Background: The objective of this study was to investigate the optimal neoadjuvant therapy (NAT) for borderline resectable pancreatic cancer invading the portal vein (BR-PV) or abutting major arteries (BR-A). Methods: We retrospectively analyzed 88 patients with BR-PV and 111 patients with BR-A. Results: In BR-PV patients who underwent upfront surgery (n = 46)/NAT (n = 42), survival was significantly better in the NAT group (3-year overall survival (OS): 5.8%/35.5%, p = 0.004). In BR-A patients who underwent upfront surgery (n = 48)/NAT (n = 63), survival was also significantly better in the NAT group (3-year OS:15.5%/41.7%, p < 0.001). The prognosis tended to be better in patients who received newer chemotherapeutic regimens, such as FOLFIRINOX and gemcitabine with nab-paclitaxel. In 36 BR-PV patients who underwent surgery after NAT, univariate analysis revealed that normalization of tumor marker (TM) levels (p = 0.028) and preoperative high prognostic nutritional index (PNI) (p = 0.022) were significantly associated with a favorable prognosis. In 39 BR-A patients who underwent surgery after NAT, multivariate analysis revealed that preoperative PNI > 42.5 was an independent prognostic factor (HR: 0.15, p = 0.014). Conclusions: NAT using newer chemotherapy is essential for improving the prognosis of BR pancreatic cancer. These findings suggest that prognosis may be prolonged by maintaining good nutritional status during preoperative treatment.

Background: The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF. Case presentation: A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up. Conclusions: The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.

Background/Objectives: Appropriate biomarkers are necessary for early diagnosis and multidisciplinary treatment of pancreatic ductal adenocarcinoma (PDAC). In recent years, the clinical utility of circulating tumor cells (CTC) as biomarkers for various can-cers has been reported; however, their detection rate in PDAC remains low, and clinical evidence is not yet established. CTC detection methods with high reliability and per-formance are essential for clarifying the importance of CTC in patients with PDAC. Methods: A total of 5 mL peripheral blood samples were collected from 38 patients newly diagnosed with PDAC and 17 healthy controls. Negatively enriched cells were immunofluorescently stained with EpCAM-phycoerythrin and cell surface vi-mentin-fluorescein isothiocyanate (CSV). Images were automatically captured using an all-in-one fluorescence microscope. Cellular regions were detected from these images, and the average luminance of the cellular regions was calculated. A total of 9086 and 1071 cell images were obtained from patients with PDAC and healthy controls, respec-tively. Results: In the EpCAM assay, a threshold that included 95% of healthy individuals was optimal for distinguishing patients with PDAC from healthy controls, with a sensi-tivity, specificity, and area under the curve of 0.74, 0.76, and 0.84, respectively. At this threshold, the CTC-positivity rate in patients with PDAC was 76.3%. Conversely, the CSV assay failed to demonstrate a valid threshold to distinguish patients with PDAC from healthy controls. No significant differences were found between CTC and clini-copathological features among patients with PDAC. Conclusions: The method using high-resolution image scanning has the potential to identify CTC with greater objectiv-ity by quantifying cell luminance values.

Background/Objectives: Appropriate biomarkers are necessary for early diagnosis and multidisciplinary treatment of pancreatic ductal adenocarcinoma (PDAC). In recent years, the effectiveness of circulating tumor cells (CTCs) as biomarkers for various cancers has been reported; however, their detection rate in PDAC remains low, and sufficient evidence are not yet established. CTC detection methods with high reliability and performance are essential for clarifying the importance of CTCs in patients with PDAC. Methods: A total of 5 mL peripheral blood samples were collected from 38 patients newly diagnosed with PDAC and 17 healthy controls. Negative enriched cells were immunoflu-orescently stained with EpCAM-phycoerythrin and cell surface vimentin-fluorescein isothiocyanate(CSV). Images were automatically captured using an all-in-one fluorescence microscope. Cellular regions were detected from the captured images and the average lu-minance of the cellular regions was calculated. A total of 9086 and 1071 cell images were obtained from patients with PDAC and healthy controls, respectively. Results: In the Ep-CAM assay, a threshold that included 95% of healthy individuals was optimal for distin-guishing patients with PDAC from healthy controls, with a sensitivity, specificity, and AUC of 0.74, 0.76, and 0.84, respectively. At this threshold, the CTC-positivity rate in pa-tients with PDAC was 76.3%. Conversely, the CSV assay failed to demonstrate a valid threshold to distinguish patients with PDAC from healthy controls. No significant differ-ences were found between CTC and clinicopathological features among patients with PDAC. Conclusions: This method using high resolution image scanning has the potential to identify CTCs with greater objectivity by quantifying cell luminance values.

Objectives: Whether lymph node dissection is necessary for pancreatic neuroendocrine neoplasms (pan-NEN) smaller than 20 mm in diameter remains controversial. We aimed to investigate the usefulness of apparent diffusion coefficient (ADC) values on diffusion-weighted magnetic resonance imaging (DW-MRI) in predicting lymph node metastasis (LNM) in pan-NENs. Methods: Data concerning 44 patients with pan-NENs who had undergone radical pancreatectomy in our department between January 2008 and December 2023 were retrospectively reviewed. ADC values of the tumor area on DW-MRI were measured and analyzed in relation to clinicopathologic factors. Results: Thirty-three patients had pan-NENs smaller than 20 mm in diameter. Six patients with LNM showed significantly lower ADC values than those without ( P = 0.0105). Of the patients with pan-NENs smaller than 20 mm in diameter, 4 patients with LNM had significantly lower ADC values ( P = 0.0010). Regarding vascular invasion, the patient group positive for lymphatic, venous, and neural invasion had significantly lower ADC values than those in the negative group ( P = 0.018, 0.036, and 0.033, respectively). Conclusion: In cases of pan-NENs smaller than 20 mm in diameter, low ADC values may predict LNM and vascular invasion.