Philippe Bachellier

Background Yttrium (Y)⁹⁰ liver radioembolization (TARE) induces both tumor downsizing and contralateral liver hypertrophy. In this study, we report the preliminary results of a sequential strategy combining Y⁹⁰ radioembolization and portal vein embolization (PVE) before major right liver resections. Methods We retrospectively reviewed clinical, radiological, and biological data of 5 consecutive patients undergoing Y⁹⁰ TARE-PVE before major right liver resections. Comparison was made with patients undergoing PVE alone or liver venous deprivation (LVD) during the same period. Results Between January 2019 and September 2022, five patients underwent sequential TARE-PVE. Type of resection included the following: right hepatectomy (n = 1), right hepatectomy + 1 (n = 2), and right hepatectomy + 1 + 4 (n = 2) with no postoperative mortality. Volumetric data showed a mean hypertrophy ratio of 30.4% after TARE and an additional 37.4% after sequential PVE. Patients undergoing sequential TARE-PVE had higher hypertrophy ratio (p = 0.02; p = 0.004), hypertrophy degree (p = 0.02; p < 0.0001), shorter time to normalize bilirubin (p = 0.04), and prothrombin time (p = 0.003; p < 0.0001) compared with patients receiving LVD or PVE. Time from diagnosis to surgery was statistically significant longer in patients undergoing sequential TARE-PVE compared with LVD or PVE (293.4 ± 169.1 vs 54.18 ±18.26 vs 58.62±13.15; p = 0.0008; p = <0.0001). Conclusions This preliminary report suggests that sequential PVE and TARE can represent a safe and an alternative strategy to downstage liver tumors and to enhance liver hypertrophy before major hepatectomies. When compared with PVE and LVD, sequential TARE/PVE takes longer times but achieves some advantages which warrant further evaluation in a larger setting.

Whether the simultaneous resection of pancreatic neuroendocrine tumors (PNET) with synchronous liver metastases (LM) is safe and oncologically efficacious remains to be debated. We retrospectively reviewed clinical data from patients who underwent the simultaneous resection of PNETs with LMs over the last 25 years. Fifty-one consecutive patients with a median age of 54 years (range 27–80 years) underwent pancreaticoduodenectomy (PD) (n = 16), distal pancreatosplenectomy (DSP) (n = 32) or total pancreatectomy (n = 3) with synchronous LM resection. There were no differences in the postoperative outcomes in term of mortality (p = 0.33) and morbidity (p = 0.76) between PD and DSP. The median overall survival (OS) was 64.78 months (95% CI: 49.7–119.8), and the overall survival rates at 1, 3, and 5 years were 97.9%, 86.2% and 61%, respectively. The OS varied according to the tumor grade (G): G1 (OS 128 months, 5-year OS 83%) vs. G2 (OS 60.5 months, 5-year OS 58%) vs. G3 (OS 49.7 months, 5-year OS 0%) (p = 0.03). Multivariate Cox analysis identified G as the only prognostic factor (HR: 5.56; 95% CI: 0.91–9.60; p = 0.01). Simultaneous PNETS with LMs can be performed safely with acceptable morbidity and mortality at tertiary centers. Well-differentiated PNETs had longer survival and might benefit the most from these extended surgeries.

Well-differentiated pancreatic neuroendocrine tumors (pNET) have an unpredictable natural history. The identification of both blood and tumor immune features associated with patients’ outcomes remains limited. Herein, we evaluated the best prognostic value of the neutrophils-to-lymphocyte ratio (NLR) in a cohort of 144 pNETs. The NLR ≥ 4 was associated with worse overall survival in both univariate analysis (HR = 3.53, CI95% = 1.50–8.31, p = 0.004) and multivariate analysis (HR = 2.57, CI95% = 1.061–6.216, p = 0.036). The presence of synchronous liver metastasis was identified as a prognostic factor in multivariate analysis (HR = 3.35, CI95% = 1.411–7.973, p = 0.006). Interestingly, the absolute tumor-associated neutrophils count was higher in liver metastasis as compared to their paired primary tumor (p = 0.048). Deconvolution of immune cells from the transcriptome of 83 primary tumors and 30 liver metastases reveals enrichment for neutrophils in metastasis relative to primary tumors (p = 0.005), and this was associated with upregulation of the complement pathway (NES = 1.84, p < 0.0001). Combining neutrophils signature and complement pathway genes, unsupervised clustering identified two pNETs subgroups, namely Neu-Comp1 and Neu-Comp2. Characterized by neutrophils infiltration and activation of the complement pathway, Neu-Comp1 was highly enriched for metastatic liver samples as compared to Neu-Comp2 (p < 0.0001). These data suggest the possible link between liver metastasis, complement pathway activation, and neutrophils infiltration in well-differentiated pNET and open avenues for targeting complement pathways in these tumors.

Background: Ischemic complications are still prevalent after distal pancreatectomy with en bloc celiac axis resection (DP‐CAR) despite the use of preoperative arterial embolization. We described our institutional experience with arterial reconstruction during DP‐CAR.Methods: We retrospectively reviewed short‐ and long‐term outcomes of all DP‐CAR performed for pancreatic adenocarcinoma between January 1, 1995 and March 30, 2020. Outcomes were compared according to the presence of arterial reconstruction.Results: Sixty consecutive DP‐CARs were reviewed. Most patients underwent induction chemotherapy (85%) based on FOLFIRINOX protocol (80.3%). The hepatic artery was reconstructed in 50 patients (83.3%). The left gastric artery was reconstructed in 4 and preserved in 14 patients. A venous resection was associated during 44 DP‐CARs (36 segmental venous resections/8 lateral venous resections). Ninety days mortality was 5.0% with 48.3% (n = 29) overall rate of morbidity. Postoperative outcomes in term of mortality, morbidity, and ischemic events between patients with and without arterial reconstruction were similar despite a higher rate of venous resection (81% vs. 40%; p = 0.005) and more complex cases (Mayo clinic DP‐CARs class 1B, 2A, and 3A) in the reconstructed group.Conclusion: Arterial reconstruction represents a safe surgical option during DP‐CAR to lessen postoperative ischemic events. This technique, reserved to high volume centers expert in vascular resection during pancreatectomy, deserves further comparison with standard technique in a larger setting.