Viktor V. Tsvirkun – Editor of the Issue.

From Editor of the Issue. Introduction. What is a modern cancer council and what is it for?

Modern histological and molecular classification of endocrine and exocrine pancreatic tumorsis reviewed. Step-bystep algorithm of pancreatic complex dissection and detailed histological protocols are described.

The purpose of this publication is to comprehend the modern achievements of radiological diagnosis in surgical oncopancreatology via a critical analysis of recent English-language publications. CT and MRI are essential diagnostic methods in surgical and oncological pancreatology. The possibilities of tomography examination regarding analysis of tumor dimension, CT criteria for pancreatic cancer diagnosis, assessment of vascular invasion, differential diagnosis of tumors, as well as estimation of possible early postoperative complications and radiological features of the region of interest after neoadjuvant and adjuvant therapy for pancreatic tumors are critically analyzed. The role of modern diagnostic methods in improvement of treatment directly related to the early staging of pancreatic tumors is negligible, since the factors affecting the phases of slow and rapid tumor growth are unclear. Most likely, cyclic clinical and radiological evaluation of the pancreas will not give the expected results and is associated with advanced financial and physical costs. Perhaps, one of the approaches for effective treatment of pancreatic cancer will be the recognition of the need for laboratory and instrumental examinations by each patient. Acceptable frequency of examinations and own funds are determined by a patients himself in this case.

Ductal adenocarcinoma accounts for 90% of all pancreatic malignancies and is the fourth leading malignant cause of mortality in the Western world and the fifth in Russia. Comprehensive preoperative examination is aimed not only at making an accurate diagnosis, but also at determining treatment strategy. The diagnostic algorithm involves endoscopic ultrasound. The modern possibilities of endosonography combined with tissue contrast enhancement and fine-needle aspiration, as well as some aspects of palliative endoscopic treatment are analyzed in the article.

Development of surgical approach for pancreatic head and periampullary cancer at the Blokhin National Medical Research Center of Oncology over the past 30 years and global surgical tendencies of surgery for pancreatic cancer are demonstrated in the article. Over this period, gastropancreaticoduodenectomy has evolved from standard procedure without complete lymph node dissection and neurodissection and extended gastropancreaticoduodenectomy with obligatory circular skeletonization of superior mesenteric artery and para-aortic lymphadenectomy to standard gastropancreaticoduodenectomy. The last procedure implies mandatory skeletonization of the right semicircle of superior mesenteric artery, all tubular structures of hepatoduodenal ligament and possible resection of portal and superior mesenteric vein for suspected invasion. Surgical possibilities in the treatment of patients with pancreatic head and periampullary cancer are exhausted. The concept of “early diagnosis” is not applicable for patients with ductal pancreatic cancer. Further progress is exclusively associated with medicamentous combined treatment based on the molecular-biological characteristics of pancreatic and periampular cancer and, possibly, with primary prevention of pancreatic cancer.

Objective. To assess the role of minimally invasive surgery for periampullary cancer.

Material and methods. A systematic literature review of original articles devoted to comparison of open, laparoscopic and robot-assisted pancreatoduodenectomy was performed. Also, our own experience of minimally invasive pancreatoduodenectomy is shown.

Results. Articles included in the analysis showed comparable results of minimally invasive and open pancreatoduodenectomy regarding morbidity, mortality and oncological outcomes. Laparoscopic and robot-assisted pancreatoduodenectomy are associated with significantly less intraoperative blood loss and length of postoperative hospital-stay. However, these procedures require more time.

Conclusion. Minimally invasive surgery does not worsen perioperative outcomes and may be considered as an alternative to open procedures in selective patients. Minimally invasive techniques should be implemented in highvolume pancreatic centers only with specialists experienced in minimally invasive surgery.

The results of treatment of localized (early) pancreatic cancer are unsatisfactory despite all achievements of modern clinical and surgical oncology. Nevertheless, certain success was achieved even in these extremely unfavorable patients regarding their prognosis. The authors analyzed evolution of adjuvant therapy, as well as new concepts in the treatment of borderline resectable and resectable pancreatic cancer. Modern anticancer therapy with acceptable toxicity profile significantly improved the outcomes. However, further research is needed to improve the effectiveness of treatment despite favorable current results.

Objective. To study effectiveness of intra-arterial chemotherapy in patients with locally advanced and metastatic pancreatic cancer.

Material and methods. There were 329 patients who underwent regional chemotherapy in 2000 – 2015 (infusion through celiac trunk – 167, chemoembolization of gastroduodenal artery – 52, combination of these methods – 72, combined chemo-radiotherapy – 38). Locally advanced unresectable pancreatic cancer with arterial invasion (T4 grade) was observed in 198 (60.2%) patients, liver metastases (stage IV) – in 131 (39.8%) patients. Chemoembolization or chemoradiation therapy was performed for patients without distant metastases.

