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Fromer MW, Hawthorne J, Philips P, Egger ME, Scoggins CR, McMasters KM, Martin RCG. An Improved Staging System for Locally Advanced Pancreatic Cancer: A Critical Need in the Multidisciplinary Era. Ann Surg Oncol 2021; 28:6201-6210. [PMID: 34089107 DOI: 10.1245/s10434-021-10174-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Locally-advanced pancreatic cancer (LAPC) is traditionally considered stage III unresectable disease. Advances in induction systemic therapy regimens, surgical technique, and perioperative care have led to successful resection of an increasing number of these tumors with reasonable perioperative outcomes and disease-free intervals. Certain anatomic characteristics that meet criteria for locally-advanced disease, however, are more likely to result in a successful surgical outcome. METHODS A practical and consistent system is needed to communicate such nuance between surgical and nonsurgical oncologists for optimal treatment planning and to improve recording for cancer registries and research studies. RESULTS The present study proposes a novel subclassification system for stage III pancreatic cancers based on their pattern of vascular involvement and examines the current evidence for resection in each scenario. Introducing needed detail into the current catch-all stage III categorization will help to direct patient referrals and increase the body of knowledge about the variable presentations of this complex malignancy. CONCLUSION This proposed staging revision for LAPC is designed to convey more actionable tumor descriptions for treating oncologists, clinical trial eligibility, and surgical patient selection in the era of effective induction systemic therapy.
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Affiliation(s)
- Marc W Fromer
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jenci Hawthorne
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Prejesh Philips
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA.
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202
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Mihaljevic AL, Hackert T, Loos M, Hinz U, Schneider M, Mehrabi A, Hoffmann K, Berchtold C, Müller-Stich BP, Diener M, Strobel O, Büchler MW. Not all Whipple procedures are equal: Proposal for a classification of pancreatoduodenectomies. Surgery 2021; 169:1456-1462. [PMID: 33386130 DOI: 10.1016/j.surg.2020.11.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreatoduodenectomy is the standard treatment for pathologies of the pancreatic head and is performed routinely worldwide. The aim of the study was to analyze this procedure in terms of extent of surgery, technical difficulty, and clinical outcomes and thereby provide a standardized surgical categorization of pancreatoduodenectomies for future reference. METHODS For this cohort study, all patients who underwent pancreatoduodenectomy at a single center within an 18-year period (October 2001 to December 2019) were identified in a prospectively maintained database. Based on technical difficulty and extent of surgery, 4 pancreatoduodenectomy types were proposed: (1) standard pancreatoduodenectomy; (2) pancreatoduodenectomy with portal vein/superior mesenteric vein resection; (3) pancreatoduodenectomy with multivisceral resection; and (4) pancreatoduodenectomy with arterial resection. Patient characteristics, surgical parameters, and perioperative morbidity and mortality were analyzed. The 4 types were compared with regard to their surgical outcomes. RESULTS A total of 3,953 pancreatoduodenectomies were performed in the study period. Standard pancreatoduodenectomy (type 1) was the most frequent procedure (n = 2,931, 74.1%), followed by pancreatoduodenectomy with portal vein/superior mesenteric vein resection (type 2: n = 568, 14.4%), pancreatoduodenectomy with multivisceral resection (type 3: n = 415, 10.5%), and pancreatoduodenectomy with arterial resection (type 4: n = 39, 1.0%). Demographic baseline characteristics were clinically comparable among pancreatoduodenectomy types. Mortality within 90-days correlated with the type of pancreatoduodenectomy (type 1: 2.9%; type 2: 4.2%; type 3: 6.3%; type 4: 10.3%; P = .0007). Overall surgical morbidity was 41.7% (type 1), 40.8% (type 2), 52.5% (type 3), and 59.0% (type 4) (P < .0001), including postoperative pancreatic fistula type B/C (type 1: 11.9%; type 2: 7.7%; type 3: 14.7%; type 4: 15.4; P = .0031) and delayed gastric emptying (type 1: 19.4%; type 2: 22.5%; type 3: 22.0%; type 4: 25.6%; P = .187) as the most frequent complications. Relaparotomies were more frequent in type 4 (20.5%) and type 3 (20.6%) than in type 2 (12.0%) or type 1 (10.4%) pancreatoduodenectomy (P < .0001). Intensive care unit stay ≥2 days was more frequent in type 4 (48.7%) compared with type 3 (25.7%) or type 2 (27.1%) and type 1 (18.6%) (P < .0001). CONCLUSION The results show different clinical outcomes for the 4 types of pancreatoduodenectomy. Morbidity and mortality correlate with pancreatoduodenectomy type. The proposed pancreatoduodenectomy classification is useful for reporting pancreatoduodenectomy procedures, enhances the comparability of future studies, may be used for training purposes, and may guide intra and postoperative decision-making.
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Affiliation(s)
- Andre L Mihaljevic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Katrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Markus Diener
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany.
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203
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Coppola A, La Vaccara V, Fiore M, Farolfi T, Ramella S, Angeletti S, Coppola R, Caputo D. CA19.9 Serum Level Predicts Lymph-Nodes Status in Resectable Pancreatic Ductal Adenocarcinoma: A Retrospective Single-Center Analysis. Front Oncol 2021; 11:690580. [PMID: 34123859 PMCID: PMC8190389 DOI: 10.3389/fonc.2021.690580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
Background The choice between upfront surgery or neoadjuvant treatments (NAT) for resectable pancreatic ductal adenocarcinoma (R-PDAC) is controversial. R-PDAC with potential nodal involvement could benefit from NT. Ca (Carbohydrate antigen) 19.9 and serum albumin levels, alone or in combination, have proven their efficacy in assessing PDAC prognosis. The objective of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC. Methods Preoperative Ca 19.9, as well as serum albumin levels, of 165 patients selected for upfront surgery have been retrospectively collected and correlated to pathological nodal status (N), resection margins status (R) and vascular resections (VR). We further performed ROC curve analysis to identify optimal Ca 19.9 cut-off for pN+, R+ and vascular resection prediction. Results Increased Ca 19.9 levels in 114 PDAC patients were significantly associated with pN+ (p <0.001). This ability, confirmed in all the series by ROC curve analysis (Ca 19.9 ≥32 U/ml), was lost in the presence of hypoalbuminemia. Furthermore, Ca 19.9 at the cut off >418 U/ml was significantly associated with R+ (87% specificity, 36% sensitivity, p 0.014). Ca 19.9, at the cut-off >78 U/ml, indicated a significant trend to predict the need for VR (sensitivity 67%, specificity 53%; p = 0.059). Conclusions In R-PDAC with normal serum albumin levels, Ca 19.9 predicts pN+ and R+, thus suggesting a crucial role in deciding on NAT.
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Affiliation(s)
| | | | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Tommaso Farolfi
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, Campus Bio-Medico University, Rome, Italy
| | - Roberto Coppola
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
| | - Damiano Caputo
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
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204
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Schneider M, Hackert T, Strobel O, Büchler MW. Technical advances in surgery for pancreatic cancer. Br J Surg 2021; 108:777-785. [PMID: 34046668 DOI: 10.1093/bjs/znab133] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate curative-intent resection in PDAC. METHODS A review of the literature addressing current technical advances in surgery for PDAC was performed, and current state-of-the-art surgical techniques summarized. RESULTS Artery-first and uncinate-first approaches, dissection of the anatomical triangle between the coeliac and superior mesenteric arteries and the portomesenteric vein, and radical antegrade modular pancreatosplenectomy were introduced to enhance the completeness of resection and reduce the risk of local recurrence. Elaborated techniques for resection and reconstruction of the mesenteric-portal vein axis and a venous bypass graft-first approach frequently allow resection of PDAC with venous involvement, even in patients with portal venous congestion and cavernous transformation. Arterial involvement does not preclude surgical resection per se, but may become surgically manageable with recent techniques of arterial divestment or arterial resection following neoadjuvant treatment. CONCLUSION Advanced techniques of surgical resection and vessel reconstruction provide a toolkit for curative-intent surgery in borderline resectable and locally advanced PDAC. Effects of these surgical approaches on overall survival remain to be proven with high-level clinical evidence.
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Affiliation(s)
- M Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - O Strobel
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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205
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Ronellenfitsch U, Michalski CW, Michl P, Krug S, Ukkat J, Kleeff J. Pre-operative/Neoadjuvant Therapy and Vascular Debranching Followed by Resection for Locally Advanced Pancreatic Cancer (PREVADER): Clinical Feasibility Trial. Front Med (Lausanne) 2021; 8:588375. [PMID: 34109185 PMCID: PMC8180544 DOI: 10.3389/fmed.2021.588375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Pancreatic cancer continues to have a poor outcome. Many patients are diagnosed with advanced disease, and in a considerable proportion, abutment or invasion of visceral arteries is present. Moreover, some patients have anatomical variations or stenosis of major visceral arteries requiring arterial reconstruction upon pancreatic cancer resection to avoid organ ischemia. Simultaneous arterial reconstruction during resection is associated with relevant morbidity and mortality. This trial evaluates the approach of visceral debranching, that is, arterial reconstruction, prior to neoadjuvant chemotherapy and tumor resection in patients with locally advanced, unresectable pancreatic cancer. Methods and Analysis: The trial includes patients with locally advanced, non-metastatic pancreatic cancer with arterial abutment or invasion (deemed primarily unresectable), variations in vascular anatomy, or stenosis of visceral arteries. The participants undergo visceral debranching, followed by current standard neoadjuvant chemotherapy (mFOLFIRINOX, gemcitabine-nab-paclitaxel, or other) and potential subsequent tumor resection. The primary outcome is feasibility, measured as the proportion of patients who start neoadjuvant therapy within 6 weeks of visceral debranching. The trial has an exact single-stage design. The proportion below which the treatment is considered ineffective is set at 0.7 (H0). The proportion above which the treatment warrants further exploration in a phase III trial is set at 0.9 (H1). With a power (1-beta) of 0.8 and a type 1 mistake (alpha) of 0.05, the required sample size is 28 patients. Feasibility of the approach will be assumed if 24 of the enrolled 28 patients proceed to neoadjuvant chemotherapy within 6 weeks from visceral debranching. Discussion: This trial evaluates a new treatment sequence, that is, visceral debranching followed by chemotherapy and resection, for pancreatic cancer with invasion or abutment of visceral arteries. The primary objective of the trial is to evaluate feasibility. Trial results will allow for estimating treatment effects and calculating the sample size of a randomized controlled trial, in which the approach will be tested if the feasibility endpoint is met. Clinical Trial Registration: clinicaltrials.gov, identifier: NCT04136769.
