Prognostic factors following curative resection for pancreatic adenocarcinoma: a population-based, linked database analysis of 396 patients

The number and ratio of positive lymph nodes affect pancreatic cancer patient survival after neoadjuvant therapy and pancreaticoduodenectomy

AIMS

This study is to examine the significance of the number and ratio of positive nodes in post-neoadjuvant therapy pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).

METHODS AND RESULTS

Our study population consisted of 398 consecutive PDAC patients, who completed neoadjuvant therapy and PD between 1999 and 2012. Lymph node status was classified as ypN0 (node-negative), ypN1 (1-2 positive nodes) and ypN2 (≥3 positive nodes) and correlated with disease-free survival (DFS) and overall survival (OS). The ypN0, ypN1 and ypN2 was present in 183 (46.0%), 117 (29.4%) and 98 (24.6%) patients, respectively. Additionally, 162 (40.7%) had a lymph node ratio (LNR) ≤0.19 and 53 (13.3%) had a LNR >0.19. Patients with ypN1 disease had shorter DFS and OS than those with ypN0 disease, but better DFS and OS than those with ypN2 disease (P < 0.05). Similarly, patients with a LNR ≤ 0.19 had better DFS and OS than those with a LNR > 0.19 (P < 0.001). In multivariate analysis, both the number of positive nodes and LNR were independent prognostic factors for DFS and OS.

CONCLUSIONS

Subclassification of post-therapy node-positive group into ypN1 (1-2 positive nodes) and ypN2 (≥3 positive nodes) should be incorporated into the American Joint Committee on Cancer (AJCC) staging of PDAC patients.

18F-fluoro-2-deoxy-D-glucose retention index as a prognostic parameter in patients with pancreatic cancer

OBJECTIVES

The objective of this study was to determine the most effective way to use dual-phase F-fluoro-2-deoxy-D-glucose (F-FDG) PET/computed tomography (CT) semiquantitative indices to predict prognosis in patients with pancreatic cancer and to guide treatment.

STUDY DESIGN

Prognostic parameters were retrospectively analyzed in 40 patients with histologically proven pancreatic cancer who received F-FDG PET/CT at Ruijin Hospital. Maximum standardized uptake values (SUVs) were determined at 1 h (SUV1) and 2 h (SUV2) after F-FDG injection. The retention index (RI) was defined as the percentage change between SUV1 and SUV2.

RESULTS

RI less than 17% was explored as having a significant independent correlation with prolonged patient survival (P<0.05). Patients with tumor resection and RI less than 17% survived significantly longer than those with or without tumor resection and RI of 17% or higher (P<0.05). Neither SUV1, nor SUV2 showed any prognostic significance, but they did show a positive correlation with tumor diameter (P1<0.01; P2<0.05); RI had a strong positive correlation with tumor, node, and metastasis stage (P<0.01). Two factors were found to be associated with RI, including pancreatitis (P<0.05) and diabetes (P<0.01).

CONCLUSION

RI served as the most accurate parameter to predict disease prognosis in pancreatic cancer and to identify patients who could benefit from surgery. However, pancreatitis and diabetes had a potential impact on RI, reflecting the influence of tumor pathophysiological changes on the metabolism of glucose in pancreatic tumor cells. Therefore, further comprehensive analyses are required.

Pancreatic cancer disparities in African Americans

OBJECTIVES

Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States. The incidence of pancreatic cancer in African Americans is 50% to 90% higher than the incidence in other racial groups. African Americans also have the worst prognosis. This is an evidence-based review of pancreatic cancer in African Americans with particular emphasis on baseline characteristics, treatment, and survival.

METHODS

We queried PubMed in search for articles describing racial disparities in pancreatic cancer. Two categories of terms were "anded" together: pancreatic cancer terms and race terms. The last search was performed on November 14, 2013.

RESULTS

We summarized the data on pancreatic cancer baseline characteristics, treatment, and survival for African Americans that we obtained from the following databases: (1) Surveillance, Epidemiology, and End Results, 1988-2008; (2) California Cancer Registry 1988-1998; (3) Cancer Survivor Program of Orange County/San Diego Imperial Organization for Cancer Control, 1988-1998; and (4) Harris County, 1998-2010.

CONCLUSIONS

Overall, pancreatic cancer survival of African Americans has not significantly improved over the past several decades despite advances in multimodality therapy; African Americans continue to face worse outcomes than whites. Although baseline characteristics, treatment, and biological factors offer some explanation, they do not completely explain the disparities in incidence and survival.

Preoperative serum CA125 levels predict the prognosis in hyperbilirubinemia patients with resectable pancreatic ductal adenocarcinoma

Serum carbohydrate antigen 19-9 (CA19-9) is widely used to predict the prognosis for pancreatic ductal adenocarcinoma (PDAC). However, hyperbilirubinemia and the CA19-9 nonsecretor phenotype restrict the usage of serum CA19-9 alone. The goal of this study was to confirm the prognostic role of preoperative serum CA125 in PDAC, especially in patients with jaundice.A total of 211 patients with resected PDAC were eligible for this retrospective study, and were classified into 2 groups based on serum bilirubin levels. The prognostic significance of all clinicopathologic factors was evaluated by univariate and multivariate analyses, and the performance of each factor in predicting overall survival (OS) and recurrence-free survival (RFS) was compared.High preoperative CA125, high TNM stage, and lymph node metastasis were independent risk predictors for OS and RFS in all patients and the 2 subgroups, but high CA19-9 was only significant when considering all patients and those with nonelevated bilirubin. Using time-dependent receiver-operating characteristic analysis, better predictive performance for OS and RFS was observed for serum CA19-9 as compared to serum CA125 in these patients.High serum CA125 can independently predict poor prognosis. Importantly, in PDAC patients with hyperbilirubinemia, preoperative serum CA125 can predict the prognosis, whereas CA19-9 cannot. Preoperative CA19-9 had better predictive performance for survival than CA125, and the performance of CA19-9 did not decline between all patients and those with nonelevated bilirubin, but was significantly affected by hyperbilirubinemia.

Research gaps in pancreatic cancer research and comparative effectiveness research methodologies

Despite advances in cancer care, pancreatic adenocarcinoma remains one of the most lethal tumors. Most patients with pancreatic cancer are diagnosed with late stage disease, and approximately 6 % of patients are alive 5 years after diagnosis. Of the 10-20 % of patients who are candidates for resection and multi-modality therapy, most will succumb to the disease with 5-year survival rates only reaching approximately 25 % (Lim et al. in Annals of surgery 237(1):74-85, 2003 [1]; Trede et al. in Annals of surgery 211(4):447-458, 1990 [2]; Crist et al. in Annals of surgery 206(3):358-365, 1987 [3]). Clearly, there is a need to improve the management of this disease. To identify gaps in research and formulate strategies to address these issues, we designed a framework to encompass the scope of research for pancreatic cancer. In this chapter, we will examine each topic heading within this framework for gaps in knowledge and present research strategies focusing on diverse comparative effectiveness research (CER) methodologies to address the identified gaps.

