.1%) patients. The 5-year overall survival (OS) rate and MST were 40.3% and 20.9 months, respectively. A squamous component of ≥ 60% (P = 0.001) and R1 resection (P < 0.001) were significantly associated with poor OS for patients with ASC CONCLUSION: This study revealed longer survival and a higher R0 resection rate after aggressive combined resection in our ASC patients than those in previous studies. Although this was only a small series, our findings suggest that local control with aggressive resection may be an effective treatment protocol for ASC patients.

[Laparoscopic versus open surgery for simultaneous resection of synchronous colorectal liver metastases]

Objective: To compare the short-term outcomes and long-term outcomes between open and laparoscopic approaches for simultaneous resection of primary colorectal cancer and synchronous liver metastases. Methods: Patients underwent simultaneous resection of primary colorectal cancer and synchronous liver metastases at Department of General Surgery, Huashan Hospital, Fudan University between January 2014 and October 2017 were included.The totally laparoscopic surgery patients were matched 1∶1 based on propensity score to the open surgery patients.Continuous and categorical variables were compared using non-parametric Mann-Whitney U test and Fisher exact test.Survival curves of overall survival(OS) and disease-free-survival(DFS) were plotted by Kaplan-Meier method, and compared according to Log-rank test. Results: A total of 41 patients were included. After propensity score matching, 12 patients fell into each of the two groups(totally laparoscopic approach group and open approach group). Baseline characteristics were similar between the two groups.There was no difference regarding the to the proportion of major liver resection.Statistically significant difference was observed in term of intra-operative blood loss (250 ml vs.450 ml, Z=-2.005, P=0.045) and fluid infusion(2 430 ml vs. 3 150 ml)(Z=-2.488, P=0.012). Post-operative stay and overall morbidity were similar between the two groups.However, adverse event worse than Clavien-Dindo Ⅱ morbidity did not occur in the laparoscopic approach group.No postoperative mortality happened in either group within 30 days of surgery. Regarding to long-term outcomes, OS and DFS were similar between the two approaches. Conclusion: Laparoscopic approaches for simultaneous resection of primary colorectal cancer and synchronous liver metastases may be associated with reduced blood loss, without adversely affecting long-term outcomes in selected patients.

Combined resection of aberrant right hepatic artery without anastomosis in panceaticoduodenectomy for pancreatic head cancer: A case report

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The aberrant right hepatic artery is often arising from superior mesenteric artery.

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Combined resection of the aberrant right hepatic artery is necessary in pancreaticoduodenectomy for pancreatic head cancer to achieve R0 resection.

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Arterial anastomosis of combined resection is not always necessary because of existence of communicating artery from the middle and left hepatic artery via hepatic hilar plate.

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R0 resection without tumor exposure at the dissected plane improves prognosis of pancreatic cancer patients.

Introduction

This case report is intended to inform pancreas surgeons of our experience in operative management of aberrant pancreatic artery.

Presentation of case

A 63-year-old woman was admitted to our institute’s Department of Surgery with obstructive jaundice, and the pancreas head tumor was found. To improve liver dysfunction, an endoscopic retrograde nasogastric biliary drainage tube was placed in the bile duct. Endoscopic fine-needle aspiration showed a pancreas head carcinoma invading the common bile duct, the aberrant right hepatic artery arising from the superior mesenteric artery, and the portal vein. Enhanced computed tomography showed the communicating artery between the right and left hepatic artery via the hepatic hilar plate. By way of imaging preoperative examination, a pancreaticoduodenectomy combined resection of the aberrant right hepatic artery and portal vein was conducted without arterial anastomosis. Hepatic arterial flow was confirmed by intraoperative Doppler ultrasonography, and R0 resection without tumor exposure at the dissected plane was achieved. The patient’s postoperative course was uneventful.

Discussion

In this case report, perioperative detail examination by imaging diagnosis with respect to hepatic arterial communication to achieve curative resection in a pancreas head cancer was necessary. Non-anastomosis of hepatic artery was achieved, and the necessity of R0 resection was stressed by such management.

Conclusion

By the preoperative and intraoperative imaging managements conducted, combined resection of the aberrant right hepatic artery without anastomosis was achieved by pancreaticoduodenectomy for pancreas head cancer. However, improvements in imaging diagnosis and careful management of R0 resection are important.

Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified?

Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.

Choice of approach for hepatectomy for hepatocellular carcinoma located in the caudate lobe: Isolated or combined lobectomy?