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Affiliation(s)
- Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Christoph W Michalski
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Patrick Michl
- Department of Internal Medicine I, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Sebastian Krug
- Department of Internal Medicine I, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Joerg Ukkat
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Joerg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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206
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Kauffmann EF, Napoli N, Genovese V, Ginesini M, Gianfaldoni C, Vistoli F, Amorese G, Boggi U. Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series. Updates Surg 2021; 73:955-966. [PMID: 34009627 PMCID: PMC8184722 DOI: 10.1007/s13304-021-01079-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 01/04/2023]
Abstract
This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.
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Affiliation(s)
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Valerio Genovese
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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207
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Okubo S, Suzuki T, Hioki M, Shimizu Y, Toyama H, Morinaga S, Gotohda N, Uesaka K, Ishii G, Takahashi S, Kojima M. The immunological impact of preoperative chemoradiotherapy on the tumor microenvironment of pancreatic cancer. Cancer Sci 2021; 112:2895-2904. [PMID: 33931909 PMCID: PMC8253289 DOI: 10.1111/cas.14914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 12/14/2022] Open
Abstract
Several therapeutic regimens, including neoadjuvant chemoradiation therapy (NACRT), have been reported to serve as anticancer immune effectors. However, there remain insufficient data regarding the immune response after NACRT in pancreatic ductal adenocarcinoma (PDAC) patients. Data from 40 PDAC patients that underwent surgical resection after NACRT (NACRT group) and 30 PDAC patients that underwent upfront surgery (US group) were analyzed to examine alterations in immune cell counts/distribution using a multiplexed fluorescent immunohistochemistry system. All immune cells were more abundant in the cancer stroma than in the cancer cell nest regardless of preoperative therapy. Although the stromal counts of CD4+ T cells, CD20+ B cells, and Foxp3+ T cells in the NACRT group were drastically decreased in comparison with those of the US group, counts of these cell types in the cancer cell nest were not significantly different between the two groups. In contrast, CD204+ macrophage counts in the cancer stroma were similar between the NACRT and US groups, while those in the cancer cell nests were significantly reduced in the NACRT group. Following multivariate analysis, only a high CD204+ macrophage count in the cancer cell nest remained an independent predictor of shorter relapse-free survival (odds ratio = 2.37; P = .033). NACRT for PDAC decreased overall immune cell counts, but these changes were heterogeneous within the cancer cell nests and cancer stroma. The CD204+ macrophage count in the cancer cell nest is an independent predictor of early disease recurrence in PDAC patients after NACRT.
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Affiliation(s)
- Satoshi Okubo
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan.,Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Japan
| | - Toshihiro Suzuki
- Division of Cancer Immunotherapy, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan.,General Medicinal Education and Research Center, Teikyo University, Tokyo, Japan
| | - Masayoshi Hioki
- Department of Gastroenterological Surgery, Fukuyama City Hospital, Hiroshima, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Soichiro Morinaga
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Kanagawa, Japan
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Genichiro Ishii
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan
| | - Shinichiro Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Motohiro Kojima
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan
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208
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Pancreatic Cancer: "Whether to Cross the Border"? Indian J Surg Oncol 2021; 12:235-237. [PMID: 34295062 DOI: 10.1007/s13193-021-01341-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022] Open
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209
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Parray A, Bhandare MS, Pandrowala S, Chaudhari VA, Shrikhande SV. Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer. HPB (Oxford) 2021; 23:777-784. [PMID: 33041206 DOI: 10.1016/j.hpb.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is more challenging in the elderly. METHODS Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL). RESULTS Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients. CONCLUSION Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.
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Affiliation(s)
- Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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210
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Nappo G, Borzomati D, Zerbi A, Spaggiari P, Boggi U, Campani D, Mrowiec S, Liszka Ł, Coppola A, Amato M, Petitti T, Vistoli F, Montorsi M, Perrone G, Coppola R, Caputo D. The Role of Pathological Method and Clearance Definition for the Evaluation of Margin Status after Pancreatoduodenectomy for Periampullary Cancer. Results of a Multicenter Prospective Randomized Trial. Cancers (Basel) 2021; 13:2097. [PMID: 33926138 PMCID: PMC8123600 DOI: 10.3390/cancers13092097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is extreme heterogeneity in the available literature on the determination of R1 resection rate after pancreatoduodenectomy (PD); consequently, its prognostic role is still debated. The aims of this multicenter randomized study were to evaluate the effect of sampling and clearance definition in determining R1 rate after PD for periampullary cancer and to assess the prognostic role of R1 resection. METHODS PD specimens were randomized to Leeds Pathology Protocol (LEEPP) (group A) or the conventional method adopted before the study (group B). R1 rate was determined by adopting 0- and 1-mm clearance; the association between R1, local recurrence (LR) and overall survival (OS) was also evaluated. RESULTS One-hundred-sixty-eight PD specimens were included. With 0 mm clearance, R1 rate was 26.2% and 20.2% for groups A and B, respectively; with 1 mm, R1 rate was 60.7% and 57.1%, respectively (p > 0.05). Only in group A was R1 found to be a significant prognostic factor: at 0 mm, median OS was 36 and 20 months for R0 and R1, respectively, while at 1 mm, median OS was not reached and 30 months. At multivariate analysis, R1 resection was found to be a significant prognostic factor independent of clearance definition only in the case of the adoption of LEEPP. CONCLUSIONS The 1 mm clearance is the most effective factor in determining the R1 rate after PD. However, the pathological method is crucial to accurately evaluate its prognostic role: only R1 resections obtained with the adoption of LEEPP seem to significantly affect prognosis.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy; (G.N.); (A.Z.)
| | - Domenico Borzomati
- Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (D.B.); (R.C.); (D.C.)
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy; (G.N.); (A.Z.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
| | - Paola Spaggiari
- Pathology Unit, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy; (P.S.); (U.B.); (F.V.)
| | - Ugo Boggi
- Pathology Unit, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy; (P.S.); (U.B.); (F.V.)
- Division of General and Transplant Surgery, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 56126 Pisa, Italy
| | - Daniela Campani
- Pathology Unit, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 56126 Pisa, Italy;
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Łukasz Liszka
- Department of Pathomorphology and Molecular Diagnostics, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Alessandro Coppola
- Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (D.B.); (R.C.); (D.C.)
| | - Michela Amato
- Pathology Unit, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (M.A.); (G.P.)
| | - Tommasangelo Petitti
- Department of Public Health, Hygiene and Statistics, Campus Bio-Medico University of Rome, 00128 Rome, Italy;
| | - Fabio Vistoli
- Pathology Unit, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy; (P.S.); (U.B.); (F.V.)
- Division of General and Transplant Surgery, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, 56126 Pisa, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy;
- Department of Surgery, Humanitas Clinical and Research Center—IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Giuseppe Perrone
- Pathology Unit, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (M.A.); (G.P.)
| | - Roberto Coppola
- Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (D.B.); (R.C.); (D.C.)
| | - Damiano Caputo
- Department of Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (D.B.); (R.C.); (D.C.)
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Miyasaka Y, Ohtsuka T, Eguchi S, Inomata M, Nishihara K, Shinchi H, Okuda K, Baba H, Nagano H, Ueki T, Noshiro H, Nakamura M. Neoadjuvant Chemotherapy with Gemcitabine Plus Nab-Paclitaxel Regimen for Borderline Resectable Pancreatic Cancer with Arterial Involvement: A Prospective Multicenter Single-Arm Phase II Study Protocol. Int J Surg Protoc 2021; 25:55-60. [PMID: 34013145 PMCID: PMC8114838 DOI: 10.29337/ijsp.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction Although neoadjuvant treatment is recommended for patients with borderline resectable pancreatic cancer (BRPC), no standard neoadjuvant regimen has been established for BRPC with arterial involvement (BRPC-A), which is associated with a higher risk of margin-positive resection and poorer prognosis than BRPC with only venous involvement. Gemcitabine plus nab-paclitaxel (GnP) has been reported to significantly reduce tumor size in metastatic pancreatic cancer, and some retrospective studies suggested that neoadjuvant GnP for BRPC improved resectability and survival. Methods and analysis A prospective multicenter single-arm phase II study is conducted to evaluate the safety and efficacy of GnP as neoadjuvant chemotherapy for BRPC-A. The primary endpoint is the R0 resection rate. The secondary endpoints are the neoadjuvant chemotherapy response rate, resection rate, pathological response rate, incidence rate of adverse events, and quality of life. Ethics and dissemination This study protocol was approved by the institutional review board of Kyushu University (no. 181). The results will be published in a peer-reviewed journal and will be presented at medical meetings. Highlights Strategy for borderline resectable pancreatic cancer involving arteries (BRPC-A).There is no standard regimen for neoadjuvant chemotherapy for BRPC-A.Gemcitabine plus nab-paclitaxel (GnP) shows significant tumor shrinkage.Neoadjuvant GnP for BRPC-A increases resectability and margin-negative resection.
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Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan.,Department of Surgery, Fukuoka University Chikushi Hospital, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan.,Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Japan
| | | | - Hiroyuki Shinchi
- Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Japan
| | - Koji Okuda
- Department of Surgery, Kurume University School of Medicine, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Saga University Faculty of Medicine, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan
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Pencovich N, Nevo N, Weiser R, Bonder E, Bogoch Y, Nachmany I. Postoperative Rise of Circulating Mitochondrial DNA Is Associated with Inflammatory Response in Patients following Pancreaticoduodenectomy. Eur Surg Res 2021; 62:18-24. [PMID: 33902043 DOI: 10.1159/000514661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 01/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Accumulation of plasma mitochondrial DNA (mtDNA) following severe trauma has been shown to correlate with the development of systemic inflammatory response syndrome (SIRS) and may predict mortality. Our objective was to investigate the relationship between levels of circulatory mtDNA following pancreaticoduodenectomy (PD) and the postoperative course. METHODS Levels of plasma mtDNA were assessed by real-time PCR of the mitochondrial genes ND1 and COX3 in 23 consecutive patients who underwent PD 1 day prior to surgery, within 8 h after surgery, and on postoperative day (POD)1 and POD5. The abundance of mtDNA was assessed relative to preoperative levels and in relation to parameters reflecting the postoperative clinical course. RESULTS When pooled for all patients, the circulating mtDNA levels were significantly increased after surgery. However, while a significant (at least >2-fold and up to >20-fold) rise was noted in 11 patients, no change in mtDNA levels was noted in the other 12 following surgery. Postoperative rise in circulating mtDNA was associated with an increased rate of postoperative fever until day 5, decreased hemoglobin and albumin levels, and increased white blood cell counts. These patients also suffered from increased rates of delayed gastric emptying. No significant differences were demonstrated in other postoperative parameters. CONCLUSION Circulating mtDNA surge is associated with an inflammatory response following PD and may potentially be used as an early marker for postoperative course. Studies of larger patient cohorts are warranted.
