Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS)

Pancreatic cancer: yesterday, today and tomorrow

Pancreatic cancer is one of our most lethal malignancies. Despite substantial improvements in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since the 1960s. Pancreatic cancer is usually detected at an advanced stage and most treatment regimens are ineffective, contributing to the poor overall prognosis. Herein, we review the current understanding of pancreatic cancer, focusing on central aspects of disease management from radiology, surgery and pathology to oncology.

[Resection for advanced pancreatic cancer following multimodal therapy]

Pancreatic cancer patients presenting with borderline resectable or locally advanced unresectable tumors remain a therapeutic challenge. Despite the lack of high quality randomized controlled trials, perioperative neoadjuvant treatment strategies are often employed for this group of patients. At present the FOLFIRINOX regimen, which was established in the palliative setting, is the backbone of neoadjuvant therapy, whereas local ablative treatment, such as stereotactic irradiation and irreversible electroporation are currently under investigation. Resection after modern multimodal neoadjuvant therapy follows the same principles and guidelines as upfront surgery specifically regarding the extent of resection, e.g. lymphadenectomy, vascular resection and multivisceral resection. Because it is still exceedingly difficult to predict tumor response after neoadjuvant therapy, a special treatment approach is necessary. In the case of localized stable disease following neoadjuvant therapy, aggressive surgical exploration with serial frozen sections at critical (vascular) margins might be necessary to minimize the risk of debulking procedures and maximize the chance of a curative resection. A multidisciplinary and individualized approach is mandatory in this challenging group of patients.

Pancreatic cancer

Pancreatic cancer is a major cause of cancer-associated mortality, with a dismal overall prognosis that has remained virtually unchanged for many decades. Currently, prevention or early diagnosis at a curable stage is exceedingly difficult; patients rarely exhibit symptoms and tumours do not display sensitive and specific markers to aid detection. Pancreatic cancers also have few prevalent genetic mutations; the most commonly mutated genes are KRAS, CDKN2A (encoding p16), TP53 and SMAD4 - none of which are currently druggable. Indeed, therapeutic options are limited and progress in drug development is impeded because most pancreatic cancers are complex at the genomic, epigenetic and metabolic levels, with multiple activated pathways and crosstalk evident. Furthermore, the multilayered interplay between neoplastic and stromal cells in the tumour microenvironment challenges medical treatment. Fewer than 20% of patients have surgically resectable disease; however, neoadjuvant therapies might shift tumours towards resectability. Although newer drug combinations and multimodal regimens in this setting, as well as the adjuvant setting, appreciably extend survival, ∼80% of patients will relapse after surgery and ultimately die of their disease. Thus, consideration of quality of life and overall survival is important. In this Primer, we summarize the current understanding of the salient pathophysiological, molecular, translational and clinical aspects of this disease. In addition, we present an outline of potential future directions for pancreatic cancer research and patient management.

Innovations in macroscopic evaluation of pancreatic specimens and radiologic correlation

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The axial slicing technique offers many advantages in accurate estimation of tumors extend and staging.

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Cross-sectional axial imaging is the best technique for accurate radiologic-pathologic correlation.

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Correlation may explain any discrepancies between radiological and histopathological findings.

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Pathology correlation may offer a better understanding of the missed findings by imaging or pitfalls

The purpose of this study was to evaluate the feasibility of a novel dissection technique of surgical specimens in different cases of pancreatic tumors and provide a radiologic pathologic correlation. In our hospital, that is a referral center for pancreatic diseases, the macroscopic evaluation of the pancreatectomy specimens is performed by the pathologists using the axial slicing technique (instead of the traditional procedure with longitudinal opening of the main pancreatic and/or common bile duct and slicing along the plane defined by both ducts). The specimen is sliced in an axial plane that is perpendicular to the longitudinal axis of the descending duodenum. The procedure results in a large number of thin slices (3–4 mm). This plane is identical to that of CT or MRI and correlation between pathology and imaging is straightforward. We studied 70 cases of suspected different solid and cystic pancreatic tumors and we correlated the tumor size and location, the structure—consistency (areas of necrosis—hemorrhage—fibrosis—inflammation), the degree of vessels’ infiltration, the size of pancreatic and common bile duct and the distance from resection margins. Missed findings by imaging or pitfalls were recorded and we tried to explain all discrepancies between radiology evaluation and the histopathological findings. Radiologic-pathologic correlation is extremely important, adding crucial information on imaging limitations and enabling quality assessment of surgical specimens. The deep knowledge of different pancreatic tumors’ consistency and way of extension helps to improve radiologists’ diagnostic accuracy and minimize the radiological-surgical mismatching, preventing patients from unnecessary surgery.

The cost of Pancreatoduodenectomy - An analysis of clinical determinants

BACKGROUND

Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD).

METHODS

The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed.

RESULTS

Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD.

CONCLUSIONS

It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

Synchronous resections of hepatic oligometastatic pancreatic cancer: Disputing a principle in a time of safe pancreatic operations in a retrospective multicenter analysis

BACKGROUND

The prognosis of patients with liver metastasis is generally considered dismal, and combined resections of the primary tumor and metastasectomies are not recommended. In highly selected patients, however, resections are performed. The evidence for this indication is limited. The aim of the current study was to assess the operative and oncologic outcomes of patients with combined pancreatic and liver resections of synchronous liver metastases.

METHODS

In a retrospective analysis of 6 European pancreas centers, we identified 69 patients with pancreatic ductal adenocarcinoma and synchronous liver metastasis who underwent simultaneous pancreas and liver metastasis resections. Patients receiving exploration without tumor resection served as the control group.

