Accuracy of preoperative T2 gallbladder tumor localization and the adequate surgical resection

INTRODUCTION

The agreement between the radiologic and histopathologic tumor locations in T2 gallbladder cancer is critical. There is no consensus regarding the extent of curative resection by tumor locations.

METHODS

Between January 2010 and December 2019, a consecutive series of 118 patients with pathological T2 gallbladder cancer who underwent surgery were retrospectively analyzed in terms of the accordance between radiologic and histopathologic tumor locations, the extents of hepatic resection and the numbers of harvested lymph nodes. Radical resection was defined as liver resection with harvesting of at least four lymph nodes.

RESULTS

The accuracy of preoperative tumor localization was only 68%. After radical resection, the 5-year overall survival (OS) was 59.4%; after nonradical resection, the figure was 46.1% (p = 0.092). In subanalyses, the 5-year OS was marginally better for patients who underwent liver resection or from whom at least four lymph nodes were harvested than those who did not undergo liver resection or from whom three or fewer lymph nodes were harvested (58.2% vs. 39.4%, p = 0.072; 59.9% vs. 50.0%, p = 0.072, respectively). In patients with peritoneal side tumor, the 5-year OSs of those who did and did not undergo liver resection were 67% and 41.2%, respectively (p = 0.028). In multivariate analysis, perineural invasion and radical resection were independently prognostic of OS.

CONCLUSION

The accuracy of preoperative tumor localization was 68%. Hepatic resection, lymph node dissection harvesting of at least four lymph nodes are required for curative resection for gallbladder cancer, regardless of tumor location.

Proposal of nomograms to predict clinical outcomes in patients with ampulla of Vater cancer based on the Korea-Japan collaborative study

BACKGROUND

In this study, we aimed to develop and validate a nomogram to predict overall survival (OS) and recurrence-free survival (RFS) in patients who underwent curative resection of ampulla of Vater (AOV) cancer. This is the first study for nomograms in AOV cancer patients using retrospective data based on an international multicenter study.

METHODS

A total of 2007 patients with AOV adenocarcinoma who received operative therapy between 2002 January and 2015 December in Korea and Japan were retrospectively assessed to develop a prediction model. Nomograms for 5-year OS and 3-year RFS were constructed by dividing the patients who received and who did not receive adjuvant therapy after surgery, respectively. Significant risk factors were identified by univariate and multivariate Cox analyses. Performance assessment of the four prediction models was conducted by the Harrell's concordance index (C-index) and calibration curves using bootstrapping.

RESULTS

A total of 2007 and 1873 patients were collected for nomogram construction to predict 5-year OS and 3-year RFS. We developed four types of nomograms, including models for 5-year OS and 3-year RFS in patients who did not receive postoperative adjuvant therapy, and 5-year OS and 3-year RFS in patients who received postoperative adjuvant therapy. The C-indices of these nomograms were 0.795 (95% confidence interval [CI]: 0.766-0.823), 0.712 (95% CI: 0.674-0.750), 0.804 (95% CI: 0.7778-0.829), and 0.703 (95% CI: 0.669-0.737), respectively.

CONCLUSIONS

This predictive model could help clinicians to choose optimal treatment and precisely predict prognosis in AOV cancer patients.

Safety of performing distal pancreatosplenectomy in patients who underwent distal gastrectomy previously: a multicenter cohort analysis with systematic literature review

Purpose

In patients who have previously undergone subtotal gastrectomy (STG), the remnant stomach is supplied with arterial blood through the splenic artery. It is currently unclear whether the remnant stomach can be safely preserved when performing distal pancreatosplenectomy (DPS) in these patients. Thus, this study aimed to evaluate the safety and feasibility of performing DPS in patients who had undergone a previous STG.

Methods

A multicenter cohort study was performed to identify patients who underwent DPS. Electronic medical data of Clinical Data Warehouse from 7 representative high-volume centers in 5 cities were retrospectively reviewed. A propensity score-matched analysis was performed to match patients who had no history of upper abdominal surgery with patients who had undergone a previous STG.

Results

Fourteen DPS patients who had a history of STG (STG group) were studied and matched to 70 patients who underwent DPS without any history of upper abdominal surgery (non-STG group). All patients in the STG group had the remnant stomach preserved. In most patients, the blood vessel supplying blood to the remnant stomach was the left inferior phrenic artery. There was no significant difference in the incidence of stomach-related complications or length of hospital stay between the 2 groups.