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Affiliation(s)
- Niv Pencovich
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roi Weiser
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ekaterina Bonder
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoel Bogoch
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Wei K, Hackert T. Surgical Treatment of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2021; 13:cancers13081971. [PMID: 33923884 PMCID: PMC8074119 DOI: 10.3390/cancers13081971] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Surgery is the only potential cure for pancreatic ductal adenocarcinoma and should always be combined with adjuvant chemotherapy or other multimodal treatment. Besides the advances in such multimodal approaches, there has been substantial progress in surgical techniques to especially address advanced resections. These techniques include specific operative steps, such as ‘artery first’ or ‘uncinate first’ approaches as well as techniques that allow safe vascular resection and reconstruction to achieve radical tumor removal. Most recently, also minimally-invasive and robotic approaches have been adopted for pancreatic cancer surgery; however, there is no high-level evidence on these evolving techniques especially with regards to long-term results compared to conventional surgical techniques. Abstract Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.
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Feo CF, Deiana G, Ninniri C, Cherchi G, Crivelli P, Fancellu A, Ginesu GC, Porcu A. Vascular resection for locally advanced pancreatic ductal adenocarcinoma: analysis of long-term outcomes from a single-centre series. World J Surg Oncol 2021; 19:126. [PMID: 33866970 PMCID: PMC8054428 DOI: 10.1186/s12957-021-02238-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/12/2021] [Indexed: 02/08/2023] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis. Radical surgery is the best option for cure and, nowadays, it is performed by many surgeons also in cases of vascular infiltration. Whether this aggressive approach to a locally advanced PDAC produces a survival benefit is under debate. Most data in the literature come from retrospective comparative studies; therefore, it is still unclear if such an extensive surgery for an advanced cancer is justified. Methods A retrospective review of patients with PDAC treated at our institution over a 12-year period was performed. Data concerning patients’ characteristics, operative details, postoperative course, and long-term survival were retrieved from prospective databases and analysed. Factors associated with poor survival were assessed via Cox regression analysis. Results A total of 173 patients with PDAC were included in the analysis, 41 subjects underwent pancreatectomy with vascular resection for locally advanced disease, and in 132 patients, only a pancreatic resection was undertaken. Demographics, major comorbidities, and tumour characteristics were similar between the two groups. Length of surgery (P=0.0006), intraoperative blood transfusions (P<0.0001), and overall complications (P<0.0001) were significantly higher in the vascular resection group. Length of hospital stay (P=0.684) and 90-day mortality (P=0.575) were comparable between groups. Overall median survival (P= 0.717) and survival rates at 1, 3, and 5 years (P=0.964, P=0.500, and P=0.445, respectively) did not differ significantly between groups. Age ≥70 years and postoperative complications were independent predictors of lower survival. Conclusions Our study confirms that pancreatectomy with vascular resection for a locally advanced PDAC is a complex operation associated with a significant longer operating time that may increase morbidity; however, in selected patients, R0 margins can be obtained with an acceptable long-term survival rate. Older patients are less likely to benefit from surgery.
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Affiliation(s)
- Claudio F Feo
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Giulia Deiana
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Chiara Ninniri
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Giuseppe Cherchi
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Paola Crivelli
- Unit of Radiology, Department of Medical, Surgical and Experimental Sciences, University of Sassary, Viale San Pietro 10, Sassari, 07100, Italy
| | - Alessandro Fancellu
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Giorgio C Ginesu
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Alberto Porcu
- Unit of General Surgery 2, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Viale San Pietro 43, 07100, Sassari, Italy
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Mechanisms of drug resistance of pancreatic ductal adenocarcinoma at different levels. Biosci Rep 2021; 40:225827. [PMID: 32677676 PMCID: PMC7396420 DOI: 10.1042/bsr20200401] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/05/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death worldwide, and the mortality of patients with PDAC has not significantly decreased over the last few decades. Novel strategies exhibiting promising effects in preclinical or phase I/II clinical trials are often situated in an embarrassing condition owing to the disappointing results in phase III trials. The efficacy of the current therapeutic regimens is consistently compromised by the mechanisms of drug resistance at different levels, distinctly more intractable than several other solid tumours. In this review, the main mechanisms of drug resistance clinicians and investigators are dealing with during the exploitation and exploration of the anti-tumour effects of drugs in PDAC treatment are summarized. Corresponding measures to overcome these limitations are also discussed.
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217
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Tyutyunnik P, Klompmaker S, Lombardo C, Lapshyn H, Menonna F, Napoli N, Wellner U, Izrailov R, Baychorov M, Besselink MG, Abu Hilal M, Fingerhut A, Boggi U, Keck T, Khatkov I. Learning curve of three European centers in laparoscopic, hybrid laparoscopic, and robotic pancreatoduodenectomy. Surg Endosc 2021; 36:1515-1526. [PMID: 33825015 DOI: 10.1007/s00464-021-08439-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 03/05/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There are limited numbers of high-volume centers performing minimally invasive pancreatoduodenectomy (MIPD) routinely. Several approaches to MIPD have been described. Aim of this analysis was to show the learning curve of three different approaches to MIPD. Focus was on determining the number of cases necessary to obtain proficient level in MIPD. PATIENTS AND METHODS Retrospective study wherein outcomes of 300 consecutive patients at three centers-at each center the initial 100 consecutive patients undergoing MIPD for malignant and benign tumors of the head of the pancreas and perimpullary area, performed by three experienced surgeons were collected and analyzed. RESULTS Overall, 300 patients after MIPD were included: the three different cohorts (laparoscopic n = 100, hybrid n = 100, robotic n = 100). CUSUM analysis of operating time in each center demonstrated that the plateau for laparoscopic PD was n = 61, for hybrid PDes was n = 32 and for robotic PD was n = 68. Median operative time for laparoscopic, hybrid, and robotic approaches was 395 min, 404 min, 510 min, respectively. Intraoperative blood loss for laparoscopic PD, hybrid PD, and robotic PD was 250 ml, 250 ml, and 413 ml, respectively. Delayed gastric emptying occurred 12% in laparoscopic cohort, 10% in hybrid, and 53% in robotic cohort. Major complications (Clavien-Dindo III/IV) rate for laparoscopic PD, hybrid PD, and robotic PD was 32%, 37%, and 22% with 5% death in each cohorts, respectively. CONCLUSION This analysis of the learning curve of three European centers found a shorter learning curve with hybrid PD as compared to laparoscopic and robotic PD. In implementation of a MIPD program, a stepwise approach might be beneficial.
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Affiliation(s)
- Pavel Tyutyunnik
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123. .,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia.
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Carlo Lombardo
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | | | - Francesca Menonna
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Ulrich Wellner
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Roman Izrailov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123.,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia
| | - Magomet Baychorov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123
| | - Mark G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moh'd Abu Hilal
- Chair of the Department of Surgery, Head of Hepatobiliary Pancreatic and Minimally Invasive Surgery, Poliambulanza Foundation Hospital, Via Bissolati, Brescia, Italy
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.,Department of Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ugo Boggi
- Department of Transplant and General Surgery, University of Pisa, Pisa, Italy
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of High-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center Named After A.C.Loginov, Entusiastov shosse, 86, Moscow, Russia, 111123.,Chair of Faculty Surgery No.2, FSBEI HE A.I. Yevdokimov MSMSU MOH, Moscow, Russia
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Preoperative risk factors for para-aortic lymph node positivity in pancreatic cancer. Pancreatology 2021; 21:606-612. [PMID: 33648880 DOI: 10.1016/j.pan.2021.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to identify the preoperative risk factors for para-aortic lymph node (PALN) positivity, including micrometastasis, in pancreatic cancer. METHODS Medical records of patients with pancreatic cancer who underwent curative resection were retrospectively reviewed, and the relationships between preoperative risk factors and PALN positivity were identified. Clinicopathological and prognostic factors for overall survival were analyzed. Micrometastasis was investigated by immunohistochemistry. RESULTS 400 patients were enrolled. PALN positivity by hematoxylin and eosin staining, micrometastasis, and negative were found in 46 (11%), 32 (8%), and 322 (81%) patients, respectively. The median overall survival times of patients with PALN positivity, including micrometastasis, was 22.5 months. Multivariate logistic regression identified borderline or locally advanced status (p=0.037), elevated preoperative carbohydrate antigen (CA) 19-9 level (p<0.001), larger tumor size ≥30 mm (p=0.001) and larger PALN size ≥10 mm (p=0.019) as independent preoperative risk factors of PALN positivity. Multivariate overall survival analysis demonstrated borderline or locally advanced status (p=0.013), elevated preoperative CA19-9 level (p<0.001) and PALN positivity (p=0.048) were independent poor prognostic factors. CONCLUSIONS Borderline or locally advanced status, elevated preoperative CA19-9 level, and larger tumor and PALN size were risk factors for PALN positivity, and thus, they may contribute to the optimization of preoperative treatments for patients with potential PALN positivity.
