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1
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Matei E, Ciurea S, Herlea V, Dumitrascu T, Vasilescu C. Surgery for an Uncommon Pathology: Pancreatic Metastases from Renal Cell Carcinoma-Indications, Type of Pancreatectomy, and Outcomes in a Single-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:2074. [PMID: 39768953 PMCID: PMC11678890 DOI: 10.3390/medicina60122074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 11/25/2024] [Accepted: 12/16/2024] [Indexed: 01/11/2025]
Abstract
Background and Objectives: The role of surgery in pancreatic metastases of renal cell carcinoma (PM_RCC) is highly controversial, particularly in the context of modern systemic therapies and the conflicting results of studies published so far. This study aims to explore a single surgical center experience (including mainly pancreatic resections) regarding the indications, the type of pancreatectomies, and early and long-term outcomes for PM_RCC. Materials and Methods: The data of all patients with surgery for PM_RCC (from 1 January 2002 to 31 December 2023) were retrospectively assessed, and potential predictors of survival were explored. Results: 20 patients underwent surgery for PM_RCC (pancreatectomies-95%). Metachronous PM_RCC was 90%, with a median interval between the initial nephrectomy and PM_RCC occurrence of 104 months. For elective pancreatectomies, the overall and severe morbidity and mortality rates were 24%, 12%, and 0%, respectively; 32% of patients underwent non-standardized pancreatic resections. The median survival of patients with negative resection margins was 128 months after pancreatectomies, with an 82% 5-year survival rate. Left kidney RCC and the body/tail PM_RCC were favorable prognostic factors for the overall survival after pancreatectomies for PM_RCC. Body/tail, asymptomatic PM_RCC, and an interval after initial nephrectomy > 2 were favorable prognostic factors for the overall survival after initial nephrectomy for RCC. Conclusions: Pancreatectomies for PM_RCC can achieve long-term survival whenever complete resection is feasible, with acceptable complication rates. Patients with left kidney RCC, body/tail, and asymptomatic PM_RCC and an interval of more than 2 years after nephrectomy exhibit the best survival rates.
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Affiliation(s)
- Emil Matei
- Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania; (E.M.); (S.C.); (C.V.)
| | - Silviu Ciurea
- Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania; (E.M.); (S.C.); (C.V.)
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania;
| | - Traian Dumitrascu
- Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania; (E.M.); (S.C.); (C.V.)
| | - Catalin Vasilescu
- Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, Fundeni Street No. 258, 022328 Bucharest, Romania; (E.M.); (S.C.); (C.V.)
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Zhou Y, Wang X, Chen S, Wang S. A pooled analysis of pancreatic resection for metastatic renal cell carcinoma. Front Oncol 2024; 14:1442256. [PMID: 39619443 PMCID: PMC11604617 DOI: 10.3389/fonc.2024.1442256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 10/25/2024] [Indexed: 01/03/2025] Open
Abstract
BACKGROUND Pancreatic metastasis from renal cell carcinoma (PMRCC) is unusual and there is no consensus on its treatment. The present study aims to evaluate the clinical outcomes of surgical resection for PMRCC. METHODS PubMed and Web of Science were searched for Eligible studies from January 1980 to January 2024. Individual-patient data were pooled. RESULTS A total of 436 participants were identified. The morbidity and 90-day mortality were 38.1% and 3.4%, respectively. Post-pancreatectomy recurrence occurred in 44.1% of the patients. The overall median survival was 116 months, with a 3-, 5- and 10-year survival rate of 85.3%, 76.6%, and 46.5% respectively. On univariate analysis, repeat metastasectomy was associated with a significantly better prognosis (P =0.003). CONCLUSION These data suggest that surgical resection is a safe and effective therapeutic option for PMRCC. Repeat metastasectomy is positively suggested for recurrent disease provided all metastases can be removed curatively. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/, identifier CRD42024525218.
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Magara N, Takahashi N, Takano Y, Takeshita K, Toya N, Yano F, Eto K. Gastric metastasis from renal cell carcinoma with submucosal invasion treated by surgical full-thickness resection: a case report. Surg Case Rep 2024; 10:245. [PMID: 39466522 PMCID: PMC11519264 DOI: 10.1186/s40792-024-02036-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 10/01/2024] [Indexed: 10/30/2024] Open
Abstract
BACKGROUND Metastatic gastric tumors are rare and malignant melanoma, breast cancer, lung cancer, and esophageal cancer are common as primary lesions. On the other hand, renal cell carcinoma is easy to metastasize hematogenously to the whole body. However, metastasis to the stomach is rare and the detailed treatment of gastric metastasis is not mentioned. In this study, we report an uncommon case of gastric metastasis from renal cell carcinoma that underwent surgical full-thickness resection and reviewed the literature for treatment options. CASE PRESENTATION The patient was a female in her 60s and in January 2007, she underwent a transabdominal left nephrectomy for clear cell carcinoma of the left kidney. The pathological diagnosis was pT2N0M0 stage II. In October 2017, a total pancreatectomy with D2 dissection was performed for multiple pancreatic masses, in which the pathological diagnosis was pancreatic metastasis of renal cell cancer. In May 2019, an esophagogastroduodenoscopy for heartburn revealed redness and erosion in the greater curvature of the residual gastric body. The pathological diagnosis was gastric metastasis from renal cell carcinoma. No metastatic findings were observed and gastric wedge resection was performed. Pathological diagnosis of the resected specimen showed a 4-mm tumor, mainly within the mucosa and partly extended to the submucosal layer in 500 µm. The resected specimen had a clear resection margin. CONCLUSIONS In this study, we report a case in which a full-thickness resection was performed for gastric metastasis 12 years after renal cancer surgery and 2 years after pancreatic metastasis surgery. The patient survived 4 years and 8 months after gastric wedge resection. Although gastric metastasis often takes the form of submucosal tumors, it is necessary to select full-thickness resection for R0 resection, even in small and flat lesions.
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Affiliation(s)
- Nanako Magara
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba, 277-8567, Japan
| | - Naoto Takahashi
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba, 277-8567, Japan.
| | - Yuta Takano
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba, 277-8567, Japan
| | - Kenji Takeshita
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba, 277-8567, Japan
| | - Naoki Toya
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba, 277-8567, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-19-18 Nishi-shinbashi, Minato-ku, Tokyo, 105-8471, Japan
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4
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Mori H, Sunagawa H, Matsumoto H. A Resected Case of Simultaneous Gastric and Multiple Pancreatic Metastases of Renal Cell Carcinoma 11 Years After Nephrectomy. Cureus 2024; 16:e69108. [PMID: 39391452 PMCID: PMC11465953 DOI: 10.7759/cureus.69108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2024] [Indexed: 10/12/2024] Open
Abstract
A 50-year-old man with a history of nephrectomy for renal cell carcinoma (RCC) 11 years prior was diagnosed with gastric and multiple pancreatic metastases of RCC. He underwent a pyloric gastrectomy and total pancreatic resection. RCC metastases to the pancreas are rare, and gastric metastases are even rarer. This case represents a rare instance of simultaneous RCC metastases to both the stomach and pancreas. Although there is no difference in prognosis between solitary and multiple pancreatic metastases, surgical resection is recommended even for multiple lesions. However, preoperative imaging often fails to identify all pancreatic metastatic lesions, making total pancreatectomy a consideration for ensuring complete resection, especially when preoperative detection is challenging.
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Affiliation(s)
- Hideki Mori
- Department of Gastroenterology, Nakagami Hospital, Okinawa, JPN
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Billon E, Dalban C, Oudard S, Chevreau C, Laguerre B, Barthélémy P, Borchiellini D, Geoffrois L, Negrier S, Joly F, Thiery-Vuillemin A, Gross-Goupil M, Rolland F, Priou F, Mahammedi H, Tantot F, Escudier B, Chabaud S, Albiges L, Gravis G. Adrenal Metastases Are Associated with Poor Outcomes in Patients with Metastatic Clear Cell Renal Cell Carcinoma Treated with Nivolumab in the GETUG-AFU-26 NIVOREN Phase 2 Trial. Eur Urol Oncol 2024; 7:742-750. [PMID: 37813745 DOI: 10.1016/j.euo.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Glandular metastases (GMs; adrenal gland, pancreas, thyroid, ovary, breast, or prostate) are rare in metastatic clear cell renal cell carcinoma (mccRCC). Previous studies have indicated that GM patients treated with antiangiogenic therapy experience significantly longer overall survival (OS). OBJECTIVES To assess outcomes for mccRCC with or without GMs treated with nivolumab. DESIGN, SETTING, AND PARTICIPANTS The GETUG-AFU-26 NIVOREN phase 2 trial evaluated the activity and safety of nivolumab in patients with mccRCC who experienced failure of antiangiogenic therapies (NCT03013335). In this ancillary study, patients were divided into two groups according to the presence or absence of at least one GM. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was OS; secondary outcomes were progression-free survival (PFS) and the objective response rate (ORR). Survival was estimated using the Kaplan-Meier method. Univariate and multivariable Cox regression models are used to estimate the hazard ratio (HR) with 95% confidence interval (CI) for survival outcomes. Subgroup analyses were performed for patients with pancreatic metastases and patients with adrenal metastases. RESULTS AND LIMITATIONS Among 720 patients treated with nivolumab between February 2016 and July 2017, 217 had GMs, of whom 151/217 had adrenal metastases and 86/217 had pancreatic metastasis. Patients with adrenal metastases had worse 12-mo OS (64% vs 71.1%) and 6-mo PFS (27.2% vs 36.6%) and a lower objective response rate (12.5%, 95% CI 7.6%-19.0%, vs 23.2%, 95% CI 19.8-27.0%; p = 0.005) than patients without adrenal metastases. Conversely, univariate analysis showed that patients with pancreatic metastases had significantly better 12-mo OS (82.3% vs 67.9%; HR 0.59, 95% CI 0.40-0.85) in comparison to patients with nonpancreatic GMs. On multivariable analysis, only adrenal metastasis remained associated with adverse prognosis. CONCLUSIONS Adrenal metastasis is an independent prognostic factor for poor response and survival in the GETUG-AFU-26 NIVOREN trial. Limited activity with nivolumab was observed for patients with mccRCC with adrenal metastases. These results warrant an evaluation of the prognostic value of adrenal metastases in patients treated with immunotherapy combinations with ipilimumab or tyrosine kinase inhibitors. PATIENT SUMMARY Our study showed that metastasis in the adrenal glands could be an independent factor associated with poor response to immunotherapy and survival for patients with metastatic kidney cancer. It would be useful to evaluate the prognostic value of adrenal gland metastasis in patients treated with immunotherapy combinations or immunotherapy agents combined with drugs called tyrosine kinase inhibitors.
