Shinshu Med J, 63⑴ :19 〜24, 2015

An Initial Case Report of a Laparoscopic Spleen‑Preserving Distal
Pancreatectomy for a Patent with a PancreaticMetastasis of Malignant MelanomaHiroaki M OTOYAMA , Akira KOBAYASHI ＊, Takahide YOKOYAMA , Akira SHIMIZU
Norihiko FURUSAWA , Hiroshi SAKAI , Noriyuki KITAGAWA , Atsuko ASHIDARyuhei OKUYAMA and Shinichi MIYAGAWA
1) First Department of Surgery, Shinshu University School of Medicine
2) Department of Dermatology, Shinshu University School of Medicine

M etastatic malignant melanoma to the pancreas accounts for 5% of all patients undergoing a pancreatic
metastasectomy.Here,we report a 76‑year‑old man with simultaneous metastases of malignant melanoma tothe left elbow and pancreatic tail 4 years after resection of the primary tumor,which was located on the left
fourth ﬁnger.Following resection of a subcutaneous mass in the left elbow,he underwent a laparoscopic spleen‑preserving distal pancreatectomy with lymph node dissection along the splenic artery. His post‑operative
course was uneventful,and he was discharged from the hospital on the 13th postoperative day.He has survived
for 7 months without exhibiting any signs of recurrence. Shinshu Med J 63 : 19 ―24, 2015
(Received for publication August 19, 2014;accepted in revised form November 18, 2014)
Key words:malignant melanoma, pancreatic metastasis, laparoscopic surgery

Introduction

worldwide acceptancebecause of its advantages,

such as reduced postoperative pain,faster recovery,

Pancreatic metastasis from a non‑pancreaticand fewer wound‑related and general morbidities

primary tumor is rare,accounting for approximate-. Recently, several authors have described thely 2% of all pancreatic tumors , and metastaticuse of a technicallychallenging laparoscopic spleen‑malignant melanoma accounts for 5% ofallpatients

preserving distal pancreatectomy (Lap SPDP) toundergoing a pancreatic metastasectomy .Although

reduce the risks associated with a splenectomy .

metastatic melanoma has been considered to be aHere, we present a patient with simultaneous

systemic disease with a poor prognosis, long‑term

pancreatic and left elbow metastases from a malig-

survival after a metastasectomy has been reported

nant melanoma that were treated with resection offor patients with not only isolated metastasis, but

a subcutaneous mass in the left elbow followed byalso multiple organ involvement including abdomi-

Lap SPDP.A review of the literature is also includ-nal organs ,provided that a curative resection wased.

secured.
With rapid developments in surgical technology,
laparoscopic distal pancreatectomy has gained

Case Report
A 76‑year‑old man underwent an amputation of
the left fourth ﬁnger and left axillary lymph node

Corresponding author:Akira Kobayashi
First Department of Surgery, Shinshu University Schoolof M edicine, 3‑1‑1 Asahi, Matsumoto, Nagano 390‑8621,

dissection for the treatment of malignant melanoma
in July 2009. The pathological stage wasJapan

pT3aN3M0, stage IIIC according to the American

E‑mail:kbys＠shinshu‑u.ac.jp

Joint Committee on Cancer (AJCC)classiﬁcation .

No. 1, 201519

Motoyama.Kobayashi.Yokoyama et al.

Fig. 1 ［ F］FDG PET/CT ﬁlms. (a) Tracer uptake was conﬁrmed in the left upper
quadrant of the abdomen (arrow)and left elbow(arrowhead).(b)The uptake in theabdomen corresponded to the pancreatic tail (arrow). (c) Contrast‑enhanced CTshowed a well‑circumscribed mass in the pancreatic tail with an enhanced outerrim on the arterial phase (arrow).(d)No signs of extrapancreatic tumor invasion
including splenic artery (SpA)and vein (SpV)were seen (arrow).

The patient received a local injection of interferon

an enhanced outer rim observed during the arterial

β after the operation. In M arch of the following

phase and no dilation of the main pancreatic duct,

year, a left brachial lymph node metastasis wassuggesting that a pancreatic adenocarcinoma wasdetected and resected. Three years later,［ F］2‑unlikely. No signs of adjacent organ invasion wereﬂuoro‑2‑deoxy‑D‑glucose‑positron emission tomo-visible (Fig. 1d).

graphy/computed tomography ［( F］
FDG‑PET/

Based on a diagnosis of pancreatic metastasis ofCT)ﬁlms showed abnormal uptakes in lesions locat-

the malignant melanoma, the patient underwent a

ed in the pancreatic tail and left elbow (Fig. 1a, b).