TCGA data and patient-derived orthotopic xenografts highlight pancreatic cancer-associated angiogenesis

Pancreatic ductal adenocarcinomas (PDACs) overexpress pro-angiogenic factors but are not viewed as vascular. Using data from The Cancer Genome Atlas we demonstrate that a subset of PDACs exhibits a strong pro-angiogenic signature that includes 37 genes, such as HDAC9, that are overexpressed in PDAC arising in KRC mice, which express mutated Kras and lack RB. Moreover, patient-derived orthotopic xenografts can exhibit tumor angiogenesis, whereas conditioned media (CM) from KRC-derived pancreatic cancer cells (PCCs) enhance endothelial cell (EC) growth and migration, and activate canonical TGF-β signaling and STAT3. Inhibition of the type I TGF-β receptor with SB505124 does not alter endothelial activation in vitro, but decreases pro-angiogenic gene expression and suppresses angiogenesis in vivo. Conversely, STAT3 silencing or JAK1-2 inhibition with ruxolitinib blocks CM-enhanced EC proliferation. STAT3 disruption also suppresses endothelial HDAC9 and blocks CM-induced HDAC9 expression, whereas HDAC9 re-expression restores CM-enhanced endothelial proliferation. Moreover, ruxolitinib blocks mitogenic EC/PCC cross-talk, and suppresses endothelial p-STAT3 and HDAC9, and PDAC progression and angiogenesis in vivo, while markedly prolonging survival of KRC mice. Thus, targeting JAK1-2 with ruxolitinib blocks a final pathway that is common to multiple pro-angiogenic factors, suppresses EC-mediated PCC proliferation, and may be useful in PDACs with a strong pro-angiogenic signature.

Long-term outcome of portomesenteric vein invasion and prognostic factors in pancreas head adenocarcinoma

BACKGROUND

The purpose of this study was to clarify the post-operative prognosis of pancreatic head cancer with pathologic portal vein (PV) or superior mesenteric vein (SMV) invasion.

METHODS

From May 1995 to December 2009, preoperative, intra-operative and post-operative data from 276 patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were reviewed retrospectively. The long-term prognosis was compared between patients with a pathologic PV-SMV invasion and those without invasion.

RESULTS

Fourty-six patients (16.7%) underwent PV-SMV resection during pancreaticoduodenectomy. Pathologic PV-SMV invasion was observed in 30 (65.2%). Post-operative severe morbidity (grade 3 or 4) was similar for patients with and without PV-SMV resection (8.7% with versus 7.0% without P = 0.754). The mortality rate was 2.2% with PV-SMV resection and 0.9% without PV-SMV resection (P = 0.423). Survival of PV-SMV resection and no resection group had no significant difference (median survival, 16 versus 12 months; P = 0.086). No significant difference in overall survival was seen between patients with and without pathologic PV-SMV invasion (median survival, 13 versus 16 months; P = 0.663). Tumour differentiation, R status, tumour size and type of operation were revealed as independent prognostic factors.

CONCLUSIONS

34.8% of patients who underwent PV-SMV resection had no pathologic invasion. And PV-SMV resection did not increase the rate of severe complications and mortality. Furthermore, the prognosis for patients with pathologic PV-SMV invasion may be nearly the same as patients with no invasion. So, PV-SMV resection with reconstruction should be considered in pancreatic head cancer patients with suspected PV-SMV invasion.

Reappraisal of Nodal Staging and Study of Lymph Node Station Involvement in Pancreaticoduodenectomy with the Standard International Study Group of Pancreatic Surgery Definition of Lymphadenectomy for Cancer

BACKGROUND

The prognostic role of lymph node (LN) dissection in pancreatic head ductal adenocarcinoma is still unclear. This study reappraised the value of the number of positive LNs and LN ratio in patients undergoing pancreaticoduodenectomy with standard lymphadenectomy according to the recent International Study Group of Pancreatic Surgery definition. In addition, the impact of nodal metastases stratified by LN stations was investigated.

STUDY DESIGN

After reviewing retrospectively clinical and pathologic data of 758 pancreaticoduodenectomies for pancreatic head ductal adenocarcinoma performed from 2002 through 2011, we extracted patients in whom the LN stations included in the International Study Group of Pancreatic Surgery definition had been sampled. Survival analysis was performed using univariate and multivariate models.

RESULTS

The study population consisted of 255 patients. Mean number of harvested LNs was 30.8. Factors with a significant prognostic impact on multivariate analysis were tumor grade, adjuvant therapy, number of positive LNs, LN metastases along station 14a-b (proximal superior mesenteric artery), and the number of metastatic LN stations. Patients with involvement of station 14a-b exhibited worse pathologic features, indicating more aggressive disease.

CONCLUSIONS

In patients receiving a uniform LN dissection, the number of positive LNs is superior to LN ratio for predicting survival. Lymph node metastases along the proximal superior mesenteric artery have a significant prognostic value, and an increasing number of metastatic stations are associated with a sharp decrease in survival. In future studies, clarification of the pattern of LN metastasis spread could offer valuable insight into the optimal treatment strategies, including selection of patients for neoadjuvant therapies.

Normalization of CA19-9 following resection for pancreatic ductal adenocarcinoma is not tantamount to being cured?

BACKGROUND

Postoperative carbohydrate antigen 19-9 (CA19-9) is an independent predictor of survival for pancreatic ductal adenocarcinoma (PDAC), and more powerful than preoperative CA19-9. However, making decisions just dependent on postoperative CA19-9 may result in necessary treatments not being performed.

MATERIALS AND METHODS

A total of 178 patients with resected PDAC were eligible for this retrospective study, classified into two corresponding subgroups according to postoperative CA19-9. Prognostic significance of all clinicopathologic factors was evaluated by univariate and multivariate analyses.

RESULTS

Postoperative CA19-9, preoperative CA125 and lymph node status were independent predictors. Better predictive performances for overall survival (OS) and recurrence-free survival (RFS) were achieved by postoperative CA19-9 compared to preoperative CA125 and lymph node status. Particularly, preoperative CA125 was associated with poor OS (p<0.001 for the normalized CA19-9 patients, p=0.012 for the elevated) and RFS (p=0.005 for the normalized, p=0.004 for the elevated). Moreover, preoperative CA125 levels related with survival in double- negative patients.