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Affiliation(s)
- Emilien Billon
- Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France.
| | | | - Stephane Oudard
- Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | | | | | | | | | - Lionnel Geoffrois
- Institut de Cancérologie de Lorraine, Centre Alexis Vautrin, Vandoeuvre-Lès-Nancy, France
| | | | | | | | - Marine Gross-Goupil
- Centre Hospitalier Universitaire de Bordeaux-Hôpital Saint-André, Bordeaux, France
| | | | - Frank Priou
- CHD Vendee-Hopital Les Oudairies, La Roche-Sur-Yon, France
| | | | | | | | | | | | - Gwenaelle Gravis
- Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France
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Assawasirisin C, Dumronggittigule W, Mahawithitwong P, Tovikkai C. Robotic subtotal left pancreatectomy with preservation of the bile duct and spleen for multifocal pancreatic metastases: a video vignette of organ-sparing pancreatectomy for tumors that do not require regional lymphadenectomy. JOURNAL OF MINIMALLY INVASIVE SURGERY 2024; 27:125-127. [PMID: 38887005 PMCID: PMC11187606 DOI: 10.7602/jmis.2024.27.2.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/06/2024] [Accepted: 03/03/2024] [Indexed: 06/20/2024]
Abstract
Pancreatectomy for pancreatic metastases (PM) yields acceptable survival outcomes in selected renal cell carcinoma (RCC) patients. We describe a technique for robotic subtotal left pancreatectomy with preservation of the common bile duct (CBD) and spleen in a patient with multifocal RCC-PM. The patient, who had RCC and underwent nephrectomy 20 years ago, presented with a pancreatic mass. Computed tomography and endoscopic ultrasonography demonstrated one mass at the head of pancreas (HOP), and other three lesions at neck, body, and tail. HOP lesion located near CBD. Subtotal left pancreatectomy was more preferred option than total pancreatectomy due to better endocrine function. The ultrasound-guided CBD and uncinate-preserving resection started at HOP, and then continued with distal pancreatectomy. The pathology revealed metastatic RCC with a negative margin. The patient experienced only biochemical pancreatic leakage. One month after surgery, the patient only required oral medication for diabetes treatment. In conclusion, the robot-assisted technique is helpful in increasing the success rate of organ-sparing pancreatectomy.
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Affiliation(s)
- Charnwit Assawasirisin
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Wethit Dumronggittigule
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Prawej Mahawithitwong
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Chutwichai Tovikkai
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
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7
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Tayeh GA, Alkassis M, De La Taille A, Vordos D, Champy CM, Pelegrin T, Ingels A. Surgical metastasectomy for metastatic renal cell carcinoma in the era of targeted and immune therapy: a narrative review. World J Urol 2024; 42:51. [PMID: 38244094 DOI: 10.1007/s00345-023-04706-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/30/2023] [Indexed: 01/22/2024] Open
Abstract
PURPOSE Metastatic renal cell carcinoma (mRCC) still harbours a big propensity for future metastasis. Combinations of immune and targeted therapies are currently the cornerstone of management with a less clear role for surgical metastasectomy (SM). METHODS We performed a narrative review of literature searching for the available evidence on the yield of surgical metastasectomy in the era of targeted and immune therapies. The review consisted of a PubMed search of relevant articles using the Mesh terms:" renal cell carcinoma", "surgery», «resection", "metastasectomy", "molecular targeted therapies", "immune checkpoint inhibitors" alone or in combination. RESULTS In this review, we exposed the place of surgical metastasectomy within a multimodal treatment algorithm for mRCC Also, we detailed the patient selection criteria that yielded the best results when SM was performed. Finally, we discussed the feasibility and advantages of SM per organ site. CONCLUSION Our work was able to show that SM could be proposed as a consolidation treatment to excise residual lesions that were deemed unresectable prior to a combination of systemic therapies. Contrastingly, it can be proposed as an upfront treatment, leaving systemic therapies as an alternative in case of future relapse. However, patient selection regarding their performance status, metastatic sites, number of lesions and tumorous characteristics is of paramount importance.
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Affiliation(s)
- Georges Abi Tayeh
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France.
| | - Marwan Alkassis
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
| | - Alexandre De La Taille
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
- INSERM Clinical Investigation Center 1430, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Dimitri Vordos
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
| | - Cécile Maud Champy
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
- INSERM Clinical Investigation Center 1430, Henri Mondor University Hospital, AP-HP, Créteil, France
| | - Tiphaine Pelegrin
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
| | - Alexandre Ingels
- Department of Urology, Henri Mondor Hospital, University of Paris Est Créteil, Créteil, France
- Biomaps, UMR1281, INSERM, CNRS, CEA, Université Paris Saclay, Villejuif, France
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8
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Sellner F, Compérat E, Klimpfinger M. Genetic and Epigenetic Characteristics in Isolated Pancreatic Metastases of Clear-Cell Renal Cell Carcinoma. Int J Mol Sci 2023; 24:16292. [PMID: 38003482 PMCID: PMC10671160 DOI: 10.3390/ijms242216292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
Isolated pancreatic metastases of renal cell carcinoma (IsPMRCC) are a rare manifestation of metastatic, clear-cell renal cell carcinoma (RCC) in which distant metastases occur exclusively in the pancreas. In addition to the main symptom of the isolated occurrence of pancreatic metastases, the entity surprises with additional clinical peculiarities: (a) the unusually long interval of about 9 years between the primary RCC and the onset of pancreatic metastases; (b) multiple pancreatic metastases occurring in 36% of cases; (c) favourable treatment outcomes with a 75% 5-year survival rate; and (d) volume and growth-rate dependent risk factors generally accepted to be relevant for overall survival in metastatic surgery are insignificant in isPMRCC. The genetic and epigenetic causes of exclusive pancreatic involvement have not yet been investigated and are currently unknown. Conversely, according to the few available data in the literature, the following genetic and epigenetic peculiarities can already be identified as the cause of the protracted course: 1. high genetic stability of the tumour cell clones in both the primary tumour and the pancreatic metastases; 2. a low frequency of copy number variants associated with aggressiveness, such as 9p, 14q and 4q loss; 3. in the chromatin-modifying genes, a decreased rate of PAB1 (3%) and an increased rate of PBRM1 (77%) defects are seen, a profile associated with a favourable course; 4. an increased incidence of KDM5C mutations, which, in common with increased PBRM1 alterations, is also associated with a favourable outcome; and 5. angiogenetic biomarkers are increased in tumour tissue, while inflammatory biomarkers are decreased, which explains the good response to TKI therapy and lack of sensitivity to IT.
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Affiliation(s)
- Franz Sellner
- Department of General, Visceral and Vascular Surgery, Clinic Favoriten Vienna, Kaiser Franz Josef Hospital, 1100 Vienna, Austria
| | - Eva Compérat
- Clinical Institute of Pathology, Medical University Vienna, 1090 Vienna, Austria
| | - Martin Klimpfinger
- Clinical Institute of Pathology, Medical University Vienna, 1090 Vienna, Austria
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9
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Torres Olivieri A, Longoria Dubocq T, Hernandez Rivera P. Metastasis of Renal Cell Carcinoma to Pancreatic Bile Duct. Am Surg 2023; 89:3877-3878. [PMID: 37146981 DOI: 10.1177/00031348231174014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Secondary pancreatic neoplasms account for less than 5% of all pancreatic malignancies, with renal cell carcinoma (RCC) being one of the most common primary tumors. Here, we present the case of a patient with obstructive jaundice secondary to an isolated metastatic RCC, to the intrapancreatic portion of the common bile duct, ampulla of Vater, and pancreatic parenchyma. Patient had a history of a left radical nephrectomy due to a primary RCC 10 years prior to presentation, and eventually underwent a pylorus-sparing pancreaticoduodenectomy (PD) with minor morbidity. While metastases of RCC to the pancreatic body and tail have been reported, isolated metastasis to the pancreatic bile duct comprises an even rarer subgroup.
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Affiliation(s)
- Andres Torres Olivieri
- Division of Hepatobiliary Surgery, Department of Surgery, University of Puerto Rico, San Juan, PR, USA
| | - Texell Longoria Dubocq
- Division of Hepatobiliary Surgery, Department of Surgery, University of Puerto Rico, San Juan, PR, USA
| | - Pedro Hernandez Rivera
- Division of Hepatobiliary Surgery, Department of Surgery, University of Puerto Rico, San Juan, PR, USA
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10
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Möller K, Jenssen C, Braden B, Hocke M, Yamashita Y, Arcidiacono PG, Ignee A, D’Onofrio M, Fusaroli P, Bhutani MS, Dong Y, Sun S, Faiss S, Dietrich CF. Comments on and Illustrations of the EFSUMB CEUS Guidelines: Transabdominal and Endoscopic Ultrasound Features of Intrapancreatic Metastases and the Role of Multiparametric Imaging and EUS-Guided Sampling in Rare Pancreatic Tumors. Cancers (Basel) 2023; 15:2546. [PMID: 37174015 PMCID: PMC10177255 DOI: 10.3390/cancers15092546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
A definite pathologic diagnosis of intrapancreatic metastasis is crucial for the management decision, i.e., curative or palliative surgery versus chemotherapy or conservative/palliative therapy. This review focuses on the appearance of intrapancreatic metastases on native and contrast-enhanced transabdominal ultrasound and endoscopic ultrasound. Differences and similarities in relation to the primary tumor, and the differential diagnosis from pancreatic carcinoma and neuroendocrine neoplasms are described. The frequency of intrapancreatic metastases in autopsy studies and surgical resection studies will be discussed. Further emphasis is placed on endoscopic ultrasound-guided sampling to confirm the diagnosis.
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Affiliation(s)
- Kathleen Möller
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, 10365 Berlin, Germany
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch-Oderland, 15344 Strausberg, Germany
- Brandenburg Institute for Clinical Ultrasound (BICUS), Medical University Brandenburg, 16816 Neuruppin, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, OX3 9DU Oxford, UK
| | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, 98617 Meiningen, Germany
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama City 641-8509, Japan
| | - Paolo Giorgio Arcidiacono
- Division of Pancreatobiliary Endoscopy and Endosonography, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - André Ignee
- Medical Clinic—Department for Gastroenterology and Rheumatology, Klinikum Wuerzburg Mitte, 97070 Wuerzburg, Germany
| | - Mirko D’Onofrio
- Department of Radiology, GB Rossi University Hospital, University of Verona, 37129 Verona, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastrointestinal Unit, University of Bologna/Hospital of Imola, 40126 Bologna, Italy
| | - Manoop S. Bhutani
- Department of Gastroenterology Hepatology and Nutrition, UTMD Anderson Cancer Center, Houston, TX 77030-4009, USA
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Siyu Sun
- Department of Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110022, China
| | - Siegbert Faiss
- Medical Department I/Gastroenterology, Sana Hospital Lichtenberg, 10365 Berlin, Germany
| | - Christoph F. Dietrich
- Department Allgemeine Innere Medizin der Kliniken (DAIM) Hirslanden Beau Site, Salem und Permanence, 3013 Bern, Switzerland
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11
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Surgical Approach in Metastatic Renal Cell Carcinoma: A Literature Review. Cancers (Basel) 2023; 15:cancers15061804. [PMID: 36980688 PMCID: PMC10046362 DOI: 10.3390/cancers15061804] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/02/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
The treatment of metastatic renal cell carcinoma has undergone considerable advances in the last two decades. Cytoreductive nephrectomy and metastasectomy retains a role in patients with a limited metastatic burden. The choice of optimal treatment regimen remains a matter of debate. The article summarises the current role of surgery in metastatic kidney cancer.
