A case of pancreatic head cancer with Trousseau’s syndrome treated with radical resection and anticoagulant therapy

Abstract Background The primary disease of Trousseau’s syndrome is often highly advanced cancer, and treatment of the primary disease after cerebral infarction is often difficult. We herein report a case of pancreatic head cancer with Trousseau’s syndrome treated with radical resection and anticoagulant therapy. Case presentation A 78-year-old man was admitted with dizziness and diagnosed with cerebral infarction. Abdominal contrast-enhanced computed tomography for a thorough checkup indicated borderline resectable pancreatic head cancer. Radical resection after neoadjuvant chemotherapy (NAC; gemcitabine plus nab-paclitaxel) was scheduled. During the second course of NAC, multiple cerebral infarctions recurred, and the patient was diagnosed with Trousseau’s syndrome. Continuous intravenous infusion of heparin was started for cerebral infarction. Since it was impossible to continue NAC and there was no worsening of imaging findings, radical resection was planned. Thereafter, he underwent pancreatoduodenectomy with superior mesenteric vein resection. The patient progressed well and was discharged on the 19th day after surgery. He continued subcutaneous injection of heparin at home and is alive without recurrence of cancer or cerebral infarction at more than 21 months after surgery. Conclusion Surgical treatment may be an option for pancreatic cancer with Trousseau’s syndrome under favorable conditions

Conversion surgery for advanced jejunal adenocarcinoma with multiple peritoneal metastases: a case report

Abstract Background Small bowel cancer (SBC) is a rare malignancy that is often diagnosed at an advanced stage. Palliative chemotherapy is the standard treatment for patients with metastatic SBC. The relevant literature on conversion surgery in patients who have responded favorably to chemotherapy is limited. Case presentation A 64-year-old man was diagnosed with jejunal carcinoma with multiple peritoneal metastases. After implanting an expandable metallic stent at the primary site, the patient underwent 6 months of FOLFOX therapy, resulting in a clinical complete response. Chemotherapy was continued, and four years after the initiation of therapy, the patient showed no evidence of disease progression. Nevertheless, anemia of continuous minor hemorrhages from the stent site and general malaise of chemotherapy got progressively worse during treatment. After confirming negative ascites cytology and the absence of peritoneal metastasis via staging laparoscopy, the patient underwent partial jejunectomy. Pathologically, no residual tumor was detected in the resected specimen. The postoperative course was uneventful, and the patient remained free of recurrence for 30 months after surgery without chemotherapy. Conclusion Although infrequent, conversion surgery may be a valid therapeutic option for selected cases of SBC with peritoneal metastasis

Laparoscopic left lateral sectionectomy for a patient with right-sided ligamentum teres

Abstract Background A right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk. RSLT creates difficulty in liver resection with respect to decision-making regarding the resection line, deviation of the vasculobiliary architecture. We report a case in which laparoscopic left lateral sectionectomy (LLLS) was performed to treat colorectal liver metastasis (CRLM) in a patient with RSLT. Case presentation A 63-year-old man with a past history of rectal cancer presented to our institution due to liver metastasis in the left lateral section from rectal cancer. In this patient, an RSLT was diagnosed and LLLS was planned. The lateral superior branch of the portal vein (P2) branched off behind the bifurcation of the portal vein and running separately from the common branch of the lateral inferior branch (P3) and left paramedian branch (P4) so that stapling could not be performed for liver resection. Frequent intraoperative ultrasonography (IOUS) was necessary to identify the root of P2 and P3. The resection line was distant from the falciform ligament and was carefully decided. The lateral superior branch of Glisson (G2) and lateral inferior branch of Glisson (G3) were separately resected. The patient had a favorable clinical course without any complications. Conclusions The resection line of LLLS, which is distant from the falciform ligament, should be carefully identified using IOUS due to the deviation of the umbilical portion and falciform ligament. The recognition of portal vein and hepatic vein anomalies and clear identification of the lateral sectional branches are important to complete LLLS in patients with an RSLT

Efficacy of lymph node dissection for duodenal cancer according to the lymph node station

Abstract Background Lymph node metastasis (LNM) is associated with poor prognosis in patients with duodenal cancer (DC). However, the efficacy and optimal extent of lymph node (LN) dissection have not been thoroughly discussed. Methods A total of 98 consecutive patients with DC who underwent surgical resection (pancreatoduodenectomy, n = 55; partial resection, n = 32; pancreas‐sparing total duodenectomy, n = 9) were retrospectively analyzed. The LN stations located upstream of the lymphatic flow were defined as Np stations according to tumor location, whereas the others were defined as Nd stations. The association between the dissection of each LN station and survival outcome was investigated using the efficacy index (EI; percentage of metastases to lymph nodes in each station multiplied by the 5‐year survival rate of metastatic cases). Results The survival of patients with LNM at the Nd stations (n = 6) was significantly worse than that of patients with LNM only at the Np stations (n = 20) (relapse‐free survival, median survival time [MST], 6.0 vs. 48.4 months, p < 0.001; overall survival, MST, 15.1 vs. 96.0 months, p < 0.001). Multivariate analysis identified LNM at Nd stations as an independent prognostic factor for overall survival (hazard ratio 9.92; p = 0.015). The Np stations had a high EI (range, 8.34–20.88), whereas the Nd stations had an EI of 0, regardless of the tumor location. Conclusions LN dissection of the Np stations contributed to acceptable survival, whereas LNM of the Nd stations led to poor survival, possibly reflecting advanced tumor progression to systemic disease in patients with DC

Genomic landscape of pancreatic cancer in the Japanese version of the Cancer Genome Atlas

Abstract Background Pancreatic cancer (PC) is one of the most aggressive cancers worldwide. Although many studies have investigated genomic alterations, the genomic landscape of Japanese PC patients has not been fully elucidated. Methods We used whole‐exome sequencing, cancer gene panel deep‐sequencing, and microarray gene expression profiling data derived from the Japanese version of the Cancer Genome Atlas (JCGA) in 93 PC cases. Results Somatic driver mutations were identified in 65.6% of samples in 19 genes. The median tumor mutation burden (TMB) value was 0.24 Muts/Mb (interquartile range, 0.15–0.64 Muts/Mb). The commonly mutated genes were KRAS (58%), TP53 (40%), CDKN2A (10%), SMAD4 (10%), FGFR2 (9%), and PKHD1 (9%). Frequent germline variation genes were BRCA1 (8%), CDH1 (5%), MET (5%), MSH6 (5%), and TEK (5%). Frequent chromosomal arm alterations included copy number gains in 2q (42%), 7q (24%), and 3q (24%), and copy number losses in 19p (62%), 19q (47%), 12q (34%), and 7q (30%). A prognostic analysis according to the presence of driver mutations showed that overall survival (OS) in the driver mutation‐positive group was significantly worse in comparison to that of the driver mutation‐negative group (median, 23.1 vs 46.7 mo; P = .010). A Cox proportional hazards analysis for OS identified driver mutation (hazard ratio [HR], 1.89; P = .025) and lymph node metastasis (HR, 3.27; P = .002) as independent prognostic factors. Conclusion The present results from the JCGA dataset constitute a fundamental resource for genomic medicine for PC patients, especially in Japan