CONCLUSIONS

Normalization of CA19-9 is not tantamount to be cured. Preoperative CA125 is a critical predictor for PDAC patients, especially in double-negative patients.

Evaluation of prognostic factors and survival results in pancreatic carcinomas in Turkey

BACKGROUND

The goal of this retrospective study was to evaluate patient characteristics, treatment modalities and prognostic factors in Turkish patients with pancreatic cancer.

MATERIALS AND METHODS

Between January 1997 and December 2012, 64 patients who presented to the Department of Radiation Oncology, Karadeniz Technical University, Faculty of Medicine with a diagnosis of pancreatic cancer were evaluated. The E/K ratio of the cases was 2.4/1 and the median age was 59.6 (32-80) years, respectively. Some 11 cases (18%) were stage 1, 21 (34.4%) were stage 2, 10 (16.4%) were stage 3, and 19 (31.1%) were metastatic.

RESULTS

The mean follow-up time was 15.7 months (0.7-117.5) and loco-regional recurrence was noted in 11 (40.7%) who underwent surgery while metastases were observed in 41 patients (66.1%). The median overall survival (OS) was 11.2 months and the 1, 3 and 5-year OS rates were 41.7%, 9.9% and 7.9% respectively. The median disease-free survival (DFS) was 5.2 month and the1, 2 and 5 year DFS were 22.6%, 7.6% and 3.8% respectively. On univariate analysis, prognostic factors affecting OS included status of the operation (p<0.001), tumor stage (p=0.008), ECOG performance status (p=0.005) and CEA level (p=0.017).On multivariate analysis, prognostic factors affecting survival included status of the operation (p=0.033) and age (p= 0.023).

CONCLUSIONS

In the current study, age and operation status were independent prognostic factors for overall survival with pancreatic patients. Thus, the patients early diagnosis and treatment ars essential. However, prospective studies with more patients are needed for confirmation.

Factors influencing survival after pancreatoduodenectomy for ductal adenocarcinoma depend on patients' age

BACKGROUND

It is supposed that a prolonged lifetime will be associated with increased incidence of PDAC among the elderly. Some studies show a tendency toward decreased survival in the elderly patients following pancreatoduodenectomy for PDAC. The aim of this study was to evaluate factors, influencing survival following pancreatoduodenectomy for PDAC in different age groups.

METHODS

Data of 251 patients after pancreatoduodenectomy for PDAC between 1999 and 2012 were analyzed. The Kaplan-Meier method and log-rank test were used to calculate survival and to compare differences between groups. The Cox proportional hazard model was applied to indentify independent prognosticators.

RESULTS

The overall median survival was 14.9 months. Postoperative morbidity was 25.5% with a 5.1% mortality rate. No significant differences in the overall morbidity (22.4 vs. 29.6%) or mortality (2.8 vs. 8.3%) rates were observed between different patients' age groups (<70 years and >70 years). Multivariate analysis revealed R1 resection (HR 1.76) and poor tumor differentiation (G3-G4) (HR 1.48) were independent negative factors for survival in patients <70 years. Lymph-node metastases (N1) - HR 4.89 and perineural invasion - HR 2.73 were independent prognosticators in the elderly.

CONCLUSIONS

Our study highlighted different factors influencing long-term survival after pancreatoduodenectomy: R1 resection and poor tumor differentiation (G3-G4) were independent negative factors for survival in patients <70 years, while perineural invasion and lymph-node metastases result in worse survival among the elderly.

Knowledge discovery for pancreatic cancer using inductive logic programming

Pancreatic cancer is a devastating disease and predicting the status of the patients becomes an important and urgent issue. The authors explore the applicability of inductive logic programming (ILP) method in the disease and show that the accumulated clinical laboratory data can be used to predict disease characteristics, and this will contribute to the selection of therapeutic modalities of pancreatic cancer. The availability of a large amount of clinical laboratory data provides clues to aid in the knowledge discovery of diseases. In predicting the differentiation of tumour and the status of lymph node metastasis in pancreatic cancer, using the ILP model, three rules are developed that are consistent with descriptions in the literature. The rules that are identified are useful to detect the differentiation of tumour and the status of lymph node metastasis in pancreatic cancer and therefore contributed significantly to the decision of therapeutic strategies. In addition, the proposed method is compared with the other typical classification techniques and the results further confirm the superiority and merit of the proposed method.

Clinical and pathological features of five-year survivors after pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Clinical factors determining short-term survival after pancreatectomy have been well studied, but factors predicting long-term survival with curative resection are poorly understood in pancreatic carcinoma. Our objective was to identify clinical and pathological features of five-year disease-free survivors after surgical resection of pancreatic adenocarcinoma.

METHODS

The clinical and pathological data from 147 patients who underwent a potentially curative resection for pancreatic adenocarcinoma at our institution between 1988 and 2012 were retrospectively analyzed.

RESULTS

Of 147 patients, 18 survived for more than five years after surgery without disease recurrence. A univariate analyses demonstrated that: two or fewer lymph node metastases (P=0.014), a preoperative serum carbohydrate antigen 19-9 (CA19-9) level of 40 U/mL or less (P=0.0018), an absence of intrapancreatic nerve invasion (P=0.028), and undergoing an R0 resection (P=0.011) were significantly associated with five-year survival. A logistic regression model identified the following independent cancer-related predictors of five-year survivors: having two or fewer lymph node metastases (odds ratio (OR): 6.02; 95% confidence interval (CI): 1.08 to 112.98; P=0.0385), a preoperative serum CA19-9 level of 40 U/mL or less (OR: 5.02; 95% CI: 1.68 to 16.48; P=0.0036), and undergoing an R0 resection (OR: 3.63; 95% CI: 1.12 to 14.28; P=0.0316).

CONCLUSIONS

We conclude that number of lymph node metastases being two or less, a preoperative serum CA19-9 level of 40 U/mL or less, and undergoing an R0 resection may be independent predictive factors to identify actual five-year survivors after pancreatectomy for pancreatic adenocarcinoma.

Nodal counts and lymph node ratio impact survival after distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

The number of lymph nodes required for accurate staging after distal pancreatectomy for pancreatic adenocarcinoma is unknown.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 1,473 patients who underwent distal pancreatectomy for pancreatic adenocarcinoma from 1998 to 2010. We evaluated the influence of the total number of lymph nodes examined (NNE) and the lymph node ratio (LNR-positive nodes/total nodes examined) on survival.

