Article信州医学雑誌 63(1):19-24(2015)journal articl

ASHIDA, Atsuko

FURUSAWA, Norihiko

KITAGAWA, Noriyuki

KOBAYASHI, Akira

MIYAGAWA, Shin-ichi

MOTOYAMA, Hiroaki

OKUYAMA, Ryuhei

SAKAI, Hiroshi

SHIMIZU, Akira

YOKOYAMA, Takahide

English

Shinshu University Institutional Repository

 An Initial Case Report of a Laparoscopic Spleen-Preserving Distal Pancreatectomy for a Patent with a Pancreatic Metastasis of Malignant Melanoma Hiroaki MOTOYAMA ,Akira KOBAYASHI ＊,Takahide YOKOYAMA ,Akira SHIMIZUNorihiko FURUSAW A ,Hiroshi SAKAI ,Noriyuki KITAGAWA ,Atsuko ASHIDARyuhei OKUYAMA and Shinichi MIYAGAWA1) First Department of Surgery, Shinshu University School of Medicine2) Department of Dermatology, Shinshu University School of Medicine Metastatic malignant melanoma to the pancreas accounts for 5% of all patients undergoing a pancreatic metastasectomy.Here,we report a 76-year-old man with simultaneous metastases of malignant melanoma to the left elbow and pancreatic tail 4 years after resection of the primary tumor,which was located on the left fourth finger.Following resection of a subcutaneous mass in the left elbow,he underwent a laparoscopic spleen-preserving distal pancreatectomy with lymph node dissection along the splenic artery.His post-operative course was uneventful,and he was discharged from the hospital on the 13th postoperative day.He has survived for 7 months without exhibiting any signs of recurrence.Shinshu Med J 63 : 19―24, 2015(Received for publication August 19,2014;accepted in revised form November 18,2014)Key words:malignant melanoma,pancreatic metastasis,laparoscopic surgeryIntroduction Pancreatic metastasis from a non-pancreatic primary tumor is rare,accounting for approximate-ly 2% of all pancreatic tumors , and metastatic malignant melanoma accounts for 5% of all patients undergoing a pancreatic metastasectomy .Although metastatic melanoma has been considered to be a systemic disease with a poor prognosis, long-term survival after a metastasectomy has been reported for patients with not only isolated metastasis, but also multiple organ involvement including abdomi-nal organs ,provided that a curative resection was secured.With rapid developments in surgical technology,laparoscopic distal pancreatectomy has gained worldwide acceptance because of its advantages,such as reduced postoperative pain,faster recovery,and fewer wound-related and general morbidities. Recently, several authors have described the use of a technically challenging laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP) to reduce the risks associated with a splenectomy .Here, we present a patient with simultaneous pancreatic and left elbow metastases from a malig-nant melanoma that were treated with resection of a subcutaneous mass in the left elbow followed by Lap SPDP.A review of the literature is also includ-ed.Case Report A 76-year-old man underwent an amputation of the left fourth finger and left axillary lymph node dissection for the treatment of malignant melanoma in July 2009. The pathological  stage was pT3aN3M0, stage IIIC according to the American Joint Committee on Cancer (AJCC)classification .19 No.1,2015 Shinshu Med J,63⑴ :19～24,2015Corresponding author:Akira Kobayashi First Department of Surgery,Shinshu University School of Medicine,3-1-1 Asahi,Matsumoto,Nagano 390-8621,Japan E-mail:kbys＠shinshu-u.ac.jp The patient received a local injection of interferonβafter the operation. In March of the following year, a left brachial lymph node metastasis was detected and resected. Three years later,［ F］2-fluoro-2-deoxy-D-glucose-positron emission tomo-graphy/computed tomography (［ F］FDG-PET/CT)films showed abnormal uptakes in lesions locat-ed in the pancreatic tail and left elbow(Fig.1a,b).In March 2013,the patient underwent resection of a subcutaneous mass in his left elbow, which was histopathologically diagnosed as a malignant melanoma. Thereafter, he was referred to our department for further investigation of the pancre-atic tumor. A contrast-enhanced computed tomo-graphy(CT)examination showed a 20-mm circum-scribed nodule in the pancreatic tail (Fig. 1c)with an enhanced outer rim observed during the arterial phase and no dilation of the main pancreatic duct,suggesting