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Sánchez Morales G, Moguel Valladares R, Flores Maza J, Clemente Gutiérrez U, Sánchez-García Ramos E, Domínguez Rosado I, Chan Núñez L. Pancreatic ductal adenocarcinoma: Eleven years of experience at a tertiary care hospital center. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021. [DOI: 10.1016/j.rgmxen.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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220
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Ahmed SA, Atta H, Hassan RA. The utility of Multi-Detector Computed Tomography criteria after neoadjuvant therapy in Borderline Resectable Pancreatic cancer: Prospective, bi-institutional study. Eur J Radiol 2021; 139:109685. [PMID: 33819805 DOI: 10.1016/j.ejrad.2021.109685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the utility of MDCT criteria for the determination of resectability and tumor response in borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT). METHODS This prospective study includes 90 consecutive BRPC patients who underwent surgery following NAT. Two radiologists assessed baseline and pre-surgical CTs for (largest tumor axis, size, attenuation, and vascular criteria). Logistic regression was used to determine which CT criteria independently associated with R0 resection and pathologic major response (pMR). Median survival and overall survival (OS) were calculated. RESULTS Seventy-three/90 (81.1 %) patients had R0 resection, and 11/90 (12.2 %) had pMR. After NAT, there were significant interval changes in the largest tumor axis, size, attenuation, and venous burden index (VBI) (P < 0.02). On the multivariable analysis, regression of the VBI and low VBI at the pre-surgical CT were independently associated with an increased likelihood of R0 resection (OR 1.82; 95 % CI 1.44-5.33) (OR 1.91; 95 % CI 1.83-6.14). The assessment of VBI at the pre-surgical CT showed moderate reproducibility (k-value, 0.56 - 0.60). On the multivariable analysis, partial response (PR) was found to be independently associated with an increased likelihood of pMR (OR 1.71; 95 % CI 1.31-3.45). The median survival was longer in patients who had R0 (P = 0.01). The overall survival was longer in patients who had pMR compared to those who did not (P = 0.02). CONCLUSION Surgical exploration could be indicated in patients who had regression of the VBI and low VBI at the pre-surgical CT. PR response is associated with pMR.
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Affiliation(s)
| | - Haisam Atta
- South Egypt Cancer Institute, Assiut University, Egypt.
| | - Ramy A Hassan
- Alrajhy Liver Hospital, Faculty of Medicine, Assiut University, Egypt.
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Zhang LP, Ren H, Du YX, Zheng XH, Zhang ZM, Wang CF. Combination of preoperative fibrinogen and D-dimer as a prognostic indicator in pancreatic ductal adenocarcinoma patients undergoing R0 resection. World J Gastrointest Surg 2021; 13:279-302. [PMID: 33796216 PMCID: PMC7993003 DOI: 10.4240/wjgs.v13.i3.279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/01/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with malignant tumors frequently exhibit hyperactivation of the coagulation system and secondary increased fibrinolytic activity. Fibrinogen and D-dimer are common indicators that are crucial in the coagulation/fibrinolysis system. Both indicators have been verified to have predictive value in the overall survival (OS) of many patients with solid malignancies.
AIM To explore the prognostic significance of fibrinogen combined with D-dimer in pancreatic ductal adenocarcinoma (PDAC) patients undergoing radical R0 resection.
METHODS We retrospectively analyzed the clinical data of 282 patients with PDAC undergoing radical R0 resection in the Cancer Hospital, Chinese Academy of Medical Sciences, between January 2010 and December 2019. The surv_cutpoint function of R language was used to determine the optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration. Enrolled patients were further divided into the any-high group (high preoperative fibrinogen concentration and/or high preoperative D-dimer concentration) and the low-low group (low preoperative fibrinogen and D-dimer concentrations) according to the optimal cutoff values.
RESULTS The optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration were 3.31 g/L and 0.53 mg/L, respectively. Furthermore, multivariate Cox regression analysis showed that the preoperative fibrinogen concentration (HR: 1.603, 95%CI: 1.201-2.140, P = 0.001) and preoperative D-dimer concentration (HR: 1.355, 95%CI: 1.019-1.801, P = 0.036) exhibited obvious correlations with the OS of PDAC patients undergoing radical R0 resection. A prognostic analysis was further performed based on the subgroup results by using fibrinogen combined with D-dimer. The median OS duration of the low-low group (31.17 mo) was significantly longer than that of the any-high group (15.43 mo). Additionally, multivariate Cox regression analysis revealed that the degree of differentiation (P < 0.001), lymph node metastasis (HR: 0.663, 95%CI: 0.497-0.883, P = 0.005), preoperative CA19-9 level (HR: 1.699, 95%CI: 1.258-2.293, P = 0.001), adjuvant therapy (HR: 1.582, 95%CI: 1.202-2.081, P = 0.001) and preoperative combined grouping (HR: 2.397, 95%CI: 1.723-3.335, P < 0.001) were independent predictors of OS in PDAC patients undergoing radical R0 resection.
CONCLUSION Preoperative fibrinogen combined with D-dimer plays a predictive role in OS, and low preoperative fibrinogen and D-dimer concentrations can indicate prolonged OS in PDAC patients undergoing radical R0 resection.
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Affiliation(s)
- Li-Peng Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hu Ren
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong-Xing Du
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao-Hao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zong-Ming Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Cheng-Feng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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222
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Feng Z, Li K, Lou J, Ma M, Wu Y, Peng C. A Novel DNA Replication-Related Signature Predicting Recurrence After R0 Resection of Pancreatic Ductal Adenocarcinoma: Prognostic Value and Clinical Implications. Front Cell Dev Biol 2021; 9:619549. [PMID: 33748108 PMCID: PMC7969722 DOI: 10.3389/fcell.2021.619549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/15/2021] [Indexed: 12/22/2022] Open
Abstract
The aim of any surgical resection for pancreatic ductal adenocarcinoma (PDAC) is to achieve tumor-free margins (R0). R0 margins give rise to better outcomes than do positive margins (R1). Nevertheless, postoperative morbidity after R0 resection remains high and prognostic gene signature predicting recurrence risk of patients in this subgroup is blank. Our study aimed to develop a DNA replication-related gene signature to stratify the R0-treated PDAC patients with various recurrence risks. We conducted Cox regression analysis and the LASSO algorithm on 273 DNA replication-related genes and eventually constructed a 7-gene signature. The predictive capability and clinical feasibility of this risk model were assessed in both training and external validation sets. Pathway enrichment analysis showed that the signature was closely related to cell cycle, DNA replication, and DNA repair. These findings may shed light on the identification of novel biomarkers and therapeutic targets for PDAC.
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Affiliation(s)
- Zengyu Feng
- Department of General Surgery, Pancreatic Disease Center, Research Institute of Pancreatic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China.,Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Kexian Li
- Department of General Surgery, Pancreatic Disease Center, Research Institute of Pancreatic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianyao Lou
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mindi Ma
- Department of Nuclear Medicine, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yulian Wu
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Research Institute of Pancreatic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
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223
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Garnier J, Traversari E, Ewald J, Marchese U, Delpero JR, Turrini O. Venous Reconstruction During Pancreatectomy Using Polytetrafluoroethylene Grafts: A Single-Center Experience with Standardized Perioperative Management. Ann Surg Oncol 2021; 28:5426-5433. [PMID: 33655364 DOI: 10.1245/s10434-021-09716-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although primary end-to-end anastomosis is preferred for portal vein-superior mesenteric vein (PV-SMV) reconstruction, interposition graft use may be required in some situations. We investigated the efficacy of polytetrafluoroethylene (PTFE) grafts when used during pancreatectomy in this context. METHODS From 2014 to 2019, 19 patients who underwent pancreatectomy requiring PV-SMV reconstruction using ringed PTFE grafts were entered prospectively into a clinical database (NCT02871336, CNIL No. Sy50955016U). Unfractionated heparin was used during the first 24 h postoperatively. The administration of low-molecular-weight heparin was initiated twice a day (two injections of 1 mg/kg enoxaparin) on postoperative day 2 and was continued until the first clinical follow-up. Patency was assessed by CT scan before home discharge. Patients were switched to antiplatelet therapy (75 mg of aspirin-based drug Kardegic®) without a deadline. RESULTS Pancreatoduodenectomy was the most commonly performed procedure (15 patients, 79%), and pancreatic duct adenocarcinoma was the predominant etiology (17 patients, 89%). The median PTFE graft diameter and length were 10 mm and 8 cm, respectively. The median clamping time was 25 min. The overall severe morbidity and 90-day mortality values were 21% and 10%, respectively. None of the patients experienced anticoagulation-related morbidity or PTFE graft-related infection. The 6-month PTFE graft patency rate was 68%. Patients who underwent distal pancreatectomy showed a higher late thrombosis rate than those who underwent a pancreaticoduodenectomy (50% vs. 8%, p = 0.049). The median long-term PTFE graft patency duration was 37 months. CONCLUSIONS PTFE reconstruction can be safely performed with simple perioperative management in cases requiring interposition graft use.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Eddy Traversari
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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224
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Prognostic Nomogram for pancreatic cancer with lung metastasis: a SEER database-based study. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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225
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Kato H, Horiguchi A, Ito M, Asano Y, Arakawa S. Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors. Ann Gastroenterol Surg 2021; 5:132-151. [PMID: 33860134 PMCID: PMC8034700 DOI: 10.1002/ags3.12427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/26/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022] Open
Abstract
Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.
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Affiliation(s)
- Hiroyuki Kato
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Akihiko Horiguchi
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Masahiro Ito
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Yukio Asano
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
| | - Satoshi Arakawa
- Department of Gastroenterological SurgeryBantane HospitalFujita Health University School of MedicineNagoyaAichiJapan
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226
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Al-Sadairi AR, Mimmo A, Rhaiem R, Esposito F, Rached LJ, Tashkandi A, Zimmermann P, Memeo R, Sommacale D, Kianmanesh R, Piardi T. Laparoscopic hybrid pancreaticoduodenectomy: Initial single center experience. Ann Hepatobiliary Pancreat Surg 2021; 25:102-111. [PMID: 33649262 PMCID: PMC7952661 DOI: 10.14701/ahbps.2021.25.1.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD. Methods During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients. Results Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 >0<1 mm was 10.5% and R1 0 mm was 9.5%. Conclusions Hydrid-LPD is safe and feasible. Careful patient selection and increasing experience can reduce the risk of post-operative complications.