RESULTS

The median NNE was 8. No nodes were examined in 232 (16%) of the patients, and 843 (57%) had <10 NNE. Of the patients who had at least one node examined, 612 (49%) were node positive. In the node-negative subset, the median and 5-year overall survival for patients with ≤10 NNE was significantly worse than patients with >10 NNE (16 vs. 20 months and 13 vs. 19%, respectively, p < 0.011). For node-positive patients, those with LNR ≤0.1 had better 5-year overall survival compared with LNR >0.1 (17 vs. 6%, p = 0.002).

DISCUSSION

Patients with pancreatic cancer undergoing distal pancreatectomy should ideally have at least 11 lymph nodes examined to avoid understaging. For node-positive patients, LNR may be a better prognostic indicator than the total number of positive nodes.

Diagnostic accuracy of CT in assessing extra-regional lymphadenopathy in pancreatic and peri-ampullary cancer: a systematic review and meta-analysis

OBJECTIVES

Computed tomography (CT) is the most widely used method to assess resectability of pancreatic and peri-ampullary cancer. One of the contra-indications for curative resection is the presence of extra-regional lymph node metastases. This meta-analysis investigates the accuracy of CT in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer.

METHODS

We systematically reviewed the literature according to the PRISMA guidelines. Studies reporting on CT assessment of extra-regional lymph nodes in patients undergoing pancreatoduodenectomy were included. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data.

RESULTS

After screening, 4 cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or peri-ampullary cancer were included. Overall, diagnostic accuracy, specificity and NPV varied from 63 to 81, 80-100% and 67-90% respectively. However, PPV and sensitivity ranged from 0 to 100% and 0-38%. Pooled sensitivity, specificity, PPV and NPV were 25%, 86%, 28% and 84% respectively.

CONCLUSIONS

CT has a low diagnostic accuracy in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer. Therefore, suspicion of extra-regional lymph node metastases on CT alone should not be considered a contra-indication for exploration.

Improved long-term outcomes after resection of pancreatic adenocarcinoma: a comparison between two time periods

BACKGROUND

Despite reduced perioperative mortality and routine use of adjuvant therapy following pancreatectomy for pancreatic ductal adenocarcinoma (PDAC), improvement in long-term outcome has been difficult to ascertain. This study compares outcomes in patients undergoing resection for PDAC within a single, high-volume academic institution over two sequential time periods.

METHODS

Retrospective review of patients with resected PDAC, in two cohorts: period 1 (P1), 1991-2000; and period 2 (P2), 2001-2010. Univariate and multivariate analyses using the Cox proportional hazards model were performed to determine prognostic factors associated with long-term survival. Survival was evaluated using Kaplan-Meier analyses.

RESULTS

A total of 179 pancreatectomies were performed during P1 and 310 during P2. Perioperative mortality was 6.7 % (12/179) in P1 and 1.6 % (5/310) in P2 (p = 0.003). P2 had a greater number of lymph nodes resected (17 [0-50] vs. 7 [0-31]; p < 0.001), and a higher lymph node positivity rate (69 % [215/310] vs. 58 % [104/179]; p = 0.021) compared with P1. The adjuvant therapy rate was 30 % (53/179) in P1 and 63 % (195/310) in P2 (p < 0.001). By multivariate analysis, node and margin status, tumor grade, adjuvant therapy, and time period of resection were independently associated with overall survival (OS) for both time periods. Median OS was 16 months (95 % confidence interval [CI] 14-20) in P1 and 27 months (95 % CI 24-30) in P2 (p < 0.001).

CONCLUSIONS

Factors associated with improved long-term survival remain comparable over time. Short- and long-term survival for patients with resected PDAC has improved over time due to decreased perioperative mortality and increased use of adjuvant therapy, although the proportion of 5-year survivors remains small.

Pathology handling of pancreatoduodenectomy specimens: Approaches and controversies

Pancreatic cancer, with a 5% 5-year survival rate, is the fourth leading cause of cancer death in Western countries. Unfortunately, only 20% of all patients benefit from surgical treatment. The need to prolong survival has prompted pathologists to develop improved protocols to evaluate pancreatic specimens and their surgical margins. Hopefully, the new protocols will provide clinicians with more powerful prognostic indicators and accurate information to guide their therapeutic decisions. Despite the availability of several guidelines for the handling and pathology reporting of duodenopancreatectomy specimens and their continual updating by expert pathologists, there is no consensus on basic issues such as surgical margins or the definition of incomplete excision (R1) of pancreatic ductal adenocarcinoma. This article reviews the problems and controversies that dealing with duodenopancreatectomy specimens pose to pathologists, the various terms used to define resection margins or infiltration, and reports. After reviewing the literature, including previous guidelines and based on our own experience, we present our protocol for the pathology handling of duodenopancreatectomy specimens.

Multi-institutional pooled analysis on adjuvant chemoradiation in pancreatic cancer

PURPOSE

To determine the impact of chemoradiation therapy (CRT) on overall survival (OS) after resection of pancreatic adenocarcinoma.

METHODS AND MATERIALS

A multicenter retrospective review of 955 consecutive patients who underwent complete resection with macroscopically negative margins (R0-1) for invasive carcinoma (T1-4; N0-1; M0) of the pancreas was performed. Exclusion criteria included metastatic or unresectable disease at surgery, macroscopic residual disease (R2), treatment with intraoperative radiation therapy (IORT), and a histological diagnosis of no ductal carcinoma, or postoperative death (within 60 days of surgery). In all, 623 patients received postoperative radiation therapy (RT), 575 patients received concurrent chemotherapy (CT), and 462 patients received adjuvant CT.

RESULTS

Median follow-up was 21.0 months. Median OS after adjuvant CRT was 39.9 versus 24.8 months after no adjuvant CRT (P<.001) and 27.8 months after CT alone (P<.001). Five-year OS was 41.2% versus 24.8% with and without postoperative CRT, respectively. The positive impact of CRT was confirmed by multivariate analysis (hazard ratio [HR] = 0.72; confidence interval [CI], 0.60-0.87; P=.001). Adverse prognostic factors identified by multivariate analysis included the following: R1 resection (HR = 1.17; CI = 1.07-1.28; P<.001), higher pT stage (HR = 1.23; CI = 1.11-1.37; P<.001), positive lymph nodes (HR = 1.27; CI = 1.15-1.41; P<.001), and tumor diameter >20 mm (HR = 1.14; CI = 1.05-1.23; P=.002). Multivariate analysis also showed a better prognosis in patients treated in centers with >10 pancreatic resections per year (HR = 0.87; CI = 0.78-0.97; P=.014) CONCLUSION: This study represents the largest comparative study on adjuvant therapy in patients after resection of carcinoma of the pancreas. Overall survival was better in patients who received adjuvant CRT.