that a pancreatic adenocarcinoma was unlikely.No signs of adjacent organ invasion were visible (Fig. 1d).Based on a diagnosis of pancreatic metastasis of the malignant melanoma, the patient underwent a Lap SPDP with lymph node dissection.During the subsequent laparoscopic observation,a mass with a maximum diameter of approximately 20 mm was confirmed in the pancreatic tail using intraoperative ultrasonography.First, the splenic artery and vein were dissected gently from the pancreas;a window was then created and enlarged until a laparoscopic linear stapler could be placed between the pancreas and the splenic vein. After the transection of the Motoyama.Kobayashi.Yokoyama et al.Shinshu Med J Vol.63 Fig.1 ［ F］FDG PET/CT films. (a)Tracer uptake was confirmed in the left upper quadrant of the abdomen(arrow)and left elbow(arrowhead).(b)The uptake in the abdomen corresponded to the pancreatic tail (arrow).(c)Contrast-enhanced CT showed a well-circumscribed mass in the pancreatic tail with an enhanced outer rim on the arterial phase(arrow).(d)No signs of extrapancreatic tumor invasion including splenic artery(SpA)and vein (SpV)were seen (arrow).20 pancreas,a continuous dissection starting from the cut end of the pancreas, which was grasped and retracted anteriorly, was made towards the tail until the pancreas was freed (Fig. 2). Finally, the whole specimen was placed in a bag and extracted through the enlarged trocar site at the umbilicus.The operation time and intraoperative blood loss were 175 minutes and 100 mL,respectively.Macroscopically,a pale black tumor with a diam-eter of 17 mm was observed (Fig. 3). Histopath-ological examination revealed a pancreatic metas-tasis of malignant melanoma with clear resection margins and no lymph node involvement.The pos-toperative course was uneventful, and the patient was discharged from the hospital on the 13th pos-toperative day. The patient has survived for 7 months without exhibiting any signs of recurrence.Discussion Previous studies have shown that the prognosis of patients with distant metastases from malignant melanoma depends on the initial  metastatic site ;specifically, patients with visceral metas-tases in organs other than the lung had the lowest survival rate.However,several studies have shown that a complete surgical resection can be associated with an improved overall survival, even among patients with abdominal metastases of malignant A pancreatic metastasis of a malignant melanoma resected by a laparoscopic spleen-preserving distal pancreatectomy Fig.2 Laparoscopic view of the preserved SpA (arrow)and SpV (arrowhead).Fig.3 Resected specimen of the pancreas.The arrow indicates a metastatic melanoma.21 No.1,2015 melanoma .Because the number of metastases at distant sites has been documented as an important prognostic factor ,the exact role of surgical resection has remained undefined in patients with multiple organ metastases.Wood et al. reported that a complete resection of the metastatic tissue provides a similar median overall survival for patients with synchro-nous multisite metastases to single-site metas-tasis . Similarly, Essner and colleagues have shown that the number of metastases was not selected as one of the predictive factors for overall survival in patients undergoing curative surgical resection of metastatic malignant melanoma in a multivariate analysis .These results indicated that the surgical resection of metastatic malignant melanoma might be efficacious for selected patients with multiple metastases,provided that a curative resection is possible.Laparoscopic pancreatic surgery is an emerging field that has shown several benefits over open surgery,with a faster recovery and quicker return to normal activities .The common indications for laparoscopic distal pancreatectomy are thought to be benign or low-grade malignant tumors located in the pancreatic body or tail. However, laparos-copic surgery for malignant pancreatic lesions remains controversial because of concerns regard-ing the oncological consequences .Previous studies have shown the inferiority of laparoscopic distal pancreatectomy because of the smaller number of lymph nodes that are removed, compared with an open distal