Background The prognosis and recurrence patterns of early-diagnosed pancreatic ductal adenocarcinoma (PDAC), particularly following surgical resection, remain unclear. Methods This multicenter retrospective study analyzed patients who underwent surgical resection for PDAC between 2005 and 2023. Patients were categorized according to pathological stages 0, I, and II. Recurrence patterns and survival outcomes were compared among the three groups. Multivariate analysis was performed to identify independent risk factors for remnant pancreatic recurrence, including early-stage disease, postoperative follow-up of more than 5 years, and receipt of adjuvant chemotherapy. Results A total of 349 patients were included: 51 with stage 0, 77 with stage I, and 221 with stage II PDAC. The 5-year overall survival rates were 87%, 71%, and 49% for patients with stage 0, I, and II PDAC, respectively. Remnant pancreatic recurrence was observed in 10% of patients with stage 0 PDAC and 18% of patients with stage I PDAC, compared with 5% of those with stage II PDAC. Recurrence was significantly more frequent in stage I (P < 0.001) and tended to be higher in stage 0 (P = 0.062) than in stage II. Multivariate analysis identified pathological stage 0-I and postoperative follow-up of > 5 years as independent risk factors for remnant pancreatic recurrence. Conclusions Patients with early-stage PDAC exhibit a higher risk of remnant pancreatic recurrence than those with stage II disease. These findings underscore the importance of long-term pancreas-focused surveillance in early-stage PDAC to enable timely detection of late recurrence and potentially improve patients outcomes.
BACKGROUND:There is a paucity of data regarding the efficacy and safety of lenvatinib as a second-line treatment following first-line combination immunotherapy with durvalumab and tremelimumab (Dur + Tre). METHODS:This retrospective multicenter study included 14 patients with unresectable hepatocellular carcinoma who received lenvatinib after progression on Dur + Tre therapy, conducted at five institutions, including Hiroshima University. In cases where the multidisciplinary team determined that concurrent transcatheter arterial chemoembolization (TACE) would be beneficial, on-demand TACE was administered concomitantly with lenvatinib. The therapeutic response and safety profile of lenvatinib were evaluated in all enrolled patients, including those who underwent TACE. RESULTS:The objective response rate (ORR), disease control rate (DCR), and median progression-free survival (PFS) for Dur + Tre and subsequent lenvatinib treatment were 14.3%/30.7%, 57.1%/61.5%, and 2.4/2.3 months, respectively. Five patients (35.7%) received combined lenvatinib and TACE therapy. Among these, one patient each with stable disease (SD) and progressive disease (PD) on Dur + Tre improved to partial response (PR) during lenvatinib therapy. Two patients (14.3%) remained on lenvatinib at the time of analysis. Six patients (42.9%) transitioned to subsequent lines of systemic therapy, all receiving atezolizumab combined with bevacizumab. Overall, five patients (35.7%) had died at the data cutoff, with a median overall survival (OS) of 18.4 months. Grade 3 or higher adverse events (AEs) were observed in 7 patients (50%) across both Dur + Tre and lenvatinib treatment phases. CONCLUSIONS:Lenvatinib administered after progression on Dur + Tre demonstrates promising efficacy and an acceptable safety profile in patients who tolerate the therapy. The integration of TACE in suitable candidates warrants further exploration, and timely transition to subsequent systemic therapies should be considered when adverse events or intolerance are encountered.
Unexpected azygos vein injury during thoracoscopic lung resection is rare. Here, we describe a case of azygos vein arch injury caused by an ultrasonic scalpel. The patient underwent segmentectomy for right upper lobe lung cancer. The ultrasonic scalpel was activated while its blade tip was inadvertently grasping the vascular wall of the azygos vein arch during management of bleeding from the pulmonary artery stump, resulting in injury to the azygos vein arch. Because the injury site was temporarily sealed, it was not initially detected. When the right upper lobe was retracted ventrally to dissect the upper lobe bronchus, tension was applied to the injured site of the azygos vein arch, leading to massive haemorrhage. Conversion to thoracotomy was required, and haemostasis was achieved using a fibrin sealant patch. The azygos vein is a low-pressure system; most injuries can be managed with a fibrin sealant patch.
The fillet toe flap embodies the "spare parts" concept, utilizing tissue from a nonsalvageable toe for local reconstruction; however, its use in ischemic limbs has traditionally been limited by compromised digital arterial inflow. Increasing evidence from studies on angiosomes and perforasomes suggests that collateral and subdermal vascular networks can sustain tissue perfusion under ischemic conditions. Based on these findings, we developed a modified fillet toe flap incorporating a limited plantar releasing incision to enhance flap mobility while preserving the dorsal subdermal vascular plexus, allowing the flap to be conceptualized as a random-pattern pedicled flap. Five patients underwent reconstruction following toe amputation using this technique. One patient had a diabetic neuropathic ulcer, and four had chronic limb-threatening ischemia treated with revascularization. The flap was applied only after improvement in local perfusion was confirmed. The plantar releasing incision enabled three-dimensional unfolding of the flap and facilitated coverage of defects that would be difficult to reconstruct with conventional fillet flaps. No total flap necrosis occurred. Minor complications included partial wound dehiscence and mild distal perfusion disturbance, and no patient required reamputation. During a mean follow-up of 23 months in surviving patients, stable wound coverage was maintained. This modified fillet toe flap extends the conventional axial concept by reinterpreting the fillet flap as a random-pattern technique. When applied in appropriately selected patients after revascularization, it may represent a practical reconstructive option for ischemic or neuropathic forefoot defects while adhering to the spare parts concept.
INTRODUCTION:A cancer of unknown primary site is a malignant tumor for which the primary site is unknown despite a thorough examination, and which has been histologically proven to be a metastatic lesion. Metastases to intraperitoneal and to gastric regional lymph nodes are rare. CASE PRESENTATION:A 75-year-old woman was diagnosed with a gastric submucosal tumor with infiltration to other organs. Endoscopic ultrasound-guided fine needle aspiration revealed cells that appeared to be derived from epithelial tissue, but a definitive diagnosis could not be obtained. Because the possibility of gastric cancer could not be ruled out, an open proximal gastrectomy with systematic lymph node dissection and combined resection of other organs were performed. A grade II pancreatic fistula developed, but resolved with conservative treatment, and the patient was discharged 15 days after surgery. Histopathologically, the tumor was a lymph node metastasis consisting of squamous cell carcinoma cells that had grown primarily outside the gastric wall, but involved the gastric wall and pancreas and protruded into the gastric mucosa. Thirty-five gastric lymph nodes were dissected, and metastases were found in five of them. Primary squamous cell carcinoma of the stomach and pancreas was ruled out. Because no head and neck, esophageal, or pulmonary lesions that could be squamous cell carcinoma were identified, the primary tumor could not be identified. The diagnosis was a gastric regional lymph node metastasis of a cancer of unknown primary site protruding into the gastric wall. Nivolumab was initiated after surgery, and the patient has remained alive and free of recurrence 7 months after surgery. CONCLUSIONS:In cases of metastases originating from a cancer of unknown primary site to lymph nodes in the gastric region, the removal of the affected lymph nodes followed by inability to detect the primary lesion might be considered to be equivalent to an R0 resection.
