Case Discussion-1 “A case of hepatoportal bile duct cancer” The patient was a 54-year-old male, complaining of yellow staining of skin and sclera for 3 weeks. After admission, PTCD was performed to reduce yellowing, and total bilirubin decreased slowly from 362umol/L to 234umol/L. Enhanced CT of the upper abdomen was investigated: after intrahepatic bile duct placement and drainage in the right lobe of the liver; common bile duct nodule, considering possible common hepatic duct cancer; chronic cholecystitis. MRCP: occupancy at the beginning of the common hepatic duct with marked dilatation of intrahepatic bile duct, considering possible malignancy; chronic cholecystitis. 3D dynamic imaging of the liver was also performed, suggesting hepatoportal bile duct cancer. The timing of surgery and surgical approach were brought up for discussion. Director: 3D dynamic reconstruction technology can clearly show the location of the lesion and its relationship with blood vessels and bile ducts, and can assess the volume of each liver lobe. This patient should be able to withstand surgery if the residual liver volume is about 45% with right hemicolectomy. Director: With the help of new imaging technology, the tumor staging can be clarified. This patient involves the left hepatic duct and should be hepatobiliary carcinoma type IIIb. Can the interventional department adjust the position of the PTCD tube so that both the right and left hepatic ducts can be adequately drained? Physician: Considering that the left and right hepatic ducts are still in communication with each other, the PTCD tube was placed in the right hepatic duct, but now the jaundice index has dropped to 234umol/L and entered the plateau phase, suggesting that the drainage effect of the left hepatic duct is not good. The left hepatic duct was drained to reduce yellowing. The patient was admitted to the hospital with “intermittent fever for six months and a duodenal papilla occupancy for 3 days”, CT scan + enhancement of the pancreas: possible duodenal papilla tumor; multiple cysts in the liver; chronic cholecystitis; multiple calcified foci in the spleen; left renal cyst. enlargement, dilated superior common bile duct, mildly dilated intrahepatic bile duct, dilated main pancreatic duct, multiple cysts in the liver. Gastroscopy: interrupted esophageal diverticulum, chronic superficial gastritis, slightly enlarged duodenal papilla, biopsy suggests: duodenal papillary adenoma. ca19-9: 129.70 u/ml, remaining tumor markers normal. Director: Duodenal papilla has various manifestations. Although the biopsy suggests adenoma, this patient has incomplete biliary obstruction with biliary infection, MRCP suggests biliopancreatic duct dilatation, suggesting a high possibility of malignancy, and if local excision is performed, it will easily lead to tumor residual and recurrence, so pancreaticoduodenectomy should be chosen. Professor: We agree with Director Shao’s point of view. When we performed duodenoscopy for this patient, we considered malignancy not excluded, so we only took biopsy and did not do endoscopic resection. The patient was admitted to the hospital for “six months after the discovery of pancreatic body-caudal occupancy” and was considered to have pancreatic body cancer with invasion of splenic artery and enlarged peri-pancreatic tail lymph nodes and retroperitoneal lymph nodes. Left adrenal nodule, metastasis possible. Localized fatty infiltration in the right anterior lobe of the liver. Hepatic cysts. Multiple cysts in both kidneys.PET-CT (2016-01-08): pancreatic body occupancy with increased FDG metabolism, malignant lesion first consideration; left adrenal nodule with cystic lesion, no abnormal FDG metabolism, benign first consideration.CA19-9: 1775u/ml, brought to MDT for discussion: 1. nature of tumor 2. patient is post hypertensive stroke, taking aspirin anticoagulation before admission. How is the perioperative period managed? Director: The patient’s diagnosis was considered pancreatic body malignancy, with clear surgical indications and a deadline for radical resection of pancreatic tail cancer. The left adrenal gland is involved and may need to be removed at the same time during surgery. How should the perioperative anticoagulant medication be adjusted in stroke patients? Professor: 1 year after stroke into the stable stage, that is, not belong to the high-risk group, regular aspirin can be taken, one week before surgery to stop, transition to low-molecular heparin subcutaneous injection, 2 days after surgery to resume oral aspirin. The patient was admitted to the hospital with “epigastric discomfort for 1 week”. Gastroscopy: superficial gastritis. Abdominal MRI: 1, retroperitoneal paravalvular occupancy, abnormal signal in the left lobe of the liver, 2, multiple cysts in the right lobe of the liver. Enhanced CT of abdomen: 1, occupying lesion over the neck of the pancreas (in front of the great vessels) in the hilar region; carcinoid tumor of pancreatic neck origin? neurogenic tumor or mesenchymal tumor?2. Cysts in the left lobe of the liver and right kidney.3. Cholecystitis and gallbladder stones. Routine blood, liver function, renal function, biochemistry, and coagulation indexes were normal. None of the tumor markers were high. MDT was brought in to discuss: 1. source and nature of tumor 2. surgical approach. Director: The mass has high density, fine sand-like calcification or intra-tumoral hemorrhage may be present, peripheral enhancement in the arterial phase, the source is unclear, it may be