RESULTS

Overall survival (OS) appeared to be prolonged in the group of resected patients (median 14 vs 8 months, P < .001). Subgroup analysis revealed that the survival benefit of the resected patients was driven by pancreatic ductal adenocarcinomas localized in the pancreatic head (median OS 13.6 vs 7 months, P < .001). Body/tail pancreatic ductal adenocarcinomas showed no benefit of resection (median OS 14 vs 15 months, P = .312). In the multivariate analysis, tumor resection was the only independent prognosticator for OS (hazard ratio 2.044, 95% confidence interval 1.342-3.114).

CONCLUSION

The data of this retrospective and selective patient cohort suggested a clear survival benefit for patients undergoing synchronous pancreas and liver resections for pancreatic ductal adenocarcinoma, but due to the limitations of this retrospective study and very strong potential for selection bias, a strong conclusion for resection cannot be drawn. Prospective trials must validate these data and investigate the use of combined operative and systemic treatments in case of resectable metastatic pancreatic cancer. Is it time for a multicenter, prospective trial?

Long-term survival after resections for pancreatic ductal adenocarcinoma. Single centre study

AIM

To analyse the 5-year survival rate of patients undergoing radical surgery for pancreatic ductal adenocarcinoma (PDAC) and to identify prognostic factors.

METHODS

A prospectively maintained database of 90 consecutive patients who underwent radical resection for PDAC was analysed. Survival was evaluated using the Kaplan-Meier method. Log-rank test and Cox regression analysis were used for the evaluation of prognostic factors. P values less than 0.05 were considered significant.

RESULTS

Mean age (± standard deviation) was 63.2±8.6 years (female 28.9% and male 71.1%). Tumour localisation was in the head in 76 (84.5%), multifocal in 3 (3.3%) and in the body/tail in 11 (12.2%). Pancreatic head resection was performed in 75 (83.3%), total pancreatectomy in 4 (4.4%) and distal pancreatectomy with splenectomy in 11 (12.2%), with standard lymphadenectomy. Venous resection was in 4 (4.4%). Thirty-day and in-hospital mortality occurred in 1 (1.1%), 90-day mortality was 3.3%. On univariate analysis absence of perineural and vascular invasion, stage, absence of lymph node infiltration and no need for transfusion were associated with improved overall survival. On multivariate analysis vascular invasion HR=3.137 (95%CI: 1.692-5.816; P = 0.0003) and postoperative complications HR=2.004 (95%CI: 1.198-3.354; P = 0.008) were identified as significant independent predictors of survival. The five-year survival rate was 18.9%, with five-year recurrence-free survival of 16.7%.

CONCLUSION

Vascular invasion and postoperative complications were independent prognostic factors after curative resections of pancreatic cancer in studied cohort.

Progress in treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor of the digestive system with a high degree of malignancy, accounting for about 90% of cases of pancreatic cancer. It has an occult onset and progresses rapidly, with a poor treatment effect and prognosis. It is one of malignant tumors with the worst prognosis. Surgical resection, as the only effective treatment, can be performed in only 20%-30% of patients, and the average period of survival after surgery is still less than 2 years. The main treatment strategy for PDAC are surgery-based individualized treatment modalities under comprehensive multidisciplinary collaboration. Currently, the therapeutic effect on pancreatic cancer is still not satisfactory. In recent years, various treatments for PDAC is becoming a hot spot of research. This article reviews the progress in the treatment of PDAC in terms of radical surgery, palliative surgery, adjuvant therapy, and other treatment opinions.

Pancreatic Cancer Diagnostics and Treatment--Current State

Pancreatic ductal adenocarcinoma (PDAC) represents permanent and ever rising issue worldwide. Five-year survival does not exceed 3 to 6%, i.e. the worst result among solid tumours. The article evaluates the current state of PDAC diagnostics and treatment specifying also development and trends. Percentage of non-resectable tumours due to locally advanced or metastatic condition varies 60-80%, mostly over 80%. Survival with non-resectable PDAC is 4 to 8 months (median 3.5). In contrast R0 resection shows the survival 18-27 months. Laboratory and imaging screening methods are not indicated on large scale. Risk factors are smoking, alcohol abuse, chronic pancreatitis, diabetes mellitus. Genetic background in most PDAC has not been detected yet. Some genes connected with high risk of PDAC (e.g. BRCA2, PALB2) have been identified as significant and highly penetrative, but link between PDAC and these genes can be seen only in 10-20%. This article surveys perspective oncogenes, tumour suppressor genes, microRNA. Albeit CT is still favoured over other imaging methods, involvement of NMR rises. Surgery prefers the "vessel first" approach, which proves to be justified especially in R0 resection. According to EBM immunotherapy same as radiotherapy are not significant in PDAC treatment. Chemotherapy shows limited importance in conversion treatment of locally advanced or borderline tumours or in case of metastatic spread. Unified procedures cannot be defined due to inhomogenous arrays. Surgical resection is the only chance for curative treatment of PDAC and depends mainly on timely indication for surgery and quality of multidisciplinary team in a high-volume centre.

Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer

BACKGROUND

A superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy.

METHODS

A modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration.

RESULTS

Of 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years.

CONCLUSIONS

Short-term results with the procedure may encourage surgical management for BRPHC.

Borderline resectable pancreatic cancer

Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20-25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications. The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.

Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma

INTRODUCTION

Several studies have confirmed the safety of pancreatoduodenectomy with portal/mesenteric vein resection and reconstruction in select patients. The effect of vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portal/mesenteric vein and long-term survival.

METHODS

A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed. Survival was compared using the Kaplan-Meier method and log-rank test. P < 0.05 was considered statistically significant.

