Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial

OBJECTIVE

This study compared the postoperative pancreatic anastomosis leakage rate of a new binding technique with the conventional technique of pancreaticojejunostomy after pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. The reported incidence after conventional pancreaticojejunostomy ranged from 10% to 29%. We previously reported a new binding pancreaticojejunostomy technique with a leakage of 0%.

METHODS

We conducted a prospective randomized study on 217 patients who underwent pancreaticoduodenectomy for benign and malignant diseases of the pancreatic head and the periampullary region comparing the 2 techniques of pancreaticojejunostomy.

RESULTS

Of the 111 patients randomized to the conventional group, pancreaticojejunostomy leakage occurred in 8 patients, while no patient in the 106 patients randomized to the binding group developed leakage (chi test, P = 0.014). The overall postoperative complications developed in 41 patients (36.9%) in the conventional group compared with 26 patients (24.5%) in the binding group (chi test, P = 0.048). Seven patients (6.3%) died in the perioperative period in the conventional group compared with 3 patients (2.8%) in the binding group (chi test, P = 0.37). The postoperative hospital stay (mean +/- SD) for the conventional group was 22.4 +/- 10.9 days, which was significantly longer than the binding group (18.4 +/- 4.7 days) (Mann-Whitney U test, P < 0.001).

CONCLUSIONS

Binding pancreaticojejunostomy after panceaticoduodenectomy significantly decreased postoperative complication and pancreaticojejunostomy leakage rates and shortened hospital stay when compared with conventional pancreaticojejunostomy.

Identification of metastasis-associated proteins involved in gallbladder carcinoma metastasis by proteomic analysis and functional exploration of chloride intracellular channel 1

Advanced gallbladder cancer has an extremely poor prognosis because of metastasis. Identification of metastasis-related biomarkers is essential to improve patient survival. In the present study, metastasis-associated proteins were identified by comparative proteomic analysis and the metastasis-related function of the candidate protein, chloride intracellular channel 1 (CLIC1), was further elucidated. Two cell lines with high or low metastatic potential (termed GBC-SD18H and GBC-SD18L, respectively), originating from the same parental gallbladder carcinoma GBC-SD cell line, were identified by spontaneous metastasis in vivo and characterized by metastatic phenotypes analysis in vitro. Subsequently, a proteomic approach comprised of two-dimensional gel electrophoresis analysis and mass spectroscopy was used to identify and compare the protein expression patterns between GBC-SD18L and GBC-SD18H. Twenty-six proteins were identified and further verified by one-dimensional Western blotting and semiquantitative reverse transcriptase polymerase chain reaction analysis. It was determined that CLIC1, ezrin, vimentin, annexin A3, WD repeat domain 1, triosephosphate isomerase, C1-tetrahydrofolate synthase, Rho GDP-dissociation inhibitor 1, T-complex protein 1, heterogeneous nuclear ribonucleoprotein K, glutamate dehydrogenase 1, proteasome activator complex subunit 3 and Rab GDP-dissociation inhibitor beta were significantly up-regulated in the highly metastatic GBC-SD18H cell line compared to the poorly metastatic GBC-SD18L cell line. However, phosphoglycerate kinase 1 and programmed cell death protein 8 were significantly down-regulated in the highly metastatic GBC-SD18H cell line compared to GBC-SD18L. Considering that CLIC1 was profuse in highly metastatic GBC-SD18H but scarce in poorly metastatic GBC-SD18L, the association of CLIC1 with metastasis was further elucidated by the overexpression and RNA interference of CLIC1 in GBC-SD18L cells and GBC-SD18H cells, respectively. The results demonstrated that the overexpression of CLIC1 promoted cell motility and invasion of GBC-SD18L in vitro, while RNA interference of CLIC1 remarkably decreased cell motility and invasive potency of GBC-SD18H in vitro, indicating that CLIC1 might play an important role in metastasis of gallbladder carcinoma.

Functional recovery in acute traumatic spinal cord injury after transplantation of human umbilical cord mesenchymal stem cells

OBJECTIVE

Spinal cord injury results in loss of neurons, degeneration of axons, formation of glial scar, and severe functional impairment. Human umbilical cord mesenchymal stem cells can be induced to form neural cells in vitro. Thus, these cells have a potential therapeutic role for treating spinal cord injury.