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12
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Kinoshita S, Yamashita YI, Kitano Y, Hayashi H, Sugimachi K, Nishizaki T, Fukuzawa K, Kajiyama K, Miyanari N, Yoshizumi T, Takamori H, Baba H. Survival impact of pancreatic resection for metastases in the pancreas: A retrospective multi-center study. Surg Oncol 2023; 48:101942. [PMID: 37043926 DOI: 10.1016/j.suronc.2023.101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Pancreatic metastases from other primary malignancies are rare. There is no clear evidence for a treatment strategy for this condition. The purpose of this study was to assess the clinical outcomes, including prognostic factors for pancreatic resection of metastatic tumors in the pancreas, through a retrospective review. METHODS Data of 35 patients who underwent pancreatic resection for pancreatic metastasis between 2005 and 2020 in eight Japanese institutions were included in this study. Survival analyses were performed using the Kaplan-Meier method, and comparisons were made using the Cox proportional hazards model. RESULTS The median follow-up period was 35 months (range, 5-102 months). Median duration from resection for primary tumor to resection for metastatic pancreatic tumor was 10.6 years (range, 0.6-29.2 years). The 3- and 5-year survival rates after resection for metastatic tumors in the pancreas were 89% and 69%, respectively. In contrast, the 3- and 5-year disease-free survival rates after resection for metastatic tumors in the pancreas were 48% and 21%, respectively. Performance status ≥1 at the time of resection for metastatic tumors in the pancreas (HR: 7.56, p = 0.036) and pancreatic metastasis tumor diameter >42 mm (HR: 6.39, p = 0.02) were significant poor prognostic factors only in the overall survival. CONCLUSIONS The prognosis of pancreatic resection for metastatic tumors in the pancreas is relatively good for selected patients. However, because it is prone to recurrence after radical surgery, it should only be considered in patients with good PS.
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13
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Moletta L, Friziero A, Serafini S, Grillo V, Pierobon ES, Capovilla G, Valmasoni M, Sperti C. Safety and Efficacy of Surgery for Metastatic Tumor to the Pancreas: A Single-Center Experience. J Clin Med 2023; 12:1171. [PMID: 36769817 PMCID: PMC9918219 DOI: 10.3390/jcm12031171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Pancreatic metastases from other neoplasms are rare. The role of surgery for this clinical entity is unclear. The aim of this study was to investigate the role of resection in patients with pancreatic secondary lesions. We observed 44 patients with pancreatic metastases from other tumors. Renal cell carcinoma was the most common primary tumor (n = 19, 43.2%). Thirty-seven patients underwent surgery, and pancreatic resection with curative intent was feasible in 35 cases. Fifteen patients (43.2%) experienced major postoperative complications (Clavien-Dindo > 2), and postoperative mortality rate was 5.4%. The median overall survival and disease-free survival were 38 (range 0-186) and 11 (range 0-186) months, respectively. Overall survival and disease-free survival were significantly longer for pancreatic metastases from renal cell carcinoma when compared to other primary tumors. Multivariate analysis confirmed a pathological diagnosis of metastasis from RCC as an independent prognostic factor for overall survival (OR 2.48; 95% CI, 1.00-6.14; p = 0.05). In conclusion, radical resection of metastases to the pancreas is feasible and safe, and may confer a survival benefit for selected patients. There is a clear benefit of metastasectomy in terms of patient survival for metastases from renal cell carcinoma, while for those with other primary tumors, surgery seems to be mainly palliative.
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Affiliation(s)
| | | | | | | | | | | | | | - Cosimo Sperti
- Department of Surgery, Oncology and Gastroenterology, 1st Surgical Clinic, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
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14
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Sellner F, Thalhammer S, Klimpfinger M. Isolated Pancreatic Metastases of Renal Cell Carcinoma-Clinical Particularities and Seed and Soil Hypothesis. Cancers (Basel) 2023; 15:339. [PMID: 36672289 PMCID: PMC9857376 DOI: 10.3390/cancers15020339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 01/06/2023] Open
Abstract
A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed, that, in addition to the unusual exclusive occurrence of pancreatic metastases and the favourable treatment results, the isPMRCC is characterised by further peculiarities of the clinical course: The lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. As an explanation for all these peculiarities, according to today's knowledge, a strong acting seed and soil mechanism can serve, which allows embolized tumour cells to grow to metastases only in the pancreas, and prevents them definitively or for years in all other organs. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. Genetic studies revealed specific changes in cases of PM of RCC: Lack of loss of 9p21.3 and 14q31.2, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, i.e., high genetic stability, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC is still unclear, so only those factors that have been identified as promoting organotropism in other, more frequent tumour entities can be presented: Formation of the pre-metastatic niche, chemokine receptor-ligand mechanism, ability to metabolic adaptation, and immune surveillance.
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Affiliation(s)
- Franz Sellner
- Department of General, Visceral and Vascular Surgery, Clinic Favoriten, Kaiser Franz Josef Hospital, 1100 Vienna, Austria
| | - Sabine Thalhammer
- Department of General, Visceral and Vascular Surgery, Clinic Favoriten, Kaiser Franz Josef Hospital, 1100 Vienna, Austria
| | - Martin Klimpfinger
- Clinical Institute of Pathology, Medical University, 1090 Vienna, Austria
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15
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Chen WG, Shan GD, Zhu HT, Chen LH, Xu GQ. Gastric metastasis presenting as submucosa tumors from renal cell carcinoma: A case report. World J Clin Cases 2022; 10:9805-9813. [PMID: 36186204 PMCID: PMC9516902 DOI: 10.12998/wjcc.v10.i27.9805] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastric metastasis from renal cell carcinoma (RCC) is an extremely rare clinical entity. Due to an easily neglected RCC history, nonspecific symptoms and under-recognized endoscopic presentation may lead to a potential diagnostic pitfall in daily clinical practice.
CASE SUMMARY We present a case of metastatic gastric tumors arising from RCC 5 years after radical nephrectomy. Simultaneous, multifocal metastases to the gallbladder, pancreas and soft tissue were observed. One year previously, a solitary submucosal discoid tumor with a central depression was detected in the gastric fundus in a 65-year-old man. Endoscopic ultrasonography (EUS) showed a 1.12 x 0.38 cm lesion originating from the deeper mucosal layers with partially discontinuous submucosa. One year later, the endoscopic findings of the lesion showed various changes. A large lesion of the protruding type (2.5 cm × 2 cm) was found in the fundus at the same location. EUS showed a heterogeneous mass that involved the mucosa and submucosal layer. In addition, two small similar submucosal lesions 0.4-0.6 cm in size were detected. These lesions had a central depression, surface mucosal congestion and thickened vessels. The two adjacent lesions in the fundus were resected by endoscopic submucosal dissection. Based on the postoperative pathological analysis, the patient was diagnosed with gastric metastasis from RCC.
CONCLUSION Gastric metastasis from RCC should be considered in patients with a history of RCC irrespective of the time interval involved.
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Affiliation(s)
- Wen-Guo Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Guo-Dong Shan
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Hua-Tuo Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Li-Hua Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Guo-Qiang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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16
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Hopkins DT, Waters D, Manecksha RP, Lynch TH. Isolated soft tissue mass of the finger as the first presentation of oligometastatic renal cell carcinoma. BMJ Case Rep 2022; 15:e248718. [PMID: 35580945 PMCID: PMC9114857 DOI: 10.1136/bcr-2021-248718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s was referred to plastic surgery with a suspected foreign body in the pulp of his right index finger. An excisional biopsy was performed for a presumed foreign body granuloma. Histology revealed metastatic renal cell carcinoma (mRCC). CT imaging demonstrated a 7.4 cm heterogeneous mass arising from the upper pole of the left kidney consistent with primary renal malignancy, in addition to a 9 mm lung nodule. He underwent an uncomplicated left laparoscopic cytoreductive nephrectomy and made a satisfactory recovery. To our knowledge, this is the first reported case of primary mRCC presenting with digital soft tissue metastasis. Cytoreductive nephrectomy with metastasectomy is the preferred management for mRCC where feasible. For unfavourable mRCC cases, first-line systemic therapy is indicated. Adjuvant systemic therapy in mRCC is currently limited to clinical trials, though promising data emerging on the use of pembrolizumab may herald a future shift in practice.
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Affiliation(s)
- David T Hopkins
- Department of Urology, Saint James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Darragh Waters
- Department of Urology, Saint James's Hospital, Dublin, Ireland
| | - Rustom P Manecksha
- Department of Urology, Saint James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College Dublin School of Medicine, Dublin, Ireland
| | - Thomas H Lynch
- Department of Urology, Saint James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College Dublin School of Medicine, Dublin, Ireland
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17
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Sellner F, Thalhammer S, Klimpfinger M. Isolated Pancreatic Metastases of Renal Cell Cancer: Genetics and Epigenetics of an Unusual Tumour Entity. Cancers (Basel) 2022; 14:1539. [PMID: 35326690 PMCID: PMC8945920 DOI: 10.3390/cancers14061539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/14/2022] [Indexed: 12/16/2022] Open
Abstract
Isolated pancreatic metastases of renal cell carcinoma (isPMRCC) are a rare manifestation of metastatic renal cell carcinoma (mRCC) characterized by two peculiarities: (1). The definite or at least long-term exclusive occurrence of metastases in the pancreas and (2). an unusual low tumour aggressiveness with slow tumour progression and consecutive, good treatment results. According to current knowledge, the exclusive occurrence of pancreatic metastases is due to a highly specific and highly selective seed and soil mechanism, which does not allow metastases settlement outside the pancreas, and whose detailed genetic/epigenetic causes are not yet elucidated. Recent studies have shed light on some of the pathways involved for the protracted course of the disease and highlighted a special genetic profile (lack of loss of 9p, lower weight genome instability index, low frequency of BAP1 alterations, and a high frequency of PBRM1 loss), which deviates from the conventional mRCC profile. Finally, the question of the reasons for the long-term relative genetic stability of the involved cell clones, which is an essential prerequisite for a favourable prognosis, remains unanswered.