Role of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas

BACKGROUND

Studies have claimed that in the surgical treatment of pancreas body and tail cancer, radical antegrade modular pancreatosplenectomy (RAMPS) is associated with effective tangential margin and extensive lymph node dissection. In the present study, the authors have compared the surgical outcomes between RAMPS and conventional distal pancreatosplenectomy (DPS) in patients with adenocarcinoma of the pancreas body and tail, and also identified prognostic factors associated with survival after surgery.

METHODS

Retrospective review of 92 consecutive patients who underwent surgical resection for pancreas body and tail adenocarcinoma with curative intent between 1995 and 2010. Median follow-up duration was 16.1 months.

RESULTS

Of the 92 patients, 38 patients received RAMPS and 54 patients received DPS. Patients who underwent RAMPS had a greater number of retrieved lymph nodes than patients undergoing DPS [median 14 (5-52) vs. 9 (1-36), p < 0.05]. Conventional DPS, no adjuvant chemoradiation therapy (CRT), and non-curative resection were associated with poor overall survival (OS) on univariate analysis. After multivariate analysis for these variables, only the lack of adjuvant CRT and resection margin status were found to adversely affect OS.

CONCLUSIONS

While the RAMPS procedure is effective in performing an extensive LN dissection, it is not associated with better retroperitoneal resection margin or retrieval of more positive LNs, and it does not lead to better curability or OS survival compared to DPS. Lack of adjuvant CRT and resection margin status are poor prognostic factors in patients with pancreas body and tail cancer.

Antiproliferative effects and mechanisms of liver X receptor ligands in pancreatic ductal adenocarcinoma cells

Pancreatic ductal adenocarcinoma (PDAC) is difficult to detect early and is often resistant to standard chemotherapeutic options, contributing to extremely poor disease outcomes. Members of the nuclear receptor superfamily carry out essential biological functions such as hormone signaling and are successfully targeted in the treatment of endocrine-related malignancies. Liver X receptors (LXRs) are nuclear receptors that regulate cholesterol homeostasis, lipid metabolism, and inflammation, and LXR agonists have been developed to regulate LXR function in these processes. Intriguingly, these compounds also exhibit antiproliferative activity in diverse types of cancer cells. In this study, LXR agonist treatments disrupted proliferation, cell-cycle progression, and colony-formation of PDAC cells. At the molecular level, treatments downregulated expression of proteins involved in cell cycle progression and growth factor signaling. Microarray experiments further revealed changes in expression profiles of multiple gene networks involved in biological processes and pathways essential for cell growth and proliferation following LXR activation. These results establish the antiproliferative effects of LXR agonists and potential mechanisms of action in PDAC cells and provide evidence for their potential application in the prevention and treatment of PDAC.

Effect of adjuvant radiotherapy on survival in resected pancreatic cancer: a propensity score surveillance, epidemiology, and end results database analysis

BACKGROUND AND OBJECTIVES

The role of adjuvant radiotherapy for resected pancreatic cancer remains controversial. The aim is to demonstrate a survival benefit of adjuvant radiotherapy for resected pancreatic cancer.

METHODS

The Surveillance, Epidemiology and End Results database was used to identify patients who were diagnosed with adenocarcinoma of the pancreas from 2004 to 2009, underwent cancer-directed surgery, and received either no radiotherapy or postoperative radiotherapy. Kaplan-Meier and multivariable Cox proportional hazards analyses using a propensity score matching were conducted to determine the effect of adjuvant radiotherapy on overall and disease-specific survival.

RESULTS

A total of 2,532 patients were included. The median overall and disease-specific survival were significantly longer in the adjuvant radiotherapy group than in no radiotherapy group (overall survival, 20 months vs. 16 months, respectively; disease-specific survival, 22 months vs. 18 months, respectively; both P < 0.0001). In multivariable Cox proportional analyses, adjuvant radiotherapy was associated with a significant overall and disease-specific survival benefit (both P < 0.001).

CONCLUSIONS

There is a survival benefit of adjuvant radiotherapy in patients with resected pancreatic cancer. We concluded that adjuvant radiotherapy might be included in the standard treatment for resected pancreatic cancer.

Adjuvant Gemcitabine and Gemcitabine-based Chemoradiotherapy Versus Gemcitabine Alone After Pancreatic Cancer Resection: The Indiana University Experience

OBJECTIVES

Adjuvant therapy after surgical resection is the current standard for pancreatic adenocarcinoma; however, the role of chemoradiotherapy (CRT) remains unclear. This study was conducted to compare the efficacy outcomes with adjuvant gemcitabine and gemcitabine-based CRT (CT-CRT) versus gemcitabine chemotherapy (CT) alone after pancreaticoduodenectomy.

METHODS

Among 165 patients who underwent surgical resection for pancreatic cancer at Indiana University Medical Center between 2004 and 2008, we retrospectively identified 53 consecutive patients who received adjuvant therapy (CT-CRT=34 patients; CT=19 patients) and had adequate follow-up medical records. The median follow-up was 19.1 months. Median disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier method, and a Cox-regression model was used to compare survival outcomes after adjusting for age, status of resection margins, and lymph node involvement.

RESULTS

The OS for the CT-CRT group was significantly higher compared with the CT group (median, 20.4 vs. 16.6 mo; hazard ratio, 2.42; 95% CI, 1.17-5.01). The median DFS for the CT-CRT group was 13.7 versus 11.1 months for the CT group (hazard ratio, 2.88; 95% CI, 1.37-6.06). On subgroup analyses, significantly superior OS and DFS were observed among patients younger than 65 years, T3/T4 tumor stage, negative resection margins, and positive lymph node involvement.

CONCLUSION

Gemcitabine plus gemcitabine-based CRT compared with gemcitabine alone leads to superior DFS and OS for patients with resected pancreatic cancer.

Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us?

The role of adjuvant chemoradiation (CRT) for pancreas cancer remains unclear. A handful of randomized trials conducted decades of ago ignited a debate that continues today about whether CRT improves survival after surgery. The many flaws in these trials are well described in the literature, which include the use of antiquated radiation delivery techniques and suboptimal doses. Recent prospective randomized data is lacking, and we eagerly await the results the ongoing Radiation Therapy Oncology Group (RTOG) 0848 trial that is evaluating the utility of high quality adjuvant CRT in resected pancreas cancer patients. Until the results of RTOG 0848 are available we should look to other studies from the modern era to guide adjuvant treatment recommendations. Here we review the current state of the art for adjuvant pancreas CRT with respect to patient selection, radiation techniques, radiation dose, and integration with novel systemic agents.