DESIGN AND SETTING

Rats were randomly divided into three groups: sham operation group, control group, and human umbilical cord mesenchymal stem cell group. All groups were subjected to spinal cord injury by weight drop device except for sham group.

SUBJECTS

Thirty-six female Sprague-Dawley rats.

INTERVENTIONS

The control group received Dulbecco's modified essential media/nutrient mixture F-12 injections, whereas the human umbilical cord mesenchymal stem cell group undertook cells transplantation at the dorsal spinal cord 2 mm rostrally and 2 mm caudally to the injury site at 24 hrs after spinal cord injury.

MEASUREMENTS

Rats from each group were examined for neurologic function and contents of brain-derived neurotrophic factor, glial cell line-derived neurotrophic factor, and neurotrophin-3. Survival, migration, and differentiation of human umbilical cord mesenchymal stem cells, regeneration of axons, and formation of glial scar were also explored by using immunohistochemistry and immunofluorescence.

MAIN RESULTS

Recovery of hindlimb locomotor function was significantly enhanced in the human umbilical cord mesenchymal stem cells grafted animals at 5 wks after transplantation. This recovery was accompanied by increased length of neurofilament-positive fibers and increased numbers of growth cone-like structures around the lesion site. Transplanted human umbilical cord-mesenchymal stem cells survived, migrated over short distances, and produced large amounts of glial cell line-derived neurotrophic factor and neurotrophin-3 in the host spinal cord. There were fewer reactive astrocytes in both the rostral and caudal stumps of the spinal cord in the human umbilical cord-mesenchymal stem cell group than in the control group.

CONCLUSIONS

Treatment with human umbilical cord mesenchymal stem cells can facilitate functional recovery after traumatic spinal cord injury and may prove to be a useful therapeutic strategy to repair the injured spinal cord.

Guidelines for Diagnosis and Treatment of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus in China (2021 Edition)

Portal vein tumor thrombus (PVTT) is very common and it plays a major role in the prognosis and clinical staging of hepatocellular carcinoma (HCC). We have published the first version of the guideline in 2016 and revised in 2018. Over the past several years, many new evidences for the treatment of PVTT become available, especially for the advent of new targeted drugs and immune checkpoint inhibitors which have further improved the prognosis of PVTT. So, the Chinese Association of Liver Cancer and Chinese Medical Doctor Association revised the 2018 version of the guideline to adapt to the development of PVTT treatment. Future treatment strategies for HCC with PVTT in China would depend on new evidences from more future clinical trials.

Lactate dehydrogenases amplify reactive oxygen species in cancer cells in response to oxidative stimuli

Previous studies demonstrated that superoxide could initiate and amplify LDH-catalyzed hydrogen peroxide production in aqueous phase, but its physiological relevance is unknown. Here we showed that LDHA and LDHB both exhibited hydrogen peroxide-producing activity, which was significantly enhanced by the superoxide generated from the isolated mitochondria from HeLa cells and patients’ cholangiocarcinoma specimen. After LDHA or LDHB were knocked out, hydrogen peroxide produced by Hela or 4T1 cancer cells were significantly reduced. Re-expression of LDHA in LDHA-knockout HeLa cells partially restored hydrogen peroxide production. In HeLa and 4T1 cells, LDHA or LDHB knockout or LDH inhibitor FX11 significantly decreased ROS induction by modulators of the mitochondrial electron transfer chain (antimycin, oligomycin, rotenone), hypoxia, and pharmacological ROS inducers piperlogumine (PL) and phenethyl isothiocyanate (PEITC). Moreover, the tumors formed by LDHA or LDHB knockout HeLa or 4T1 cells exhibited a significantly less oxidative state than those formed by control cells. Collectively, we provide a mechanistic understanding of a link between LDH and cellular hydrogen peroxide production or oxidative stress in cancer cells in vitro and in vivo.