RESULTS

After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal/mesenteric vein were excluded, there were 567 eligible patients. Of these, segmental vein resection was performed in 90 (16 %) with end-to-end primary anastomosis (67) or interposition graft reconstruction (23). Patients with vein resection more likely received neoadjuvant systemic therapy (59 vs. 4 %, p < 0.0001). Histopathology of patients undergoing vein resection revealed a distribution of T stage toward larger tumors and higher rates of perineural invasion. Portal/mesenteric vein resection, however, was not associated with differences in hospital stay, postoperative complications, or operative mortality. Patients with or without vein resection had comparable overall survival rates at 1-, 3-, and 5-years. On final surgical histopathology, only 52 of 90 (58 %) vein resections had adenocarcinoma involvement of the venous wall. Of these, depth of invasion was at the level of the adventitia (9), media/intima (34), and full thickness/intraluminal (9). Venous wall invasion (52) did not significantly influence overall survival (14 vs. 21 months, p = 0.08) but was associated with significantly shorter median disease-free survival (11.3 vs. 15.8 months, p = 0.03), predominantly due to local recurrence. The extent of invasion (adventitia, media/intima, full thickness/intraluminal) did not impact overall survival or disease-free survival (14.4 vs. 15.5 vs. 7.4 months, p = 0.08 and 11.2 vs. 12.2 vs. 5 months, 0.59, respectively). Portal/mesenteric vein resection, histopathologic invasion, or the extent of invasion were not independent predictors of overall survival in Cox regression analysis.

CONCLUSION

Although Portal/mesenteric vein resection is associated with increased 90-day mortality, venous resection is not prognostic of overall survival. Although a subgroup analysis showed that a direct tumor invasion into the vein wall on final histopathology was associated with a higher rate of local recurrence but with no difference in overall survival (even when stratified according to extent of venous wall invasion), larger studies with an increased power will be needed to confirm these findings.

Advances in Surgical Management of Pancreatic Diseases

The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.

Adjuvant and neoadjuvant therapies in resectable pancreatic cancer: a systematic review of randomized controlled trials

The timing of surgery and antineoplastic therapies in patients with resectable non-metastatic pancreatic cancer is still a controversial matter of debate, with special regard to neoadjuvant approaches. Following the criteria of the PRISMA statement, a literature search was conducted looking for RCTs focusing on adjuvant and neoadjuvant therapies in resectable pancreatic cancer. The quality of the available evidence was assessed using the Cochrane Collaboration's tool for assessing risk of bias. Data extraction was carried out by two independent investigators. The search led to the identification of 2830 papers of which 14 RCTs focusing on adjuvant and neoadjuvant treatment of resectable pancreatic cancer eligible for the systematic review. Risk of bias was estimated "unclear" in 3 studies and "high" in 5 studies. Median age ranged between 53 and 66. Overall survival in the surgery-only arms ranged between 11 and 20.2 months; in the adjuvant treatment arms 12.5-29.8 months; and in the neoadjuvant setting 9.9-19.4 months. Neoadjuvant protocols should be offered only in randomized clinical trials comparing the standard of care (surgery followed by adjuvant treatments) to a neoadjuvant approach followed by surgery and adjuvant treatment.

The prognostic impact of para-aortic lymph node metastasis in pancreatic cancer: A systematic review and meta-analysis

PURPOSE

To evaluate by a meta-analytic approach the long-term prognostic impact of para-aortic lymph node (PALN) involvement in resected ductal adenocarcinoma of the pancreas.

METHODS

MEDLINE, Embase, PubMed and the Cochrane Library were searched from January 1990 to June 2015. Trials reporting Kaplan-Meier curves and comparing overall long-term survival of negative and metastatic PALN in patients who underwent resection for pancreatic cancer were included. Lymph nodes were classified according to the Japan Pancreatic Society rules and identified using hematoxylin and eosin staining. Hazard ratios (HRs) and 95%CI were estimated for each trial and pooled in a meta-analysis.

RESULTS

Thirteen eligible studies including 2141 patients (364 positive PALN; 1777 negative PALN) were identified. Most of the studies were retrospective. Heterogeneity among trials was high (I(2) = 98.7%; p < .001). PALN metastasis was associated with increased mortality when compared with patients with negative PALN regardless regional nodal status [HR 1.85, 95%CI 1.48-2.31; p < .001]. Median survival was significantly decreased in patients with positive PALN (WMD = -4.92 months 95%CI -6.40; -3.43; p < .001). Moreover, metastatic PALN affected mortality also when regional lymph nodes were positive [HR 1.67, 95%CI 1.34-2.08; p < .001]. No publication bias was detected.

CONCLUSIONS

PALN metastasis appears to correlate with poor prognosis in patients with pancreatic adenocarcinoma. The assessment of PALN status may be considered for a more accurate staging of the disease and appropriated subgroup survival reporting. However, the definitive avoidance of the resection in case of intraoperative metastatic PALN needs further investigation.

Current standards and new innovative approaches for treatment of pancreatic cancer

Pancreatic adenocarcinoma remains a devastating disease with a 5-year survival rate not exceeding 6%. Treatment of this disease remains a major challenge. This article reviews the state-of-the-art in the management of this disease and the new innovative approaches that may help to accelerate progress in treating its victims. After careful pre-therapeutic evaluation, only 15-20% of patients diagnosed with a pancreatic cancer (PC) are eligible for upfront radical surgery. After R0 or R1 resection in such patients, evidence suggests a significantly positive impact on survival of adjuvant chemotherapy comprising 6 months of gemcitabine or fluorouracil/folinic acid. Delayed adjuvant chemoradiation is considered as an option in cases of positive margins. Borderline resectable pancreatic cancer (BRPC) is defined as a tumour involving the mesenteric vasculature to a limited extend. Resection of these tumours is technically feasible, yet runs the high risk of a R1 resection. Neoadjuvant treatment probably offers the best chance of achieving successful R0 resection and long-term survival, but the best treatment options should be determined in prospective randomised studies. Gemcitabine has for 15 years been the only validated therapy for advanced PC. Following decades of negative phase III studies, increasing evidence now suggests that further significant improvements to overall survival can be achieved via either Folfirinox or gemcitabine + nab-paclitaxel regimens. Progress in systemic therapy may improve the chances of resection in borderline resectable pancreatic cancer (BRPC) or locally advanced PC. This requires first enhancing knowledge of the genetic events driving carcinogenesis, which may then be translated into clinical studies.