Conclusion

Our study results suggest that the remnant stomach could be safely preserved when performing DPS in patients with a prior STG. However, it is necessary to carefully evaluate the vascular structure of the remnant stomach through preoperative imaging study and closely observe changes to the blue stomach during the operation.

Superior gallstone dissolubility and safety of tert-amyl ethyl ether over methyl-tertiary butyl ether

BACKGROUND

The use of methyl-tertiary butyl ether (MTBE) to dissolve gallstones has been limited due to concerns over its toxicity and the widespread recognition of the safety of laparoscopic cholecystectomy. The adverse effects of MTBE are largely attributed to its low boiling point, resulting in a tendency to evaporate. Therefore, if there is a material with a higher boiling point and similar or higher dissolubility than MTBE, it is expected to be an attractive alternative to MTBE.

AIM

To determine whether tert-amyl ethyl ether (TAEE), an MTBE analogue with a relatively higher boiling point (102 °C), could be used as an alternative to MTBE in terms of gallstone dissolubility and toxicity.

METHODS

The in vitro dissolubility of MTBE and TAEE was determined by measuring the dry weights of human gallstones at predetermined time intervals after placing them in glass containers with either of the two solvents. The in vivo dissolubility was determined by comparing the weights of solvent-treated gallstones and control (dimethyl sulfoxide)-treated gallstones, after the direct infusion of each solvent into the gallbladder in both hamster models with cholesterol and pigmented gallstones.

RESULTS

The in vitro results demonstrated a 24 h TAEE-dissolubility of 76.7%, 56.5% and 38.75% for cholesterol, mixed, and pigmented gallstones, respectively, which represented a 1.2-, 1.4-, and 1.3-fold increase in dissolubility compared to that of MTBE. In the in vitro experiment, the 24 h-dissolubility of TAEE was 71.7% and 63.0% for cholesterol and pigmented gallstones, respectively, which represented a 1.4- and 1.9-fold increase in dissolubility compared to that of MTBE. In addition, the results of the cell viability assay and western blot analysis indicated that TAEE had a lower toxicity towards gallbladder epithelial cells than MTBE.

CONCLUSION

We demonstrated that TAEE has higher gallstone dissolubility properties and safety than those of MTBE. As such, TAEE could present an attractive alternative to MTBE if our findings regarding its efficacy and safety can be consistently reproduced in further subclinical and clinical studies.

Efficacy and safety of a novel topical agent for gallstone dissolution: 2-methoxy-6-methylpyridine

BACKGROUND

Although methyl-tertiary butyl ether (MTBE) is the only clinical topical agent for gallstone dissolution, its use is limited by its side effects mostly arising from a relatively low boiling point (55 °C). In this study, we developed the gallstone-dissolving compound containing an aromatic moiety, named 2-methoxy-6-methylpyridine (MMP) with higher boiling point (156 °C), and compared its effectiveness and toxicities with MTBE.

METHODS

The dissolubility of MTBE and MMP in vitro was determined by placing human gallstones in glass containers with either solvent and, then, measuring their dry weights. Their dissolubility in vivo was determined by comparing the weights of solvent-treated gallstones and control (dimethyl sulfoxide)-treated gallstones, after directly injecting each solvent into the gallbladder in hamster models with cholesterol and pigmented gallstones.

RESULTS

In the in vitro dissolution test, MMP demonstrated statistically higher dissolubility than did MTBE for cholesterol and pigmented gallstones (88.2% vs. 65.7%, 50.8% vs. 29.0%, respectively; P < 0.05). In the in vivo experiments, MMP exhibited 59.0% and 54.3% dissolubility for cholesterol and pigmented gallstones, respectively, which were significantly higher than those of MTBE (50.0% and 32.0%, respectively; P < 0.05). The immunohistochemical stains of gallbladder specimens obtained from the MMP-treated hamsters demonstrated that MMP did not significantly increase the expression of cleaved caspase 9 or significantly decrease the expression of proliferation cell nuclear antigen.

CONCLUSIONS

This study demonstrated that MMP has better potential than does MTBE in dissolving gallstones, especially pigmented gallstones, while resulting in lesser toxicities.