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Affiliation(s)
- Franz Sellner
- Department of General-, Visceral- and Vascular Surgery, Clinic Favoriten—Kaiser Franz Josef Hospital, 1100 Vienna, Austria;
| | - Sabine Thalhammer
- Department of General-, Visceral- and Vascular Surgery, Clinic Favoriten—Kaiser Franz Josef Hospital, 1100 Vienna, Austria;
| | - Martin Klimpfinger
- Clinical Institute of Pathology, Medical University, 1090 Vienna, Austria;
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18
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Brassetti A, Proietti F, Leonardo C, Simone G. The Value of Metastasectomy in Renal Cell Carcinoma in 2021. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03267-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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19
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Kai K, Imamura N, Hiyoshi M, Hamada T, Uchise Y, Hatada H, Kawakami H, Mukai S, Kamoto T, Nanashima A. Usefulness of intraoperative contrast-enhanced ultrasonography in laparoscopic enucleation of small pancreatic metastases from renal cell carcinoma: A case report. Asian J Endosc Surg 2022; 15:211-215. [PMID: 34342149 PMCID: PMC9292423 DOI: 10.1111/ases.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022]
Abstract
Pancreatic metastasis from renal cell carcinoma (RCC) is relatively rare. Surgical resection of the lesion is recommended if no residual tumor remains. Although there is no clear standard for surgical procedures, enucleation can be considered for small lesions. Lesion identification is important for enucleation, and contrast-enhanced ultrasound which takes advantage of the characteristics of hypervascular lesions was useful in a 68-year-old woman who underwent a left nephrectomy for RCC 11 years ago that was pathologically diagnosed as clear cell carcinoma. Recent computed tomography checkup showed a hypervascular tumor of 6 mm in the uncinated process and 10 mm in the pancreatic tail. Endoscopic ultrasonography-guided fine-needle aspiration was performed for the tail lesion, a diagnosis of clear cell carcinoma was made, and laparoscopic enucleation of the pancreatic tumors was performed aided by intraoperative contrast-enhanced ultrasound. The postoperative course was uneventful, and no pancreatic fistula occurred.
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Affiliation(s)
- Kengo Kai
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Naoya Imamura
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Masahide Hiyoshi
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Takeomi Hamada
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Yukako Uchise
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Hiroshi Hatada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of MedicineUniversity of MiyazakiMiyazakiJapan
| | - Hiroshi Kawakami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of MedicineUniversity of MiyazakiMiyazakiJapan
| | - Shoichiro Mukai
- Department of UrologyUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Toshiyuki Kamoto
- Department of UrologyUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
| | - Atsushi Nanashima
- Department of SurgeryUniversity of Miyazaki Faculty of MedicineMiyazakiJapan
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20
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Vilar Tabanera A, Muñoz Muñoz P, Molina Villar JM, Gajate P, Sanjuanbenito A. Surgery of pancreatic metastasis from renal cell carcinoma. Cir Esp 2021; 100:50-52. [PMID: 34863662 DOI: 10.1016/j.cireng.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/11/2020] [Indexed: 10/19/2022]
Affiliation(s)
- Alberto Vilar Tabanera
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Paula Muñoz Muñoz
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José Manuel Molina Villar
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Pablo Gajate
- Unidad de Oncología Médica, Sección de tumores digestivos, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alfonso Sanjuanbenito
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, Spain
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21
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Bruckschen F, Gerharz CD, Sagir A. Renal cell carcinoma with unusual metachronous metastasis up to 22 years after nephrectomy: two case reports. J Med Case Rep 2021; 15:490. [PMID: 34607612 PMCID: PMC8491385 DOI: 10.1186/s13256-021-03098-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Renal cell carcinoma is the third most common malignant tumor in the urogenital tract. An estimated 25% of renal cell carcinomas are in stage IV when diagnosed. The 5-year-survival with stage IV is about 20%. Late metastases are found after an extended disease-free interval up to 20 years after primary nephrectomy. Case presentation Here, we present two cases with late-onset metastasis of renal cell carcinoma with different clinical presentations. The first patient, an 88-year-old Caucasian man, presented with bleeding of the upper gastrointestinal tract. Biopsies taken from the duodenal bulb showed a tumor compatible with a solitary metastasis from renal cell carcinoma 22 years ago. The second patient, a 79-year-old Caucasian man, consulted our gastroenterological department with results of an outpatient computed tomography scan with multiple suspected tumor areas in the liver, omentum, thyroid, and mediastinum. A computed tomography-guided liver biopsy was performed that showed a clear-cell tumor consistent with a metastasis of the renal cell carcinoma 17 years ago. Conclusion Both cases show that patients with a history of renal cell carcinoma should be followed up for a longer time than patients with other malignant tumors.
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Affiliation(s)
- F Bruckschen
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany
| | - C D Gerharz
- Department of Pathology, Academic teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany
| | - A Sagir
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany.
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22
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Casadei R, Ricci C, Ingaldi C, Alberici L, Minni F. Contemporary indications for upfront total pancreatectomy. Updates Surg 2021; 73:1205-1217. [PMID: 34390466 DOI: 10.1007/s13304-021-01145-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.
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Affiliation(s)
- Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy. .,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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23
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Malleo G, Salvia R, Maggino L, Marchegiani G, D'Angelica M, DeMatteo R, Kingham P, Pulvirenti A, Sereni E, Jarnagin WR, Bassi C, Allen PJ, Butturini G. Long-term Outcomes After Surgical Resection of Pancreatic Metastases from Renal Clear-Cell Carcinoma. Ann Surg Oncol 2021; 28:3100-3108. [PMID: 33575870 PMCID: PMC8119267 DOI: 10.1245/s10434-021-09649-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic metastases (PM) from renal cell carcinoma (RCC) are uncommon. We herein describe the long-term outcomes associated with pancreatectomy at two academic institutions, with a specific focus on 10-year survival. METHODS This investigation was limited to patients undergoing pancreatectomy for PM between 2000 and 2008 at the University of Verona and Memorial Sloan Kettering Cancer Center, allowing a potential for 10 years of surveillance. The probabilities of further RCC recurrence and RCC-related death were estimated using a competing risk analysis (method of Fine and Gray) to account for patients who died of other causes during follow-up. RESULTS The study population consisted of 69 patients, mostly with isolated metachronous PM (77%). The median interval from nephrectomy to pancreatic metastasectomy was 109 months, whereas the median post-pancreatectomy follow-up was 141 months. The 10-year cumulative incidence of new RCC recurrence was 62.7%. In the adjusted analysis, the relative risk of repeated recurrence was significantly higher in PM synchronous to the primary RCC (sHR = 1.27) and in patients receiving extended pancreatectomy (sHR = 3.05). The 10-year cumulative incidence of disease-specific death was 25.5%. The only variable with an influence on disease-specific death was the recurrence-free interval following metastasectomy (sHR = 0.98). In patients with repeated recurrence, the 10-year cumulative incidence of RCC-related death was 35.4%. CONCLUSION In a selected group of patients followed for a median of 141 months and mostly with isolated metachronous PM, resection was associated with a high possibility of long-term disease control in surgically fit patients with metastases confined to the pancreas.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery-DSCOMI University of Verona, Verona, Italy.
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery-DSCOMI University of Verona, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Michael D'Angelica
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald DeMatteo
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter Kingham
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessandra Pulvirenti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elisabetta Sereni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - William R Jarnagin
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Peter J Allen
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Duke University, Durham, NC, USA
| | - Giovanni Butturini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
- Unit of Pancreatic Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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24
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Alzahrani AM, Aggamy MA, Joudeh AA, Alabdullatif HA, Alzahrani H, Gomha MA. Metastasectomy of Sequential Asynchronous Metastatic Renal Cell Carcinoma to the Pancreas, Thyroid, Skin, Contralateral Kidney, and Lung with Cumulative Survival Beyond 10 Years: A Case Report and Clinicopathologic Review. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931696. [PMID: 33956773 PMCID: PMC8112462 DOI: 10.12659/ajcr.931696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient: Female, 46-year-old Final Diagnosis: Metastasis of renal clear cell carcinoma Symptoms: Renal carcinoma Medication:— Clinical Procedure: — Specialty: Urology
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Affiliation(s)
- Abdullah Mousa Alzahrani
- Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohamed A Aggamy
- Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Amani A Joudeh
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hanoof A Alabdullatif
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hassan Alzahrani
- Department of Radiology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mohamed A Gomha
- Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Hirashita T, Iwashita Y, Endo Y, Fujinaga A, Shin T, Mimata H, Inomata M. How Should We Treat Pancreatic Metastases from Renal Cell Carcinoma? A Meta-Analysis. World J Surg 2021; 45:2191-2199. [PMID: 33768307 DOI: 10.1007/s00268-021-06071-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The treatment strategy for pancreatic metastasis (PM) from renal cell carcinoma (RCC) is unclear due to its rarity. The aim of this study was to reveal the role of surgery for PM from RCC. METHODS A systematic literature search was conducted using PubMed and the Cochrane Library. The effectiveness of surgery for PM was evaluated based on the primary outcome of overall survival (OS), which was investigated in relation to surgical procedures and metastatic sites via subgroup analyses. RESULTS There was no significant difference in the rate of 2-year OS between the surgery and control group (OR 0.43, 95% CI 0.14-1.26, P = 0.12). However, the rate of 5-year OS was significantly higher in the surgery group than the control group (OR = 0.41, 95% CI 0.18-0.93, P = 0.03). The rates of the complications and OS were not significantly different between radical and conservative pancreatectomies. The rate of 5-year OS of the patients with PM was higher than that with other metastases (OR 0.38, 95% CI 0.20-0.74, P = 0.004). CONCLUSION Surgical resection for PM from RCC is associated with good prognosis. Limited surgery may be a useful option depending on the location of the lesion.