Inframesocolic Superior Mesenteric Artery First Approach as an Introductory Procedure of Radical Antegrade Modular Pancreatosplenectomy for Carcinoma of the Pancreatic Body and Tail

Superior mesenteric artery (SMA)-first approaches are operative tactics used to determine tumor resectability early during pancreatoduodenectomy. With locally advanced carcinoma of the pancreatic body and tail, early determination of SMA involvement also helps establish whether curative resection is feasible. During either radical antegrade modular pancreatosplenectomy (RAMPS) or classic left-to-right distal pancreatectomy, dissection of the SMA is performed after transection of the pancreas or wide detachment of the distal pancreas and spleen. Herein, we describe an inframesocolic SMA-first approach as an introductory procedure when treating carcinoma of the pancreatic body and tail. This first approach procedure provides a reliable and safe introduction to RAMPS.

Prominent gastroduodenal artery: Endosonographic sign of celiac artery stenosis

Celiac artery (CA) stenosis is a relatively common finding in patients undergoing pancreaticoduodenectomy (PD). In the presence of CA stenosis, arterial blood supply to the celiac territory is usually sustained from the superior mesenteric artery (SMA) through well-developed collaterals. In this paper, the authors report endosonographically identified prominent gastroduodenal artery as the sign of CA stenosis for the first time. Uncovering previously unidentified vascular abnormality, endoscopic ultrasound (EUS) has improved patient management. The patient had uneventful collateral preserving PD.

Mesopancreatic Stromal Clearance Defines Curative Resection of Pancreatic Head Cancer and Can Be Predicted Preoperatively by Radiologic Parameters: A Retrospective Study

Pancreatic ductal adenocarcinoma (PDAC) is characterized by a strong fibrotic stromal reaction and diffuse growth pattern. Peritumoral fibrosis is often evident during surgery but only distinguishable from tumor by microscopic examination. The aim of this study was to investigate the role of clearance of fibrotic stromal reaction at the mesopancreatic resection margin as a criterion for radical resection and preoperative assessment of resectability.Mesopancreatic stromal clearance status (S-status) was defined as the presence or absence (S+/S0) of fibrotic stromal reaction at the mesopancreatic resection margin. Detailed retrospective clinicopathologic re-evaluation of margin status and preoperative cross-sectional imaging was performed in a cohort of 91 patients operated for pancreatic head PDAC from 2001 to 2011.Conventional margin positive resection (R+, tumor cells directly at the margin) was found in 36%. However, S-status further divided the margin negative (R0) group into patients with median survival of 14 months versus 31 months (S+ versus S0, P = 0.005). Overall rate of S+ was 53%. S-status and lymph node ratio constituted the only independent predictors of survival. Stranding of the superior mesenteric artery fat sheath was the only independent radiologic predictor of S+ resection, and achieved a 71% correct prediction of S-status.Mesopancreatic stromal clearance is a major determinant of curative resection in PDAC, and preoperative prediction by cross-sectional imaging is possible, setting the basis for a new definition of borderline resectability.

International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer

BACKGROUND

Pancreatic cancer is one of the most devastating diseases with an extremely high mortality. Medical organizations and scientific societies have published a number of guidelines to address active treatment of pancreatic cancer. The aim of this consensus review was to identify where there is agreement or disagreement among the existing guidelines and to help define the gaps for future studies.

METHODS

A panel of expert pancreatologists gathered at the 46th European Pancreatic Club Meeting combined with the 18th International Association of Pancreatology Meeting and collaborated on critical reviews of eight English language guidelines for the clinical management of pancreatic cancer. Clinical questions (CQs) of interest were proposed by specialists in each of nine areas. The recommendations for the CQs in existing guidelines, as well as the evidence on which these were based, were reviewed and compared. The evidence was graded as sufficient, mediocre or poor/absent.

RESULTS

Only 4 of the 36 CQs, had sufficient evidence for agreement. There was also agreement in five additional CQs despite the lack of sufficient evidence. In 22 CQs, there was disagreement regardless of the presence or absence of evidence. There were five CQs that were not addressed adequately by existing guidelines.

CONCLUSION

The existing guidelines provide both evidence- and consensus-based recommendations. There is also considerable disagreement about the recommendations in part due to the lack of high level evidence. Improving the clinical management of patients with pancreatic cancer, will require continuing efforts to undertake research that will provide sufficient evidence to allow agreement.

[Vascular resection and reconstruction techniques in pancreatic surgery]

BACKGROUND

Vascular resection interventions and the associated necessity of a reconstruction for maintenance particularly of hepatic and small intestinal perfusion are important aspects especially for the surgical treatment of pancreatic cancer. An R0 resection is the only curative treatment option for patients with pancreatic cancer. Venous or arterial vascular infiltration by the tumor and the associated resection and reconstruction for complete tumor removal and establishment of a sufficient perfusion of the dependent organs represents one of the greatest challenges in pancreatic surgery. In addition the oncological significance with respect to arterial vascular resections is controversial.

OBJECTIVE

In this review article the indications and technical aspects of vascular resection and reconstruction in the therapy of pancreatic cancer are presented and discussed based on the current literature.