Randomized controlled study of the effect of octreotide on pancreatic exocrine secretion and pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Octreotide is known to decrease the rate of postoperative complication after pancreatic resection by diminishing exocrine function of the pancreas. The aim of this study was to evaluate the effect of octreotide in decreasing exocrine excretion of pancreas and preventing pancreatic fistula.

MATERIALS AND METHODS

Prospective randomized trial was conducted involving 59 patients undergoing pancreaticoduodenectomy for either malignant or benign tumor, 29 patients were randomized to receive octreotide; 30 patients allotted to placebo. All pancreaticojejunal anastomosis was performed with external stent of negative-pressured drainage and the amount of pancreatic juice through the external stent was measured until postoperative 7th day. Pancreatic fistula was recorded.

RESULTS

There were no differences in demographics, pancreatic texture and pancreatic duct diameter between the octreotide and placebo group. The median output of pancreatic juice was not significantly different between both groups during 7 days after surgery. When the patients were stratified according to the diameter of pancreatic duct (duct ≤5 mm, > 5 mm), there were no significant differences in daily amount of pancreatic juice, however, when stratified according to pancreatic texture, median output of pancreatic juice was significantly lower in patients with hard pancreas compared with those with soft pancreas from 5 day to 7 day after surgery (p < 0.05). No significant differences in pancreatic fistula and postoperative complications were found between the octreotide and placebo groups.

CONCLUSIONS

Prophylactic octreotide is not effective to inhibit the exocrine secretion of the remnant pancreas and does not decrease the incidence of pancreatic fistula after pancreaticoduodenectomy.

Prognostic factors after curative resection hepatocellular carcinoma and the surgeon's role

Purpose

Patient, surgical, and tumor factors affect the outcome after surgical resection for hepatocellular carcinoma (HCC). The surgical factors are only modifiable by the surgeon. We reviewed our experience with curative resection for HCC in terms of surgical factors.

Methods

After analyses of the prospectively collected clinical data of 256 consecutive patients undergoing surgical resection for HCC, prognostic factors for disease-free survival (DFS) and overall survival (OS) were identified; all patients were stratified by tumor diameters > or <5 cm and their outcomes were compared.

Results

Multivariate analyses showed that microvascular invasion, estimated blood loss, blood transfusion, and the number of tumors were independent adverse prognostic factors for DFS, whereas microvascular invasion, serum alpha fetoprotein, and tumor diameter were independent adverse prognostic factors for OS. Blood transfusion had borderline significance (P = 0.076). After stratification by tumor diameter, blood transfusion was only associated with poor DFS and OS in patients with tumor diameters > 5 cm.

Conclusion

Tumor recurrence after liver resection for HCC depends on tumor status, bleeding, and transfusions, which subsequently lead to poor patient survival. Surgeons can help improve the prognosis of patients by minimizing blood loss and transfusion, particularly in patients with larger tumors.

Comparison between operative versus non-operative management of traumatic liver injury

Backgrounds/Aims

The aim of this study was to compare operative versus non-operative management of patients with liver injury and to ascertain the differences of the clinical features.

Methods

From April 2000 to July 2012, 191 patients were admitted to Seoul St. Mary's Hospital and St. Vincent's Hospital for liver injuries. Of these, 148 patients were included in this study. All patients were diagnosed using computed tomography (CT). The liver injury was graded in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups: those who underwent surgery and those treated with non-operative management (NOM). There was a comparison between these two groups concerning the clinical characteristics, grade of liver injury, hemodynamic stability, laboratory findings, and mortality.

Results

According to the 148 patient records evaluated, 108 (72.9%) patients were treated with NOM, and 40 (27.1%) underwent surgery. Patients treated with NOM had significantly fewer severe injuries as rated using the Revised Traumatic Injury Scale, Injury Severity Score, and Glasgow Coma Scale. Grade of liver injury and number of patients with extravasation of contrast dye on CT and hemoperitoneum were higher in the operative group than in the NOM group. There were significant differences between the two groups for: heart rate, respiratory rate, systolic blood pressure, and mean hemoglobin levels at admission and after 4 hours. The operative group experienced a significantly higher mortality than the NOM group.

