Clinical features and treatment outcome of borderline resectable pancreatic head/body cancer: a multi-institutional survey by the Japanese Society of Pancreatic Surgery

BACKGROUND

Optimal treatment types and prognosis for patients with borderline resectable pancreatic cancer (BRPC) remain unclear because of the lack of studies involving large series of patients.

METHODS

We retrospectively analyzed various prognostic factors for 624 BRPC (pancreatic head/body) patients treated from June 2002 to May 2007, by distributing questionnaires to member institutions of the Japanese Society of Pancreatic Surgery in 2010. BRPC was defined according to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines (2009).

RESULTS

Among 624 patients, 539 (86.4 %) underwent curative-intent resection, showing an R0 resection rate of 65.9 %. The 3- and 5-year survival rates were 16.1 and 9.9 % in all patients, 22.8 and 12.5 % in the resected patients, and 4.4 and 0 % (P < 0.0001) in the unresected patients, respectively. The following factors influencing survival in all patients were selected as independent prognostic factors using multivariate analysis: major arterial involvement on imaging study; preoperative treatment; surgical resection; and postoperative chemotherapy. Among the resected cases, multivariate analysis revealed that major arterial involvement and remnant tumor status were independent prognostic factors.

CONCLUSION

BRPC included two distinct categories of tumors influencing survival: those with portal vein/superior mesenteric vein invasion alone and those with major arterial invasion, which was the most exacerbating factor in the analysis.

Impact of histological response after neoadjuvant chemoradiotherapy on recurrence-free survival in UICC-T3 pancreatic adenocarcinoma but not in UICC-T4

OBJECTIVES

Although the prognostic benefit of neoadjuvant chemoradiotherapy (NCRT) against pancreatic cancer has been indicated by several reports, it is controversial whether histological response is associated with prognosis. The objective was to explore the relationship between histological response and prognosis in T3 and T4 pancreatic adenocarcinoma.

METHODS

We histologically examined the resected specimens obtained from 58 patients (T3, n = 40; and T4, n = 18) for whom we performed curative-intent resection after NCRT. Histological response was evaluated according to Evans's criteria to determine whether it influenced survival.

RESULTS

In T3 tumors, 13 (32.5%) belonged to high responders (tumor destruction of >50%) (R0, n = 13) and 27 (67.5%) belonged to low responders (tumor destruction of ≤50%) (R0, n = 22, R1, n = 3, R2, n = 2). Recurrence-free survival rate was significantly higher in high responders than in low responders (3-year recurrence-free survival rates: 71.3% vs 13.1%, P = 0.0095). In T4 tumors, however, only 1 (5.6%) was a high responder, and R0 resection was obtained only in 5 patients (27.8%).

CONCLUSIONS

In T3 tumors, histological response is considered a significant prognostic indicator, securing the surgical margin, whereas in T4 tumors, NCRT did not provide beneficial histological response, not securing the surgical margin.

Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence

INTRODUCTION

For the surgical management of chronic pancreatitis with an inflammatory pancreatic head mass, extended drainage operations such as Beger and Frey procedures were established in the 1980s as an alternative to resectional procedures like pancreaticoduodenectomy and as opposed to simple drainage operations such as lateral pancreaticojejunostomy, that is, the Partington procedure. With the relatively rapid adoption of the two procedures, it seems that the Partington procedure has become a thing of the past.

MATERIALS AND METHODS

The Partington procedure was re-evaluated with regard to the historical aspects and its present status by a literature review.

RESULTS

The results show that this procedure relieves chronic abdominal pain in 66-91% of patients with a mean follow-up of 3.5-9.1 years. It is important to note that this procedure is generally used for inflammatory disease left of the gastroduodenal artery and is specifically not used as the procedure of choice for inflammatory disease of the pancreatic head.

CONCLUSION

For patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass, the Partington procedure is still the procedure of choice, since it is technically simple to perform with a minimum of morbidity and mortality, preserving pancreatic endocrine and exocrine function. Because it is a relatively simple technique, the laparoscopic approach will be justified as a treatment of appropriate patients in the near future.