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Affiliation(s)
- Abdul Rahman Al-Sadairi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Antonio Mimmo
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Rami Rhaiem
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Francesco Esposito
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Linda J Rached
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Ahmad Tashkandi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Perrine Zimmermann
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Daniele Sommacale
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, AP-HP, Université Paris-Est Créteil (UPEC), France
| | - Reza Kianmanesh
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Hepato-Pancreato-Biliary Unit, General Surgery Department, Simone Veil Hospital, Troyes, University of Champagne-Ardenne, Reims, France
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227
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Kwon W, Thomas A, Kluger MD. Irreversible electroporation of locally advanced pancreatic cancer. Semin Oncol 2021; 48:84-94. [PMID: 33648735 DOI: 10.1053/j.seminoncol.2021.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
Locally advanced pancreatic cancer (LAPC) constitutes approximately one-third of all pancreatic cancer, with standard of care inconsistently defined and achieving modest outcomes at best. While resection after downstaging offers the chance for cure, only a fraction of patients with LAPC become candidates for resection. Chemotherapy remains the mainstay of treatment for the remainder. In these patients, ablative therapy may be given for local control of the tumor. Irreversible electroporation (IRE) is an attractive ablative technique. IRE changes the permeability of tumor cell membranes to induce apoptosis. Unlike other ablative therapies, IRE causes little thermal injury to the target area, making it ideal for LAPC involving major vessels. Compared to systemic chemotherapy alone, IRE seems to offer some survival benefit. Although early studies reported notable morbidity and mortality rates, IRE presents opportunities for those who cannot undergo resection and who otherwise have limited options. Another role of IRE is to extend the margins of resected tumors when there is a concern for R1 resection. Perhaps most exciting, IRE is thought to have effects beyond local ablation. IRE has immunomodulatory effects, which may induce in vivo vaccination and may potentially synergize with immunotherapy. Through electrochemotherapy, IRE may enhance drug delivery to residual tumor cells. Ultimately the role of IRE in the treatment of LAPC still needs to be validated through well designed randomized trials. Investigations of its future possibilities are in the early stages. IRE offers the potential to provide more options to LAPC patients.
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Affiliation(s)
- Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Alexander Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
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228
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Kaiser J, Hinz U, Mayer P, Hank T, Niesen W, Hackert T, Gaida MM, Büchler MW, Strobel O. Clinical presentation and prognosis of adenosquamous carcinoma of the pancreas - Matched-pair analysis with pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2021; 47:1734-1741. [PMID: 33622577 DOI: 10.1016/j.ejso.2021.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/31/2021] [Accepted: 02/07/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Adenosquamous carcinoma of the pancreas (ASCP) is a rare subtype of pancreatic adenocarcinoma. The aim of this study was to investigate the characteristics and outcomes of ASCP in comparison to pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS All patients with ASCP treated between December 2001 and December 2017 were identified from a prospective database. Clinicopathological and follow-up data were analyzed. A nested case-control-study with matched-pair analysis was performed to compare overall survival of ASCP and PDAC. RESULTS Of 4009 patients undergoing surgery for pancreatic adenocarcinoma 91 patients had ASCP. Compared to PDAC ASCP were larger (4.0 vs. 3.2 cm; p < 0.0001), more frequently involved lymph nodes (88% vs. 78%; p = 0.0216), more frequently showed poor differentiation (G3: 79% vs. 36%; p < 0.0001) and more frequently were located in the pancreatic tail (19% vs. 10%; p = 0.0179). Overall median post-resection-survival was shorter in ASCP (10.8 vs. 20.5 months in PDAC; p = 0.0085), but 5-year survival rates were comparable (18.2% vs. 17.5%). After matching for the unevenly distributed prognostic factors survival after resection of ASCP and PDAC was comparable (p = 0.8301). Localization in the head or several parts of the pancreas, high CA 19-9 levels, and M1 disease were independent predictors of survival in patients with ASCP. CONCLUSION ASCP is more aggressive with poorer differentiation and higher rates of lymph node metastases compared to PDAC. In spite of a shorter median survival, 5-year survival rates after surgical resection of about 18% can be expected in ASCP and support resection as part of a multimodal therapy as the treatment of choice in this rare cancer.
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Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp Mayer
- Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Hank
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Willem Niesen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias M Gaida
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany; Current Affiliation: Institute of Pathology, University of Mainz, Mainz, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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229
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Mayer P, Giannakis A, Klauß M, Gaida MM, Bergmann F, Kauczor HU, Feisst M, Hackert T, Loos M. Radiological evaluation of pancreatic cancer: What is the significance of arterial encasement >180° after neoadjuvant treatment? Eur J Radiol 2021; 137:109603. [PMID: 33618209 DOI: 10.1016/j.ejrad.2021.109603] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/16/2021] [Accepted: 02/08/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE This study aimed to evaluate contrast-enhanced computed tomography (CE-CT) features for prediction of arterial tumor invasion in pancreatic cancer (PDAC) patients in the event of arterial encasement >180° after neoadjuvant (radio-)chemotherapy (NAT). METHODS Seventy PDAC patients with seventy-five arteries showing encasement >180° after completion of NAT were analyzed. All patients underwent surgical exploration with either tumor resection including arterial resection, periadventitial dissection (arterial divestment) or confirmation of locally irresectable disease. CE-CT scans were assessed regarding tumor extent and artery-specific imaging features. The results were analyzed on a per-artery basis. Based on the intraoperative and histopathological findings, encased arteries were classified as either invaded or non-invaded. RESULTS Eighteen radiologically encased arteries were resected; of these, nine had pathologic evidence for tumor invasion. In 42 encased arteries, the tumor could be removed by arterial divestment. In 13 patients with 15 encased arteries, the tumor was deemed technically irresectable. Median tumor size, length of solid soft tissue contact, and degree of circumferential contiguity by solid soft tissue along the artery in CE-CT were significantly lower in the non-invaded than in the invaded artery group (p ≤ 0.017). Imaging features showed moderate accuracies for prediction of arterial invasion (≤72.0 %). The thresholds ≤26 mm for post-NAT solid soft tissue contact and ≤270° for circumferential contiguity by solid soft tissue had high negative predictive values (≥87.5 %). CONCLUSION Although post-NAT prediction of arterial invasion remains difficult, arteries with ≤270° contiguity by soft tissue and arteries with ≤26 mm length of solid soft tissue contact are unlikely to be invaded, with possible implications for surgical planning.
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Affiliation(s)
- P Mayer
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
| | - A Giannakis
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Klauß
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M M Gaida
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
| | - F Bergmann
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - H U Kauczor
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Feisst
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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230
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Jiang L, Ning D, Chen XP. Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas. World J Surg Oncol 2021; 19:49. [PMID: 33588845 PMCID: PMC7885351 DOI: 10.1186/s12957-021-02159-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Background Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy. Main body To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity. Conclusion This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.
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Affiliation(s)
- Li Jiang
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Deng Ning
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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231
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Zhang Z, Song J, Xie C, Pan J, Lu W, Liu M. Pancreatic Cancer: Recent Progress of Drugs in Clinical Trials. AAPS JOURNAL 2021; 23:29. [PMID: 33580411 DOI: 10.1208/s12248-021-00556-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/06/2021] [Indexed: 12/18/2022]
Abstract
Pancreatic cancer is a highly malignant tumor and one of the primary causes of cancer-related death. Because pancreatic cancer is difficult to diagnose in the early course of the disease, most patients present with advanced lesions at the time of diagnosis, and only 20% of patients are eligible for surgery. Consequently, drug treatment has become extremely important. At present, the main treatment regimens for pancreatic cancer are gemcitabine and the FORFIRINOX and MPACT regimens. However, none of these regimens substantially improves the prognosis of patients with pancreatic cancer. Extensive efforts have been dedicated to the study of pancreatic cancer in recent years. With the development and clinical application of biological targeted drugs, the biological targeted treatment of tumors has been widely accepted. Therefore, this article used relevant clinical trial data to summarize the research progress of traditional chemotherapy drugs and biological targeted drugs for the treatment of pancreatic cancer.
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Affiliation(s)
- Zhiyi Zhang
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China
| | - Jie Song
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China
| | - Cao Xie
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China
| | - Jun Pan
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China
| | - Weiyue Lu
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China
| | - Min Liu
- Key Laboratory of Smart Drug Delivery, Ministry of Education, Department of Pharmaceutics, School of Pharmacy, Fudan University, 826 Zhangheng Road, Shanghai, 201203, People's Republic of China.
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232
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Kamarajah SK, Chatzizacharias N, Hodson J, Marcon F, Kalisvaart M, Punia P, Ting Ma Y, Dasari B, Marudanayagam R, Sutcliffe RP, Muiesan P, Mirza DF, Isaac J, Roberts KJ. Intention to treat outcomes among patients with pancreatic cancer treated using International Study Group on Pancreatic Surgery recommended pathways for resectable and borderline resectable disease. ANZ J Surg 2021; 91:1549-1557. [PMID: 33576568 DOI: 10.1111/ans.16643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The International Study Group on Pancreatic Surgery recommends upfront surgery for resectable pancreatic cancer or borderline resectable-venous (BR-V) disease and neoadjuvant therapy (NAT) among those with arterial involvement (BR-A or locally advanced, LA). Though neoadjuvant therapy (NAT) is a promising strategy, outcomes are rarely reported on intention-to-treat (ITT) basis. This study presents ITT outcomes where pathways to surgery were in line with International Study Group on Pancreatic Surgery guidelines. METHODS Patients recommended for potentially curative treatment with PDAC between 2012 and 2017 (n = 345) were classified as resectable, BR-A/BR-V or LA, according to NCCN criteria. The primary outcome was overall survival. Secondary outcomes were resection rates, positive margins and toxicity among patients receiving NAT. RESULTS At surgery, the resection rates were 78% (172/221), 65% (35/54) and 54% (21/39) for those with resectable, BR-V and BR-A/LA disease, respectively (P < 0.0001). The median survival of those resected in the BR-A/LA cohort was 31 months. However, on an ITT basis, there was no significant difference in survival between resectable, BR-V and BR-A/LA disease (median: 19 versus 15 versus 19 months; P = 0.585). On review, some 31 (44%) patients of the BR-A/LA cohort either did not receive or did not complete NAT. CONCLUSION To realize benefits of NAT, more patients need to complete NAT and to undergo resection. Upfront resection for BR-V disease is associated with equivalent outcomes to upfront surgery for resectable disease or NAT for BR-A/LA disease. Strategies to increase the proportion of patients who complete NAT and undergo resection are needed.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - James Hodson
- Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Francesca Marcon
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Marit Kalisvaart
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Pankaj Punia
- Department of Oncology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yuk Ting Ma
- Department of Oncology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Bobby Dasari
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ravi Marudanayagam
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert P Sutcliffe
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John Isaac
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Keith J Roberts
- Department of Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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233
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Prognostic Factors of Survival After Neoadjuvant Treatment and Resection for Initially Unresectable Pancreatic Cancer. Ann Surg 2021; 273:154-162. [PMID: 30921051 DOI: 10.1097/sla.0000000000003270] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the impact of clinical and pathological parameters, including resection margin (R) status, on survival in patients undergoing pancreatic surgery after neoadjuvant treatment for initially unresectable pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Prognostic factors are well documented for patients with resectable PDAC, but have not been described in detail for patients with initially unresectable PDAC undergoing resection after neoadjuvant therapy. METHODS Prospectively collected data of consecutive patients with initially unresectable pancreatic cancer treated by neoadjuvant treatment and resection were analyzed. The R status was categorized as R0 (tumor-free margin >1 mm), R1 ≤1 mm (tumor-free margin ≤1 mm), and R1 direct (microscopic tumor infiltration at margin). Clinicopathological characteristics and outcomes were compared among these groups and tested for survival prediction. RESULTS Between January, 2006 and February, 2017, 280 patients with borderline resectable (n = 18), locally advanced (n = 190), or oligometastatic (n = 72) disease underwent tumor resection after neoadjuvant treatment. Median overall survival from the time of surgery was 25.1 months for R0 (n = 82), 15.3 months for R1 ≤1 mm (n = 99), and 16.1 months for R1 direct (n = 99), with 3-year overall survival rates of 35.0%, 20.7%, and 18.5%, respectively (P = 0.0076). The median duration of the neoadjuvant treatment period was 5.1 months. In multivariable analysis, preoperative CA 19-9 levels, lymph node status, metastasis category, and vascular involvement were all significant prognostic factors for overall survival. The R status was not an independent prognostic factor. CONCLUSIONS In patients undergoing resection after neoadjuvant therapy for initially unresectable PDAC, preoperative CA 19-9 levels, lymph node involvement, metastasis category, and vascular involvement, but not the R status, were independent prognostic factors of overall survival.