In vitro labeling of human umbilical cord mesenchymal stem cells with superparamagnetic iron oxide nanoparticles

Human umbilical cord mesenchymal stem cells (hUC-MSCs) transplantation has been shown to promote regeneration and neuroprotection in central nervous system (CNS) injuries and neurodegenerative diseases. To develop this approach into a clinical setting it is important to be able to follow the fates of transplanted cells by noninvasive imaging. Neural precursor cells and hematopoietic stem cells can be efficiently labeled by superparamagnetic iron oxide (SPIO) nanoparticle. The purpose of our study was to prospectively evaluate the influence of SPIO on hUC-MSCs and the feasibility of tracking for hUC-MSCs by noninvasive imaging. In vitro studies demonstrated that magnetic resonance imaging (MRI) can efficiently detect low numbers of SPIO-labeled hUC-MSCs and that the intensity of the signal was proportional to the number of labeled cells. After transplantation into focal areas in adult rat spinal cord transplanted SPIO-labeled hUC-MSCs produced a hypointense signal using T2-weighted MRI in rats that persisted for up to 2 weeks. This study demonstrated the feasibility of noninvasive imaging of transplanted hUC-MSCs.

Binding pancreaticojejunostomy--a safe and reliable anastomosis procedure

BACKGROUND

Over the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas.

METHODS

To perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure - binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site.

RESULTS

From 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak.

DISCUSSION

Binding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.

Different approaches to caudate lobectomy with “curettage and aspiration” technique using a special instrument PMOD: A Report of 76 cases

AIM: To study different approaches to caudate lobectomy with “curettage and aspiration” technique using Peng’s multifunctional operative dissector (PMOD). The surgical procedure of isolated complete caudate lobectomy was specially discussed.

METHODS: In 76 cases of various types of caudate lobectomy, three approaches were used including left side approach, right side approach, and anterior approach. Among the 76 cases, isolated complete caudate lobectomy was carried out in 6 cases with transhepatic anterior approach. The surgical procedure consisted of mobilization of the total liver, ligation and separation of the short hepatic veins, splitting the liver parenchyma through the Cantlie’s plane, ligation and division of the caudate portal triads from the hilum, dissection of the root of major hepatic veins, detachment of the caudate lobe from liver parenchyma.

RESULTS: The mean operative time was 285 ± 51 min, the mean blood loss was 1600 mL. No severe complications were observed. Among the 6 cases receiving isolated complete caudate lobectomy with transhepatic anterior approach, one case died 17 months after operation due to disease recurrence and liver failure, the other 5 cases have been alive without recurrence, with one longest survival of 49 months.

CONCLUSION: The choice of approach is essential to the success of caudate lobectomy. As PMOD and “curettage and aspiration” technique can delineate intrahepatic or extrahepatic vessels clearly, caudate lobe resection has become safer, easier and faster.

Diagnosis and treatment of VIPoma in China: (case report and 31 cases review) diagnosis and treatment of VIPoma

OBJECTIVES

To discuss the experience of diagnosis and treatment of VIPoma by summarizing clinical information of 31 patients with VIPoma in China.

METHODS

To analyze clinical manifestations, laboratory examinations, imaging features, operation, pathologic findings, and follow-up survey of 31 patients, among them 1 case was from our hospital and the other 30 cases were reported in Chinese literature from 1977 to 2002.

RESULTS

Periodical backache, skin rash, and polyps of colon were never reported previously, all of which except polyps disappeared after operation. Partial resection of superior mesenteric vein was also never reported. The mean serum value of VIP which had been very high before operation, decreased markedly after the operation (963.2 pg/ml Versus 131.9 pg/ml),the immunohistochemical expression of many kinds of digestive hormone including VIP presented positive. Hepatic involvement was 29.0%,nodal metastasis was 9.7%.

CONCLUSIONS

VIPoma is rare. Typical symptoms and the serum value of VIP are keys to diagnosis before operation, Surgical resection is the most effective means for cure. surgical debulking of the tumor, somatostatin analogues can be used for good palliation.

Congenital choledochal cysts in adults: twenty-five-year experience

BACKGROUND

Choledochal cyst is rare in western countries. The relatively high incidence of coexistent hepatobiliary disease increases the difficulty of the surgical management of choledochal cyst. Here we analyze the diagnosis and treatment of congenital bile duct cyst in 122 Chinese adults.