MATERIAL AND METHODS

A systematic search of Medline, Embase and the Cochrane Library was carried out to identify studies reporting the results of venous or arterial vascular resection techniques, postoperative morbidity, mortality and patient survival after surgery for pancreatic cancer. Results Pancreatic cancer with vascular infiltration should not principally be seen as non-resectable but must always be checked for the possibility of a curative resection. A decisive factor is the differentiation between venous and arterial vascular involvement. Various safe technical options are available for venous vascular resection, depending on the extent of tumor infiltration. Arterial vascular resections are associated with an increased morbidity and mortality. In selected patients a complete tumor resection and prolonged survival can be achieved by arterial vascular resection.

Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection.

METHODS

A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes.

RESULTS

Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results.

CONCLUSION

This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.

Neoadjuvant therapy for patients with borderline resectable pancreatic cancer: A systematic review and meta-analysis of response and resection percentages

BACKGROUND

We systematically reviewed and performed a meta-analysis of the available data regarding neoadjuvant chemo- and/or radiotherapy with special emphasis on tumor response/progression rates, toxicities, and clinical benefit, i.e. resection probabilities and survival estimates.

METHODS AND FINDINGS

Trials were identified by searching PUBMED, MEDLINE, and the Cochrane Central Register of Controlled Trials from 1966 to Feb 2015. A total of 18 studies (n = 959) were analyzed. the estimated fraction of patients with complete response was 2.8% (CI 0.8-4.7%) and with partial response 28.7% (CI 18.9%-38.5%). Stable disease was averaged to 45.9% (CI 32.9%-58.9%) in all patients and tumor progression under therapy occurred by estimation in 16.9% (CI 10.2%-23.6%) of the patients. The weighted frequency of those who underwent resection was 65.3% (CI 54.2%-76.5%), and the proportion of R0 resection amounted to 57.4% (CI 48.2%-66.5%). The weighted mean of median survival amounted to 17.9 months (range: 14.7-21.2 months) for the overall cohort of patients, 25.9 months (range: 21.1-30.7 months) for those who were resected, and 11.9 months (range: 10.4-13.5 months) for unresected patients.

CONCLUSIONS

The resection and R0 resection rates in the group of borderline resectable tumor patients after neoadjuvant therapy are similar to the resectable tumor patients, much higher than those in unresectable tumor patients. The survival estimates of borderline resectable tumor patients after neoadjuvant therapy were similar to resectable tumor patients. Patients with borderline resectable pancreatic cancer should be included in neoadjuvant protocols and subsequently be reevaluated for resection. How to find chemo-responsiveness before neoadjuvant chemotherapy so as to give individualized treatment is still an important issue.

Cattell-Braasch Maneuver Combined with Artery-First Approach for Superior Mesenteric-Portal Vein Resection During Pancreatectomy

Pancreatectomy associated with superior mesenteric-portal vein (SMPV) resection is currently considered the standard of care for patients with pancreatic tumors involving the major peripancreatic veins. However, a standard approach for resection and reconstruction is not defined yet. The aim of this study is to analyze the feasibility and short-term results of an original Cattell-Braasch artery-first approach (CBAF) for the resection of SMPV during pancreatectomy. Of 144 pancreatectomies with vascular resection undertaken from 2008 to 2013 at Karolinska University Hospital, 45 (31.2 %) were performed combining a Cattell-Braasch maneuver with an artery-first approach (from 2011 to 2013). The mean patient age was 65.2 years. Thirty-seven (82.2 %) patients underwent pancreatoduodenectomy and 8 (17.8 %) total pancreatectomy. Histology showed pancreatic ductal adenocarcinoma in 42 patients (93.3 %). The median length of the resected SMPV segment was 4.6 cm (range 3-7). In all patients, a direct end-to-end anastomosis was performed without graft interposition. In nine cases (20 %), an arterial resection was also performed. There was no mortality in this series, and the morbidity rate was 35.5 %. Combined CBAF for the resection of SMPV during pancreatectomy seems to be safe and effective. The reconstruction of the resected vessels is possible in many cases without graft interposition, even if the resected vein segment is of considerable length.

The concept and controversy of retroperitoneal nerve dissection in pancreatic head carcinoma (Review)

Pancreatic head cancer is a common but the most lethal cancer of the human digestive system. It is invasive, resulting in early infiltration of adjacent structures and lymph node and distant metastases. Its biological characteristics of neurotropic growth lead to early neural invasion (NI) which is an independent prognostic factor of survival for pancreatic cancer. Radical surgical resection remains the only form of curative treatment. The extent of surgical resection and whether extended resection results in better long-term survival have been controversial. Studies have reported that peripancreatic plexus invasion is a frequent cause of pancreatic cancer recurrence and death. The relationship between cancer microenvironment and nerve cells, and whether the peripancreatic nerve plexus nearby needs to be resected require further studies. The present review aims to discuss the role of peripancreatic nerve and its implications in pancreatic head cancer resection.

Outcomes of arterial resection during pancreatectomy for tumor

OBJECTIVE

Arterial resection (AR) during pancreatic tumor resection is controversial. We examined the safety and efficacy of AR during pancreatectomy.

METHODS

We used a prospective institutional database that includes 6522 patients who underwent pancreatectomy from 1970 to 2014; 35 had AR. We performed a 2:1 propensity match for patients without and with AR on the basis of preoperative patient and tumor variables. We then compared operative and postoperative outcomes between matched groups.