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234
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He C, Sun S, Huang X, Zhang Y, Lin X, Li S. Survival Comparison of Neoadjuvant Chemotherapy Followed by Irreversible Electroporation Versus Conversional Resection for Locally Advanced Pancreatic Cancer. Front Oncol 2021; 10:622318. [PMID: 33604301 PMCID: PMC7884752 DOI: 10.3389/fonc.2020.622318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/17/2020] [Indexed: 01/04/2023] Open
Abstract
Locally advanced pancreatic cancer (LAPC) is a lethal disease and neoadjuvant chemotherapy and conversional resection is shown to provide the best survival for LAPC patients. Irreversible electroporation (IRE) is a new and effective method for the treatment of LAPC. This study aimed to compare the long-term survival of LAPC patients after neoadjuvant chemotherapy followed by conversional resection and IRE. A total of 140 LAPC patients were included from August 2015 to March 2020. The survival outcomes of patients after treatment with chemotherapy, chemotherapy combined with conversional resection or IRE were analyzed and compared. Patients in these three groups had similar clinical and pathological characteristics. Patients in the resection and IRE groups had similar median OS time (resection group vs. IRE group: 25.3 months vs. 26.0 months, P>0.050), which was significantly longer than that of the chemotherapy group (8.7 months, P<0.001). Additionally, patients in the resection and IRE groups had a median PFS of 10.6 and 12.0 months, respectively. Also, they were significantly higher than that of patients in the chemotherapy group. Chemotherapy combined with conversional resection and IRE was identified as significant prognostic factors for OS and PFS in LAPC patients. It was shown that compared with neoadjuvant chemotherapy followed by surgical resection, chemotherapy and IRE provided similar OS and PFS for LAPC patients with minimal invasion. This combination therapy may be a suitable treatment for LAPC patients.
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Affiliation(s)
- Chaobin He
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shuxin Sun
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xin Huang
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Lin
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shengping Li
- Department of Pancreatobiliary Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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235
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Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India. World J Surg 2021; 44:2784-2793. [PMID: 31641837 DOI: 10.1007/s00268-019-05235-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.
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236
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Peng JS, Morris-Stiff G, Ali NS, Wey J, Chalikonda S, El-Hayek KM, Walsh RM. Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis. Hepatobiliary Pancreat Dis Int 2021; 20:74-79. [PMID: 32861576 DOI: 10.1016/j.hbpd.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/07/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy. METHODS Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery. RESULTS There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096). CONCLUSIONS NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.
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Affiliation(s)
- June S Peng
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA 17033-0850, USA; Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA.
| | - Gareth Morris-Stiff
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
| | - Noaman S Ali
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
| | - Jane Wey
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
| | - Sricharan Chalikonda
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
| | - Kevin M El-Hayek
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA
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237
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Casolino R, Braconi C, Malleo G, Paiella S, Bassi C, Milella M, Dreyer SB, Froeling FEM, Chang DK, Biankin AV, Golan T. Reshaping preoperative treatment of pancreatic cancer in the era of precision medicine. Ann Oncol 2021; 32:183-196. [PMID: 33248227 PMCID: PMC7840891 DOI: 10.1016/j.annonc.2020.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
This review summarises the recent evidence on preoperative therapeutic strategies in pancreatic cancer and discusses the rationale for an imminent need for a personalised therapeutic approach in non-metastatic disease. The molecular diversity of pancreatic cancer and its influence on prognosis and treatment response, combined with the failure of 'all-comer' treatments to significantly impact on patient outcomes, requires a paradigm shift towards a genomic-driven approach. This is particularly important in the preoperative, potentially curable setting, where a personalised treatment allocation has the substantial potential to reduce pancreatic cancer mortality.
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Affiliation(s)
- R Casolino
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - C Braconi
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK
| | - G Malleo
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - S Paiella
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - C Bassi
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - M Milella
- Department of Medicine, Medical Oncology, University and Hospital Trust of Verona, Verona (VR), Italy
| | - S B Dreyer
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - F E M Froeling
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - D K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK; South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Liverpool, NSW, Australia.
| | - T Golan
- Oncology Institute, Sheba Medical Center, Tel Hashomer, Israel
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238
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Plasma Extracellular Vesicle Characteristics Correlate with Tumor Differentiation and Predict Overall Survival in Patients with Pancreatic Ductal Adenocarcinoma Undergoing Surgery with Curative Intent. J Pers Med 2021; 11:jpm11020077. [PMID: 33525618 PMCID: PMC7910876 DOI: 10.3390/jpm11020077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/15/2021] [Accepted: 01/26/2021] [Indexed: 12/11/2022] Open
Abstract
Better preoperative characterization of patients with pancreatic ductal adenocarcinoma (PDAC) would aid in treatment optimization. Extracellular vesicles (EV) are promising, largely unexplored biomarkers in PDAC. This study aimed to evaluate if plasma EV characteristics are associated with PDAC clinical characteristics and overall survival (OS). The prospective cohort included 34 PDAC patients undergoing surgery with curative intent. Patient data and plasma samples were collected preoperatively, intraoperatively and one month postoperatively. Small plasma EV (sEV) concentration and size were determined by nanoparticle-tracking analysis. A Mann-Whitney test, Spearman's rho and Cox regression were used in statistical analysis. Preoperatively, patients with poorly differentiated tumors had significantly larger plasma sEVs when compared to patients with well/moderately differentiated tumors (mean diameter 176.9 vs. 149.2 nm, p = 0.021), the sEV size even enabling discrimination of the two groups (AUC = 0.742, 95% CI = 0.560-0.923). Plasma sEV characteristics were also a predictor of OS in multivariable analysis. Patients with a more than 33.8% increase in sEV concentration after one month had 7.2 months shorter median OS (p = 0.002), while patients with a more than 28.0% decrease in sEV size had 9.2 months shorter median OS (p = 0.045). Plasma sEV concentration and size correlate with tumor differentiation and may predict OS in PDAC patients. In the future, plasma sEV characteristics could contribute to improved patient stratification for optimized treatment.
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239
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Cai B, Lu Z, Neoptolemos JP, Diener MK, Li M, Yin L, Gao Y, Wei J, Chen J, Guo F, Tu M, Xi C, Wu J, Gao W, Dai C, Jiang K, Büchler MW, Miao Y. Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 2021; 406:691-701. [PMID: 33507403 DOI: 10.1007/s00423-021-02080-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/04/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To introduce sub-adventitial divestment technique (SDT), a procedure to remove the tumor while preserving the artery during curative pancreatectomy. Peri-operative safety profile was also evaluated. METHODS In a single center consecutive series of pancreatectomy for pancreatic cancer, the outcome of patients who had pancreatectomy with SDT was compared to standard pancreatic surgery. RESULTS From June 2014 to June 2016, 72 patients had pancreatectomy with SDT and 235 had standard surgery. Tumor stage was T4 in all 72 (100%) tumors removed using SDT compared to four (2%) with standard pancreatectomy (p < 0.001). All 72 (100%) tumors in the SDT group were stage III compared to 24 (10%) in the standard surgery group (p < 0.001). Both groups had a high proportion of poorly differentiated tumors (52 (72%) and 163 (69%) respectively) and perineural tumor invasion (62 (86%) and 186 (79%) respectively). R1 (< 1 mm) was found in 24 (86%) of 28 tumors in the SDT group, and in 72 (60%) out of 120 standard pancreatectomy tumors (p = 0.01). Complications occurred in 29 (40%) of the SDT group and in 88 (37%) of the standard group. The in-hospital mortality was four (6%) in the SDT group and one (0.4%) in the standard group (p = 0.01), with a 90-day mortality of 5 (8%)/60 and 6 (3%)/209 (p = 0.07) respectively. CONCLUSIONS The sub-adventitial divestment technique appeared to be an effective surgical technique to remove the tumor while preserving the artery. This approach warrants further validation in prospective studies.
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Affiliation(s)
- Baobao Cai
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Zipeng Lu
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - John P Neoptolemos
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China.,Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Mingna Li
- Pathology Department, First Affiliated Hospital, Nanjing Medical University, Nanjing, People's Republic of China
| | - Lingdi Yin
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Yong Gao
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Jishu Wei
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Jianmin Chen
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Feng Guo
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Min Tu
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Chunhua Xi
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Junli Wu
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Wentao Gao
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Cuncai Dai
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Kuirong Jiang
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Yi Miao
- Pancreas Centre, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, People's Republic of China. .,Pancreas Centre, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, People's Republic of China.
