Robotic Extended Ultrasound-Guided Distal Pancreatectomy for Pancreatic Metastases from Uveal Melanoma

Abstract

Background

Isolated pancreatic metastasis from melanoma is extremely uncommon and accounts for approximately only 2% of visceral disseminations of melanoma.^1,2,3 Interestingly, pancreatic localizations disproportionately derive from primary ocular melanoma.^1,2 Despite the currently available evidence on this argument being scarce, the survival outcomes of patients receiving resection for visceral melanoma metastases are reported to be superior than those managed by non-surgical modalities.^4,5

Case Presentation

A 59-year-old female with a history of uveal melanoma presented with surveillance-detected metastatic disease confined to the pancreas. Computed tomography demonstrated one lesion located in the body of the pancreas and one further lesion in the head. The presented video illustrates the details of an extended, ultrasound-guided, robotic distal pancreatectomy.

Discussion

Metastatic ocular melanoma has a highly variable natural history, which ranges from a fulminant course to prolonged stable disease.⁶ In contrast to cutaneous melanoma derivation, metastases mostly occur via hematogenous spread, in the absence of lymphatic drainage of the eye.^6,7 Liver is the most common site of secondary localization and is not involved by metastatic disease in <10% of cases. Interestingly, patients with extrahepatic metastases tend to have significantly better survival rates than those with hepatic disease.^6,7 Fewer than 100 cases of pancreatic metastasis from malignant melanoma are reported in the medical literature, including a relatively high percentage of primary ocular malignancies.^1,5 Furthermore, the prognosis of these patients is essentially unknown, although metastatic melanoma of both cutaneous and ocular origin generally indicates poor survival.^1,5,6 Although no robust evidence is available, a number of reports suggest that pancreatic resection may improve survival in these patients.^1,2,3,4 A large retrospective review investigating the association between treatment modalities and survival of patients with abdominal visceral melanoma metastases showed that patients receiving resection had a superior median survival compared with patients treated medically. Although patients with metastases of the gastrointestinal tract showed the best outcomes following surgery, patients with pancreas metastasis (of both cutaneous and ocular origin) undergoing resection also exhibited a significant survival advantage compared with those treated non-surgically.⁵ Minimally invasive pancreatectomy is gaining momentum.⁸ In fact, in selected patients there are distinct advantages compared with conventional surgery owing to reduced postoperative morbidity and earlier return to daily activities, while maintaining the oncological tenets of resection.^8,9,10 Recent reports suggest that the application of robots may provide some advantages over conventional laparoscopy, especially for patients necessitating technically challenging surgeries.^8,11 Such benefits are mainly in relation to the rate of conversion, length of postoperative hospital stay, and number of cases necessary to surmount the learning curve and reach optimal performance; however, no definitive conclusions can be drawn due to the lack of high-level evidence.^8,10