hepatic caudate lobe hemangioma, the inferior vena cava is pushed out from the enhanced CT, it may also be a tumor of retroperitoneal origin. Director: The origin of this patient’s tumor is unknown and can be clarified intraoperatively. If the tumor is a caudate lobe hemangioma, left hemicolectomy is required, and the scope of surgery is large; it may also be a retroperitoneal nerve sheath tumor. Case discussion-5 A case of SPT of the tail of the pancreas The patient was a 29-year-old female who was admitted to the hospital for “one week of occupancy of the tail of the pancreas found by ultrasound”, with abdominal signs (-) and normal tumor index. CT scan+enhancement of the pancreas: a type of rounded, slightly hypointense shadow with clear borders was seen in the tail of the pancreas, with a long diameter of about 4.6 cm, and uneven mild to moderate enhancement after enhancement scan. The possibility of solid pseudopapillary tumor was considered. MDT was brought in to discuss: 1. diagnosis 2. surgical approach. Director: Delayed enhancement at the edges of the mass, uneven density within, clear surrounding fatty gap, consider SPT as a high possibility, 30-40% of such patients have combined intra-tumor hemorrhage, which is more obvious on MRI. Physician: SPT is mostly seen in young women, and the tail of the pancreatic body is more common, and it appears as a cystic mass with uneven enhancement on CT. If it is difficult to separate the spleen from the blood vessels, the spleen can be preserved by the Warshaw method or the pancreatic body and tail splenectomy can be performed instead. Director: SPT is the abbreviation of “pancreatic solid pseudopapillary tumor”, which is named after the pseudopapillary-like proliferation of tumor cells arranged along the blood vessels under the microscope. This patient does not have any. The surgical approach agreed with Dr. Chen Danlei, and laparoscopy was used. The patient was 41 years old, admitted to the hospital with “pain in the upper abdomen for 1 month” and abdominal signs (-). PET-CT: 1, pancreatic cancer with retroperitoneal involvement; 2, no abnormal foci of increased FDG metabolism on brain PET imaging; 3, right maxillary sinusitis; 4, small cysts in the liver; 5, right renal cysts and small cysts of left renal complexity; 6, spinal degeneration, lumbar 5/sacral 1 disc herniation. CEA13.47ug/L,CA12541.69U/ml,Hepatitis B major triple positive. The MDT was brought in for discussion regarding the diagnosis and surgical approach. Director: From the CT film, the tumor has invaded the abdominal trunk, SMV, and partially encircled the SMA, is it resectable? Director: This patient is a pancreatic body cancer, the tumor has invaded the abdominal trunk, but the root remains, Appleby surgery is feasible, through the SMA, GDA and PHA countercurrent evidence to the hepatic artery blood flow, the SMV and PV union is invaded by the tumor, wedge resection reconstruction can be done intraoperatively, although the SMA is encircled by the tumor, but there is still a gap on the left side, it can be peeled out, so the patient is Therefore, the patient is a “borderline resectable pancreatic cancer”, and whether it can be successfully resected depends on the extent of tumor invasion of blood vessels and the experience of the surgical team. The patient was 56 years old, admitted to the hospital with “skin sclera yellowing for 1 month”. One week after ENBD reduction of yellowing, TBIL decreased from 218 to 166u/ml. Director: reading the film, we can find obvious varices in the hepatic portal vein, the PV trunk does not show well, the pancreatic head is full, the biliopancreatic duct is dilated, the distal pancreas is atrophied, the possibility of occupancy is high, and mass-type pancreatitis is not excluded. Director: This patient has a high possibility of pancreatic head tumor with peri-pancreatic head exudation and inflammation, slow decline of jaundice, heavy liver damage, extensive vascular invasion, and difficulty in reconstruction, so we can consider temporary retention of biliary stent to reduce yellowing, regular review and observation of changes in condition. Professor: For such patients, it is usually considered that those who have indications for surgery do not have ERCP to place stents to reduce yellowness, so as not to make surgery more difficult due to tissue edema; while those who do not have indications for surgery can have biliary stents placed to improve the quality of life. The patient underwent pancreaticoduodenectomy for pancreatic head cancer in Changzheng Department of General Surgery and was successfully discharged after surgery. The following MDT discussion points were raised: 1. Is preoperative PET/CT staging necessary? 2. The value of preoperative MRI examination? 3. Is preoperative biopsy necessary? 4. Criteria for determining resectable tumor. 5. Is neoadjuvant and adjuvant chemotherapy necessary for this patient? 6. How to follow up? Director: PET-CT cannot replace conventional enhanced CT, but can be used as a supplement to facilitate preoperative staging. MRI and CT have their own strengths. Director: PET-CT is recommended for patients with pancreatic cancer considered by CT to clarify the presence of distant metastases. Neoadjuvant chemotherapy is not recommended for patients with clearly resectable pancreatic cancer because it is mainly for borderline resectable pancreatic cancer. Current studies suggest that pancreatic cancer should receive adjuvant chemotherapy after surgery, which may prolong survival.