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Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
| | - Toshitaka Shin
- Department of Urology, Faculty of Medicine, Oita University, 1-1 Hasama-machi, Yufu , Oita, 879-5593, Japan
| | - Hiromitsu Mimata
- Department of Urology, Faculty of Medicine, Oita University, 1-1 Hasama-machi, Yufu , Oita, 879-5593, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
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Sellner F, Thalhammer S, Klimpfinger M. Tumour Evolution and Seed and Soil Mechanism in Pancreatic Metastases of Renal Cell Carcinoma. Cancers (Basel) 2021; 13:1342. [PMID: 33809634 PMCID: PMC8002056 DOI: 10.3390/cancers13061342] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/06/2021] [Accepted: 03/12/2021] [Indexed: 02/07/2023] Open
Abstract
In metastatic renal cell carcinoma, pancreatic metastases can appear in two clinical manifestations: (a) very rarely as isolated pancreatic metastases and (b) in the context with multi-organ metastatic disease. Both courses are characterised by rare, unusual clinical features. For isolated pancreatic metastases, the literature shows no effect on survival in all 11 publications that examined the effect of singular versus multiple pancreatic metastases; a lack of effect on survival time was also present in all 8 studies on pancreatic metastases size, in 7 of 8 studies on the influence of disease-free interval (DFI), and in 6 of 7 studies on the influence of synchronous versus metachronous metastases. In multi-organ site metastases observations, on the other hand, all five available references showed significantly better results in patients with concurrent pancreatic metastases compared to those without pancreatic metastases, although the total number of affected organs in the pancreatic metastases cohort was larger. Tumour volume-dependent risk factors thus remain surprisingly ineffective in both groups, which contradicts the usual behaviour of solid tumours. The reasons for this unusual behaviour and possible relations to tumour evolution and the hypothesis of an influence of a seed and soil mechanism in the occurrence of pancreatic metastases in metastatic renal cell carcinoma are discussed.
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Affiliation(s)
- Franz Sellner
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Sabine Thalhammer
- Department of General-, Visceral- and Vascular Surgery, Clinic Favoriten—Kaiser Franz Josef Hospital, 1100 Vienna, Austria;
| | - Martin Klimpfinger
- Clinical Institute of Pathology, Medical University, 1090 Vienna, Austria;
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Pancreatic Metastasis of Renal Cell Carcinoma: A Surgical Indication for a Disseminated Disease. Case Rep Med 2021; 2021:5579385. [PMID: 33747092 PMCID: PMC7960060 DOI: 10.1155/2021/5579385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 12/25/2022] Open
Abstract
Pancreatic metastasis (PM) of renal cancer is a rare condition. It is characterized by a long period after initial nephrectomy and a favorable prognosis compared to other pancreatic malignancies. Its diagnosis may confuse clinicians if the medical history is not known. In the era of targeted therapies for metastatic renal carcinoma, surgery stands as the best treatment option for PM of renal cancer. We report the case of a woman who underwent successfully left splenopancreatectomy for corporeal PM of renal cancer treated seven years ago. This case underlines the necessity of long-term follow-up of patients treated for kidney cancer.
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Safety and Efficacy of Robotic Radiosurgery for Visceral and Lymph Node Metastases of Renal Cell Carcinoma: A Retrospective, Single Center Analysis. Cancers (Basel) 2021; 13:cancers13040680. [PMID: 33567564 PMCID: PMC7915686 DOI: 10.3390/cancers13040680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary In metastatic renal cell carcinoma (mRCC), systemic treatment with checkpoint inhibitors or tyrosine kinase inhibitors is recommended in guidelines. However, the treatment of patients with oligometastatic disease or mixed responses remains challenging. We aimed to investigate the safety and efficacy of robotic radiosurgery in patients with mRCC. Sixty patients with visceral and lymph node metastases were selected for robotic radiosurgery. The median progression free survival of all patients was 17.4 months, local tumor control was achieved in 96.7% of patients, and only 8.3% of patients experienced adverse events. Robotic radiosurgery might be a powerful tool in addition to systemic treatment for patients with mRCC, but additive effects of both treatments require further investigation. Abstract Despite rapid advances of systemic therapy options in renal cell carcinoma (RCC), local tumor or metastases treatment remains important in selected patients. Here, we assess the safety and efficacy of robotic radiosurgery (RRS) as an ablative therapy for visceral and lymph node metastases of RCC. Patients with histologically confirmed RCC and radiologically confirmed progression of visceral or lymph node metastases underwent RRS and were retrospectively analyzed. Overall survival and progression free survival were calculated by the Kaplan–Meier method and log-rank test. Sixty patients underwent RRS and were included in the analysis. Patients presented for RRS treatment with a median age at RRS treatment of 64 years (range 42–83), clear cell histology (88.3%) and favorable international metastatic renal cell carcinoma database (IMDC) risk score (58.3%). Treatment parameters differed for the number of fractions (median visceral metastases: 1, range 1–5; median lymph node metastases: 1, range 0–5; p = 0.003) and prescription dose (median visceral metastases 24 Gy, range 8–26; median lymph node metastases 18 Gy, range 7–26, p < 0.001). The median overall survival was 65.7 months (range: 2.9–108.6), the median progression free survival was 17.4 months (range: 2.7–70.0) and local tumor control was achieved in 96.7% of patients. Adverse events were limited to 8.3% of patients, with one grade 4 toxicity within 6 weeks after RRS therapy. RRS is a safe and effective treatment option in selected patients with metastatic RCC in a multimodal approach. Further research is warranted to confirm our findings prospectively.
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Sakamoto S, Matsumura M, Tani K, Nemoto S, Tsuchida K, Koga F, Seyama Y. Jejunal limb obstruction by a tumor thrombus from pancreatic metastasis of renal cell carcinoma: a case report. Surg Case Rep 2021; 7:37. [PMID: 33534019 PMCID: PMC7859002 DOI: 10.1186/s40792-021-01122-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/27/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Renal cell carcinoma (RCC) is a primary tumor with the highest frequency of pancreatic metastasis. Although surgical resection can improve the prognosis of some patients with pancreatic metastasis of RCC (PM-RCC), the role of palliative surgery remains unclear. Herein, we described a case of jejunal limb occlusion caused by a tumor thrombus arising from a PM-RCC which was treated by surgical resection. CASE PRESENTATION A 75-year-old, male patient with metastatic RCC was admitted to our hospital with new-onset dysphagia and weight loss. Twenty years earlier he underwent a right nephrectomy with an adrenalectomy for the first surgical resection of RCC, and 12 years ago he underwent a left partial nephrectomy for metachronous primary RCC. Nine years later, multiple pancreatic metastases were detected. After discontinuing interferon therapy, he was followed up at his request without anticancer treatment. Multiple, pulmonary metastases developed 3 years ago, and resection of a brain metastasis was performed 6 months ago. He had also undergone a total gastrectomy with Roux-en Y reconstruction and splenectomy for gastric cancer 23 years ago. Computed tomography revealed a metastatic lesion in the pancreatic tail extending into the jejunal limb, which was obstructed by a tumor thrombus. Jejunal limb resection was performed concomitantly with a distal pancreatectomy as palliative surgery. The jejunal limb remnant was approximately 30 cm long and was re-anastomosed to the esophagus using a circular stapler. Blood perfusion at the anastomotic site was confirmed by indocyanine green fluorescence imaging. He was discharged on postoperative day 24 and was followed in the outpatient clinic. He achieved sufficient oral intake at 8 months postoperatively. CONCLUSIONS PM-RCC can invade the gastrointestinal tract and cause tumor thrombus formation resulting in bowel occlusion requiring surgical intervention.
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Affiliation(s)
- Shinya Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Masaru Matsumura
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Keigo Tani
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Satoshi Nemoto
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Kazuhito Tsuchida
- Department of Gastric Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasuji Seyama
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan.
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Bauschke A, Altendorf-Hofmann A, Ali Deeb A, Kissler H, Tautenhahn HM, Settmacher U. [Surgical treatment of hepato-pancreatic metastases from renal cell carcinoma]. Chirurg 2021; 92:948-954. [PMID: 33398387 PMCID: PMC8463519 DOI: 10.1007/s00104-020-01331-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/03/2023]
Abstract
Hintergrund Der Stellenwert der chirurgischen Therapie hepatopankreatischer Metastasen des oligometastasierten Nierenzellkarzinoms ist Gegenstand der aktuellen Diskussion. Material und Methoden Wir berichten über 51 Patienten, von denen 33 wegen Lebermetastasen und 19 wegen Pankreasmetastasen im Zeitraum von 1995 bis 2018 operiert wurden. Ergebnisse Die 5‑Jahres-Überlebensrate aller Patienten nach Leberteilresektion war statistisch signifikant geringer (38 %, mediane Überlebenszeit 34 Monate) als nach Pankreasresektion (69 %, mediane Überlebenszeit 69 Monaten; p = 0,017). 21 Patienten haben bislang die Metastasenentfernung länger als 5 Jahr überlebt, 4 Patienten länger als 10 Jahre. Bei den R0-resezierten Patienten wurden Rezidive in 13 Fällen nach Leber- und 9 Fällen nach Pankreasresektion beobachtet. Die kumulative Rezidivrate nach 5 Jahren betrug bei der Leber 38 % und beim Pankreas 57 %. Bei R0-Leberteilresektionen erwiesen sich ein Intervall von <24 Monaten zwischen Nephrektomie und Leberresektion sowie multiple Metastasen als negative Prognosefaktoren. Diskussion Unsere Ergebnisse gestatten eine aktive chirurgische Strategie in der Behandlung hepatopankreatischer Metastasen oligometastasierter Nierenzellkarzinome, insbesondere bei kompletter Resektion solitärer, metachroner Metastasen. Wiederholte Eingriffe bei komplett resektablen Metastasen führen zu langen tumorfreien Intervallen und tragen damit zu guten Langzeitergebnissen bei.
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Affiliation(s)
- Astrid Bauschke
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland.
| | - Annelore Altendorf-Hofmann
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - Aladdin Ali Deeb
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - Herman Kissler
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - Hans-Michael Tautenhahn
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland
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Abstract
PURPOSE OF REVIEW The role of metastasectomy in the management of metastatic renal cell carcinoma (mRCC) remains controversial. The aim of this review is to summarize and evaluate the recent findings about the surgical treatment of patients with mRCC focusing on the literature published in the last 2 years. RECENT FINDINGS Despite the lack of randomized controlled trials, the benefit of metastasectomy in term of cancer-specific and overall survival have been demonstrated in large observational studies. Results of ongoing clinical trials evaluating the impact of combination of surgical and systemic therapies are eagerly awaited and may shed the light on a new treatment armamentarium in this subset of patients. SUMMARY Several novel systemic agents have emerged and is continuously changing the treatment paradigm in patients with advanced RCC. However, surgical resection of the primary tumor and metastatic deposits represents a definitive cure option in well selected patients.
