IntroductionPancreatic and periampullary adenocarcinomas are associated with abnormal body composition visible on CT scans, including low muscle mass (sarcopenia) and low muscle radiodensity due to fat infiltration in muscle (myosteatosis). The biological and clinical correlates to these features are poorly understood.MethodsClinical characteristics and outcomes were studied in 123 patients who underwent pancreaticoduodenectomy for pancreatic or non-pancreatic periampullary adenocarcinoma and who had available preoperative CT scans. In a subgroup of patients with pancreatic cancer (n = 29), rectus abdominus muscle mRNA expression was determined by cDNA microarray and in another subgroup (n = 29) 1H-NMR spectroscopy and gas chromatography-mass spectrometry were used to characterize the serum metabolome.ResultsMuscle mass and radiodensity were not significantly correlated. Distinct groups were identified: sarcopenia (40.7%), myosteatosis (25.2%), both (11.4%). Fat distribution differed in these groups; sarcopenia associated with lower subcutaneous adipose tissue (P<0.0001) and myosteatosis associated with greater visceral adipose tissue (P<0.0001). Sarcopenia, myosteatosis and their combined presence associated with shorter survival, Log Rank P = 0.005, P = 0.06, and P = 0.002, respectively. In muscle, transcriptomic analysis suggested increased inflammation and decreased growth in sarcopenia and disrupted oxidative phosphorylation and lipid accumulation in myosteatosis. In the circulating metabolome, metabolites consistent with muscle catabolism associated with sarcopenia. Metabolites consistent with disordered carbohydrate metabolism were identified in both sarcopenia and myosteatosis.DiscussionMuscle phenotypes differ clinically and biologically. Because these muscle phenotypes are linked to poor survival, it will be imperative to delineate their pathophysiologic mechanisms, including whether they are driven by variable tumor biology or host response.

There has been considerable literature on breast conservation therapy over the past few years, with an emphasis on cosmesis and less emphasis on the possible disadvantages of excision with inadequate margins at initial surgery.Recent literature 1 suggests that 1 in 4 women who have had breast conservation therapy require a second operation to remove residual tumours, an improvement over the last few years, but still substantial. Recent literature 1,2 suggests that inadequate margins at in itial surgery are disadvantageous for patients from a psychological and economic standpoint. There does not ap pear to be emphasis that having a positive margin at initial surgery negatively influences the likelihood of remaining disease free, although studies 3,4 have demonstrated that local recurrence after breast conservation surgery increases systemic disease, which can lead to increased mortality. It has been stated 5 that cancer cells have growth factor re ceptors that are compatible with growth factors in the wound environment and that cancer cells that shed intraoperatively can contribute to both local re currence and distant metastases.It is suggested that the cosmetic advantages of removing a specimen 1-2 cm smaller does not warrant the disadvantage of removing a specimen with inadequate margins, particularly since a second procedure negates the cosmetic advantage of removing a smaller specimen. Silverstein and colleagues 6 in discussing ductal carcin oma in situ made a comment that should also apply to lumpectomy for neoplasm: "the first excision is the best opportunity to achieve both goals, complete excision and good cosmetic result." Competing interests: None declared. References 1. McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA 2012; 307: 467-75. 2. Lovrics PJ, Cornacchi SD, Farrokhyar F, et al. Technical factors, surgeon case volume and positive margin rates after breast conservation surgery for early-stage breast cancer. Can J Surg 2010;53:305-12. 3. Punglia RS, Morrow M, Winer EP, et al. Local therapy and survival in breast cancer. N Engl J Med 2007;356:2399-405. 4. Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancer improve survival? The role of surgical management. Br J Cancer 2004;90:1920-5. 5. Reid SE, Kaufman MW, Murthy S, et al. Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast cancer. J Am Coll Surg 1997; 185:290-306. 6. Silverstein MJ, Parker R, Grotting JC, et al. Ductal carcinoma in situ of the breast.

Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.

Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.