METHODS

The clinical data of 122 patients with congenital choledochal cysts admitted from 1981 to 2006 were analyzed.

RESULTS

Clinical symptoms in most cases were nonspecific, resulting in delayed diagnosis. Sixty-one patients (50%) had coexistent pancreatobiliary disease. Among the 122 patients, 119 patients underwent ultrasonic examination; ERCP/MRCP was performed in 63 cases and CT in 102 cases. Abnormal pancreatobiliary duct junction was found in 48 patients. Sixteen patients had malignant lesions in the bile duct, arising in 11 of them from incomplete choledochal cyst that underwent various operations including cystenterostomy or cystojejunostomy. There was significant difference between the patients who underwent incomplete cyst resection and complete cyst resection in malignancy rate of bile duct (Chi square test, P = 0.000; odds ratio, 7.800; 95% confidence interval, 2.450 to 24.836).

CONCLUSIONS

ERCP, CT and MRCP had proved their great values in the classification of the disease. Cyst excision with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice for patients with type I or type IV cysts. For type V cyst (Caroli's disease) with recurrent cholangitis, liver transplantation should be considered.

Better surgical treatment method for hepatocellular carcinoma with portal vein tumor thrombus

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is a disease that is not uncommon, but the treatments vary drastically between Eastern and Western countries. In Europe and America, the first line of treatment is systemic therapy such as sorafenib and the surgical treatment is not a recommend option. While an increasing number of studies from China and Japan have suggested that surgical treatment results in better outcomes when compared to transcatheter arterial chemoembolization (TACE), sorafenib, or other nonsurgical treatments, and two classification systems, Japanese Vp classification and Chinese Cheng's classification, were very useful to guide the surgical treatment. We have also found that surgical treatment may be more effective, as we have performed surgical treatment for HCC-PVTT patients over a period of approximately 15 years and achieved good results with the longest surviving time being 13 years and onward. In this study, we review the efficacy and principles of current surgical treatments and introduce our new, more effective surgical technique named "thrombectomy first", which means the tumor thrombus in the main portal vein, the bifurcation or the contralateral portal vein should be removed prior to liver resection. Thus, compression and crushing of PVTT during the operation could be avoided and new intrahepatic metastases caused by tumor thrombus to the remnant liver minimized. The new technique is even beneficial to the prognosis of Cheng's classification Types III and IV PVTT. The vital tips and tricks for the surgical approach are described.

Interleukin-1 receptor associated kinases-1/4 inhibition protects against acute hypoxia/ischemia-induced neuronal injury in vivo and in vitro

Neuronal Toll-like receptors (TLRs)-2 and -4 have been shown to play a pivotal role in ischemic brain injury, and the interleukin-1 receptor associated kinases (IRAKs) are considered to be the key signaling molecules involved downstream of TLRs. Here, we investigated the expression levels of IRAK-1 and -4 and the effects of IRAK-1/4 inhibition on brain ischemic insult and neuronal hypoxia-induced injury. Male Sprague-Dawley (SD) rats and the rat neuroblastoma B35 cell line were used in these experiments. Permanent middle cerebral artery occlusion (MCAO) was induced by the intraluminal filament technique, and B35 cells were stimulated with the hypoxia-mimetic, cobalt chloride (CoCl(2)). Following induction of hypoxia/ischemia (H/I), B35 cells and cerebral cortical neurons expressed higher levels of IRAK-1 and -4. Furthermore, IRAK-1/4 inhibition decreased the mortality rate, functional deficits, and ischemic infarct volume by 7 days after MCAO. Similarly, IRAK-1/4 inhibition attenuated CoCl(2)-induced cytotoxicity and apoptosis in B35 cells in vitro. Our results show that IRAK-1/4 inhibition decreased the nuclear translocation of the nuclear factor-kappaB (NF-κB) p65 subunit, the levels of activated (phosphorylated) c-jun N-terminal kinase (JNK) and cleaved caspase-3, and the secretion of TNF-α and IL-6 in B35 cells at 6 h after CoCl(2) treatment. These data suggest that IRAK-1/4 inhibition plays a neuroprotective role in H/I-induced brain injury.

