Pancreaticoduodenectomy for locally advanced stomach cancer: preliminary results

Minimally invasive elective gastrectomy after preoperative chemotherapy in a patient with frailty who presented with locally far advanced-stage gastric cancer: a case report

BACKGROUND

Herein, we report a case of gastric antrum cancer with multiple invasions to other organs that was completely cured with laparoscopic distal gastrectomy after preoperative chemotherapy in a patient with poor general condition.

CASE PRESENTATION

An 80-year-old male patient was diagnosed with anemia during follow-up for cerebral lacunar infarction at another hospital. He was diagnosed with advanced-stage gastric antrum cancer and was referred to our hospital. On esophagogastroduodenoscopy, type 2 advanced-stage gastric cancer was detected at the greater curvature of the antrum, and the biopsy results revealed tubular adenocarcinoma. Contrast-enhanced computed tomography scan revealed multiple invasions to other organs, thick gastric wall with contrast effect, and superior mesenteric vein tumor thrombus. However, there was no evidence of distant metastasis on positron emission tomography/computed tomography scan. The clinical diagnosis was stage IVA gastric cancer. Pancreatoduodenectomy with portal vein resection could be important at this point. However, preoperative chemotherapy with S-1 and oxaliplatin was administered instead of performing extended surgery because the patient had poor general condition (performance status score of 3). The patient received three cycles of preoperative chemotherapy at the hospital along with rehabilitation and nutritional management with oral nutritional supplements. After treatment, the performance status score of the patient improved from 3 to 1. Furthermore, in terms of clinical therapeutic effect, the patient achieved partial response. Hence, laparoscopic distal gastrectomy with D2 lymph node dissection and partial transverse colectomy was performed. After surgery, the patient was admitted for oral intake on postoperative day 6 and was discharged on postoperative day 21. Based on the histopathological examination, gastric cancer had disappeared, and there were no evident malignant findings. Therefore, gastric cancer was classified as grade 3 according to the histological treatment efficacy criteria. The patient did not present with recurrence at 2 years after surgery.

CONCLUSIONS

By actively administering preoperative chemotherapy, minimally invasive radical surgery with maximum preservation of the surrounding organs can be performed for locally far advanced-stage gastric cancer in older patients with poor general condition.

Impact of Pancreatic Resection on Survival in Locally Advanced Resectable Gastric Cancer

Whether gastric adenocarcinoma (GC) patients with adjacent organ invasion (T4b) benefit from aggressive surgery involving pancreatic resection (PR) remains unclear. This study aimed to clarify the impact of PR on survival in patients with locally advanced resectable GC. Between 1995 and 2017, patients with locally advanced GC undergoing radical-intent gastrectomy with and without PR were enrolled and stratified into four groups: group 1 (G1), pT4b without pancreatic resection (PR); group 2 (G2), pT4b with PR; group 3 (G3), positive duodenal margins without Whipple's operation; and group 4 (G4), cT4b with Whipple's operation. Demographics, clinicopathological features, and outcomes were compared between G1 and G2 and G3 and G4. G2 patients were more likely to have perineural invasion than G1 patients (80.6% vs. 50%, p < 0.001). G4 patients had higher lymph node yield (40.8 vs. 31.3, p = 0.002), lower nodal status (p = 0.029), lower lymph node ratios (0.20 vs. 0.48, p < 0.0001) and higher complication rates (45.2% vs. 26.3%, p = 0.047) than G3 patients. The 5-year disease-free survival (DFS) and overall survival (OS) rates were significantly longer in G1 than in G2 (28.1% vs. 9.3%, p = 0.003; 32% vs. 13%, p = 0.004, respectively). The 5-year survival rates did not differ between G4 and G3 (DFS: 14% vs. 14.4%, p = 0.384; OS: 12.6% vs. 16.4%, p = 0.321, respectively). In conclusion, patients with T4b lesion who underwent PR had poorer survival than those who underwent resection of other adjacent organs. Further Whipple's operation did not improve survival in pT3-pT4 GC with positive duodenal margins.