pancreatectomy . However, recent studies revealed that the short-term and long-term outcomes were similar between a laparoscopic and an open distal pancreatectomy in patients with invasive ductal carcinoma . These results sug-gest that malignant lesions are also potential candi-dates for a laparoscopic distal pancreatectomy.There is no consensus on the need to perform spleen preservation in surgical resection for inva-sive ductal adenocarcinoma of the pancreas since preservation of splenic vessels is hazardous for oncologic radicality . However, splenic preserva tion is thought to be preferable in the setting of non-invasive malignant neoplasm, such as neuroendo-crine or metastatic tumor,because of the favorable role of the spleen for regulating the balance of the hematologic and immune systems .In open pan-creatic surgery, it has been revealed that SPDP is associated with a reduction in postoperative infec-tious complication,severe complications,and length of hospital stay compared with conventional distal pancreatectomy with splenectomy without the need for extending operative time or increasing operative blood loss .Furthermore,additional advantages of splenic preservation were observed in the long-term follow-up survey,with better results in terms of fatigue and general condition .Despite the aforementioned advanteges of splenic preserva-tion,Lap SPDP has not been regarded as a main-stay of laparoscopic distal  pancreatectomies because of its technical difficulty:that is, the deli-cate vascular dissection from the pancreas,which is associated with a substantial risk of bleeding .In the present case,we adopted Lap SPDP after com-prehensively considering the following points:type of tumor,no radiological findings of adjacent organ invasion,and postoperative quality of life.In conclusion,we herein reported an initial case of a Lap SPDP procedure performed for a metastatic pancreas tail tumor from a malignant melanoma.This technique is feasible as long as under careful identification of the posterior pancreatic branches are carefully identified to prevent bleeding from the splenic artery and vein .References1) Reddy S,Wolfgang CL:The role of surgery in the management of isolated metastases to the pancreas.Lancet Oncol 10:287-293,20092) Fletcher WS,Pommier RF,Lum S,Wilmarth TJ:Surgical treatment of metastatic melanoma.Am J Surg 175:413-417,1998 22 Motoyama.Kobayashi.Yokoyama et al.Shinshu Med J Vol.633) Mori T,Abe N,Sugiyama M,Atomi Y:Laparoscopic pancreatic surgery.J Hepatobiliary Pancreat Surg 12:451-455,20054) Sa Cunha A,Rault A,Beau C,Laurent C,Collet D,Masson B :A single-institution prospective study of laparos-copic pancreatic resection.Arch Surg 143:289-295;discussion 295,20085) Baker MS,Bentrem DJ,Ujiki MB,Stocker S,Talamonti MS:A prospective single institution comparison of peri-operative outcomes for laparoscopic and open distal pancreatectomy. Surgery 146:635-643;discussion 643-635,20096) Nigri GR,Rosman AS,Petrucciani N,Fancellu A,Pisano M,Zorcolo L,Ramacciato G,Melis M :Metaanalysis of trials comparing minimally invasive and open distal pancreatectomies.Surg Endosc 25:1642-1651,20117) Vijan SS,Ahmed KA,Harmsen WS,Que FG,Reid-Lombardo KM,Nagorney DM,Donohue JH,Farnell MB,Kendrick ML:Laparoscopic vs open distal pancreatectomy:a single-institution comparative study.Arch Surg 145:616-621,20108) Choi SH,Seo MA,Hwang HK,Kang CM,Lee WJ:Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy?Perioperative and patient-reported outcome analysis.Surg Endosc 26:3149-3156,20129) Gagner M,Pomp A,Herrera MF:Early experience with laparoscopic resections of islet cell tumors.Surgery 120:1051-1054,199610) Balch CM,Gershenwald JE,Soong SJ,Thompson JF,Atkins MB,Byrd DR,Buzaid AC,Cochran AJ,Coit DG,Ding S,Eggermont AM,Flaherty KT,Gimotty PA,Kirkwood JM,McMasters KM,Mihm MC Jr,Morton DL,Ross MI,Sober AJ,Sondak VK:Final version of 2009 AJCC melanoma staging and classification.J Clin Oncol 27:6199-6206,200911) Ollila DW :Complete metastasectomy in patients with stage IV metastatic melanoma.Lancet Oncol 7:919-924,200612) Karakousis CP,Velez A,Driscoll DL,Takita H :Metastasectomy in malignant melanoma.Surgery 115:295-302,199413) de Wilt JH,McCarthy WH,Thompson JF:Surgical treatment