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Vilar Tabanera A, Muñoz Muñoz P, Molina Villar JM, Gajate P, Sanjuanbenito A. Surgery of pancreatic metastasis from renal cell carcinoma. Cir Esp 2020; 100:S0009-739X(20)30319-5. [PMID: 33323279 DOI: 10.1016/j.ciresp.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/01/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Alberto Vilar Tabanera
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - Paula Muñoz Muñoz
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, España
| | - José Manuel Molina Villar
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Pablo Gajate
- Unidad de Oncología Médica, Sección de tumores digestivos, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Alfonso Sanjuanbenito
- Unidad de Cirugía general y aparto digestivo, Sección Cirugía Biliopancreática, Hospital Universitario Ramón y Cajal, Madrid, España
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Di Franco G, Palmeri M, Sbrana A, Gianardi D, Furbetta N, Guadagni S, Bianchini M, Stefanini G, Adamo G, Pollina LE, Galli L, Di Candio G, Morelli L. Renal cell carcinoma: The role of radical surgery on different patterns of local or distant recurrence. Surg Oncol 2020; 35:106-113. [PMID: 32866943 DOI: 10.1016/j.suronc.2020.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/29/2020] [Accepted: 08/02/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION With the increasing reliance on targeted therapies and immunotherapy, no standard management strategy is today available for the treatment of locally, distant, or both renal cell carcinoma (RCC) recurrences, and their surgical treatment seems to play a crucial role. We report the 20-year experience of our center evaluating the short- and long-term outcomes of patients undergone surgical resection of RCC recurrences, and the possible role of repeated surgical resections of RCC recurrences. MATERIALS AND METHODS From January 1999 to January 2019, 40 patients underwent surgical resection of isolated locally recurrent RCC (iLR-RCC-group), locally recurrent RCC associated with the presence of distant recurrence (LR-DR-RCC-group), and distant-only recurrent RCC (DR-RCC-group). Data regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in an institutional database, were retrospectively analyzed and compared. RESULTS iLR-RCC-group was composed of 9 patients, LR-DR-RCC-group of 6 patients, and DR-RCC-group of 25 patients. The recurrence rate was 55.6% (5/9 patients) in iLR-RCC-group, 50% (3/6 patients) in LR-DR-RCC-group, and 44% (11/25) patients in DR-RCC-group, p = 0.830. 3/5 (60%) patients in iLR-RCC-group, 2/3 (66.7%) patients in LR-DR-RCC-group, and 7/11 (63.6%) patients in DR-RCC group underwent to almost one further local treatments of their recurrences, respectively (p = 0.981). No differences in the mean disease-free survival (p = 0.384), overall survival (OS) (p = 0.881), and cancer-specific survival (p = 0.265) were reported between the three groups. In DR-RCC-group, patients who underwent further local treatments of new recurrences presented a longer OS: 150.7 versus 66.5 months (p = 0.004). CONCLUSIONS A surgical resection of RCC recurrences should be always taken in consideration, also in metastatic patients and/or in those who have already undergone surgery of previous RCC recurrence, whenever radicality is still possible, because this approach may offer a potentially long survival.
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Affiliation(s)
- Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Andrea Sbrana
- Unit of Oncology 2, University Hospital of Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Gianni Stefanini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Giulia Adamo
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | | | - Luca Galli
- Unit of Oncology 2, University Hospital of Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy; EndoCAS (Center for Computer-Assisted Surgery), University of Pisa, Italy.
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Milanetto AC, Morelli L, Di Franco G, David A, Campra D, De Paolis P, Pasquali C. A Plea for Surgery in Pancreatic Metastases from Renal Cell Carcinoma: Indications and Outcome from a Multicenter Surgical Experience. J Clin Med 2020; 9:3278. [PMID: 33066168 PMCID: PMC7601970 DOI: 10.3390/jcm9103278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/03/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic metastases from renal-cell carcinoma (RCC-PMs) are rare. Surgery may play a role in improving overall (OS) and disease-free survival (DFS). METHODS Clinical-pathological features, surgery and follow-up data of patients with RCC-PMs operated on in three pancreatic surgical centers (2000-2019) were retrospectively evaluated. RESULTS Thirty-nine patients (21 male/18 female, averaging 65 years) were enrolled. RCC-PMs were metachronous in 36 patients (mean 94 months, up to 24 years after nephrectomy), multiple in 21 patients, and with a median size of 2.5 (range, 0.7-7.5) cm. All the patients underwent pancreatic surgery (33 standard resections, 6 limited resections). Fifteen patients had post-operative complications (morbidity 38.5%). The median DFS was 63 months, and 19 out of 36 patients showed a disease recurrence. The median OS was 134 months, and 13 out of 36 patients were alive with no evidence of disease. At univariate analysis, lymph node positivity (HR 5.1, 95% CI 1.5-18), multi-visceral resection (HR 3.4, 95% CI 1.1-10) and synchronous RCC-PMs (HR 13, 95% CI 3-55) were significantly associated with a short OS. CONCLUSION Surgery may allow a DFS up to 17 years in more than one third of patients, even after limited resections. Splenectomy and lymph node dissection are not mandatory.
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Affiliation(s)
- Anna Caterina Milanetto
- Clinica Chirurgica 1 - Pancreatic and Endocrine Digestive Surgical Unit. Department of Surgery, Oncology and Gastroenterology – University of Padua, via Giustiniani, 2 – 35128 Padova, Italy; (A.D.); (C.P.)
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Paradisa, 2 – 56125 Pisa, Italy; (L.M.); (G.D.F.)
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Paradisa, 2 – 56125 Pisa, Italy; (L.M.); (G.D.F.)
| | - Alina David
- Clinica Chirurgica 1 - Pancreatic and Endocrine Digestive Surgical Unit. Department of Surgery, Oncology and Gastroenterology – University of Padua, via Giustiniani, 2 – 35128 Padova, Italy; (A.D.); (C.P.)
| | - Donata Campra
- Chirurgia Generale e d’Urgenza 3, AOU Città della Salute e della Scienza di Torino, Corso Bramante, 88 – 10126 Torino, Italy; (D.C.); (P.D.P)
| | - Paolo De Paolis
- Chirurgia Generale e d’Urgenza 3, AOU Città della Salute e della Scienza di Torino, Corso Bramante, 88 – 10126 Torino, Italy; (D.C.); (P.D.P)
| | - Claudio Pasquali
- Clinica Chirurgica 1 - Pancreatic and Endocrine Digestive Surgical Unit. Department of Surgery, Oncology and Gastroenterology – University of Padua, via Giustiniani, 2 – 35128 Padova, Italy; (A.D.); (C.P.)
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Hou T, Stewart JM, Lee JH, Gan Q. Solid Tumor Metastases to the Pancreas Diagnosed Using Fine-Needle Aspiration. Am J Clin Pathol 2020; 154:692-699. [PMID: 32651950 DOI: 10.1093/ajcp/aqaa090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Solid tumor metastases to the pancreas are rare, and only limited literature on the topic is available. In this retrospective study, we reviewed 107 cases of solid tumor metastases to the pancreas diagnosed by fine-needle aspiration (FNA) from 2005 to 2019. METHODS Information including the patients' clinical histories, radiologic and pathologic findings, treatments, and follow-up were collected. RESULTS The mean age of the patients was 62.4 years. The mean tumor size was 2.64 cm with even distribution throughout the pancreas (head, neck and body, and tail). The most common primary site was the kidney, followed by the lung, skin, and breast and the gynecologic, gastrointestinal, and genitourinary tracts. The most common tumor type was carcinoma, followed by melanoma and sarcoma. In comparison to patients with nonkidney primary cancers, those with primary renal cell carcinoma had a longer median interval between primary diagnosis and metastasis (8.5 vs 4.0 years; P < .01), less often had metastasis outside the pancreas (38% vs 74%; P < .01), and had a significantly longer 5-year survival rate (65.7% vs 24.8%; P < .01). CONCLUSIONS FNA plays a crucial role in diagnosing metastases to the pancreas. Metastases originating from kidney and nonkidney primary tumors have distinct clinicopathologic features and prognoses.
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Affiliation(s)
- Tieying Hou
- Department of Anatomical Pathology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston
| | - John M Stewart
- Department of Anatomical Pathology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston
| | - Qiong Gan
- Department of Anatomical Pathology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston
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Choucair K, Parker NA, Al-Obaidi A, Alderson J, Truong P. Solitary, Late Metastatic Recurrence of Renal Cell Carcinoma to the Pancreas: A Case Report. Cureus 2020; 12:e8521. [PMID: 32537281 PMCID: PMC7286586 DOI: 10.7759/cureus.8521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies and is known for metastatic initial presentation, unpredictable metastatic pathway, and late recurrence post-curative resection. We report a case of solitary late metastatic renal cell carcinoma to the pancreas more than 10 years after radical nephrectomy. A high index of suspicion must be maintained to detect RCC late recurrence and metastasis to rare and atypical locations. A lifelong follow-up is recommended.
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Affiliation(s)
- Khalil Choucair
- Internal Medicine, University of Kansas School of Medicine, Wichita, USA
| | - Nathaniel A Parker
- Internal Medicine, University of Kansas School of Medicine, Wichita, USA
| | - Ammar Al-Obaidi
- Internal Medicine, University of Kansas School of Medicine, Wichita, USA
| | - Joel Alderson
- Pathology, Ascension Via Christi St. Francis Hospital, Wichita, USA
| | - Phu Truong
- Hematology/Oncology, Cancer Center of Kansas, Wichita, USA
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Brozzetti S, Sterpetti AV. Unexpected Prolonged Survival After Extended and Emergent Resection of Pancreatic Metastases from Renal Cell Carcinoma. J Gastrointest Cancer 2020; 50:1055-1058. [PMID: 30767105 DOI: 10.1007/s12029-019-00209-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sellner F. Isolated Pancreatic Metastases of Renal Cell Carcinoma-A Paradigm of a Seed and Soil Mechanism: A Literature Analysis of 1,034 Observations. Front Oncol 2020; 10:709. [PMID: 32547940 PMCID: PMC7273884 DOI: 10.3389/fonc.2020.00709] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Previously documented arguments, in favor of the suspected impact of a seed and soil mechanism, in the development and progression of isolated pancreatic metastasis of renal cell carcinomas (isPM) are: (1) uniform and independent from the side of the primary tumor distribution of isPM within the pancreas and, (2) the similar survival rates for singular and multiple isPM. In addition, the present study adds new arguments that further confirm the importance of an seed and soil mechanism in isPM: (1) Within the singular isPM, the size of the metastasis does not affect the overall survival; (2) Within the group of multiple isPMs, the overall survival does not depend on the number of metastases; (3) For synchronous and metachronous isPM, survival rates are also not different, and (4) Within the group of metachronous isPM there is also no correlation between the overall survival and interval until metastases occurs. This unusual ineffectiveness of otherwise known risk factors of solid cancers can be explained plausibly by the hypothesis of a very selective seed and soil mechanism in isPM. It only allows embolized renal carcinoma cells in the pancreas to complete all steps required to grow into clinically manifest metastases. In all other organs, on the other hand, the body is able to eliminate the embolized tumor cells or at least put them into a dormant state for many years. This minimizes the risk of occult micrometastases in distant organs, which could later—after isPM treatment—grow into clinically manifest metastases, so that the prognosis of the isPM is only determined by an adequate therapy of the pancreatic foci, and prognostic factors, such as total tumor burden or interval until the occurrence of the isPM remain ineffective.