Pancreaticoduodenectomy after neoadjuvant chemotherapy for gastric cancer invading the pancreatic head: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high morbidity and mortality rates and low survival rate. However, neoadjuvant chemotherapy for advanced gastric cancer has improved, and chemotherapy combined with trastuzumab may have a preoperative tumor-reducing effect, especially for human epidermal growth factor receptor 2 (HER2)-positive cases.

CASE SUMMARY

We report a case of successful radical resection with PD after neoadjuvant S-1 plus oxaliplatin (SOX) and trastuzumab in a patient (66-year-old male) with advanced gastric cancer invading the pancreatic head. Initial esophagogastroduodenoscopy detected a type 3 advanced lesion located on the lower part of the stomach obstructing the pyloric ring. Computed tomography detected lymph node metastasis and tumor invasion to the pancreatic head without distant metastasis. Pathological findings revealed adenocarcinoma and HER2 positivity (immunohistochemical score of 3 +). We performed staging laparoscopy and confirmed no liver metastasis, no dissemination, negative lavage cytological findings, and immobility of the distal side of the stomach due to invasion to the pancreas. Laparoscopic gastrojejunostomy was performed at that time. One course of SOX and three courses of SOX plus trastuzumab were administered. Preoperative computed tomography showed partial response; therefore, PD was performed after neoadjuvant chemotherapy, and pathological radical resection was achieved.

CONCLUSION

We suggest that radical resection with PD after neoadjuvant chemotherapy plus trastuzumab is an option for locally advanced HER2-positive gastric cancer invading the pancreatic head in the absence of non-curative factors.

Laparoscopic Whipple's Operation for Locally Advanced Gastric Cancer Invading the Pancreas and Duodenum: a Case Report

Few surgeons have adopted pancreaticoduodenectomy (PD) for the treatment of advanced gastric cancer (AGC) invading the pancreas or duodenum because it remains controversial whether its prognostic benefits outweigh the high morbidity rates in such advanced cases. However, recent technical advances have revived diverse surgical procedures in minimally invasive approaches. Inspired by this trend, laparoscopic PD procedures have been performed for AGC in our institute since 2014. We recently performed a laparoscopic Whipple's operation in a case of cT4b gastric cancer with invasion of the pancreatic head and duodenum.

Pancreaticoduodenectomy for locally advanced gastric cancer: Results from a pooled analysis

Little is known about the clinical outcome of pancreaticoduodenectomy (PD) for locally advanced gastric cancer invading the duodenum and/or pancreas. The aim of this study was to define the clinical outcome and prognostic determinants of PD for locally advanced gastric cancer through a systematic review and pooled analysis of relevant data in the literature. A total of 13 articles involving 69 patients were eligible for inclusion. Postoperative morbidity and mortality were 59.4% and 1.4%, respectively. Overall 5-year survival and median survival were 39.3% and 26 months, respectively. Positive peritoneal lavage cytology represented the only independent prognostic factor for the poor outcome at multivariate analysis (hazard ratio 3.470, 95% confidence interval 1.011-11.909; P = 0.048). In summary, PD is a feasible option for locally advanced gastric cancer invading the duodenum and/or pancreas with an acceptable operative risk and offers survival benefits in selected patients.

A case of multiorgan resection for locally advanced stomach cancer

Extensive surgical resection may be required in locally advanced gastric cancers, with involvement of other organs. Our purpose was to present a case where vascular reconstruction was performed during multiple organ resections in a patient with locally advanced gastric cancer. An emergent laparotomy was performed on a patient who presented with upper gastrointestinal system hemorrhage; and he was diagnosed with locally advanced gastric cancer. Total gastrectomy, D II dissection, pancreaticoduodenectomy, transverse colectomy and end-to-end anastomosis were performed. Additionally, the superior mesenteric vein was partially excised and re-implanted to the portal vein. Neither recurrence nor distant metastasis was observed during the post-operative follow-up. Adjacent organ resections may be necessary for a curative treatment in locally advanced gastric cancer. In addition, partial resection and reconstruction may be required for extensive vascular invasion.

Simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis: indications and literature review

OBJECTIVE

This study was aimed to identify the potential indications for simultaneous resection of abdominal cancer and synchronous pancreaticoduodenal metastasis (SRAPM) and improve the efficacy of SRAPM.

METHODS

The data of 34 patients who underwent SRAPM were retrospectively reviewed. The intraoperative findings, morbidity and mortality, patterns of tumor invasion in the pancreas and duodenum, lymph node metastases, long-term outcomes and causes of death were evaluated.

RESULTS

Fourteen patients (41.2%) developed complications, and 2 died of pancreatic fistulas with abdominal bleeding. The in-hospital mortality was 5.9%. The overall 1-year, 2-year and 3-year survival rates were 52.9%, 32.3% and 21.8%, respectively. The survival rates depended on the primary tumor, the invasion pattern, the presence of metastatic lymph nodes at the paraaortic site and the presence of residual tumor. The follow-up outcomes revealed that the main causes of death were as follows: systemic metastasis (n = 7), peritoneal metastasis (n = 6) and intrahepatic metastasis (n = 6).

CONCLUSIONS

SRAPM is indicated for low-grade malignant tumors and in cases with direct invasion of the pancreaticoduodenum. The presence of metastatic lymph nodes at the paraaortic site, intrahepatic metastasis, micro-peritoneal metastasis, and distinct metastasis should be contraindications for the surgical procedure.

Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND

The purpose of this study was to identify and synthesize findings from all articles on surgical and long-term outcomes in patients with gastric cancer undergoing gastrectomy combined with pancreaticoduodenectomy (PD).

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and Cochrane databases from January 1, 1985, to December 31, 2009.

RESULTS

Eight retrospective case series were included, with 132 patients having PD combined with gastrectomy. PD was combined with total gastrectomy in 27 patients, and subtotal gastrectomy in 81 patients; 24 patients had undocumented gastric resection type. Clinical stage was available for 92 patients (4 stage I, 7 stage II, 26 stage III, and 55 stage IV). Five studies (98 patients having PD combined with gastrectomy) compared PD and gastrectomy to gastrectomy alone. In the four studies reporting morbidity, PD had a higher morbidity. The pooled pancreatic anastomotic leak rate was 24.5% for the seven studies in which complications were reported; however, there were no peri-operative deaths. Long-term survival (37.3% at 5 years) in gastric cancer patients with PD combined with gastrectomy was described; however, survival was poor in the setting of incurable factors. Due to heterogeneity of patients and staging techniques in the case series no recommendations can be made on the appropriate selection criteria for patients undergoing PD and gastrectomy.

CONCLUSION

PD for gastric cancer invading the pancreas is associated with a higher morbidity; given the heterogeneous data, defining exact selection criteria is difficult.

Resection for secondary malignancy of the pancreas

OBJECTIVES

This study tried to clarify the role of pancreatic resection in the treatment of secondary malignancy with metastasis or local invasion to the pancreas in terms of surgical risk and survival benefit.

METHODS

Data of secondary malignancy of the pancreas from our 19 patients and cases reported in the English literature were pooled together for analysis.

RESULTS

There were 329 cases of resected secondary malignancy of the pancreas, including 241 cases of metastasis and 88 cases of local invasion. The most common primary tumor metastatic to the pancreas and amenable to resection was renal cell carcinoma (RCC) (73.9%). More than half (52.3%) of the primary cancers with local invasion to the pancreas were colon cancer, and nearly half (40.9%) were stomach cancer. The median metastatic interval was 84 months (7 years) for overall primary tumors and 108 months (9 years) for RCC. The 5-year survival for secondary malignancy of the pancreas after resection was 61.1% for metastasis and 58.9% for local invasion, with 72.8% for RCC metastasis, 69.0% for colon cancer, and 43.8% for stomach cancer with local invasion to the pancreas.

CONCLUSIONS

Pancreatic resection should not be precluded for secondary malignancy of the pancreas because long-term survival could be achieved with acceptable surgical risk in selected patients.