Identification of serologic biomarkers for predicting microvascular invasion in hepatocellular carcinoma

Microvascular invasion (MVI) of hepatocellular carcinoma (HCC) is a major risk factor for early recurrence and poor survival after curative surgical therapies. However, MVI can only be diagnosed by pathological examination following resection. The aim of this study is to identify serologic biomarkers for predicting MVI preoperatively to help facilitate treatment decisions. We used the sero-proteomic approach to identify antigens that induce corresponding antibody responses either specifically in the serum from MVI (+) patients or from MVI (-) patients. Six antigens were subsequently identified as HSP 70, HSP 90, alpha-enolase (Eno-1), Annexin A2, glutathione synthetase and beta-actin by mass spectrometry. The antibodies titers in sera corresponding to four of these six antigens were measured by ELISA and compared between 35 MVI (+) patients and 26 MVI (-) patients. The titers of anti-HSP 70 antibodies were significantly higher in MVI (-) patients than those in MVI (+) patients; and the titers of anti-Eno-1 antibodies were significantly lower in MVI (-) patients than those in MVI (+) patients. The results were subjected to multivariate analysis together with other clinicopathologic factors, suggesting that antibodies against HSP 70 and Eno-1 in sera are potential biomarkers for predicting MVI in HCC prior to surgical resection. These biomarkers should be further investigated as potential therapeutic targets.

Pancreatic benign schwannoma treated by simple enucleation: case report and review of literature

Benign schwannoma in the pancreatic head is very rare, with only 11 patients being reported in the English literature from a Medline search. Furthermore, only 1 of them was treated by simple enucleation. Herein, we present another enucleation case: a 71-year-old male patient with a 1.5 x 1.2-cm low-density mass, mimicking a cystic lesion located at the head of pancreas, which was detected by computed tomography. This tumor failed to be discovered by abdominal ultrasound. At laparotomy, a solid mass 1 cm in diameter was identified; it was the smallest one in the pancreatic head according to the 11 previous reported cases. No complications were found after the operation. At 10-month follow-up, the patient remains asymptomatic and has no signs of recurrence. The data of the 12 patients indicated that simple minimal invasive enucleation for small benign schwannoma in the pancreatic head was feasible and safe; early detection and early treatment of the tumor were helpful in increasing the ratio of enucleation and avoiding a very invasive Whipple operation.

Surgical treatment of hepatocellular carcinoma originating from caudate lobe--a report of 39 cases

The study objective was to study the therapeutic effect of surgical treatment for hepatocellular carcinoma (HCC) originating from the caudate lobe. From 1995 to 2003, caudate lobe resection was carried out for 97 cases; among them 39 were for HCC, who were divided into two groups. Group A consisted of 19 cases undergoing isolated caudatectomy, and group B consisted of 20 cases undergoing caudatectomy combined with other liver resections. The factors that might influence postoperative recovery were compared between the two groups. A special instrument, Peng's Multifunctional Operative Dissector, was used for surgical dissection. All tumors were resected successfully. One patient died of postoperative renal failure. Hydrothorax occurred in three patients, ascites occurred in four patients, and bile leakage occurred in one patient. Thirty cases received long-term follow-up with survival rates at 1, 3, and 5 years of 53%, 50%, and 39%, respectively. Caudate lobectomy is an effective therapeutic method for HCC originating in the caudate lobe. Isolated caudatectomy should be performed as the first choice whenever possible. Anterior transhepatic approach is appropriate in some cases. Peng's Multifunctional Operative Dissector is a very useful instrument for surgical dissection.

Local delivery of vascular endothelial growth factor via nanofiber matrix improves liver regeneration after extensive hepatectomy in rats

Vascular endothelial growth factor (VEGF) is a potent regulator for liver regeneration following partial hepatectomy. However, intravenous delivery of VEGF has yielded limited success in promoting the regeneration of remnant liver. Here we report a new approach to locally deliver recombinant VEGF from an electrospun poly-ε-caprolactone nanofiber mesh and its effect on improving rat liver regeneration after 70% hepatectomy. After applying the VEGF-releasing nanofiber mesh to the remnant liver lobes following hepatectomy in rats, the fractions of proliferating hepatocytes increased markedly at 48 h and 72 h in comparison with the control group receiving nanofiber meshes without VEGF. The expression of endogenous VEGF in liver tissue was also higher in the VEGF-nanofiber group than those in the control group. These results demonstrate that biodegradable nanofiber meshes offer a convenient and effective approach for local and sustained delivery of VEGF to the remnant liver following partial hepatectomy.