of splenic metastases in patients with melanoma.J Am Coll Surg 197:38-43,200314) Essner R, Lee JH, Wanek LA, Itakura H, Morton DL:Contemporary surgical treatment of advanced-stage melanoma.Arch Surg 139 :961-966;discussion 966-967,200415) Gutman H,Hess KR,Kokotsakis JA,Ross MI, Guinee VF,Balch CM :Surgery for abdominal metastases of cutaneous melanoma.World J Surg 25:750-758,200116) Meyer T,Merkel S,Goehl J,Hohenberger W :Surgical therapy for distant metastases of malignant melanoma.Cancer 89 :1983-1991,200017) Wornom IL 3rd,Smith JW,Soong SJ,McElvein R,Urist MM,Balch CM :Surgery as palliative treatment for distant metastases of melanoma.Ann Surg 204:181-185,198618) Wood TF,DiFronzo LA,Rose DM,Haigh PI,Stern SL,Wanek L,Essner R,Morton DL:Does complete resection of melanoma metastatic to solid intra-abdominal organs improve survival?Ann Surg Oncol 8:658-662,200119) Misawa T,Shiba H,Usuba T,Nojiri T,Kitajima K,Uwagawa T,Toyama Y,Ishida Y,Ishii Y,Yanagisawa A,Kobayashi S, Yanaga K:Systemic inflammatory response syndrome after hand-assisted laparoscopic distal pancreatectomy.Surg Endosc 21:1446-1449,200720) Fernandez-Cruz L,Blanco L,Cosa R,Rendon H :Is laparoscopic resection adequate in patients with neuroendo-crine pancreatic tumors?World J Surg 32:904-917,200821) Melotti G,Butturini G,Piccoli M,Casetti L,Bassi C,Mullineris B,Lazzaretti MG,Pederzoli P:Laparoscopic distal pancreatectomy:results on a consecutive series of 58 patients.Ann Surg 246:77-82,200722) Mabrut JY,Fernandez-Cruz L,Azagra JS,Bassi C,Delvaux G,Weerts J,Fabre JM,Boulez J,Baulieux J,Peix 23 No.1,2015 A pancreatic metastasis of a malignant melanoma resected by a laparoscopic spleen-preserving distal pancreatectomy JL,Gigot JF,Hepatobiliary,Pancreatic Section of the Royal Belgian Society of S,Belgian Group for Endoscopic S,Club C:Laparoscopic pancreatic resection:results of a multicenter European study of 127 patients.Surgery 137:597-605,200523) Asbun HJ,Stauffer JA:Laparoscopic approach to distal and subtotal pancreatectomy:a clockwise technique.Surg Endosc 25:2643-2649,201124) Kooby DA,Hawkins WG,Schmidt CM,Weber SM,Bentrem DJ,Gillespie TW,Sellers JB,Merchant NB,Scoggins CR,Martin RC 3rd,Kim HJ,Ahmad S,Cho CS,Parikh AA,Chu CK,Hamilton NA,Doyle CJ,Pinchot S,Hayman A, McClaine R, Nakeeb A, Staley CA, McMasters KM, Lillemoe KD:A multicenter analysis of distal pan-createctomy for adenocarcinoma:is laparoscopic resection appropriate?J Am Coll Surg 210:779-785,786-777,201025) Andren-Sandberg A,Wagner M,Tihanyi T, Lofgren P, Friess H :Technical aspects of left-sided pancreatic resection for cancer.Dig Surg 16:305-312,199926) Shoup M,Brennan MF,McWhite K,Leung DH,Klimstra D,Conlon KC:The value of splenic preservation with distal pancreatectomy.Arch Surg 137:164-168,200227) Balcom JHt, Rattner DW,Warshaw AL, Chang Y, Fernandez-del Castillo C:Ten-year experience with 733 pancreatic resections:changing indications,older patients,and decreasing length of hospitalization.Arch Surg 136:391-398,200128) Carrere N,Abid S, Julio CH,Bloom E,Pradere B :Spleen-preserving distal pancreatectomy with excision of splenic artery and vein:a case-matched comparison with conventional distal pancreatectomy with splenectomy.World J Surg 31:375-382,200729) Tang CW,Feng WM,Bao Y,Fei MY,Tao YL:Spleen-preserving distal pancreatectomy or distal pancreatectomy with splenectomy?:Perioperative and patient-reported outcome analysis.J Clin Gastroenterol 48:e62-66,201430) Pryor A,Means JR,Pappas TN :Laparoscopic distal pancreatectomy with splenic preservation.Surg Endosc 21:2326-2330,200731) Pietrabissa A,Moretto C,Boggi U,Di Candio G,Mosca F:Laparoscopic distal pancreatomy:are we ready for a standardized technique?Semin Laparosc Surg 11:179-183,2004（2014.8.19received;2014.11.8accepted）24 Motoyama.Kobayashi.Yokoyama et al.Shinshu Med J Vol.63

An Initial Case Report of a Laparoscopic Spleen-Preserving Distal Pancreatectomy for a Patent with a Pancreatic Metastasis of Malignant Melanoma

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An Initial Case Report of a Laparoscopic Spleen-Preserving Distal Pancreatectomy for a Patent with a Pancreatic Metastasis of Malignant Melanoma

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