Metastasis, the dissemination and growth of neoplastic cells in an organ distinct from that in which they originated, is the most common cause of death in cancer patients. This is particularly true for pancreatic cancers, where most patients are diagnosed with metastatic disease and few show a sustained response to chemotherapy or radiation therapy. Whether the dismal prognosis of patients with pancreatic cancer compared to patients with other types of cancer is a result of late diagnosis or early dissemination of disease to distant organs is not known. Here we rely on data generated by sequencing the genomes of seven pancreatic cancer metastases to evaluate the clonal relationships among primary and metastatic cancers. We find that clonal populations that give rise to distant metastases are represented within the primary carcinoma, but these clones are genetically evolved from the original parental, non-metastatic clone. Thus, genetic heterogeneity of metastases reflects that within the primary carcinoma. A quantitative analysis of the timing of the genetic evolution of pancreatic cancer was performed, indicating at least a decade between the occurrence of the initiating mutation and the birth of the parental, non-metastatic founder cell. At least five more years are required for the acquisition of metastatic ability and patients die an average of two years thereafter. These data provide novel insights into the genetic features underlying pancreatic cancer progression and define a broad time window of opportunity for early detection to prevent deaths from metastatic disease.

SF-010-4 Distant metastasis occurs late during the genetic evolution of pancreatic cancer

Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

Management of post-hepatectomy complications

Introduction:In pancreatic adenocarcinoma (PA), a margin negative resection (R0) is critical for long-term survival.Background:Although pancreaticoduodenectomy (PD) with en-bloc portal vein/superior mesenteric vein (PV/SMV) resection is used in patients with venous involvement by tumor, its utility

Should the portal vein be routinely resected during pancreaticoduodenectomy for adenocarcinoma

OBJECTIVE. The purpose of this article is to discuss the normal findings and complications after pancreaticoduodenectomy. The Whipple procedure is associated with a set of common complications, including pancreatic fistula, postsurgical hemorrhage, postoperative pancreatitis, portomesenteric venous thrombosis, hepatic infarction, delayed gastric emptying, and anastomotic strictures. CONCLUSION. Appropriate diagnosis of these complications is contingent on an understanding of the surgical anatomy, normal postoperative imaging appearance in both the immediate postoperative and chronic settings, and typical CT appearance of each of these complications.

https://www.ajronline.org/doi/pdf/10.2214/AJR.12.9647

CT after pancreaticoduodenectomy: spectrum of normal findings and complications.

Cattell-Braasch Maneuver Combined with Artery-First Approach for Superior Mesenteric-Portal Vein Resection During Pancreatectomy

Management of Delayed Post-Pancreaticoduodenectomy Arterial Bleeding: Interventional Radiological Treatment First

Long Mesentericoportal Vein Resection and End-to-End Anastomosis Without Graft in Pancreaticoduodenectomy

Reactive lymphoid hyperplasia is a rare disease that forms a mass-like lesion and is characterized by the proliferation of non-neoplastic, polyclonal lymphocytes forming follicles. We recently encountered 2 cases of reactive lymphoid hyperplasia of liver, both of which were asymptomatic and mimicked hepatocellular carcinoma by various imaging modalities. Based on the clinical impression of hepatocellular carcinoma, surgical resections were performed. Microscopic findings revealed that both lesions consisted of an aggregation of lymphocytes consisting of predominantly B-cells, with multiple lymphoid follicles positive for CD10 and negative for bcl-2, consistent with the diagnosis of reactive lymphoid hyperplasia. Polyclonality of both lesions was further confirmed by B cell receptor gene rearrangement study. The incidence of reactive lymphoid hyperplasia in the liver is exceedingly rare, and it is difficult to differentiate such lesions from hepatic malignancies based upon clinical grounds. The clinicopathological findings and literature review of this report may be helpful to improve the clinical decision-making.

Reactive lymphoid hyperplasia of the liver mimicking hepatocellular carcinoma: incidental finding of two cases.

Aims To compare the short- and long-term outcomes in patients with pancreatic benign or borderline neoplasm who underwent central pancreatectomy (CP) and distal pancreatectomy (DP). Methods The inclusion criteria were as follows: (1) single benign or low-grade malignant tumor; (2) tumor conﬁned to the pancreatic neck or proximal body; and (3) tumor amenable to either CP or DP. Short and long-term outcomes, including complications, pancreatic exocrine and endocrine function, and quality of life (QoL) were analyzed retrospectively. Results Sixteen patients who underwent CP and 26 patients who underwent DP were included. The median follow-up period was 53 months (range 21-117 months). Patients undergoing CP were significantly more likely to experience complications (68.7 vs. 23%, p = 0.003) especially grade B/C postoperative pancreatic fistula (62.5 vs. 23%, p = 0.011) than those undergoing DP. During the long-term follow-up, 2 patients in the DP group developed new-onset diabetes mellitus, but no patient in CP group developed this condition (8 vs. 0%, p = 0.382). Evidence of exocrine insufficiency, including severe diarrhea or steatorrhea, was not observed in either group. Both groups were equally satisfied with the overall health status and overall QoL. Conclusion CP is associated with excellent pancreatic function but a significantly increased postoperative morbidity and risk compared to DP. Therefore, the indication of CP should be chosen strictly.

Is Central Pancreatectomy Truly Recommendable? A 9-Year Single-Center Experience.

This report aims to investigate the feasibility and outcomes of neoadjuvant imatinib mesylate (IM) administration followed by organ-preserving surgery (OPS) for patients with locally advanced duodenal gastrointestinal stromal tumor (GIST). Between 2012 and 2015, 10 consecutive patients with locally advanced duodenal GISTs were treated in Peking University Cancer Hospital. Multidisciplinary assessment was implemented, and pancreaticoduodenectomy (PD) was initially indicated as the most probable surgical procedure for all 10 patients. To attempt to create opportunities of less-invasive OPS for patients, neoadjuvant IM was administered followed by radical resection. All data were prospectively collected, and the short-and long-term outcomes of the treatment strategy were analyzed. The median treatment duration of neoadjuvant IM administration was 5 mo (range 2-18 mo). Significant tumor shrinkage (from 9.2 to 5.9 cm on average) was observed in all patients, and partial response was achieved in eight patients (80.0%) according to the Response Evaluation Criteria in Solid Tumors 1.1. No tumor perforation occurred, and nine patients (90.0%) underwent successful OPS with four different operation types. Postoperative morbidity rate of OPS was 55.6% (5/9), and no mortality occurred. After a median follow-up of 36 mo, one patient developed multiple distant metastases, but no local recurrence was observed. For long-term follow-up, patients who underwent OPS did not show any degradation in quality of life, whereas the patient who underwent PD suffered weight loss of similar to 10 kg. In conclusion, in patients with locally advanced duodenal GISTs, neoadjuvant IM administration followed by OPS is a feasible treatment strategy which leads to favorable short-and long-term outcomes.

Hong-Gang Qian

Papers

Management of Delayed Post-Pancreaticoduodenectomy Arterial Bleeding: Interventional Radiological Treatment First

Long Mesentericoportal Vein Resection and End-to-End Anastomosis Without Graft in Pancreaticoduodenectomy

Reactive lymphoid hyperplasia of the liver mimicking hepatocellular carcinoma: incidental finding of two cases.

Is Central Pancreatectomy Truly Recommendable? A 9-Year Single-Center Experience.

Organ-preserving surgery for locally advanced duodenal gastrointestinal stromal tumor after neoadjuvant treatment