RESULTS

AR included 18 hepatic, 8 celiac, 3 splenic, 3 middle colic, 2 superior mesenteric, and 1 left renal artery. There were 20 primary, 4 vein, and 2 graft reconstructions; 11 were emergent and 24 elective. Before matching, patients with AR were younger (58 ± 2 vs 63 ± 0.2 years old; P = .05), more likely to be of black race (26% vs 9%; P = .003), to have received preoperative chemotherapy (17% vs 2%; P < .001), have a later stage and larger tumor (4 ± 0.8 vs 3 ± 0.04 cm; P = .05), more resections that included removal of all macroscopic disease, but microscopic residual tumor remained (31% vs 14%; P = .02), greater blood loss (1285 ± 276 vs 822 ± 16 mL; P = .02), and more frequent cardiac complications (11% vs 4%; P = .03) compared with patients without AR. After propensity matching, baseline patient characteristics were similar between groups. For perioperative outcomes, the groups did not differ in surgical time, blood loss, length of stay, or complications including anastomotic leaks, bleeding, cardiac, infectious complications, or liver infarct or failure (all; P = not significant). Patency was 97% at a mean follow-up of 510 ± 184 days with 1 hepatic artery AR thrombosis. Long-term outcomes were significantly different: patients with AR had a lower rate of local tumor recurrence (20% vs 47%; P = .007) but also lower 1-year (50% vs 87%; P = .002) and median survival (22 ± 18 vs 49 ± 7 months; P = .002).

CONCLUSIONS

AR during pancreatectomy is safe and not associated with increased complications. Although it significantly reduces the risk of local tumor recurrence, AR is associated with worse survival compared with patients who do not undergo AR.

Current State of Vascular Resections in Pancreatic Cancer Surgery

Pancreatic cancer (PDAC) is the fourth leading cause of cancer-related mortality in the Western world and, even in 2014, a therapeutic challenge. The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis. As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies. In contrast to adjuvant treatment which has to be regarded as a cornerstone to achieve long-term survival after resection, neoadjuvant treatment strategies for locally advanced findings are currently under debate. This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.

Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group

BACKGROUND

Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas.

METHODS

This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS).

RESULTS

1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality.

CONCLUSION

This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.

Mesenteric-Portal Vein Resection during Pancreatectomy for Pancreatic Cancer

The aim of the present study was to determine the outcome of patients undergoing pancreatic resection with (VR+) or without (VR−) mesenteric-portal vein resection for pancreatic carcinoma. Between January 1998 and December 2012, 241 patients with pancreatic cancer underwent pancreatic resection: in 64 patients, surgery included venous resection for macroscopic invasion of mesenteric-portal vein axis. Morbidity and mortality did not differ between the two groups (VR+: 29% and 3%; VR−: 30% and 4.0%, resp.). Radical resection was achieved in 55/64 (78%) in the VR+ group and in 126/177 (71%) in the VR− group. Vascular invasion was histologically proven in 44 (69%) of the VR+ group. Survival curves were not statistically different between the two groups. Mean and median survival time were 26 and 15 months, respectively, in VR− versus 20 and 14 months, respectively, in VR+ group (p = 0.52). In the VR+ group, only histologically proven vascular invasion significantly impacted survival (p = 0.02), while, in the VR− group, R0 resection (p = 0.001) and tumor's grading (p = 0.01) significantly influenced long-term survival. Vascular resection during pancreatectomy can be performed safely, with acceptable morbidity and mortality. Long-term survival was the same, with or without venous resection. Survival was worse for patients with histologically confirmed vascular infiltration.

Management of borderline resectable pancreatic cancer

Pancreatic cancer is the fourth most common cause of cancer death in the United States. Surgery remains the only curative option; however only 20% of the patients have resectable disease at the time of initial presentation. The definition of borderline resectable pancreatic cancer is not uniform but generally denotes to regional vessel involvement that makes it unlikely to have negative surgical margins. The accurate staging of pancreatic cancer requires triple phase computed tomography or magnetic resonance imaging of the pancreas. Management of patients with borderline resectable pancreatic cancer remains unclear. The data for treatment of these patients is primarily derived from retrospective single institution experience. The prospective trials have been plagued by small numbers and poor accrual. Neoadjuvant therapy is recommended and typically consists of chemotherapy and radiation therapy. The chemotherapeutic regimens continue to evolve along with type and dose of radiation therapy. Gemcitabine or 5-fluorouracil based chemotherapeutic combinations are administered. The type and dose of radiation vary among different institutions. With neoadjuvant treatment, approximately 50% of the patients are able to undergo surgical resections with negative margins obtained in greater than 80% of the patients. Newer trials are attempting to standardize the definition of borderline resectable pancreatic cancer and treatment regimens. In this review, we outline the definition, imaging requirements and management of patients with borderline resectable pancreatic cancer.

Vascular Resection in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignant tumors and represents the fifth most common cause of cancer-related deaths. It is associated with a poor prognosis, likely due to the tendency of the tumor for early local and distant spread. One of the major obstacles of effectively treating PDAC is the often late diagnosis. Among all options currently available for PDAC, surgical resection offers the only potential cure with 5-year survival rate of approximately 15-20 %. However, in the absence of metastatic disease, which precludes resection, assessment of vascular invasion is an important parameter for determining resectability for pancreatic cancer. The vascular involvement in patients with pancreatic carcinoma ranges between 21 and 64 %. Historically, vascular involvement has been considered a contraindication to resective cure. Meanwhile, the surgical approach of pancreatoduodenectomy (PD) combined with vascular resection and reconstruction has been widely applied in clinical practice to remove the tumor completely. Therefore, vascular invasion is no longer a surgical contraindication and the rate of surgical resection has greatly increased. Moreover, PD combined with vascular resection can account for 20 to 25 % of the total cases of PD surgery in a number of the larger pancreas treatment centers. The aim of this review is to provide an overview of management and outcome of vascular resection in PDAC surgery.

Surgery for Pancreatic and Periampullary Carcinoma

Surgical resection for pancreatic and periampullary cancer has evolved over several decades. The postoperative mortality for these resections has declined to less than 5 %. However, morbidity associated with these resections is still considerable. Various technical modifications like pylorus preservation, reconstruction techniques and methods to perform pancreaticoenteric anastomosis have been suggested to improve postoperative outcomes after pancreaticoduodenectomy. Surgical modifications to improve oncological clearance and decrease fistula rates after distal pancreatic resections have also been suggested. Dilemma still exists whether interventions like pancreatic duct stents, octreotide and drains help to improve postoperative outcomes. The role of extended lymph node dissection and extended resections for pancreatic and periampullary cancer is still controversial, as is the management of borderline resectable pancreatic cancer. In this review, we discuss the literature pertaining to various surgical aspects of pancreatic and periampullary carcinoma.