Expression of Gli1 and Wnt2B correlates with progression and clinical outcome of pancreatic cancer

OBJECTIVE

The aim of this study was to investigate the expression and clinical significance of Gli1 and Wnt2B in pancreatic cancer.

METHODS

We have constructed a formalin-fixed paraffin embedded pancreatic tissue microarrays 180 cylindrical tissue cores of human pancreatic cancer and its paracancerous nonmalignant pancreatic specimens (NMPs) from 90 patients. Levels of Gli1 and Wnt2B were measured by immunohistochemistry. We analyzed the correlations between the expression of these factors and clinicopathological parameters including prognosis.

RESULTS

The expressions of both Gli1 and Wnt2B in human pancreatic cancer tissues were significantly higher than those of normal pancreatic tissues (P=0.000, P=0.004 respectively). The analysis showed that the high cytoplasmic expression levels of Gli1 in pancreatic cancer tissues had significant correlation with lymph node metastasis (P=0.036) and Wnt2B had significant correlation with perineural invasion (P=0.045). Gli1 and Wnt2B have no positive correlation. Survival analysis by Kaplan-Meier demonstrated that elevated Wnt2B expression in cancer tissue predicted worse overall survival (OS) compared with group in lower expression (P=0.024). No correlation was found between the expression of Gli1 and overall survival of pancreatic cancer patients (P>0.05).

CONCLUSIONS

In conclusion, these results indicate that the high-expression levels of Gli1 and Wnt2B might play a pivotal role during tumorigenesis of pancreatic cancer, and the high expression of Wnt2B might be associated with poor prognosis.

Extended lymphadenectomy in patients with pancreatic cancer is debatable

Lymph node staging is one of the most important factors in determining the prognosis after resection of pancreatic ductal adenocarcinoma. Despite ongoing efforts to further refine lymph node staging, the debate on the extent of lymphadenectomy during pancreaticoduodenectomy is still open. The purpose of this review was to summarize the evidence about performing standard lymphadenectomy during curative resection of pancreatic cancer. All four prospective randomized controlled trials published concluded that extended lymphadenectomy does not contribute to better oncologic outcome for patients with adenocarcinoma of the pancreatic head. Indeed, one major drawback of extended lymphadenectomy is the higher risk of persistent postoperative diarrhea. No prospective randomized studies could be found on the role of extended lymphadenectomy in patients with adenocarcinoma of the corpus and tail. Based on current evidence there is no indication that extended lymphadenectomy should be performed routinely during resection of pancreatic cancer.

Severe postoperative complications adversely affect long-term survival after R1 resection for pancreatic head adenocarcinoma

BACKGROUND

Survival after pancreatic head adenocarcinoma surgery is determined by tumor characteristics, resection margins, and adjuvant chemotherapy. Few studies have analyzed the long-term impact of postoperative morbidity. The aim of the present study was to assess the impact of postoperative complications on long-term survival after pancreaticoduodenectomy for cancer.

METHODS

Of 294 consecutive pancreatectomies performed between January 2000 and July 2011, a total of 101 pancreatic head resections for pancreatic ductal adenocarcinoma were retrospectively analyzed. Postoperative complications were classified on a five-grade validated scale and were correlated with long-term survival. Grade IIIb to IVb complications were defined as severe.

RESULTS

Postoperative mortality and morbidity were 5 and 57 %, respectively. Severe postoperative complications occurred in 16 patients (16 %). Median overall survival was 1.4 years. Significant prognostic factors of survival were the N-stage of the tumor (median survival 3.4 years for N0 vs. 1.3 years for N1, p = 0.018) and R status of the resection (median survival 1.6 years for R0 vs. 1.2 years for R1, p = 0.038). Median survival after severe postoperative complications was decreased from 1.9 to 1.2 years (p = 0.06). Median survival for N0 or N1 tumor or after R0 resection was not influenced by the occurrence and severity of complications, but patients with a R1 resection and severe complications showed a worsened median survival of 0.6 vs. 2.0 years without severe complications (p = 0.0005).

CONCLUSIONS

Postoperative severe morbidity per se had no impact on long-term survival except in patients with R1 tumor resection. These results suggest that severe complications after R1 resection predict poor outcome.

Metabolic tumour burden assessed by ¹⁸F-FDG PET/CT associated with serum CA19-9 predicts pancreatic cancer outcome after resection

PURPOSE

Tumour burden is one of the most important prognosticators for pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to investigate the predictive significance of metabolic tumour burden measured by (18)F-FDG PET/CT in patients with resectable PDAC.

METHODS

Included in the study were 122 PDAC patients who received preoperative (18)F-FDG PET/CT examination and radical pancreatectomy. Metabolic tumour burden in terms of metabolic tumour volume (MTV) and total lesion glycolysis (TLG), pathological tumour burden (tumour size), serum tumour burden (baseline serum CA19-9 level), and metabolic activity (maximum standard uptake value, SUVmax) were determined, and compared for their performance in predicting overall survival (OS) and recurrence-free survival (RFS).

RESULTS

MTV and TLG were significantly associated with baseline serum CA19-9 level (P = 0.001 for MTV, P < 0.001 for TLG) and tumour size (P < 0.001 for MTV, P = 0.001 for TLG). Multivariate analysis showed that MTV, TLG and baseline serum CA19-9 level as either categorical or continuous variables, but not tumour size or SUVmax, were independent risk predictors for both OS and RFS. Time-dependent receiving operating characteristics analysis further indicated that better predictive performances for OS and RFS were achieved by MTV and TLG compared to baseline serum CA19-9 level, SUVmax and tumour size (P < 0.001 for all).

CONCLUSION

MTV and TLG showed strong consistency with baseline serum CA19-9 level in better predicting OS and RFS, and might serve as surrogate markers for prediction of outcome in patients with resectable PDAC.

Age Influences Likelihood of Pancreatic Cancer Treatment, but not Outcome

Background

Pancreatic cancer (PanCA) is predominantly diagnosed in elderly patients; nevertheless, a significant number of young patients are affected. We hypothesized more aggressive treatment of young PanCA patients would result in better overall survival (OS).

Methods

A retrospective review of our institutional cancer database identified subjects for inclusion. Age 50 years was selected to stratify patients into age groups.

Results

Of 309 PanCA patients, 54 (17%) were ≤ 50 years old. Exocrine cancer was the most common histology (90%). Patients ≤ 50 years old were more likely to have endocrine cancer (22% vs. 7%, P = 0.001). There was no difference in stage or curative intent surgery between age groups. Despite patients ≤ 50 years old receiving more chemotherapy (61% vs. 41%, P = 0.007) and radiotherapy (28% vs. 15%, P = 0.03), there was no difference in OS (24.1 months vs. 14.1 months, P = 0.08). When only exocrine cancers were considered, there was no difference between young and old patients regarding stage, grade, location or surgery. Exocrine cancer patients ≤ 50 years old received more chemotherapy (67% vs. 42%, P = 0.003) and radiation therapy (36% vs. 17%, P = 0.004), but there was no difference in OS.