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240
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Garnier J, Robin F, Ewald J, Marchese U, Bergeat D, Boudjema K, Delpero JR, Sulpice L, Turrini O. Pancreatectomy with Vascular Resection After Neoadjuvant FOLFIRINOX: Who Survives More Than a Year After Surgery? Ann Surg Oncol 2021; 28:4625-4634. [PMID: 33462718 DOI: 10.1245/s10434-020-09520-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Experienced pancreatic surgeons, for whom complexity is not an issue, must decide at the end of neoadjuvant therapy whether to continue or discontinue surgery, when pancreatectomy with vascular resection is planned in patients with pancreatic ductal adenocarcinoma (PDAC). OBJECTIVE Our study aimed to determine preoperative factors that can predict short postoperative survival in such situations. METHODS Overall, 105 patients with borderline or locally advanced PDAC received neoadjuvant FOLFIRINOX (followed by chemoradiation in 22% of patients) and underwent pancreatectomy with segmental venous and/or arterial resection at two high-volume centers. The primary endpoint was overall survival (OS) of < 1 year after surgery for patients who did not die from the surgery. RESULTS Tumors were classified as borderline in 78% of cases and locally advanced in 22% of cases. Mean CA19-9 at diagnosis was 934 U/mL, which significantly decreased to 213 U/mL (p < 0.01) after a median of six cycles of FOLFIRINOX. Pancreaticoduodenectomy was performed most often (76%). The vast majority of patients underwent venous resection (92%), and a simultaneous arterial resection was performed in 16 patients (15%). The severe morbidity rate and 30- and 90-day mortality rates were 21%, 8.5%, and 10.4%, respectively. The median OS after surgery was 23 months. In the multivariate analysis, preoperative CA19-9 ≥ 450 U/mL was the only preoperative factor independently associated with OS of < 1 year (p = 0.044). CONCLUSION The preoperative CA19-9 value should be considered in the clinical decision-making process when complex vascular resection is required.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Fabien Robin
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Damien Bergeat
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Karim Boudjema
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Sulpice
- Department of Hepato-Biliary and Digestive Surgery, CHU Rennes, Université Rennes 1, Rennes, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Aix-Marseille University, CRCM, Marseille, France
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Kurlinkus B, Ahola R, Zwart E, Halimi A, Yilmaz BS, Ceyhan GO, Laukkarinen J. In the Era of the Leeds Protocol: A Systematic Review and A Meta-Analysis on the Effect of Resection Margins on Survival Among Pancreatic Ductal Adenocarcinoma Patients. Scand J Surg 2021; 109:11-17. [PMID: 32192417 DOI: 10.1177/1457496920911807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS A positive resection margin is considered to be a factor associated with poor prognosis after pancreatic ductal adenocarcinoma resection. However, analysis of the resection margin is dependent on the pathological slicing technique. The aim of this systematic review and meta-analysis was to study the impact of resection margin on the survival of pancreatic ductal adenocarcinoma patients whose specimens were analyzed using the axial slicing technique. MATERIAL AND METHODS A systematic search in the PubMed, Cochrane, and Embase datasets covering the time period from November 2006 to January 2019 was performed. Only studies with axial slicing technique (Leeds Pathology Protocol or Royal College of Pathology Protocol) were included in the final database. Meta-analysis between the marginal distance and survival was performed with the Inverse Variance Method in RevMan. RESULTS The systematic search resulted in nine studies meeting the inclusion criteria. The median survival for a resection margin 0 mm ranged from 12.3 to 23.4 months, for resection margin <0.5 mm 16 months, for resection margin <1 mm ranged from 11 to 27.5 months, for resection margin <1.5 mm ranged from 16.9 to 21.2 months, and for resection margin >2 mm ranged from 53.9 to 63.1 months. Five studies were eligible for meta-analysis. The pooled multivariable hazard ratio favored resection margin ⩾1 mm (hazard ratio: 1.32 and 95% confidence interval: 1.03-1.68, p = 0.03). CONCLUSION Resection margins ⩾1 mm seem to lead to better survival in pancreatic ductal adenocarcinoma patients than resection margin <1 mm. However, there is not enough data to evaluate the effect of oncologic therapy or to analyze the impact of other resection margin distances on survival.
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Affiliation(s)
- B Kurlinkus
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - R Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - E Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - A Halimi
- Pancreas Unit, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - B S Yilmaz
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - G O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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242
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Muttillo EM, Ciardi A, Troiano R, Saullo P, Masselli G, Guida M, Tortora A, Sperduti I, Marinello G, Chirletti P, Caronna R. Pancreatic ductal adenocarcinoma and distal cholangiocarcinoma: a proposal of preoperative diagnostic score for differential diagnosis. World J Surg Oncol 2021; 19:10. [PMID: 33430887 PMCID: PMC7802249 DOI: 10.1186/s12957-021-02120-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/02/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The differential diagnosis between primary adenocarcinoma of the pancreas head and distal cholangiocarcinoma remains a clinical challenge. Recent studies have shown important differences in terms of survival between these tumors. Therefore, different treatments should be considered, but the preoperative histological diagnosis is still difficult. Aim of this study is to create a preoperative diagnostic score for differential diagnosis between primary pancreatic adenocarcinoma and primary distal cholangiocarcinoma. METHODS One hundred eighty consecutive patients who underwent pancreaticoduodenectomy at Sapienza University of Rome from January 2010 to December 2019 were retrospectively analyzed. Inclusion criteria were pancreatic or biliary histologic origin obtained by definitive postoperative histological examination. Exclusion criteria were diagnosis of ampullary carcinoma, non-ampullary duodenal adenocarcinoma, pancreatic metastasis, and benign disease. One hundred one patients were considered eligible for the retrospective study. Preoperative biological, clinical, and radiological parameters were considered. RESULTS CRP > 10 mg/dL (p = 0.001), modified Glasgow Prognostic Score 2 (p = 0.002), albumin < 35 g/L (p = 0.05), CA 19-9 > 230 U/mL (p = 0.001), and Wirsung diameter > 3 mm (p < 0.001) were significant at univariate logistic analysis. Multivariate logistic analysis has shown that parameters independently associated with primary pancreatic adenocarcinoma were CRP > 10 mg/dL (p = 0.012), CA 19-9 > 230 U/mL (p = 0.043), and diameter of the Wirsung > 3 mm (p = 0.005). Through these parameters, a diagnostic score has been developed to predict a primary pancreatic adenocarcinoma when > 1 and a primary distal cholangiocarcinoma when < 1. CONCLUSION This feasible and low-cost diagnostic score could have a potential impact to differentiate pancreatic cancer histologic origin and to improve target therapeutic strategy.
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Affiliation(s)
- Edoardo Maria Muttillo
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Antonio Ciardi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Raffaele Troiano
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Paolina Saullo
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gabriele Masselli
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marianna Guida
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandra Tortora
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Italy, Viale del Policlinico 155, 00161 Rome, Italy
| | - Isabella Sperduti
- Biostatistical Unit – Clinical Trials Center, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
| | - Giulio Marinello
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Piero Chirletti
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Fusai GK, Tamburrino D, Partelli S, Lykoudis P, Pipan P, Di Salvo F, Beghdadi N, Dokmak S, Wiese D, Landoni L, Nessi C, Busch ORC, Napoli N, Jang JY, Kwon W, Del Chiaro M, Scandavini C, Abu-Awwad M, Armstrong T, Hilal MA, Allen PJ, Javed A, Kjellman M, Sauvanet A, Bartsch DK, Bassi C, van Dijkum EJMN, Besselink MG, Boggi U, Kim SW, He J, Wolfgang CL, Falconi M. Portal vein resection during pancreaticoduodenectomy for pancreatic neuroendocrine tumors. An international multicenter comparative study. Surgery 2021; 169:1093-1101. [PMID: 33357999 DOI: 10.1016/j.surg.2020.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/18/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The role of portal vein resection for pancreatic cancer is well established but not for pancreatic neuroendocrine neoplasms. Evidence from studies providing information on long-term outcome after venous resection in pancreatic neuroendocrine neoplasms patients is lacking. METHODS This is a multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection with standard pancreaticoduodenectomy in patients with pancreatic neuroendocrine neoplasms. The primary endpoint was to evaluate the long-term survival in both groups. Progression-free survival and overall survival were calculated using the method of Kaplan and Meier, but a propensity score-matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. The secondary outcome was Clavien-Dindo ≥3. RESULTS Sixty-one (11%) patients underwent pancreaticoduodenectomy with vein resection and 480 patients pancreaticoduodenectomy. Five (1%) perioperative deaths were recorded in the pancreaticoduodenectomy group, and postoperative clinically relevant morbidity rates were similar in the 2 groups (pancreaticoduodenectomy with vein resection 48% vs pancreaticoduodenectomy 33%). In the initial survival analysis, pancreaticoduodenectomy with vein resection was associated with worse 3-year progression-free survival (48% pancreaticoduodenectomy with vein resection vs 83% pancreaticoduodenectomy; P < .01) and 5-year overall survival (67% pancreaticoduodenectomy with vein resection vs 91% pancreaticoduodenectomy). After propensity score matching, no significant difference was found in both 3-year progression-free survival (49% pancreaticoduodenectomy with vein resection vs 59% pancreaticoduodenectomy; P = .14) and 5-year overall survival (71% pancreaticoduodenectomy with vein resection vs 69% pancreaticoduodenectomy; P = .98). CONCLUSION This study demonstrates no significant difference in perioperative risk with a similar overall survival between pancreaticoduodenectomy and pancreaticoduodenectomy with vein resection. Tumor involvement of the superior mesenteric/portal vein axis should not preclude surgical resection in patients with locally advanced pancreatic neuroendocrine neoplasms.