Results. The best results for unresectable pancreatic cancer were obtained in 160 patients after chemoembolization combined with infusion. Partial response was obtained in 24.1% of cases compared with 8.9% and 13.4% of cases after infusion or chemoembolization alone. Mean life expectancy was 15.5 months compared with 14.6 and 10.6 months, respectively. Median of life expectancy was 15.6 months compared with 11.7 and 10.8 months, respectively. At the same time, progression of disease was observed in the majority of 131 patients with metastatic cancer. Partial response was noted only in 2.3% of patients only after chemoinfusion. Survival and median survival after chemoinfusion and combination of chemoembolization with chemoinfusion were similar (10.1 (8.3) and 10.9 (7.5) months). Chemoradiotherapy in 4 patients with initially unresectable pancreatic cancer resulted reduction of tumor dimension by 28% (24–32%). Therefore, radical operations were performed later. One-year survival was achieved in 20 (58.8%) out of 34 patients with unresectable pancreatic cancer. Mean life expectancy was 15.4 months (median 13.8 months).

Conclusion. Intra-arterial chemotherapy is effective treatment in patients with pancreatic cancer stage III and IV. Combination of celiac axis infusion with arterial embolization, as well as infusion with radiotherapy resulted the best survival. Certain advantage of chemoinfusion was found for liver metastases. The use of new chemotherapy modes for intra-arterial infusion requires further study.

Minimally invasive ablative technologies is a promising direction in the treatment of some cancer patients including pancreatic cancer. Cryodestruction, radiofrequency ablation, irreversible electroporation and ultrasound ablation show encouraging results regarding destruction of tumor tissue, cytoreduction. These methods are associated with small number of complications and relatively easy to tolerate by patients. However, there is no single approach to their use in the complex treatment of these patients. Accumulation of data followed by comparative analysis of various ablation techniques is being carried out in many specialized clinics of the world including national hospitals. Ablation mechanisms of technologies, literature data and the authors' own experience in the treatment of pancreatic cancer are reported in the article. Further randomized prospective trials are required to determine the role of ablation methods in the complex treatment of tumors of parenchymal organs including pancreatic cancer.

Preoperative diagnosis of comorbidities is essential for identifying the limiting factors inperioperative period and correct assessment of patient’s ability to undergo surgery. Severe concomitant diseases followed by advanced risk of adverse events require development and implementation of the strategy of preoperative preparation of patient. These measuress hould include both medicamentous and surgical correction of concomitant diseases in order to reduce perioperative risks. Thus, multidisciplinary perioperative approach makes it possible to reduce significantly the risks and mortality in patients undergoing surgery for pancreatic cancer. Diagnosis and correction of limiting factors approach operability to absolute one. However, operation should be avoided or alternative approaches should be preferred if co-morbidities are significant and failed to be corrected.

Modern treatment strategy for pancreatic cancer.

Organizational aspects of specialized including high-tech oncological medical care in a multi-field hospital are shown. A 10-year experience of the Pirogov National Medical and Surgical Center regarding optimization of the treatment of cancer patients is reported. Effectiveness of oncological care organization in a multi-field hospital is preliminary concluded. It is emphasized that multidisciplinary approach is essential for selecting a personalized program of cancer treatment in these patients. The need for further searching for ways to improve the diagnosis and treatment of cancer patients by accumulating and analyzing large clinical material is marked.

Aim. To improve the results of diagnosis and surgical treatment of liver alveococcosis.

Material and methods. There were 415 patients with liver alveococcosis for the period 2009–2018. Liver resection was performed in 364 patients. Metastases in the brain were detected in 7 patients, lungs – in 3 cases, soft tissues involvement – in another 3 ones. Hepatic-bronchial fistula occurred in 2 cases. Mean age of patients was 41 ± 2.3 years. There were 128 (30.8%) men and 287 (69.2%) women.

Results. Advanced liver resection was performed in 187 patients, atypical resection – in 177 cases. R0-resection was carried out in 62.4% of cases, R1–2 procedures – in 37.6%, diagnostic laparotomy – in 4.4%. Four patients died in early postoperative period.

Conclusion. The final decision about resectability may be made after intraoperative assessment, intraoperative ultrasound, Doppler sonography and liver mobilization. Liver resection for advanced alveococcosis is extensive, needs for resection and replacement of great vessels, as well as bile ducts repair. Radical treatment is R0-resection if distant metastases are absent. Redo surgery is advisable for liver alveococcosis.

Spontaneous liver rupture is rare and highly dangerous, life-threatening condition occurring in 1–2% of pregnant women with preeclampsia and eclampsia. There are more than 100 similar case reports in the literature. It is believed that liver rupture is caused by HELLP syndrome as one of the signs of preeclampsia. The results of surgical treatment is still unsatisfactory. Appropriate treatment strategy is absent because of rareness of this condition. It is presented case report of a woman with spontaneous liver rupture associated with HELLP syndrome. Patient underwent perihepatic tamponade, endovascular embolization of right hepatic artery followed by right-sided hemihepatectomy.

Abstracts of Current Foreign Publications.

Valeri A. Kubishkin To 75th anniversary.

Vladimir I. Lupaltsov To 80th anniversary.