Gastric foregut cystic developmental malformation: Case series and literature review

Foregut cystic developmental malformation (FCDM) is a very rare lesion of the alimentary tract, especially in the stomach. We discuss the concepts of gastric duplication cyst, bronchogenic cysts, and FCDM. Nomenclature has been inconsistent and confusing, but, by some definitions, gastric duplication cysts involve gastric mucosa and submucosal glands, bronchogenic cysts involve respiratory mucosa with underlying cartilage and glands, and FCDM lacks gastric mucosa or underlying glands or cartilage but has pseudostratified ciliated columnar epithelium (PCCE). We searched our departmental case files from the past 15 years and identified 12 cases of FCDM in the alimentary tract. We summarize the features of these 12 cases including a report in detail on a 52-year-old man with a submucosal cyst lined with simple PCCE and irregular and stratified circular muscle layers that merged with gastric smooth muscle bundles near the lesser curvature of the gastric cardia. A literature review of cases with this histology yielded 25 cases. We propose the term gastric-FCDM for such cases. Our own series of 12 cases confirms that preoperative recognition of the entity is infrequent and problematic. The rarity of this developmental disorder, as well as a lack of understanding of its embryologic origins, may contribute to missing the diagnosis. Not appreciating the diagnosis preoperatively can lead to an inappropriate surgical approach. In contrast, presurgical recognition of the entity will contribute to a good outcome and reduced risk of complications.

Photodynamic therapy leads to death of C6 glioma cells partly through AMPAR

Glioma cells release glutamate during growth, which promotes proliferation and migration of itself and causes excitotoxicity to the surrounding neurons by Ca(2+) influx through glutamate receptors. However, the role of glutamate and its receptors in the photodynamic therapy (PDT) on glioma cells is still unclear. Here we administered α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid glutamate receptor (AMPAR) antagonist prior to PDT on C6 glioma cells. The changes of glutamate release, expression of AMPAR, apoptosis of C6 cells, and intracellular free calcium ([Ca(2+)](i)) were examined after PDT. We found that PDT increased extracellular glutamate and expression of AMPAR subunit GluR1 and GluR2, which might result in Ca(2+) influx and apoptosis of C6 cells. When AMPAR antagonist was added, intracellular free calcium reduced and apoptosis rate of C6 cells decreased. These results indicate that PDT may lead to death of C6 glioma cells partly through glutamate and its receptors AMPAR, which induces Ca(2+) influx and then cells apoptosis. This study allows us to further understand the effects and molecular mechanism of PDT on glioma.

The clinical utility of CA125/MUC16 in pancreatic cancer: A consensus of diagnostic, prognostic and predictive updates by the Chinese Study Group for Pancreatic Cancer (CSPAC)

The prognosis for pancreatic cancer (PC) is poor; however, the timely and accurate treatment of this disease will significantly improve prognosis. Serum biomarkers involve non-invasive tests that facilitate the early detection of tumors, predict outcomes and assess responses to therapy, so that the patient can be continuously monitored and receive the most appropriate therapy. Studies have reported that cancer antigen (CA)125 [also known as mucin 16 (MUC16)] has functional significance in the tumorigenic, metastatic and drug resistant properties of PC. Our aim was to use this biomarker in the diagnosis, detection of metastasis, prognosis and in the monitoring of the treatment effects of PC. Members of the Chinese Study Group for Pancreatic Cancer (CSPAC) reviewed the literature on CA125/MUC16 and developed an objective consensus on the clinical utility of CA125/MUC16 for PC. They confirmed the role of CA125/MUC16 in tumorigenesis and the progression of PC, and recommended monitoring CA125/MUC16 levels in all aspects of the diagnosis and treatment of PC, particularly those that involve the monitoring of treatments. In addition, they suggested that the combination of other biomarkers and imaging techniques, together with CA125/MUC16, would improve the accuracy of the clinical decision-making process, thereby facilitating the optimization of treatment strategies. Periodic clinical updates of the use of CA125/MUC16 have been established, which are important for further analyses and comparisons of clinical results from affiliates and countries, particularly as regards the in-depth biological function and clinical translational research of this biomarker.