Conclusions

A substantial number of PanCA patients are ≤ 50 years old. Patients ≤ 50 years old received more treatment but did not have improved OS. Significant improvements in PanCA survival await development of new treatment strategies.

Jaundice: an important, poorly recognized risk factor for diminished survival in patients with adenocarcinoma of the head of the pancreas

OBJECTIVES

Jaundice impairs cellular immunity, an important defence against the dissemination of cancer. Jaundice is a common mode of presentation in pancreatic head adenocarcinoma. The purpose of this study was to determine whether there is an association between preoperative jaundice and survival in patients who have undergone resection of such tumours.

METHODS

Thirty possible survival risk factors were evaluated in a database of over 400 resected patients. Univariate analysis was used to determine odds ratio for death. All factors for which a P-value of <0.30 was obtained were entered into a multivariate analysis using the Cox model with backward selection.

RESULTS

Preoperative jaundice, age, positive node status, poor differentiation and lymphatic invasion were significant indicators of poor outcome in multivariate analysis. Absence of jaundice was a highly favourable prognostic factor. Interaction emerged between jaundice and nodal status. The benefit conferred by the absence of jaundice was restricted to patients in whom negative node status was present. Five-year overall survival in this group was 66%. Jaundiced patients who underwent preoperative stenting had a survival advantage.

CONCLUSIONS

Preoperative jaundice is a negative risk factor in adenocarcinoma of the pancreas. Additional studies are required to determine the exact mechanism for this effect.

Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension

BACKGROUND

Our aim was to evaluate the perioperative morbidity and survival of a selected group of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) and malignant obstruction of portal axis inducing portal hypertension (PH) who underwent a curative intent pancreatic resection, after neoadjuvant chemotherapy, adopting a new type of temporary intraoperative mesentericoportal shunt (TMPS).

METHODS

We analyzed the perioperative data and survival outcome of 15 patients with locally advanced PDAC and PH who underwent pancreatoduodenectomy combined with vascular resections between October 2008 and October 2012 using this TMPS.

RESULTS

There was no perioperative mortality. Postoperative morbidity occurred in 7 patients without any postoperative liver failure. All patients underwent mesentericoportal venous resection, 11 of whom had a concomitant arterial resection. The mean ± SD follow-up was 16 ± 10 months (range, 4-40; median 15). Overall survival rates of patients were 78% and 11% at 1 and at 3 years, respectively. Median survival was 17 months. The 1-year disease-free survival was 36%.

CONCLUSION

The use of this form of TMPS allowed us to achieve PD or total pancreatectomy in patients with locally advanced PDAC and PH without postoperative mortality but with increased morbidity. The relevance of such an aggressive approach is yet to be determined.

Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage

BACKGROUND

Some suggest that metastatic lymph node ratio (LNR) may be prognostic of survival in patients with pancreatic cancer. However, this phenomenon was confused by inclusion of node-negative patients in the analysis. The present study was designed to evaluate the prognostic impact of metastatic LNR and the absolute number of metastatic LNs in patients resected for pancreatic cancer.

METHODS

Data were collected from 398 patients who underwent curative surgery for pancreatic head cancer at Seoul National University Hospital. Long-term survival was analyzed according to LNR and absolute number of metastatic LNs.

RESULTS

Of the patients, 227 (57.0 %) had LN metastasis. The mean numbers of total retrieved and metastatic LNs were 19.5 and 1.9, respectively, and the mean LNR was 0.11. Median overall survival (OS) of patients was significantly higher in N0 than in N1 patients after curative resection (25.4 vs. 14.8 months, p < 0.001). Median OS was significantly lower in patients with 1 than in those with 0 positive LNs (17.3 vs. 25.4 months, p = 0.001). Among N1 patients, those with 0 < LNR ≤ 0.2 had comparable prognosis than those with >0.2 LNR (median OS 17.2 vs. 12.8 months, p = 0.096), and the number of metastatic LNs did not correlate with median OS (p = 0.365).

CONCLUSIONS

The presence of a single positive metastatic LN was associated with significantly poorer OS in patients with pancreatic cancer. When LN metastasis was present, the number of metastatic LNs and LNR had limited prognostic relevance.

Pancreatic cancer, treatment options, and GI-4000

Although pancreatic cancer is but the eleventh most prevalent cancer in the US, it is predicted that of all the patients newly diagnosed with this disease in 2014, only 27% will still be alive at the end of the first year and only 6% will make it past 5 years. The choice of chemotherapy in the treatment of pancreatic cancer is dependent on disease stage and patient performance status but, in general, the most widely used approved regimens include 5-fluorouracil (5-FU) combinations and gemcitabine combinations. Recent therapeutic strategies have resulted in an improvement in survival of patients with pancreatic cancer but the magnitude of change is disappointing and vast improvements are still needed. The goal of immunotherapy is to enhance and guide the body's immune system to recognize tumor-specific antigens and mount an attack against the disease. Among newer immune therapies, GI-4000 consists of 4 different targeted molecular immunogens, each containing a different Ras protein (antigen) encoded by the most commonly found mutant RAS genes in solid tumors--RAS mutations exist in over 90% of pancreatic ductal adenocarcinomas. We will review pancreatic cancer epidemiology and its current treatment options, and consider the prospects of immunotherapy, focusing on GI-4000. We discuss the potential mechanism of action of GI-4000, and the performance of this vaccination series thus far in early phase clinical trials.

Borderline resectable/locally advanced pancreatic adenocarcinoma: improvements needed in population-based registries

BACKGROUND

Management of patients with borderline resectable/locally advanced (BR/LA) pancreatic adenocarcinoma is based on knowledge of natural history and patterns of treatment failure, information of great importance to large data registries. Using the SEER database, we examined the survival for patients with BR/LA tumors and critically evaluated the utility of the data.

METHODS

T3/T4 tumors from 2004 to 2007 were divided into those that involved the portal vein/superior mesenteric vein/gastroduodenal artery/hepatic artery and those that involved the superior mesenteric artery (SMA) or celiac axis. The control group (CG) included patients who were recommended surgery but did not undergo it. Multivariate disease-specific survival analyses were performed using the Cox proportional hazards model.