Distal pancreatectomy with celiac axis resection for pancreatic body and tail cancer invading celiac axis

Purpose

Pancreatic body/tail cancer often involves the celiac axis (CA) and it is regarded as an unresectable disease. To treat the disease, we employed distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and reviewed our experiences.

Methods

We performed DP-CAR for seven patients with pancreatic body/tail cancer involving the CA. The indications of DP-CAR initially included tumors with definite invasion of CA and were later expanded to include borderline resectable disease. To determine the efficacy of DP-CAR, the clinico-pathological data of patients who underwent DP-CAR were compared to both distal pancreatectomy (DP) group and no resection (NR) group.

Results

The R0 resection rate was 71.4% and was not statistically different compared to DP group. The operative time (P = 0.018) and length of hospital stay (P = 0.022) were significantly longer in DP-CAR group but no significant difference was found in incidence of the postoperative pancreatic fistula compared to DP group. In DP-CAR group, focal hepatic infarction and transient hepatopathy occurred in 1 patient and 3 patients, respectively. No mortality occurred in DP-CAR group. The median survival time (MST) was not statistically different compared to DP group. However, the MST of DP-CAR group was significantly longer than that of NR group (P < 0.001).

Conclusion

In our experience, DP-CAR was safe and offered high R0 resection rate for patients with pancreatic body/tail cancer with involvement of CA. The effect on survival of DP-CAR is comparable to DP and better than that of NR. However, the benefits need to be verified by further studies in the future.

Meta-analysis of radical resection rates and margin assessment in pancreatic cancer

BACKGROUND

R0 resection rates (complete tumour removal with negative resection margins) in pancreatic cancer are 70-80 per cent when a 0-mm margin is used, declining to 15-24 per cent with a 1-mm margin. This review evaluated the R0 resection rates according to different margin definitions and techniques.

METHODS

Three databases (MEDLINE from 1946, PubMed from 1946 and Embase from 1949) were searched to mid-October 2014. The search terms included 'pancreatectomy OR pancreaticoduodenectomy' and 'margin'. A meta-analysis was performed with studies in three groups: group 1, axial slicing technique (minimum 1-mm margin); group 2, other slicing techniques (minimum 1-mm margin); and group 3, studies with minimum 0-mm margin.

RESULTS

The R0 rates were 29 (95 per cent c.i. 26 to 32) per cent in group 1 (8 studies; 882 patients) and 49 (47 to 52) per cent in group 2 (6 studies; 1568 patients). The combined R0 rate (groups 1 and 2) was 41 (40 to 43) per cent. The R0 rate in group 3 (7 studies; 1926 patients) with a 0-mm margin was 72 (70 to 74) per cent The survival hazard ratios (R1 resection/R0 resection) revealed a reduction in the risk of death of at least 22 per cent in group 1, 12 per cent in group 2 and 23 per cent in group 3 with an R0 compared with an R1 resection. Local recurrence occurred more frequently with an R1 resection in most studies.

CONCLUSION

Margin clearance definitions affect R0 resection rates in pancreatic cancer surgery. This review collates individual studies providing an estimate of achievable R0 rates, creating a benchmark for future trials.

Resectability After First-Line FOLFIRINOX in Initially Unresectable Locally Advanced Pancreatic Cancer: A Single-Center Experience

BACKGROUND

FOLFIRINOX is an active but relatively toxic chemotherapeutic regimen for patients with metastatic pancreatic ductal adenocarcinoma (PDAC). The increased frequency of responding tumors shift interest to neoadjuvant approaches. We report our institutional experience with FOLFIRINOX for therapy-naïve patients with locally advanced and initially unresectable PDAC.

METHODS

All patients with unresectable locally advanced PDAC who underwent treatment with FOLFIRINOX at a single center between 2011 and 2014 were identified and evaluated retrospectively regarding chemotherapy response, toxicity, conversion to resectability, and survival. Resectability, response to chemotherapy, and postoperative complications were reported according to NCCN-guidelines, RECIST-criteria, and Clavien-Dindo-classification, respectively.

RESULTS

Overall, 14 patients received FOLFIRINOX as first-line therapy for locally advanced and unresectable PDAC. Fifty-seven percent of the patients had severe tumor-related comorbidities at the time of diagnosis, and in 86 %, dose reduction due to toxicity was necessary during a median of seven cycles. Nevertheless, only one patient had progressive disease during FOLFIRINOX, whereas the others experienced stable disease (n = 6) or partial remission (n = 6; no restaging in one patient). Oncological tumor resection was possible in 4 patients (29 % of all patients) with no postoperative mortality and only one grade 2 surgical complication. After a median follow-up of 10 months, 4 of the 14 patients were still in remission, 5 were alive with stable disease under ongoing systemic chemotherapy, and 5 died tumor-related.

CONCLUSIONS

FOLFIRINOX is a powerful first-line regimen that leads to resectability in a substantial portion of patients with initially unresectable pancreatic cancer.

National Comprehensive Cancer Network Resectability Status for Pancreatic Carcinoma Predicts Overall Survival

BACKGROUND

The aim of this study was to evaluate the validity of preoperative resectability status, as defined by the National Comprehensive Cancer Network (NCCN), from the viewpoint of overall survival.