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Affiliation(s)
- Franz Sellner
- Surgical Department, Kaiser Franz Josef Hospital, Vienna, Austria
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Brozzetti S, Bini S, De Lio N, Lombardo C, Boggi U. Surgical-only treatment of pancreatic and extra-pancreatic metastases from renal cell carcinoma - quality of life and survival analysis. BMC Surg 2020; 20:101. [PMID: 32404091 PMCID: PMC7218538 DOI: 10.1186/s12893-020-00757-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 04/28/2020] [Indexed: 01/04/2023] Open
Abstract
Background Treatment of pancreatic metastases (PM) from renal cell carcinoma (RCC) is still an issue between surgeons and oncologists, in the era of target-therapy. Methods Data from 26 patients undergoing resection of PM and extra-PM from RCC, with R0 intention were retrospectively analysed. No one received adjuvant chemotherapy. Patients were divided into two groups; Group A comprehends 14 patients who developed synchronous (5) or methacronous (9) extra-PM. Group B comprehends 12 patients that developed PM only. Results No intraoperative mortality was recorded. Complications occurred in 14 patients (53.8%), all but 2 (7.26%) were graded I and II according to Clavien-Dindo classification. Recurrences occurred in 8 patients (30.8%), of whom, 5 (62.5%) were submitted for further resections in other sites. Three-, five- and ten-year observed overall survival were respectively 88,5% [95%CI: 0,56 – 1,33], 76,9% [95%CI: 0,47 – 1,19] and 50% [95%CI: 0,20 – 1,03]. Disease-free survival was 65,4% [95%CI: 0,38 – 1,05], at 3 years, 57,7% [95%CI 0,323 – 0,952] at 5 years and 42,9% [95%CI 0,157 – 0,933], at 10 years. QoL analysis, through WHOQOL-BREF questionnaire, assessed at last available follow up revealed a mean score of 75,9 ± 11,6 on 100 points. Conclusion Despite no significant differences in survival between patients affected by Pancreatic or Extra-Pancreatic metastases, PM patients seems to show better outcome when managed surgically. mRCC patients, eligible for radical metastasectomy, tend to have long survival rates, reduced recurrence rates and good QoL. Study registration This paper was registered retrospectively in ClinicalTrials.gov with Identification number: NCT03670992.
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Affiliation(s)
- Stefania Brozzetti
- Surgical Department "Pietro Valdoni", Policlinico Umberto I, University of Rome "La Sapienza", Viale del Policlinico 155, 00161, Rome, Italy.
| | - Simone Bini
- Surgical Department "Pietro Valdoni", Policlinico Umberto I, University of Rome "La Sapienza", Viale del Policlinico 155, 00161, Rome, Italy
| | - Nelide De Lio
- Division of General and Transplantation Surgery, University of Pisa, Pisa, Italy
| | - Carlo Lombardo
- Division of General and Transplantation Surgery, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplantation Surgery, University of Pisa, Pisa, Italy
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Berghen C, Joniau S, Vulsteke C, Albersen M, Devos G, Rans K, Haustermans K, De Meerleer G. Metastasis-directed therapy for oligometastatic urological tumours: still no second-hand news. Ecancermedicalscience 2020; 14:1036. [PMID: 32565889 PMCID: PMC7289610 DOI: 10.3332/ecancer.2020.1036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 12/31/2022] Open
Abstract
For patients presenting with limited metastatic disease burden, known as the oligometastatic state of disease, a more aggressive treatment approach targeting the new or progressive metastatic lesions might improve patient outcome, with no or only limited toxicity to be expected from the treatment. This review provides an overview of the existing evidence and on-going trials on oligometastatic disease and metastasis-directed therapy in the field of renal, bladder and prostate cancer.
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Affiliation(s)
- Charlien Berghen
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Steven Joniau
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Christof Vulsteke
- Department of Oncology, Ghent Maria Middelares Hospital, Ghent, Belgium
- Department of Molecular Imaging, Pathology, Radiotherapy and Oncology (MIPRO), Center for Oncological Research (CORE), University of Antwerp, Antwerp, Belgium
| | - Maarten Albersen
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Gaëtan Devos
- Department of Urology, Leuven University Hospital, Leuven, Belgium
| | - Kato Rans
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiation Oncology, Leuven University Hospital, Leuven, Belgium
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Di Franco G, Gianardi D, Palmeri M, Furbetta N, Guadagni S, Bianchini M, Bonari F, Sbrana A, Vasile E, Pollina LE, Mosca F, Di Candio G, Morelli L. Pancreatic resections for metastases: A twenty-year experience from a tertiary care center. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:825-831. [PMID: 31806518 DOI: 10.1016/j.ejso.2019.11.514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/11/2019] [Accepted: 11/27/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Literature data about pancreatic resections for metastases are limited to small series, so that the role of surgery in this setting remains unclear. We herein report our experience from a tertiary care center, analyzing the outcomes of patients who underwent pancreatic resections for metastases and discussing the role of surgical resection in their management. MATERIALS AND METHODS From January 1999 to January 2019, 26 patients underwent pancreatic resections for metastases from renal cell carcinoma (RCC-group) or other primitive tumors (non-RCC-group). Details regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in a database of pancreatic resection, were retrospectively analyzed and compared. RESULTS RCC-group was composed of 21 patients, non-RCC-group of 5 patients. RCC-group presented a longer disease-free interval: 96.4 vs. 5.4 months (p < 0.001). In 9/21 patients (42.9%) of RCC-group the surgical resection of other organs or vascular structures was performed, while in non-RCC-group pancreatic resection alone was performed in all cases, p = 0.070. No local recurrence was reported in all cases. The systemic recurrence rate was 42.9% (9/21 patients) in RCC-group and 80% (4/5 patients) in non-RCC-group, p = 0.135. RCC-group presented a longer DFS and OS: 107.5 vs. 25.2 months (p = 0.002), and 109.1 vs. 36.2 months (p = 0.016), respectively. CONCLUSIONS Radical pancreatic resection may confer a survival benefit for RCC metastases, while for other primitive tumors it should be applied more selectively. For RCC pancreatic metastases, an aggressive surgical approach, even in patient with locally advanced tumors, or associated extra-pancreatic localizations, or recurrent metastases should be taken in consideration.
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Affiliation(s)
- Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Federica Bonari
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Andrea Sbrana
- Unit of Oncology 2, University Hospital of Pisa, Italy
| | - Enrico Vasile
- Unit of Oncology 2, University Hospital of Pisa, Italy
| | | | - Franco Mosca
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy; EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Italy.
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Jaen-Torrejimeno I, Rojas-Holguín A, López-Guerra D, Ramia JM, Blanco-Fernández G. Pancreatic resection for metastatic renal cell carcinoma. A systematic review. HPB (Oxford) 2020; 22:479-486. [PMID: 31672281 DOI: 10.1016/j.hpb.2019.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Renal cell carcinoma (RCC) can lead to secondary pancreatic tumors even years after nephrectomy was performed. Surgical resection in selected patients shows appropriate survival rates. METHODS A systematic review was performed following PRISMA guidelines. This review finished in May 2019 and included patients with resected pancreatic metastasis(es). The main purpose was to evaluate the results of surgical resection of pancreatic tumors secondary to kidney cancer. RESULTS After the screening process of articles, 21 were selected for the systematic review, which included 354 patients, whose disease-free interval (DFI) was 105.11 (0-361.56) months. Of these patients, 34.6% had additional metastases elsewhere at the time of the surgery, and 48.6% were symptomatic. Postoperative morbidity was 40.2%, The 5-year overall survival (OS) rate was 53.9% (26-75). CONCLUSION Pancreatic surgery for the resection of RCC metastasis(es) is considered safe and shows low morbidity and mortality rates among selected patients in medical institutions where this type of procedure is commonly performed.
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Affiliation(s)
- Isabel Jaen-Torrejimeno
- Department of HBP and Liver Transplant Surgery, University Complex Hospital Badajoz, University of Extremadura, Badajoz, Spain
| | - Adela Rojas-Holguín
- Department of HBP and Liver Transplant Surgery, University Complex Hospital Badajoz, University of Extremadura, Badajoz, Spain
| | - Diego López-Guerra
- Department of HBP and Liver Transplant Surgery, University Complex Hospital Badajoz, University of Extremadura, Badajoz, Spain.
| | - Jose M Ramia
- Department of Surgery, Guadalajara University Hospital, University of Alcala, Guadalajara, Spain
| | - Gerardo Blanco-Fernández
- Department of HBP and Liver Transplant Surgery, University Complex Hospital Badajoz, University of Extremadura, Badajoz, Spain
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A 22-year experience with pancreatic resection for metastatic renal cell carcinoma. HPB (Oxford) 2020; 22:312-317. [PMID: 31345661 PMCID: PMC7673067 DOI: 10.1016/j.hpb.2019.05.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 05/17/2019] [Accepted: 05/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The pancreas is a rare site of metastases, although metastatic renal cell carcinoma (mRCC) is the most commonly reported secondary tumor. Pancreatectomy has been described in selected patients with localized metastases, but long-term benefit remains poorly defined. METHODS A retrospective review of a prospectively maintained database was performed to evaluate the outcomes of patients undergoing pancreatectomy for mRCC at a tertiary care center from 1995-2017. Postoperative complications were evaluated using the Modified Accordion Grading System (MAGS) and Kaplan-Meier curves and log-rank tests were utilized for survival analysis. RESULTS 29 patients underwent pancreatectomy for mRCC including 15 distal pancreatectomies (DP), 10 pancreaticoduodenectomies (PD) and 4 total-pancreatectomies (TP). The mean age was 67 ± 8 years, and 15 were male. The median time from index nephrectomy to pancreatectomy was 8 (IQR: 3.72-12.2) years. There was no 90 Day post-pancreatectomy mortalities and the morbidity incidence included 13 Minor MAGS and 8 Severe MAGS complications respectively. Post-pancreatectomy disease specific survival at 2- and 4-years were 89% and 80% with 12 patients being alive at last follow up. CONCLUSIONS Pancreatic resection can be safely performed in select patients with localized mRCC with favorable long-term outcomes.
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Yoshida R, Yoshizako T, Ando S, Shibagaki K, Ishikawa N, Kitagaki H. Dynamic CT findings of a polypoid gastric metastasis of clear renal cell carcinoma: a case report with literature review. Radiol Case Rep 2020; 15:237-240. [PMID: 31908709 PMCID: PMC6940632 DOI: 10.1016/j.radcr.2019.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/29/2019] [Accepted: 12/08/2019] [Indexed: 01/12/2023] Open
Abstract
Metastatic disease involving the stomach is very rare. The gastric metastases of renal cell carcinoma (RCC) have rarely been reported, occurring in 0.2% of all RCC cases. Sometimes gastric metastases cause gastrointestinal bleeding and require treatment. We present the case of an 85-year-old woman with gastric metastasis from RCC diagnosed by anemia and bleeding. A dynamic contrast-enhanced computed tomography revealed a pedunculated and hypervascular polypoid mass approximately 100 mm in size with a washout enhancement pattern in the stomach. In addition to describing the case of our patient, we have reviewed computed tomography findings of gastric metastases from clear RCC.