AIM: To investigate the significance of the surgical approaches in the prognosis of hepatocellular carcinoma (HCC) located in the caudate lobe with a multivariate regression analysis using a Cox proportional hazard model.

METHODS: Thirty-six patients with HCC underwent caudate lobectomy at a single tertiary referral center between January 1995 and June 2010. In this series, left-sided, right-sided and bilateral approaches were used. The outcomes of patients who underwent isolated caudate lobectomy or caudate lobectomy combined with an additional partial hepatectomy were compared. The survival curves of the isolated and combined resection groups were generated by the Kaplan-Meier method and compared by a log-rank test.

RESULTS: Sixteen (44.4%) of 36 patients underwent isolated total or partial caudate lobectomy whereas 20 (55.6%) received a total or partial caudate lobectomy combined with an additional partial hepatectomy. The median diameter of the tumor was 6.7 cm (range, 2.1-15.8 cm). Patients who underwent an isolated caudate lobectomy had significantly longer operative time (240 min vs 170 min), longer length of hospital stay (18 d vs 13 d) and more blood loss (780 mL vs 270 mL) than patients who underwent a combined caudate lobectomy (P < 0.05). There were no perioperative deaths in both groups of patients. The complication rate was higher in the patients who underwent an isolated caudate lobectomy than in those who underwent combined caudate lobectomy (31.3% vs 10.0%, P < 0.05). The 1-, 3- and 5-year disease-free survival rates for the isolated caudate lobectomy and the combined caudate lobectomy groups were 54.5%, 6.5% and 0% and 85.8%, 37.6% and 0%, respectively (P < 0.05). The corresponding overall survival rates were 73.8%, 18.5% and 0% and 93.1%, 43.6% and 6.7% (P < 0.05).

CONCLUSION: The caudate lobectomy combined with an additional partial hepatectomy is preferred because this approach is technically less demanding and offers an adequate surgical margin.

Combined resection and radiofrequency ablation for multifocal hepatocellular carcinoma: Prognosis and outcomes

AIM: To analyze the combined treatment of resection and intraoperative radiofrequency ablation (RFA) for multifocal hepatocellular carcinoma in terms of prognosis and surgical outcomes.

METHODS: This study was a retrospective case comparison study using prospectively collected data. The study covered the period from April 2001 to December 2006. The data of 200 patients with histologically confirmed hepatocellular carcinoma were reviewed. Nineteen patients (17 men and 2 women) having received resection in combination with RFA were chosen as subjects of the study (the combination group). Fifty-four patients (43 men and 11 women) having received resection alone were selected for comparison (the resection group). The two groups matched tumor number and tumor size, and all the patients in the two groups displayed no tumor rupture, major vascular involvement and distant metastasis. Their demographics, preoperative assessment, disease recurrence patterns, overall survival and disease-free survival were compared.

RESULTS: In the combination group, the median age was 65 years (range, 34-77 years), the median tumor number was 3 (range, 2-9), and the median tumor size was 6 cm (range, 1.2-14 cm). In the resection group, the median age was 51.5 years (range, 27-80 years, P = 0.003), the median tumor number was 3 (range, 2-9, P = 0.574), and the median tumor size was 6 cm (range, 1-14 cm, P = 0.782). The two groups were similar in characteristics of tumors and comorbidities, and had comparable results in preoperative liver function tests. All patients had Child-Pugh class A status. Bilobar involvement occurred in 14 patients (73.6%) in the combination group and 3 patients (5.5%) in the resection group (P = 0.04). Six patients (32%) in the combination group and 35 patients (65%) in the resection group underwent major hepatectomy. Thirteen patients (68%) in the combination group and 19 patients (35%) in the resection group underwent minor hepatectomy (P = 0.012). The combination group had fewer major resections (32% vs 65%, P = 0.012), less blood loss (400 vs 657 mL, P = 0.007), shorter operation time (270 vs 400 min, P = 0.001), and shorter hospital stay (7 vs 8.5 d, P = 0.042). The two groups displayed no major differences in surgical complications (15.8% vs 31.5%, P = 0.24), disease recurrence (63.2% vs 50%, P = 0.673), hospital mortality (5.3% vs 5.6%, P = 1), and overall survival (53 vs 44.5 mo, P = 0.496).

CONCLUSION: Safe and effective for selected patients with multifocal hepatocellular carcinoma, the combination of resection and intraoperative RFA widens the applicability of surgical intervention for the disease.