Human Equilibrative Nucleoside Transporter 1 Expression in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration Biopsy Samples Is a Strong Predictor of Clinical Response and Survival in the Patients With Pancreatic Ductal Adenocarcinoma Undergoing Gemcitabine-Based Chemoradiotherapy

OBJECTIVES

This study aimed to clarify whether pretreatment human equilibrative nucleoside transporter (hENT1) expressions in endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNAB) specimens obtained from resectable, borderline resectable, and locally advanced unresectable pancreatic ductal adenocarcinoma (PDAC) are concordant with those in the resected specimen after gemcitabine-based chemoradiotherapy (Gem-CRT) and to validate the utility of hENT1 expression using EUS-FNAB samples as a prognostic marker.

METHODS

We evaluated the relationship between hENT1 expressions assessed by immunohistochemical staining and clinical outcomes in 51 of 76 patients with PDAC who were diagnosed by EUS-FNAB and received preoperative Gem-CRT.

RESULTS

The concordance rate of hENT1 expressions was 89.2% (K = 0.681). Median survival time (month) in the 51 whole patients and 37 patients with resection was significantly longer in hENT1 positive than in hENT1 negative: 25.0 and 30.0 versus 9.0 and 9.0, respectively. A multivariate analysis confirmed that hENT1 expression was an independent prognostic factor in both whole patients and those with resection. Regardless of T3 and T4, hENT1-positive patients with resection had significantly better prognosis than hENT1-negative patients, whose prognosis was similar to those without resection.

CONCLUSIONS

The assessment of hENT1 expression using EUS-FNAB samples before Gem-CRT provides important information on patients with PDAC who can benefit from curative-intent resection.

Effect of IS-741 (a new synthetic antiinflammatory agent) on acute necrotizing pancreatitis in dogs. Significance of its inhibitory effect on cytosolic phospholipase A2

IS-741, a new synthetic anti-inflammatory agent, is known to have some inhibitory effect on cytosolic phospholipase A2 (cPLA2), an enzyme which hydrolyzes cellular phospholipids, liberating fatty acids and lysophospholipids and providing the precursor substrates for the biosynthesis of eicosanoids and platelet-activating factor. cPLA2 is therefore an attractive target for the development of novel therapies. During infusion of lactated Ringer's solution at a rate of 10 ml/kg/h, acute pancreatitis was induced in dogs by injecting autologous gallbladder bile into the main pancreatic duct. The dogs were then divided into two groups: group A (nontreatment), no treatment during the experiment, and group B (IS-741), intravenously injected with IS-741 at 6 and 30 h after induction of acute pancreatitis. As a result, the survival rate was significantly higher in group B than in group A. Mean arterial pressure and PaO2 were well maintained in group B as compared with group A. The NAG index, which is known to be markedly increased in renal tubular damage, was significantly lower in group B than in group A. Histological examination of the pancreas, lung, and kidney in group B showed milder changes than in group A. cPLA2 activity in the pancreas, lung and renal cortex was much lower in group B than in group A, but sPLA2 activity in these tissues did not differ significantly between the two groups. In conclusion, IS-741 exerts a potentially therapeutic effect on experimental acute pancreatitis by mitigating the degree of damage in the pancreas, lung, and kidney. The inhibitory effect of IS-741 on cPLA2 may contribute to one of the antiinflammatory mechanisms of actions of this agent.

Factor Analysis Influencing Postoperative Hospital Stay and Medical Costs for Patients with Definite, Suspected, or Unmatched Diagnosis of Acute Cholecystitis according to the Tokyo Guidelines 2013

Purpose. To identify significant independent preoperative factors influencing postoperative hospital stay (PHS) and medical costs (MC) in 171 patients who underwent cholecystectomy for benign gallbladder diseases and had definite, suspected, or unmatched acute cholecystitis (AC) diagnosis according to the Tokyo Guidelines 2013 (TG13). Methods. The 171 patients were classified according to the combination of diagnostic criteria including local signs of inflammation (A), systemic signs of inflammation (B), and imaging findings (C): A+ B+ C (definite diagnosis, n = 84), A+ B (suspected diagnosis, n = 25), (A or B) + C (n = 10), A (n = 41), and B (n = 11). Results. The A+ B + C and (A or B) + C groups had equivalent PHS and MC, suggesting that imaging findings were essential for AC diagnosis. PHS and MC were significantly increased in the order of severity grades based on TG13. Performance status (PS), white blood cell count, and severity grade were identified as preoperative factors influencing PHS by multivariate analysis, and significant independent preoperative factors influencing MC were age, PS, preoperative biliary drainage, hospital stay before surgery, albumin, and severity grade. Conclusion. PS and severity grade significantly influenced prolonged PHS and increased MC.