Conclusions

The results of our study suggest that hemodynamic stability and the following should be considered for deciding the treatment for liver injuries: grade of liver injury, amount of blood loss, and injury scales scores.

Solid pseudopapillary tumor with hepatic metastasis

Solid pseudopapillary tumor of the pancreas is a rare tumor that affects young females with low malignant potential and good prognosis with more than 90% survival at 5 years. Metastasis is very rare. We report the case of a 74-year-old female who had pancreatic solid-pseudopapillary tumor and synchronous hepatic metastasis.

Significance of CD133 as a cancer stem cell markers focusing on the tumorigenicity of pancreatic cancer cell lines

Purpose

The cancer stem cell hypothesis states that the capacity of a cancer to grow and propagate is dependent on a small subset of cells. To determine the significances of the cancer stem cell markers CD133, CD44, and CD24 using a comparative analysis with a focus on tumorigenicity.

Methods

Four pancreatic cancer cell lines, Capan-1, Mia-PACA-2, Panc-1, and SNU-410 were analyzed for the expressions of CD133, CD44, and CD24 by flow cytometry. The tumorigenicity was compared using tumor volumes and numbers of tumors formed/numbers of injection in nonobese diabetic severe combined deficiency mice. Fluorescence-activated cell sorting (FACS) analysis was used to confirm that xenograft explants originated from human pancreatic cancer cells.

Results

CD133 was positive in only Capan-1, CD44 positive in all, CD24 partially positive in Panc-1. After injecting 2 × 10⁶ cells, all mice administered Capan-1 or Mia-Paca-2 developed tumors, 3 of 5 administered Panc-1 developed tumors, but no mouse administered SNU-410 developed any tumors. The volumes of Capan-1 tumors were seven times larger than those of Mia-Paca-2 tumors. When 2 × 10⁵ or 2 × 10⁴ of Capan-1 or Mia-Paca-2 was injected, tumors developed in all Capan-1 treated mice, but not in Mia-Paca-2 treated mice. Furthermore, xenograft explants of Capan-1 expressed CD133+CD44+ and Capan-1 injected mice developed lung metastasis. FACS analysis showed that xenograft explants originated from human pancreatic cancer cell lines.

Conclusion

CD133 positive cells have higher tumorigenic and metastatic potential than CD44 and CD24 positive cells, which suggests that CD133 might be a meaningful cell surface marker of pancreatic cancer stem cells.

Clinical significance of pathologic subtype in curatively resected ampulla of vater cancer

BACKGROUND

Ampullary cancer is considered to have a better prognosis than cancers of the distal bile duct and pancreas, and recent publications emphasize the prognostic importance of the histologic differentiation of the intestinal and pancreatobiliary types of ampullary cancer. The aims of this study were to identify those factors that affect recurrence after curative resection and to investigate differences between the clinicopathologic features of these two pathologic subtypes.

PATIENTS AND METHODS

The medical records of patients that underwent pancreatoduodenectomy for ampullary carcinoma from February 1995 to March 2009 at our institute were retrospectively reviewed. One hundred and four patients that underwent curative resection for ampullary carcinoma were enrolled in this study. One pathologist reviewed all pathologic reports and histopathologic findings. Data on clinicopathologic factors and disease free and overall survival were analyzed.

RESULTS

The 3- and 5-year disease free survival rates of the 104 study subjects were 62.2% and 57.7%, respectively, and overall survival rates were 69.4% and 60.1%, respectively. Multivariate analysis showed that an advanced T stage (P = 0.049), the presence of lymph node metastasis (P = 0.003), poor differentiation (P = 0.039), and the pancreatobiliary type (P = 0.022) significantly increased the risk of recurrence. Furthermore, the pancreatobiliary type was found to be more associated with an advanced T stage (P = 0.009), regional lymph node metastasis (P = 0.007), and perineural invasion (P = 0.026) than the intestinal type. In addition, pathologic subtype analysis showed that Carcinoembryonic antigen (CEA) level and lymph node metastasis were important predictors of recurrence in patients with the intestinal (P = 0.013) and pancreatobiliary types, respectively (P = 0.003).