Malignant solitary fibrous tumor of the pancreas with systemic metastasis: A case report and review of the literature

BACKGROUND

Pancreatic solitary fibrous tumor (SFT) is a rare neoplasm of intermediate biological potential. So far, only 22 cases have been reported since 1999. All the cases, except one, exhibited benign features. Here, we report the first case of malignant pancreatic SFT with typical Doege-Potter syndrome, along with the clinical and pathologic evidence of its systemic metastasis.

CASE SUMMARY

The patient was a 48-year-old man with a 1-year history of pancreatic and liver masses and refractory hypoglycemia. Increased uptake of the tracer fluorodeoxyglucose (FDG) was found in the liver and bones by fluorine-18 FDG positron emission tomography/computed tomography. After multidisciplinary discussion, a distal pancreatectomy procedure was performed, and histological examination showed a lesion composed of abundant heterogeneous spindle cells with localized necrosis. On immunohistochemistry evaluation, STAT6 was found to be diffusely expressed in the tumor. Based on the overall evidence, the patient was diagnosed with malignant pancreatic SFT with liver and bone metastases.

CONCLUSION

The diagnosis of malignant SFT requires comprehensive evidence including clinical, immunohistochemistry, and histological features. This case may be presented as a reference for diagnoses and management of malignant pancreatic SFTs with systemic metastasis.

International Summit on Laparoscopic Pancreatic Resection (ISLPR) "Coimbatore Summit Statements"

The International Summit on Laparoscopic Pancreatic Resection (ISLPR) was held in Coimbatore, India, on 7th and 8th of October 2016 and thirty international experts who regularly perform laparoscopic pancreatic resections participated in ISPLR from four continents, i.e., South and North America, Europe and Asia. Prior to ISLPR, the first conversation among the experts was made online on August 26th, 2016 and the structures of ISPLR were developed. The aims of ISPLR were; i) to identify indications and optimal case selection criteria for minimally invasive pancreatic resection (MIPR) in the setting of both benign and malignant diseases; ii) standardization of techniques to increase the safety of MIPR; iii) identification of common problems faced during MIPR and developing associated management strategies; iv) development of clinical protocols to allow early identification of complications and develop the accompanying management plan to minimize morbidity and mortality. As a process for interactive discussion, the experts were requested to complete an online questionnaire consisting of 65 questions about the various technical aspects of laparoscopic pancreatic resections. Two further web-based meetings were conducted prior to ISPLR. Through further discussion during ISPLR, we have created productive statements regarding the topics of Disease, Implementation, Patients, Techniques, and Instrumentations (DIPTI) and hereby publish them as "Coimbatore Summit Statements".

Regional lymphadenectomy vs. extended lymphadenectomy for hilar cholangiocarcinoma (Relay-HC trial): study protocol for a prospective, multicenter, randomized controlled trial

Background

The prognostic benefits and safety of extended lymphadenectomy for hilar cholangiocarcinoma remain uncertain. The available evidence is still insufficient concerning its retrospective aspect. The aim of this study is to explore the clinical effect and safety of extended lymphadenectomy compared to regional lymphadenectomy in patients with hilar cholangiocarcinoma.

Methods

The Relay-HC trial is a prospective, multicenter, and randomized controlled trial. Seven hundred and thirty-four eligible patients with resectable perihilar cholangiocarcinoma across 15 tertiary hospitals in China will be randomly assigned (1:1) to receive either regional lymphadenectomy or extended lymphadenectomy. The primary objective is to determine the overall survival after the two approaches. Secondary objectives of the study include the evaluation of perioperative mortality, postoperative complication, and disease-free survival. This study has been approved by the ethics committee of each participating hospital.