Lap SPDP with lymph node dissection. During theIn March 2013,the patient underwent resection of asubsequent laparoscopic observation,a mass with asubcutaneous mass in his left elbow, which wasmaximum diameter of approximately 20 mm was

histopathologically diagnosed as a malignant

conﬁrmed in the pancreatic tail using intraoperativemelanoma. Thereafter, he was referred to ourultrasonography. First, the splenic artery and vein

department for further investigation of the pancre-

were dissected gently from the pancreas;a window

atic tumor. A contrast‑enhanced computed tomo-

was then created and enlarged until a laparoscopic

graphy (CT)examination showed a 20‑mm circum-

linear stapler could be placed between the pancreas

scribed nodule in the pancreatic tail (Fig. 1c) withand the splenic vein. After the transection of the20Shinshu Med J Vol.63

A pancreatic metastasis of a malignant melanoma resected by a laparoscopic spleen‑preserving distal pancreatectomy

Fig. 2 Laparoscopic view of the preserved SpA (arrow)and SpV (arrowhead).

Fig. 3 Resected specimen of the pancreas. The arrow indicates a metastatic melanoma.

pancreas, a continuous dissection starting from thewas discharged from the hospital on the 13th pos-cut end of the pancreas, which was grasped andtoperative day. The patient has survived for 7

retracted anteriorly, was made towards the tailmonths without exhibiting any signs of recurrence.

until the pancreas was freed (Fig. 2). Finally, theDiscussion

whole specimen was placed in a bag and extracted
through the enlarged trocar site at the umbilicus.

Previous studies have shown that the prognosis of

The operation time and intraoperative blood loss

patients with distant metastases from malignant

were 175 minutes and 100 mL, respectively.

melanoma depends on the initial metastatic

M acroscopically,a pale black tumor with a diam-site; speciﬁcally, patients with visceral metas-

eter of 17 mm was observed (Fig. 3). Histopath-tases in organs other than the lung had the lowest

ological examination revealed a pancreatic metas-

survival rate.However,several studies have showntasis of malignant melanoma with clear resectionthat a complete surgical resection can be associatedmargins and no lymph node involvement. The pos-with an improved overall survival, even among

toperative course was uneventful, and the patientpatients with abdominal metastases of malignant

No. 1, 201521

Motoyama.Kobayashi.Yokoyama et al.

melanoma.

dates for a laparoscopic distal pancreatectomy.

Because the number of metastases at distant sites

There is no consensus on the need to perform

has been documented as an important prognostic

spleen preservation in surgical resection for inva-factor, the exact role of surgical resection has

sive ductal adenocarcinoma of the pancreas sinceremained undeﬁned in patients with multiple organ

preservation of splenic vessels is hazardous formetastases. Wood et al. reported that a complete

oncologic radicality . However, splenic preserva

resection of the metastatic tissue provides a similartion is thought to be preferable in the setting of non‑median overall survival for patients with synchro-invasive malignant neoplasm, such as neuroendo-

nous multisite metastases to single‑site metas-

crine or metastatic tumor,because of the favorable

tasis . Similarly, Essner and colleagues haverole of the spleen for regulating the balance of theshown that the number of metastases was nothematologic and immune systems

selected as one of the predictive factors for overallcreatic surgery, it has been revealed that SPDP issurvival in patients undergoing curative surgicalassociated with a reduction in postoperative infec-

resection of metastatic malignant melanoma in atious complication,severe complications,and length

multivariate analysis .These results indicated thatof hospital stay compared with conventional distal

the surgical resection of metastatic malignant

pancreatectomy with splenectomy without themelanoma might be eﬃcacious for selected patientsneed for extending operative time or increasing

with multiple metastases, provided that a curative

operative blood loss

resection is possible.

advantages of splenic preservation were observed in. In open pan-

. Furthermore, additional

Laparoscopic pancreatic surgery is an emerging

the long‑term follow‑up survey,with better resultsﬁeld that has shown several beneﬁts over open

in terms of fatigue and general condition .Despite

surgery, with a faster recovery and quicker return

the aforementioned advanteges of splenic preserva-

to normal activities. The common indications

tion, Lap SPDP has not been regarded as a main-for laparoscopic distal pancreatectomy are thoughtstay of laparoscopic distal pancreatectomies

to be benign or low‑grade malignant tumors locatedbecause of its technical diﬃculty:that is, the deli-in the pancreatic body or tail. However, laparos-cate vascular dissection from the pancreas,which is

copic surgery for malignant pancreatic lesions

associated with a substantial risk of bleeding . In

remains controversial because of concerns regard-

the present case, we adopted Lap SPDP after com-

ing the oncological consequences .Previous studies

prehensively considering the following points:typehave shown the inferiority of laparoscopic distalof tumor,no radiological ﬁndings of adjacent organ

pancreatectomy because of the smaller number ofinvasion, and postoperative quality of life.

