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This column aims to present readers with challenging cases and/or provide alternative treatment options related to oncology and surgical oncology that are both timely and worthy of discussion. In addition to my commentary, the cases and/or alternative treatment options will be presented to other experts in related fields for “second opinions” regarding evaluation and treatment.

This issue focuses on laparoscopy for distal pancreatectomy. I am very honored to have R. Matthew Walsh, MD, chairman of the Department of General Surgery at Cleveland Clinic Foundation in Cleveland, Ohio, participate in this issue by providing an expert “second opinion.”

I hope readers enjoy the column and benefit from the timely discussions and multiple opinions presented as they relate to oncologic challenges and alternative—and sometimes controversial—treatments.

The focus is on discussion and I hope to hear from readers with their opinions and comments on topics presented in each column. I also greatly welcome and encourage suggestions or case submissions for future issues.

Enjoy!

Conrad Simpfendorfer, MD Editor, The Tumor Board
Hepato-pancreato-biliary and Transplant Surgeon
Cleveland Clinic
Weston, Florida


Case 1

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Figure 1

A 66-year-old woman presents with a mass in the tail of the pancreas, discovered during evaluation for changes in bowel movement. Computed tomography (CT) scan reports a 2.6-cm hypodense lesion in the tail of the pancreas (figure 1). A follow-up magnetic resonance imaging (MRI) scan reports a 3×2.3-cm heterogeneous mass in the tail of the pancreas. There is no evidence of distant metastasis.

An endoscopic ultrasound (EUS) reported a 3.5-cm heterogeneous mass in the distal body of the pancreas. The mass abuts the splenic artery and vein.

Fine-needle aspiration (FNA) of the mass reported a cystic neoplasm with papillary architecture. Carcinoembryonic antigen (CA) 19-9 level is greater than 3 U/mL.


Case 2

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An 84-year-old man presents with a mass in the tail of the pancreas, discovered during evaluation for abdominal pain. CT scan reports a 5.2-cm complex mass in the tail of the pancreas (figure 2). The mass is reported to have cystic and solid components. No evidence of distant metastasis is noted. The patient denies any history of pancreatitis.

CA 19-9 level is 84 U/mL.


Dr. Simpfendorfer’s Commentary

How would you treat these two patients?

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I would advocate treating these patients based on the presumed pathology. The first patient would appear to have an asymptomatic lesion, and the description of the EUS findings is difficult to interpret. The MRI is not presented, and the CT is of poor quality on one image. I am suspicious that the lesion is a serous cystadenoma that can appear incidentally as a “mass lesion” because the size of the cysts may be quite small. The other major diagnostic consideration would be a solid pseudopapillary neoplasm. I would review the imaging and FNA result, including cytology, in more depth before determining the exact approach.

The second patient is more concerning for a pancreatic neoplasm. The description of pain is nonspecific, and I would question the patient more closely on the symptoms, which in general can help guide the workup. The presence of a mass component is an indication for resection, and for this patient, I would advise a distal pancreatectomy with splenectomy.

Would you perform open or laparoscopic pancreatectomy?

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The operative approach should be guided by disease extent and presumed diagnosis, as well as surgeon experience. It is unclear whether the patient in the first case requires resection, but the patient in the second case should have a distal pancreatectomy with splenectomy, both due to the location of the lesion and presumed carcinoma diagnosis. He is a suitable candidate for a laparoscopic resection provided the surgeon has adequate experience. This patient appears to be quite thin and some of the advantages of a minimally invasive approach may not be realized.

Is tissue diagnosis necessary before a planned surgery?

The patient in the first case has already undergone FNA, which should be reviewed for the cytologic features. “Papillary architecture” is an uncharacteristic cytologic feature that would need to be reviewed with an experienced pancreatic cytopathologist. The patient presented in the second case has radiographic features of a mass component, which would be an independent indication for resection.


‘Second Opinion’:

Expert Opinion by R. Matthew Walsh, MD

Advances in instrument technology and surgeon experience have made laparoscopic surgery the standard technique for several abdominal surgical procedures. Minimally invasive surgery for the pancreas has been undertaken with more caution. Recently, laparoscopic distal pancreatectomy (LDP) has gained popularity. Studies comparing open distal pancreatectomy (OPD) and LDP have reported advantages with minimally invasive surgery, including reduced postoperative pain, faster recovery, decreased wound complications, less intraoperative blood loss and fewer postoperative complications.1,2

A meta-analysis comparing LDP with OPD concluded that lower blood loss and reduced hospital length of stay were associated with the laparoscopic approach. LDP also was associated with a lower risk for overall postoperative complications and wound infection.3 A multicenter analysis comparing LDP with OPD for the treatment of adenocarcinoma of the pancreas reported similar short- and long-term oncologic outcomes between the two groups, suggesting that LDP is an acceptable approach for resection of pancreatic ductal carcinoma of the left pancreas.4

References

  1. Belli G, Fantni C, D’Agostino A, et al. Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis. Surg Endosc. 2012;26:1830-1836.
  2. Kooby D, Kneuertz P, Patel S, et al. Laparoscopic distal pancreatectomy: trends and lessons learned through an 11-year experience. J Am Coll Surg. 2012;215:167-176.
  3. Wolfgang C, Venkat R, Edil B, et al. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg. 2012;255:1048-1059.
  4. Kooby D, Hawkins W, Schmidt C, et al. A multicenter analysis of distal pancreatectomy for adenocarcinoma: is laparoscopic resection appropriate? J Am Coll Surg. 2010;210:779-787.
  5.  


Case Challenge

A 67-year-old man had elective cholecystectomy with intraoperative cholangiogram for an episode of gallstone pancreatitis; during surgery a thickened area was noted at the fundus that resembled impacted stones. The patient denied fever, chills, jaundice or significant weight loss. He had no significant past medical or surgical history. All preoperative labs were normal, as was chest x-ray. Surgery was performed uneventfully and the patient was discharged home the next day. The pathology report returned four days later reported:

  • Invasive moderately differentiated adenocarcinoma of the fundus of the gallbladder, 2.7 cm in greatest dimension, infiltrating the entire thickness of the gallbladder wall and involving the surrounding soft tissue
  • Focal perineural invasion is identified
  • No definitive evidence of vascular invasion
  • Cystic duct margin of resection is free of invasive carcinoma
  • Cystic duct margin of resection is involved by highly dysplastic epithelium
  • Cholelithiasis
  • Benign cystic duct lymph node

What would you do?