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Affiliation(s)
- Rika Yoshida
- Faculty of Medicine, Department of Radiology, Shimane University, 89-1, Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Takeshi Yoshizako
- Faculty of Medicine, Department of Radiology, Shimane University, 89-1, Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Shinji Ando
- Faculty of Medicine, Department of Radiology, Shimane University, 89-1, Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Kotaro Shibagaki
- Faculty of Medicine, Department of Gastroenterology, Shimane University, Shimane, Japan
| | - Noriyoshi Ishikawa
- Faculty of Medicine, Department of Organ Pathology, Shimane University, Shimane, Japan
| | - Hajime Kitagaki
- Faculty of Medicine, Department of Radiology, Shimane University, 89-1, Enya-cho, Izumo, Shimane, 693-8501, Japan
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[CLINICAL RESULTS OF TWO PATIENTS WITH LATE RECURRENCE OF RENAL CELL CARCINOMA AFTER LONG TERM OBSERVATION WITHOUT TREATMENT]. Nihon Hinyokika Gakkai Zasshi 2020; 111:39-43. [PMID: 33883357 DOI: 10.5980/jpnjurol.111.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Two patients with late recurrence of renal cell carcinoma were observed long term without treatment. Case 1 is an 83-year-old woman who underwent right nephrectomy at 57 years of age following a renal tumor diagnosis. Histopathological results revealed clear cell renal cell carcinoma, G2, pT1aN0M0. Pancreatic metastasis developed at age 71, and pancreatic tail excision was performed. A metastatic lesion appeared again at the head of the pancreas at age 74. The patient has been followed by observation only for 9 years without any new lesions. Tumor doubling time calculated from abdominal ultrasonography was 13.3 months.Case 2 is a 91-year-old male. At 78 years of age, right nephrectomy and inferior vena cava tumor embolectomy were performed for renal tumor. Histopathological results revealed clear cell renal cell carcinoma, G2, pT3bN0M0. Left adrenal metastasis appeared at age 84, and the patient has been followed for 7 years without new lesions. Tumor doubling time calculated from abdominal computed tomography (CT) images was 14.1 months.In both patients, no symptoms due to tumor recurrence ever appeared, and their activities of daily living (ADL) were maintained fairly well. In the case of solitary late recurrence in elderly renal cancer patients, observation may be a treatment option that avoids adverse effects and complications caused by treatment. In addition, it appears possible to predict the need for subsequent treatment by calculating the doubling time using several sequential CT images obtained after recurrence. If a new recurrent metastatic lesion appears or if the doubling time during a 2-to 3-year follow-up period is relatively short, however, new treatment should be considered without delay.
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Kato S, Demura S, Murakami H, Tsuchiya H. Surgical metastasectomy for renal cell carcinoma: which patients are the real candidates for surgery? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S273. [PMID: 32015992 DOI: 10.21037/atm.2019.11.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Satoshi Kato
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Satoru Demura
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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Wespiser M, Goujon M, Nguyen Tan Hon T, Maurina T, Kleinclauss F, Créhange G, Thiery-Vuillemin A. [Radiotherapy of oligometastases: Sequences and interactions with systemic therapies, example of kidney cancer]. Cancer Radiother 2019; 23:896-903. [PMID: 31591034 DOI: 10.1016/j.canrad.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 10/25/2022]
Abstract
This article is a review of the literature that aims to clarify the place of systemic and locoregional treatments, with a focus on radiotherapy and surgery in the management of patients with oligometastatic kidney cancer. We have selected articles of interest published in Medline indexed journals. We have also analysed the related guidelines: National Comprehensive Cancer Network (NCCN) 2019, European Association of Urology (EAU) 2019, European Society of Medical Oncology (ESMO) 2019, Association française d'urologie (Afu) 2018 as well as some abstracts of international congresses. The main treatments evaluated were surgery and radiotherapy. We defined the different scenarios conventionally encountered in clinical practice. The evolution of systemic therapies (increased overall survival and response rate) is likely to increase the number of patients potentially accessible to locoregional treatments. The complete analysis of the literature underlines the place of locoregional treatments whatever the scenarios mentioned. Data on stereotactic radiotherapy found a local control rate consistently above 70% in all studies with a maintained response and positive impact on overall survival and progression-free survival. The improvement of overall survival by sequential use of the various therapeutic classes confirms the need for optimization of locoregional treatments in the model of oligometastatic kidney cancer. The dogma of radioresistance must definitely be set aside with current irradiation techniques.
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Affiliation(s)
- M Wespiser
- Service d'oncologie médicale, centre hospitalier régional universitaire Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon cedex, France.
| | - M Goujon
- Service d'oncologie médicale, centre hospitalier régional universitaire Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon cedex, France
| | - T Nguyen Tan Hon
- Service d'oncologie médicale, centre hospitalier régional universitaire Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon cedex, France
| | - T Maurina
- Service d'oncologie médicale, centre hospitalier régional universitaire Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon cedex, France
| | - F Kleinclauss
- Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France; Service d'urologie-andrologie et transplantation rénale, centre hospitalier régional universitaire Jean-Minjoz, 25030 Besançon cedex, France
| | - G Créhange
- Département de radiothérapie oncologique, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Thiery-Vuillemin
- Service d'oncologie médicale, centre hospitalier régional universitaire Jean-Minjoz, 3, boulevard Fleming, 25030 Besançon cedex, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France
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Sellner F. Observations on Solitary Versus Multiple Isolated Pancreatic Metastases of Renal Cell Carcinoma: Another Indication of a Seed and Soil Mechanism? Cancers (Basel) 2019; 11:E1379. [PMID: 31533220 PMCID: PMC6770877 DOI: 10.3390/cancers11091379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/02/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022] Open
Abstract
Isolated pancreas metastases are a rare type of metastasis of renal cell carcinoma, characterized by the presence of pancreatic metastases, while all other organs remain unaffected. In a previous study, we determined arguments from the literature which (a) indicate a systemic-haematogenic metastasis route (uniform distribution of the metastases across the pancreas and independence of the metastatic localization in the pancreas of the side of the renal carcinoma); and (b) postulate a high impact of a seed and soil mechanism (SSM) on isolated pancreatic metastasis of renal cell carcinoma (isPM) as an explanation for exclusive pancreatic metastases, despite a systemic haematogenous tumor cell embolization. The objective of the study presented was to search for further arguments in favor of an SSM with isPM. For that purpose, the factor's histology, grading, and singular/multiple pancreas metastases were analyzed on the basis of 814 observations published up to 2018. While histology and grading allowed for no conclusions regarding the importance of an SSM, the comparison of singular/multiple pancreas metastases produced arguments in favor of an SSM: 1. The multiple pancreas metastases observed in 38.1% prove that multiple tumor cell embolisms occur with isPM, the exclusive "maturation" of which in the pancreas requires an SSM; 2. The survival rates (SVR), which are consistent with singular and multiple pancreas metastases (despite the higher total tumor load with the latter), prove that the metastasized tumor cells are not able to survive in all other organs because of an SSM, which results in identical SVR when the pancreatic foci are treated adequately.
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Affiliation(s)
- Franz Sellner
- Surgical Department, Kaiser-Franz-Josef-Hospital, 1100 Wien, Austria.
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Wcislak SM, Stiles ZE, Deneve JL, Glazer ES, Behrman SW, Farooq FT, Dickson PV. Hypervascular lesions of the pancreas: Think before you act. Am J Surg 2019; 218:362-367. [DOI: 10.1016/j.amjsurg.2018.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/31/2022]
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Yamaguchi H, Kimura Y, Nagayama M, Imamura M, Tanaka S, Yoshida M, Yoshida E, Fujino H, Machiki T, Miyanishi K, Mizuguchi T, Kato J, Takemasa I. Central pancreatectomy in portal annular pancreas for metastatic renal cell carcinoma: a case report. World J Surg Oncol 2019; 17:76. [PMID: 31039791 PMCID: PMC6492400 DOI: 10.1186/s12957-019-1622-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/23/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Portal annular pancreas (PAP) is a rare congenital anatomical abnormality of the pancreas in which the portal vein is encircled by aberrant parenchyma, and special attention is needed for pancreatic resections. This is the first report of central pancreatectomy (CP) in a PAP for metastatic renal cell carcinoma (RCC). CASE PRESENTATION A 76-year-old man who had a history of left nephrectomy for renal cancer not otherwise specified 36 years earlier and radical cystectomy for bladder cancer 4 years earlier was incidentally found to have a pancreatic tumor and a liver tumor. The pancreatic tumor was diagnosed as metastasis of clear cell RCC, and the liver tumor was diagnosed as moderately differentiated hepatocellular carcinoma (HCC) on preoperative histological evaluation. Preoperative computed tomography imaging showed a type 3A PAP, in which the main pancreatic duct (MPD) ran ventral to the portal vein (anteportal type), and the aberrant parenchyma was located cranial to the confluence of the portal vein and splenic vein (suprasplenic type). After adhesiotomy and partial liver resection, CP was performed. With intraoperative ultrasound guidance, the aberrant parenchyma of the PAP could be preserved, avoiding additional resection. Thus, two pancreatic transections were performed, creating a single-cut margin that contained the MPD in the distal pancreas. Oncologically safe margins were confirmed by intraoperative pathological diagnosis. The distal pancreas was reconstructed by pancreatojejunostomy in the routine procedures. The pathological diagnosis of the surgical specimens was identical to the preoperative diagnosis. A postoperative pancreatic fistula (POPF) developed from the proximal stump of the head of the pancreas, necessitating no specific treatment other than drainage. The patient showed no signs or symptoms of recurrent RCC or abnormal pancreatic function for 2 years after the operation, although a histologically proven new HCC lesion developed distant from the initial site 8 months after the operation. CONCLUSIONS Precise preoperative evaluation of the tumor features and PAP allowed adequate surgical strategies to be planned. Intraoperative ultrasound was useful to minimize parenchymal resections of the PAP. CP is still a challenging procedure in terms of the development of POPF.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Minoru Nagayama
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Masafumi Imamura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Shingo Tanaka
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Eiji Yoshida
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Hiroki Fujino
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Takashi Machiki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
| | - Koji Miyanishi
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toru Mizuguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
- Sapporo Medical University School of Health Science, Sapporo, Japan
| | - Junji Kato
- Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, South-1, West-16, Sapporo, Hokkaido 060-8543 Japan
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