lymph nodes that are removed, compared with an

In conclusion,we herein reported an initial case ofopen distal pancreatectomy . However, recent

a Lap SPDP procedure performed for a metastatic

studies revealed that the short‑term and long‑term

pancreas tail tumor from a malignant melanoma.

outcomes were similar between a laparoscopic andThis technique is feasible as long as under careful

an open distal pancreatectomy in patients withidentiﬁcation of the posterior pancreatic branches

invasive ductal carcinoma

are carefully identiﬁed to prevent bleeding from the. These results sug-gest that malignant lesions are also potential candi-splenic artery and vein .

References
1) Reddy S, Wolfgang CL :The role of surgery in the management of isolated metastases to the pancreas. Lancet
Oncol 10:287‑293, 2009
2) Fletcher WS, Pommier RF, Lum S, Wilmarth TJ :Surgical treatment of metastatic melanoma. Am J Surg 175:413‑417, 1998
22Shinshu Med J Vol.63

A pancreatic metastasis of a malignant melanoma resected by a laparoscopic spleen‑preserving distal pancreatectomy3) M ori T,Abe N,Sugiyama M ,Atomi Y :Laparoscopic pancreatic surgery.J Hepatobiliary Pancreat Surg 12:451‑455, 2005
4) Sa Cunha A, Rault A, Beau C, Laurent C, Collet D, M asson B :A single‑institution prospective study of laparoscopic pancreatic resection. Arch Surg 143:289 ‑295;discussion 295, 2008
5) Baker M S, Bentrem DJ, Ujiki M B, Stocker S, Talamonti M S : A prospective single institution comparison ofperi‑operative outcomes for laparoscopic and open distal pancreatectomy. Surgery 146: 635‑643; discussion
643‑635, 20096) Nigri GR, Rosman AS, Petrucciani N, Fancellu A, Pisano M, Zorcolo L, Ramacciato G, M elis M :Metaanalysisof trials comparing minimally invasive and open distal pancreatectomies. Surg Endosc 25:1642‑1651, 20117) Vijan SS, Ahmed KA, Harmsen WS, Que FG, Reid‑Lombardo KM , Nagorney DM, Donohue JH, Farnell M B,Kendrick ML :Laparoscopic vs open distal pancreatectomy:a single‑institution comparative study. Arch Surg
145:616‑621, 2010
8) Choi SH,Seo M A,Hwang HK,Kang CM ,Lee WJ :Is it worthwhile to preserve adult spleen in laparoscopic distal
pancreatectomy?Perioperative and patient‑reported outcome analysis. Surg Endosc 26:3149 ‑3156, 20129) Gagner M,Pomp A,Herrera MF :Early experience with laparoscopic resections of islet cell tumors.Surgery 120:1051‑1054, 1996
10) Balch CM,Gershenwald JE,Soong SJ,Thompson JF,Atkins M B,Byrd DR,Buzaid AC,Cochran AJ,Coit DG,DingS,Eggermont AM ,Flaherty KT,Gimotty PA,Kirkwood JM ,M cM asters KM,Mihm M C Jr,Morton DL,Ross MI,Sober AJ, Sondak VK :Final version of 2009 AJCC melanoma staging and classiﬁcation. J Clin Oncol 27:6199 ‑6206, 200911) Ollila DW :Complete metastasectomy in patients with stage IV metastatic melanoma. Lancet Oncol 7:919 ‑924,
200612) Karakousis CP,Velez A,Driscoll DL,Takita H :M etastasectomy in malignant melanoma.Surgery 115:295‑302,
199413) de Wilt JH, M cCarthy WH, Thompson JF :Surgical treatment of splenic metastases in patients with melanoma.
J Am Coll Surg 197:38‑43, 2003
14) Essner R, Lee JH, Wanek LA, Itakura H, Morton DL : Contemporary surgical treatment of advanced‑stagemelanoma. Arch Surg 139 :961‑966;discussion 966‑967, 2004
15) Gutman H, Hess KR, Kokotsakis JA, Ross MI, Guinee VF, Balch CM : Surgery for abdominal metastases of
cutaneous melanoma. World J Surg 25:750‑758, 200116) M eyer T, Merkel S, Goehl J, Hohenberger W :Surgical therapy for distant metastases of malignant melanoma.
Cancer 89 :1983‑1991, 2000
17) Wornom IL 3rd, Smith JW, Soong SJ, M cElvein R, Urist M M, Balch CM :Surgery as palliative treatment for
distant metastases of melanoma. Ann Surg 204:181‑185, 1986
18) Wood TF,DiFronzo LA,Rose DM ,Haigh PI,Stern SL,Wanek L,Essner R,Morton DL :Does complete resectionof melanoma metastatic to solid intra‑abdominal organs improve survival?Ann Surg Oncol 8:658‑662, 200119) M isawa T, Shiba H, Usuba T, Nojiri T, Kitajima K, Uwagawa T, Toyama Y, Ishida Y, Ishii Y,Yanagisawa A,Kobayashi S, Yanaga K : Systemic inﬂammatory response syndrome after hand‑assisted laparoscopic distal
pancreatectomy. Surg Endosc 21:1446‑1449, 200720) Fernandez‑Cruz L, Blanco L, Cosa R, Rendon H :Is laparoscopic resection adequate in patients with neuroendocrine pancreatic tumors?World J Surg 32:904‑917, 200821) M elotti G, Butturini G, Piccoli M, Casetti L, Bassi C, Mullineris B, Lazzaretti MG, Pederzoli P :Laparoscopic
distal pancreatectomy:results on a consecutive series of 58 patients. Ann Surg 246:77‑82, 200722) M abrut JY, Fernandez‑Cruz L, Azagra JS, Bassi C, Delvaux G, Weerts J, Fabre JM , Boulez J, Baulieux J, Peix
No. 1, 201523