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Affiliation(s)
- Giuseppe K Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Panagis Lykoudis
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Peter Pipan
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Francesca Di Salvo
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Nassiba Beghdadi
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Safi Dokmak
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Dominik Wiese
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - Chiara Nessi
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - O R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Chiara Scandavini
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mahmoud Abu-Awwad
- Department of Surgery, University Hospital Southampton, United Kingdom
| | - Thomas Armstrong
- Department of Surgery, University Hospital Southampton, United Kingdom
| | - Mohamed Abu Hilal
- Department of Surgery, University Hospital Southampton, United Kingdom; Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgical Oncology, Duke University, Durham, NC
| | - Ammar Javed
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Magnus Kjellman
- Department of Molecular Medicine and Surgery, Division of Endocrine Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alain Sauvanet
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - E J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Jin He
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Christofer L Wolfgang
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Massimo Falconi
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
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Crippa S, Giannone F, Schiavo Lena M, Belfiori G, Partelli S, Tamburrino D, Delpini R, Pagnanelli M, Pecorelli N, Balzano G, Doglioni C, Falconi M. R Status is a Relevant Prognostic Factor for Recurrence and Survival After Pancreatic Head Resection for Ductal Adenocarcinoma. Ann Surg Oncol 2021; 28:4602-4612. [PMID: 33393031 DOI: 10.1245/s10434-020-09467-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prognostic role of resection margins in pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to investigate the impact that global and individual resection margin status after pancreatic head resection for PDAC has on disease-free survival (DFS) and disease-specific survival (DSS). METHODS Surgical specimens of pancreaticoduodenectomy/total pancreatectomy performed for PDAC were examined with a standardized protocol. Surgical margin status (biliary, pancreatic neck, duodenal, anterior and posterior pancreatic, superior mesenteric vein groove and superior mesenteric artery margins) was classified as the presence of malignant cells (1) directly at the inked surface (R1 direct), (2) within less than 1 mm (R1 ≤ 1 mm), or (3) with a distance greater than 1 mm (R0). Patients with a positive neck margin at the final histology were excluded from the study. RESULTS Of the 362 patients included in the study, 179 patients (49.4 %) had an R0 resection, 123 patients (34 %) had an R1 ≤ 1 mm resection, and 60 patients (16.6 %) had an R1 direct resection. The independent predictors of DFS were R1 direct resection (hazard ratio [HR], 1.49), R1 ≤ 1 mm resection (HR, 1.38), involvement of one margin (HR, 1.36), and involvement of two margins or more (HR, 1.55). When surgical margins were analyzed separately, only R1 ≤ 1 mm superior mesenteric vein margin (HR, 1.58) and R1 direct posterior margin (HR, 1.69) were independently associated with DFS. CONCLUSIONS Positive R status is an independent predictor of DFS (R1 direct and R1 ≤ 1 mm definitions) and of DSS (R1 direct). The presence of multiple positive margins is a risk factor for cancer recurrence and poor survival. Different surgical margins could have different prognostic roles.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Fabio Giannone
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Roberto Delpini
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Michele Pagnanelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Nicolo Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Claudio Doglioni
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Department of Pathology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy. .,Vita Salute San Raffaele University, Milan, Italy.
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245
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Groen JV, Stommel MWJ, Sarasqueta AF, Besselink MG, Brosens LAA, van Eijck CHJ, Molenaar IQ, Verheij J, de Vos-Geelen J, Wasser MN, Bonsing BA, Mieog JSD. Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists. HPB (Oxford) 2021; 23:80-89. [PMID: 32444267 DOI: 10.1016/j.hpb.2020.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/06/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal-superior mesenteric vein resection (VR). METHODS A systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey. RESULTS Overall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50-75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed. CONCLUSION This international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arantza F Sarasqueta
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam Department of Surgery, the Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Wang J, Lyu SC, Zhou L, Wang H, Pan F, Jiang T, Lang R, He Q. Prognostic analysis of pancreatic carcinoma with portal system invasion following curative resection. Gland Surg 2021; 10:35-49. [PMID: 33633960 DOI: 10.21037/gs-20-495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background To analyze the related factors affecting the prognosis of pancreatic carcinoma with portal system invasion. Methods We retrospectively analyzed the clinical data of 118 patients with portal venous system invasion in Beijing Chaoyang Hospital between January 2011 and December 2018. Only patients with borderline resectable pancreatic cancer were included in this study. Borderline pancreatic cancer was defined according to NCCN (The National Comprehensive Cancer Network) guidelines. All patients underwent surgical treatment combined with vascular resection and reconstruction. The prognosis was evaluated according to the follow-up results, and the related risk factors for prognosis were analyzed. The survival curve was drawn by Kaplan-Meier method, and the survival rate was compared by log-rank test. Multivariate Cox regression was used to analyze the prognostic factors. Results In our research, all of 126 patients were successfully completed the operations. Complications occurred in 29.7% of patients and perioperative death in 4.0%. A total of 118 patients were followed up and the followed-up rate was 97.5% (118/121). The overall 1-year, 2-year and 3-year survival rates were 49.2%, 27.1% and 19.8%, And the median survival time was 20 months. Multivariate analysis showed that preoperative CA19-9 (RR 1.449, 95% CI: 1.053-1.994), N status (RR 2.533, 95% CI: 1.337-4.798), degree of tumor differentiation (RR 1.592, 95% CI: 1.064-2.381) and venous invasion depth (RR 2.03, 95% CI: 1.504-2.758) were independent risk factors for the prognosis. Conclusions The long-term prognosis of pancreatic carcinoma patients with portal system invasion is poor. The venous invasion depth is an independent risk factor for the prognosis of pancreatic carcinoma with portal system invasion, the deeper of venous invasion, the worse the prognosis, and poorly differentiated tumors have the worst prognosis. Other independent risk factors included N status and the preoperative CA19-9. Those may help with patients' selection for different treatment protocols.
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Affiliation(s)
- Jing Wang
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Shao-Cheng Lyu
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lin Zhou
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Han Wang
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Fei Pan
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tao Jiang
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreatic Splenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Ushida Y, Inoue Y, Ito H, Oba A, Mise Y, Ono Y, Sato T, Saiura A, Takahashi Y. High CA19-9 level in resectable pancreatic cancer is a potential indication of neoadjuvant treatment. Pancreatology 2021; 21:130-137. [PMID: 33303373 DOI: 10.1016/j.pan.2020.11.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies on borderline resectable (BR) pancreatic cancer (PC) included patients with heterogenous preoperative states; however, the definition of resectability for PC has evolved. We aimed to investigate the prognostic factors for PC other than anatomical resectability in those who underwent upfront resection and discuss the optimal treatment strategy for PC. METHODS We retrospectively examined 431 patients who underwent upfront surgery with curative intent between 2007 and 2014. The association between clinical characteristics and survival outcomes was assessed by stratifying patients according to risk factors. The patients were categorized into four groups based on anatomical (resectable [R]/BR) and biological features (CA19-9 ≤500/>500 U/mL): anatomical R with CA19-9 ≤500 U/mL (favorable-R); anatomical BR with CA19-9 ≤500 U/mL (favorable-BR); anatomical R with CA19-9 >500 U/mL (risky-R); and anatomical BR with CA19-9 >500 U/mL (risky-BR). RESULTS Overall, 320 and 111 patients had anatomical R- and BR-PC, respectively. A modified Glasgow prognostic score = 2 (hazard ratio [HR]: 1.73), NLR>5 (hazard ratio [HR]: 1.54), CA19-9 >500 U/mL (HR: 1.86), and anatomical BR (HR: 1.38) were independent prognostic factors for overall survival. The risky-R group had likely worse prognosis (16 months vs. 19 months, P = 0.0605) and a significantly higher early recurrence rate (36% vs 18%, P = 0.0231) than the favorable-BR group. CONCLUSIONS It is essential to stratify and distinguish PC patients at a high risk of worse prognosis. Risky-R was an unfavorable prognostic factor and should thus be considered in the decision-making for treatment with neoadjuvant chemotherapy, in addition to anatomical BR-PC.
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Affiliation(s)
- Yuta Ushida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Atsushi Oba
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan; Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Hospital, 3-1-3, Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Yoshihiro Ono
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan; Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Hospital, 3-1-3, Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Ahmed SA, Mourad AF, Hassan RA, Ibrahim MAE, Soliman A, Aboeleuon E, Elbadee OMA, Hetta HF, Jabir MA. Preoperative CT staging of borderline pancreatic cancer patients after neoadjuvant treatment: accuracy in the prediction of vascular invasion and resectability. Abdom Radiol (NY) 2021; 46:280-289. [PMID: 32488556 DOI: 10.1007/s00261-020-02605-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To assess the utility of MDCT tumor-vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT). METHODS This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient. RESULTS Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact > 2 cm to predict vascular invasion, the AUCs for the two readers were 0.85-0.88 for arterial invasion and 0.92-0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact < 2 cm to predict R0 resection, the AUCs was 0.85-0.86 for the two readers. The overall inter-reader agreement was good (κ = 0.75-0.80). The κ values for venous invasion, arterial invasion and R0 resection were 0.76, 0.78, and 0.80. CONCLUSION Tumor-vessel criteria demonstrated good diagnostic performance and reproducibility in the prediction of vascular invasion after NAT in BRPC. These criteria could be helpful in the prediction of R0 resection in cases with only venous involvement.
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Lapshyn H, Schulte T, Sondermann S, May K, Petrova E, Honselmann KC, Braun R, Zemskov S, Keck T, Wellner UF, Bausch D, Bolm L. Radiological prediction of portal vein infiltration in patients with pancreatic ductal adenocarcinoma. Pancreatology 2021; 21:155-162. [PMID: 33309623 DOI: 10.1016/j.pan.2020.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/02/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy characterized by early loco-regional invasion. Portal vein resection (PVR) during pancreatoduodenectomy (PD) for PDAC is performed if tumor cell invasion to the venous wall (PVI) is suspected. The aim of this study is to evaluate radiological criteria for predicting PVR and PVI. METHODS Patients undergoing PD for PDAC were identified from a prospectively maintained database. On the basis of CT- and MRI-based imaging portal vein tumor contact (PV), stranding of the superior mesenteric artery (SMA) and any alterations of the superior mesenterico-portal vein (SMPV) were evaluated. The accuracy of PVI and PVR prediction based on the radiological parameters was calculated. RESULTS 143 patients were included in the study. 48 patients underwent PVR (34%), PVI was diagnosed in 23 patients (16%). Median overall survival was 22 months. Prediction of PVR (sensitivity 79%, negative predictive value 88%, p = 0.010) and PVI (sensitivity 95%, negative predictive value 99%, p = 0.002) was most accurate for any SMPV alterations as compared to the other radiological parameters. SMPV alterations qualified as an independent prognostic parameter (26.5 months vs. 33.5months, p = 0.034). CONCLUSION Radiological evaluation of any SMPV alterations is a simple preoperative method to accurately predict PVI. Assessing SMPV alterations may help to identify candidates for neoadjuvant therapy.
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Affiliation(s)
- Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Theresa Schulte
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Stefan Sondermann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Katharina May
- Department of Radiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical University, Bogomolets, 01601, Kiev, No 13, Shevchenko Av, Ukraine
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany; Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
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250
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Watson MD, Baimas-George MR, Murphy KJ, Pickens RC, Iannitti DA, Martinie JB, Baker EH, Vrochides D, Ocuin LM. Pure and Hybrid Deep Learning Models can Predict Pathologic Tumor Response to Neoadjuvant Therapy in Pancreatic Adenocarcinoma: A Pilot Study. Am Surg 2020; 87:1901-1909. [PMID: 33381979 DOI: 10.1177/0003134820982557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC. METHODS Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve. RESULTS A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096). CONCLUSIONS A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.
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Affiliation(s)
- Michael D Watson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Maria R Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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