CONCLUSIONS

An advanced T stage, nodal metastasis, poor differentiation, and the pancreaticobiliary type were found to be independent predictors of recurrence after curative resection of ampullary carcinoma by multivariate analysis. In addition, the pancreatobiliary type tended to present in a more advanced T stage and more frequently with regional lymph node involvement and perineural invasion than the intestinal type. Furthermore, CEA level and lymph node metastasis were found to be independent predictors of recurrence for the intestinal and pancreatobiliary types, respectively.

Surgical resection of metastasis to the pancreas

PURPOSE

Metastasis to the pancreas is rare, and the benefit of resection for pancreatic metastasis is poorly defined. The aim of this study was to review our experiences of the operative management of metastasis to the pancreas.

METHODS

Between 1995 and 2009, 11 patients (8 men and 3 women; median age, 54 years) were admitted to our institution with a metachronously metastatic lesion to the pancreas and later underwent pancreatic resection. The clinical features and outcomes of treatments were examined.

RESULTS

The primary cancers were renal cell carcinoma (RCC, n = 7), carcinoid tumor (n = 2), rectal cancer and leiomyosarcoma. Six patients underwent distal pancreatectosplenectomy, 3 pancreaticoduodenectomy and 2 patients underwent enucleation for small RCC. One patient died of metastatic RCC at 53 months after surgery and ten patients remain alive; four patients without disease at 7 to 69 months postoperatively, and the other six with disease at 11 to 68 months. Median postoperative survival of all patients was 34 months.

CONCLUSION

Patients with a low surgical risk should be considered for pancreatic metastasectomy if curative resection is possible. Primary cancer type, which is associated with survival benefit, would be the best candidate for surgical resection of metastases to the pancreas.

Clinicopathologic analysis of adenosquamous/squamous cell carcinoma of the gallbladder

BACKGROUNDS AND OBJECTIVES

Adenosquamous/squamous cell carcinoma (AS/SCC) of the gallbladder is rarely encountered and accounts for 1.4-10.6% of all gallbladder carcinomas (GBCs). This study was conducted to investigate the clinicopathologic features of AS/SCC of gallbladder.

METHODS

The authors retrospectively reviewed 16 cases of pathologically proven AS/SCC of the gallbladder among 404 patients who underwent surgery for GBC from October 1994 to March 2009. Forty-eight conventional GBC patients were selected as controls after matching for age and gender.

RESULTS

Mean patient age was 60.2 years and half were male. Tumor stages in the case group were significantly more advanced than the control group (P < 0.001). R0 resection rates in cases and controls were 50% and 81.2% (P = 0.022). Overall 1-year survival in the case group was significantly poorer than in the control group (18.8% vs. 87.3%, P < 0.001). However, no significant difference in disease-free survival rates was found between cases and controls after R0 resection (P = 0.072).

CONCLUSIONS

AS/SCC of the gallbladder is often diagnosed at an advanced stage, which results in non-curative surgical resection and a poorer prognosis than conventional GBC. However, curative surgical resection of AS/SCC of the gallbladder might result in disease-free survival rates that are comparable with those of conventional GBC.

Risk factors influencing recurrence, patterns of recurrence, and the efficacy of adjuvant therapy after radical resection for gallbladder carcinoma

BACKGROUNDS

Gallbladder carcinoma (GBC) is an aggressive neoplasm, and resection is the only curative modality. Recurrence frequently occurs after the curative resection of advanced GBC. Adjuvant treatment, particularly radiotherapy, is recommended and is used without any evidence of a beneficial effect. The aim of this study was to characterize patterns of recurrence and to identify the factors that influence recurrence and the efficacy of adjuvant therapy after the curative resection of GBC.

METHODS

The records of patients that underwent surgical resection with curative intent for gallbladder carcinoma from October 1994 and August 2007 were retrospectively reviewed. Recurrence patterns, times to recurrence, and survival rates were analyzed. Sites of recurrence were identified retrospectively and categorized as locoregional or distant.

RESULTS

One hundred sixty-six patients underwent surgical resection with curative intent for gallbladder adenocarcinoma. The 5-year recurrence rates of stages IA, IB, IIA, and IIB patients were 0%, 24.3%, 44.9%, and 58.3%, retrospectively. Positivity for lymph node metastases was found to have predictive significance for disease-free survival (p = 0.009). Regional lymph node recurrence (27.7%) was observed most frequently. There was no significant disease-free survival rates between the no adjuvant therapy and the adjuvant therapy groups.