METHODS

A total of consecutive 704 patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with upfront surgery at seven Japanese hospitals between 2001 and 2012 were evaluated retrospectively. According to the NCCN definition of preoperative resectability status, tumors were divided into resectable tumors without vascular contact (R group), resectable tumors with portal or superior mesenteric vein (PV/SMV) contact of ≦180° (R-PV group), borderline resectable(BR) tumors with PV/SMV contact of >180° (BR-PV group), and BR tumors with arterial contact (BR-A group). The relationship between the NCCN definition of preoperative resectability status and overall survival was analyzed.

RESULTS

Of the 704 patients, 389, 114, 145, and 56 were classified into the R group, the R-PV group, the BR-PV group, and the BR-A group, respectively. Overall survival of the BR-PV and BR-A groups was significantly worse than that of the R group and R-PV groups (P < 0.05), although there was no significant difference in overall survival between the R group and the R-PV group (P = 0.310). Multivariate analysis revealed that PV/SMV contact of >180° (P = 0.008) and arterial contact (P < 0.001) were independent prognostic factors of overall survival.

CONCLUSION

From the viewpoint of overall survival, the NCCN definition of preoperative resectability status was valid.

State of the art and future directions of pancreatic ductal adenocarcinoma therapy

Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second cause of cancer-related death in 2030. PDAC is the poorest prognostic tumor of the digestive tract, with 80% of patients having advanced disease at diagnosis and 5-year survival rate not exceeding 7%. Until 2010, gemcitabine was the only validated therapy for advanced PDAC with a modest improvement in median overall survival as compared to best supportive care (5-6 vs 3 months). Multiple phase II-III studies have used various combinations of gemcitabine with other cytotoxics or targeted agents, most in vain, in attempt to improve this outcome. Over the past few years, the landscape of PDAC management has undergone major and rapid changes with the approval of the FOLFIRINOX and gemcitabine plus nab-paclitaxel regimens in patients with metastatic disease. These two active combination chemotherapy options yield an improved median overall survival (11.1 vs 8.5 months, respectively) thus making longer survival a reasonably achievable goal. This breakthrough raises some new clinical questions about the management of PDAC. Moreover, better knowledge of the environmental and genetic events that underpin multistep carcinogenesis and of the microenvironment surrounding cancer cells in PDAC has open new perspectives and therapeutic opportunities. In this new dynamic context of deep transformation in basic research and clinical management aspects of the disease, we gathered updated preclinical and clinical data in a multifaceted review encompassing the lessons learned from the past, the yet unanswered questions, and the most promising research priorities to be addressed for the next 5 years.

Imaging preoperatively for pancreatic adenocarcinoma

Pancreatic cancer is a highly lethal malignancy which is increasing in incidence and mortality. The fourth leading cause of cancer death in the U.S., pancreatic cancer is projected to become the second leading cause of cancer death by 2020. Patients with pancreatic cancer have an abysmal 5-year survival of 6%, and 90% of these patients eventually die from the disease. This is in large part due to the commonly advanced stage of disease at the time of diagnosis. Currently, the only potentially curative therapy for pancreatic carcinoma is complete surgical resection. Patients who undergo incomplete resection with residual disease have similar survival rates to those patients with metastatic disease and should be spared this relatively morbid surgery. Thus, the key to impacting prognosis is the detection of smaller and earlier stage lesions, and the key to optimal management is accurately determining which patients have potentially resectable surgery and which patients would not benefit from surgery. Cross-sectional imaging plays an essential role in both the diagnosis and appropriate staging of pancreatic carcinoma. The diagnosis and staging of pancreatic adenocarcinoma is performed with cross-sectional imaging. Multi-detector computed tomography (MDCT) is the most commonly used, best-validated imaging modality for the diagnosis and staging of pancreatic cancer. Modern contrast-enhanced magnetic resonance imaging (MRI) has been demonstrated to be equivalent to MDCT in detection and staging of pancreatic cancer. Endoscopic ultrasound (EUS) is very sensitive for detecting pancreatic masses; however, due to limitations in adequate overall abdominal staging, it is generally used in addition to or after MDCT. Transabdominal ultrasound and positron emission tomography/computed tomography (PET/CT) have limited roles in the diagnosis and staging of pancreatic cancer. Preoperative imaging is used to characterize patients as having resectable disease, borderline resectable disease, locally advanced disease (unresectable) and metastatic disease (unresectable). As the definitions of borderline resectable and unresectable may vary from institution to institution and within institutions, it is essential to accurately assess and describe the factors relevant to staging including: local extent of tumor, vascular involvement, lymph node involvement and distant metastatic disease. To facilitate this, standardized reporting templates for pancreatic ductal adenocarcinoma have been created and published. Structured reporting for pancreatic cancer has been reported to provide superior evaluation of pancreatic cancer, facilitate surgical planning, and increase surgeons' confidence about tumor resectability.

Adjuvant radiation therapy for pancreatic cancer: a review of the old and the new

Surgery represents the only potential curative treatment option for patients diagnosed with pancreatic adenocarcinoma. Despite aggressive surgical management for patients deemed to be resectable, rates of local recurrence and/or distant metastases remain high, resulting in poor long-term outcomes. In an effort to reduce recurrence rates and improve survival for patients having undergone resection, adjuvant therapies (ATs) including chemotherapy and chemoradiation therapy (CRT) have been explored. While adjuvant chemotherapy has been shown to consistently improve outcomes, the data regarding adjuvant radiation therapy (RT) is mixed. Although the ability of radiation to improve local control has been demonstrated, it has not always led to improved survival outcomes for patients. Early trials are flawed in their utilization of sub-optimal radiation techniques, limiting their generalizability. Recent and ongoing trials incorporate more optimized RT approaches and seek to clarify its role in treatment strategies. At the same time novel radiation techniques such as intensity modulated RT (IMRT) and stereotactic body RT (SBRT) are under active investigation. It is hoped that these efforts will lead to improved disease-related outcomes while reducing toxicity rates.