Discussion

The Relay-HC trial is designed to investigate the prognostic benefits and safety of expanded lymphadenectomy for hilar cholangiocarcinoma. Currently, it has never been investigated in a prospective randomized controlled clinical trial.

Trial registration

Chinese Clinical Trial Registry (ChiCTR), ChiCTR1800015688. Registered on 15 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3605-z) contains supplementary material, which is available to authorized users.

Should a standard lymphadenectomy during pancreatoduodenectomy exclude para-aortic lymph nodes for all cases of resectable pancreatic head cancer? A consensus statement by the Chinese Study Group for Pancreatic Cancer (CSPAC)

Understanding and formulating an appropriate strategy for the para-aortic lymph nodes (LN16) during curative surgery for pancreatic head cancer have been controversial for some time. This study intended to provide a recommendation for surgeons to perform an optimal curative surgery on pancreatic cancer patients with or without LN16 involvement. Based on an updated literature search and review, the members of the Chinese Study Group for Pancreatic Cancer (CSPAC) from high-volume centers reached a consensus on the issue of LN16 in pancreatic head cancer. Metastasis to LN16 is quite common in pancreatic head cancer cases. Depending on the location of the tumor, including the ventral and dorsal pancreas, there could be various lymph node drainage pathways whereby LN16 does not necessarily belong to the Group 3 lymph node stations for all cases of pancreatic head cancer. Although LN16 involvement generally indicates a poor prognosis, some cohorts of LN16-involved cases have benefited from a curative surgery, and there is still a lack of level I evidence to convince surgeons to abandon all resectable cases with LN16 positivity. Resection of LN16 combined with a standard lymphadenectomy during pancreatoduodenectomy is recommended by CSPAC, except in patients with both positive LN16 and criteria based on: i) the resectability status of primary tumor; ii) the extent of involved para-aortic lymph nodes; and iii) the serum tumor burden assessed preoperatively.

"Curettage and aspiration dissection technique" using PMOD for liver resection

BACKGROUND AND AIMS

To introduce a special dissection technique named "Curettage and Aspiration Dissection Technique" (CADT) using a versatile instrument called Peng's Multifunction Operative Dissector (PMOD) for liver resection. PMOD is an electrosurgical pencil with an inline suction, bearing four functions: electric cutting, coagulation, aspiration and dissection, The above-mentioned functions can be achieved simultaneously or sequentially during liver resection. The purpose of this study was to evaluate this technique and the special electrosurgical device in hepatic surgery.

PATIENTS AND METHODS

From June 2005 to December 2006, 70 consecutive patients with segmentectomy or major hepatectomy were performed with this dissection technique by the same surgeon. Peri-operative data and the technical aspect of this device and dissection technique for various types of liver resection were summarised.

RESULTS

Forty-nine of 70 cases with various degrees of cirrhosis. Median blood loss were 470 ml (100-2400 ml), the bleeding and mortality within one month postoperatively was zero. There were postoperative complications in 20 patients: bile leak occurred in five cases, nine cases with right pleural effusion and six with ascites. No relative complications with this method were found.

CONCLUSION

The CADT and PMOD can achieve better dissection and hemostasis. It possible is a much more valuable alternative to other devices currently used for liver surgery.

Chinese Expert Consensus on Immunotherapy for Hepatocellular Carcinoma (2021 Edition)

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies in China. Most HCC patients are first diagnosed at an advanced stage, and systemic treatments are the mainstay of treatment.

SUMMARY

In recent years, immune checkpoint inhibitors have made a breakthrough in the systemic treatment of middle-advanced HCC, breaking the single therapeutic pattern of molecular-targeted agents. To better guide the clinical treatment for effective and safe use of immunotherapeutic drugs, the Chinese Association of Liver Cancer and Chinese Medical Doctor Association has gathered multidisciplinary experts and scholars in relevant fields to formulate the "Chinese Clinical Expert Consensus on Immunotherapy for Hepatocellular Carcinoma (2021)" based on current clinical studies and clinical medication experience for reference in China.

KEY MESSAGES

The consensus contained 17 recommendations, including the preferred regimen for first- and second-line immunotherapy, evaluation and monitoring before/during/after treatment, management of complications, precautions for special patients, and potential population for immunotherapy.