Motoyama.Kobayashi.Yokoyama et al.
JL,Gigot JF,Hepatobiliary,Pancreatic Section of the Royal Belgian Society of S,Belgian Group for Endoscopic
S, Club C :Laparoscopic pancreatic resection :results of a multicenter European study of 127 patients. Surgery
137:597‑605, 200523) Asbun HJ, Stauﬀer JA :Laparoscopic approach to distal and subtotal pancreatectomy:a clockwise technique.
Surg Endosc 25:2643‑2649, 201124) Kooby DA,Hawkins WG,Schmidt CM,Weber SM,Bentrem DJ,Gillespie TW,Sellers JB,Merchant NB,ScogginsCR,M artin RC 3rd,Kim HJ,Ahmad S,Cho CS,Parikh AA,Chu CK,Hamilton NA,Doyle CJ,Pinchot S,Hayman
A, M cClaine R, Nakeeb A, Staley CA, M cMasters KM , Lillemoe KD : A multicenter analysis of distal pancreatectomy for adenocarcinoma :is laparoscopic resection appropriate?J Am Coll Surg 210:779 ‑785, 786‑777,201025) Andren‑Sandberg A, Wagner M, Tihanyi T, Lofgren P, Friess H : Technical aspects of left‑sided pancreaticresection for cancer. Dig Surg 16:305‑312, 199926) Shoup M, Brennan M F, McWhite K, Leung DH, Klimstra D, Conlon KC :The value of splenic preservation withdistal pancreatectomy. Arch Surg 137:164‑168, 200227) Balcom JHt, Rattner DW, Warshaw AL, Chang Y, Fernandez‑del Castillo C : Ten‑year experience with 733
pancreatic resections:changing indications, older patients, and decreasing length of hospitalization. Arch Surg
136:391‑398, 2001
28) Carrere N, Abid S, Julio CH, Bloom E, Pradere B : Spleen‑preserving distal pancreatectomy with excision ofsplenic artery and vein :a case‑matched comparison with conventional distal pancreatectomy with splenectomy.
World J Surg 31:375‑382, 200729) Tang CW,Feng WM,Bao Y,Fei MY,Tao YL :Spleen‑preserving distal pancreatectomyor distal pancreatectomy
with splenectomy?:Perioperative and patient‑reported outcome analysis. J Clin Gastroenterol 48:e62‑66, 201430) Pryor A,M eans JR,Pappas TN :Laparoscopic distal pancreatectomy with splenic preservation.Surg Endosc 21:2326‑2330, 200731) Pietrabissa A, M oretto C, Boggi U, Di Candio G, M osca F :Laparoscopic distal pancreatomy:are we ready fora standardized technique?Semin Laparosc Surg 11:179 ‑183, 2004

（2014. 8.19 received ; 2014.11. 8 accepted）

24

Shinshu Med J Vol.63