CONCLUSIONS

The regional lymph nodes and the liver were found to be the most common sites of recurrence after curative resection. Lymph node metastases were identified as an independent predictor of tumor recurrence by multivariate analysis. Based on the disease-free survivals observed in this study, the authors find it would be difficult to advocate the routine use of adjuvant radiotherapy and/or chemotherapy.

Prognostic factors for primary duodenal adenocarcinoma

BACKGROUND

The aim of this study was to review the clinical features of primary duodenal adenocarcinoma (PDA) patients and to identify factors that influence survival. The natural history of PDA and the factors that affect patient outcome remain poorly defined.

METHODS

The authors reviewed the medical records of 53 patients treated for PDA from January 1995 to May 2007.

RESULTS

Altogether, 28 of the 53 patients (resectability 52.8%) underwent curative resection and 25 (47.2%) surgical palliation (bypass surgery or biopsy). Overall, the 3- and 5-year survival rates were 34.4% and 28.6%, respectively. Survival was significantly higher for patients who underwent curative resection (median survival 39 months; 3- and 5-year survivals 52.9% and 44.1%, respectively) than for those who underwent palliative surgery (median survival 8 months; 3-year survival 0%) (p < 0.001). T stage (p = 0.032) and nodal metastasis (p = 0.002) had significant negative effects on the survival of patients who underwent curative resection according to univariate analysis. However, multivariate analysis revealed that only nodal metastasis (p = 0.015) was significantly associated with survival.

CONCLUSIONS

The resectability of PDA was associated with increased survival, and metastasis to lymph nodes was found to be associated with reduced survival of patients with PDA. Findings indicate that an aggressive surgical approach should be pursued.

The outcomes after surgical resection in pancreatic endocrine tumors: an institutional experience

AIM

Sporadic pancreatic endocrine tumors (PET) can be managed surgically with excellent outcomes. The aim of this study was to analyze surgical outcomes and factors influencing survival.

METHODS

Between 1995 and 2007, 96 patients with sporadic PET who underwent surgery at our institution were retrospectively reviewed for clinicopathologic variables and outcomes according to the World Health Organization (WHO) classifications.

RESULTS

Thirty-nine patients had well-differentiated tumors (WDT) with benign behavior, 23 had uncertain behavior, 27 had low-grade carcinoma, and 7 were diagnosed with high-grade carcinoma. R0 resection was performed in 84 patients. No recurrence was observed in WDT regardless of its behavior or curability but 16 of 34 patients with carcinoma had recurrence. Five-year overall survival (OS) for R0-resected patients with carcinoma was 57%, and OS at 3 years for R1/R2-resected patients was 23% (P = 0.012). The WHO classification and R0 resection were independent prognostic factors in multivariate analysis.

CONCLUSIONS

This single institutional experience demonstrated that surgical resection is curative for WDT and recurrences are frequent in spite of curative resection for malignant PET. The WHO classification and R0 resection remained independent prognostic factor.

[The significance and state of pre-S2 and antibodies to pre-S2 in 30 cases of acute viral hepatitis type B]

Determination of time sequence of pre-S2 and its antibody response during the symptomatic phase of acute viral hepatitis type B, as well as their relationship to the HBV-markers, was carried out in 30 subjects after the onset of liver damage by means of monoclone antibody-captured enzyme immunoassay were analysed. The results showed that anti-pre-S2 were positive in 80.3% of patients recovering from acute viral hepatitis type B, being higher than the percentage during maximal liver damage (P less than 0.001). Such antibodies were absent in cases showing chronic evolution and were found in less than 8% of chronic hepatitis B cases, with no relation to liver damage. Anti-pre-S2 were detected after the immune clearance of HBsAg and HBV-DNA, and thereafter the anti-HBs were present in 80% of patients after recovery (P less than 0.001). Our observations significantly suggest that anti-pre-S2 may be valuable as a marker of the favourable prognosis of acute viral hepatitis type B and of HBV clearance. They did not play any role in the pathogenesis of HBV-related liver damage. The continuous presence of pre-S2 with the absence of anti-pre-S2, on the contrary, is considered as a characteristic sign and a new information of chronic viral hepatitis type B.