review of literature on clinical pancreatology - The Pancreapedia

Duodenal tumorsColorectal polyposis is the main feature <strong>of</strong> familial adenomatous polyposis (FAP), but benignand malignant lesions have also been described in the stomach, duodenum, small bowel,biliary tract and pancreas. There are few reports on FAP patients with duodenal polyps thatdeveloped at a younger age and even fewer on cases with dysplastic degeneration. Theprogression to carcinoma usually presents quite late in the clinical history <strong>of</strong> FAP patients,typically at least 20 to 25 years after proctocolectomy. One report described the rare case <strong>of</strong>a patient presenting with duodenal adenomas with dysplastic changes and tumor infiltrationas the first sign <strong>of</strong> FAP, who was treated by pancreaticoduodenectomy followed byproctocolectomy for subsequent dysplastic changes in colonic polyps [624].Local excisionLocal surgical treatment <strong>of</strong> periampullary neoplasms seems attractive in the context <strong>of</strong> thereduced morbidity and mortality than the more radical treatment options. The aim <strong>of</strong> ourstudy was to compare local excision <strong>of</strong> the ampulla with standard pancreaticoduodenectomyfor the treatment <strong>of</strong> periampullary cancer in terms <strong>of</strong> overall survival. Inclusion criteria wereprimary tumor < 2 cm with no evidence <strong>of</strong> lymph node involvement or distant metastasis onabdominal computed tomography. Between 2000 and 2004, 23 patients were enrolled ontothis study (9 in the local excision group and 14 in the standard pancreatic resection group).The two groups were homogeneous with respect to age and gender as well as the size andorigin <strong>of</strong> the primary neoplasm. There was no correlation <strong>of</strong> the survival with age, gender,presence <strong>of</strong> lymph node metastasis, size <strong>of</strong> the primary tumor, type <strong>of</strong> surgery or histologicgrade. However, the origin <strong>of</strong> the tumor had major impact on survival, with pancreatic tumorshaving the worst prognosis. Hospital stay was significantly reduced in the local excisiontreated patients. The results showed that local excision for periampullary tumors is a viableoption and is well suited for medically unfit patients or those who refuse more radicaltreatment options [625].Metastases to pancreasMetastasectomy with curative intent has become standard practice for the management <strong>of</strong>some malignancies. Resection <strong>of</strong> isolated metastatic colorectal cancer, gastrointestinalstromal tumours, neuroendocrine cancers, renal-cell cancer and sarcoma is associated withlonger survival or even cure. The strongest evidence in favour <strong>of</strong> metastasectomy exists forcolorectal cancer, in which resection <strong>of</strong> limited metastatic disease in some patients isassociated with 5-year survival rates <strong>of</strong> more than 50 percent. High incidence <strong>of</strong> the disease,predictable tumour biology, and development <strong>of</strong> successful chemotherapies has encouragedmetastasectomy. Furthermore, improved safety <strong>of</strong> complex surgeries over the past severaldecades has lowered the threshold for more aggressive surgical intervention. Most <strong>literature</strong>on metastasectomy pertains to the resection <strong>of</strong> disease involving the liver, lung, and brain.However, metastasectomy has been described for almost every organ system, including thepancreas. Pancreatic metastasectomy is most <strong>of</strong>ten done through a formal pancreaticresection such as pancreaticoduodenectomy or distal pancreatectomy. Less <strong>of</strong>ten,pancreatic metastasectomy is done by enucleation or a pancreas sparing operation such asa central pancreatectomy [626].Renal cell carcinomaPancreatic metastasis accounts for 2 percent <strong>of</strong> metastatic renal cell carcinoma cases.Surgical management is typically recommended because <strong>of</strong> the limited value <strong>of</strong>immunotherapy as an effective treatment. Sunitinib recently showed clinical efficacy in