RESULTS

Of 3,837 patients, 571 patients (15 %) were recommended surgery, and 323 (8 %) underwent surgical resection. We were unable to separate patients into BR/LA based on current NCCN guidelines. We were able to identify vascular involvement but not those who actually underwent vascular resection. Median survival of patients who underwent surgery with SMA and celiac involvement was 12 and 8 months compared with 7 and 6 months, respectively, in the CG (p = .01). Patients who underwent surgical resection with venous involvement had a longer survival than those with arterial involvement (18 vs 12 months, p = .001).

CONCLUSIONS

Analysis of patients with BR/LA pancreatic adenocarcinoma who underwent pancreatic resection in the SEER database yielded limited information. New manuals must focus on obtaining information consistent with current advances in the field; our recommendations for optimizing the SEER database are included.

Is tumour size an underestimated feature in the current TNM system for malignancies of the pancreatic head?

BACKGROUND

As the long-term survival of pancreatic head malignancies remains dismal, efforts have been made for a better patient selection and a tailored treatment. Tumour size could also be used for patient stratification.

METHODS

One hundred and fourteen patients underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma, peri-ampullary and biliary cancer stratified according to: ≤20 mm, 21-34 mm, 35-45 mm and >45 mm tumour size.

RESULTS

Patients with tumour sizes of ≤20 mm had a N1 rate of 41% and a R1/2 rate of 7%. The median survival was 3.4 years. N1 and R1/2 rates increased to 84% and 31% for tumour sizes of 21-34 mm (P = 0.0002 for N, P = 0.02 for R). The median survival decreased to 1.6 years (P = 0.0003). A further increase in tumour size of 35-45 mm revealed a further increase of N1 and R1/2 rates of 93% (P < 0.0001) and 33%, respectively. The median survival was 1.2 years (P = 0.004). Tumour sizes >45 mm were related to a further decreased median survival of 1.1 years (P = 0.2), whereas N1 and R1/2 rates were 87% and 20%, respectively.

DISCUSSION

Tumour size is an important feature of pancreatic head malignancies. A tumour diameter of 20 mm seems to be the cut-off above which an increased rate of incomplete resections and metastatic lymph nodes must be encountered and the median survival is reduced.

Prognostic value of 18F-fluorodeoxyglucose positron emission tomography in patients with resectable pancreatic cancer

PURPOSE

We evaluated the prognostic value of (18)F-2-fluoro-2-deoxyglucose positron emission tomography (FDG PET) in patients with resectable pancreatic cancer.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of pancreatic cancer patients who underwent curative resection, which included 64 consecutive patients who had preoperative FDG PET scans. For statistical analysis, the maximal standardized uptake value (SUVmax) of primary pancreatic cancer was measured. Survival time was estimated by the Kaplan-Meier method, and Cox's proportional hazard model was used to determine whether SUVmax added new predictive information concerning survival together with known prognostic factors. p<0.05 indicated statistical significance.

RESULTS

Overall survival (OS) and disease- free survival (DFS) were respectively 42.9 months (27.6-58.2; 95% CI) and 14.9 months (10.1-19.7; 95% CI). When subjects were divided into two groups according to SUVmax with a cutoff value of 3.5, the high SUVmax group (n=32; SUVmax >3.5) showed significantly shorter OS and DFS than the low SUVmax group. Multivariate analysis of OS and DFS showed that both high SUVmax and poor tumor differentiation were independent poor prognostic factors.

CONCLUSION

Our study showed that degree of FDG uptake was an independent prognostic factor in pancreatic cancer patients who underwent curative resection.

Diagnostic performance of MDCT for predicting important prognostic factors in pancreatic cancer

OBJECTIVES

Tumor stage, node metastasis, tumor size, vascular invasion, and perineural invasion are the most important prognostic factors that might be determined by preoperative multidetector computed tomography (MDCT) in pancreatic cancer. The purpose of our study is to investigate diagnostic accuracy of MDCT for determining these prognostic factors.

METHODS

For 6 years, 111 patients with surgically resected pancreatic cancer underwent preoperative MDCT. Two radiologists retrospectively assessed tumor stage, node metastasis, tumor size, and vascular invasion. They also graded perineural invasion using a 3-point scale focused on 5 routes. Statistical analyses were performed using the receiver operating characteristic analysis, McNemar test, and paired t test.

RESULTS

Statistically, tumor size on specimens (3.4 ± 1.46 cm) is larger than tumor size on MDCT (3.2 ± 1.41 cm; P = 0.001). The diagnostic accuracy rates for tumor stage were 82.9% and 77.5%, with moderate agreement (κ = 0.732). The accuracy rates for node metastasis were 59.5% and 55.0%, with fair agreement (κ = 0.597). The diagnostic accuracy rates for vascular invasion were 94% and 92%. The areas under the curve for perineural invasion were 0.733 and 0.66 (P = 0.069), with moderate agreement (κ = 0.77).

CONCLUSIONS

Multidetector computed tomography is very useful for the preoperative evaluation of tumor stage, perineural invasion, and vascular invasion of pancreatic cancer, but it has limited evaluation of node metastasis and tumor size.

Overexpression of COL11A1 by cancer-associated fibroblasts: clinical relevance of a stromal marker in pancreatic cancer

BACKGROUND

The collagen11A1 (COL11A1) gene is overexpressed in pancreatic cancer. The expression of COL11A1 protein could be involved in desmoplastic events in pancreatic cancer, but an antibody that specifically stains the COL11A1 protein is not currently available.

METHODS AND FINDINGS

A total of 54 pancreatic ductal adenocarcinomas (PDAC), 23 chronic pancreatitis (CP) samples, and cultured peritumoral stromal cells of PDAC (passages 3-6) were studied. Normal human pancreas tissue samples were obtained through a cadaveric organ donation program. 1) Validation of COL11A1 gene overexpression by q-RT-PCR.

FINDINGS

the expression of COL11A1 gene is significantly increased in PDAC samples vs. normal and CP samples. 2) Analysis of COL11A1 by immunohistochemistry using highly specific anti-proCOL11A1 antibodies.

FINDINGS

anti-proCOL11A1 stains stromal cells/cancer-associated fibroblasts (CAFs) of PDAC but it does not stain chronic benign condition (chronic pancreatitis) stromal cells, epithelial cells, or normal fibroblasts. 3) Evaluation of the discrimination ability of the antibody.

FINDINGS

anti-proCOL11A1 immunostaining accurately discriminates between PDAC and CP (AUC 0.936, 95% CI 0.851, 0.981). 4) Phenotypic characterization of proCOL11A1+ stromal cells co-staining with mesenchymal, epithelial and stellate cell markers on pancreatic tissue samples and cultured peritumoral pancreatic cancer stromal cells.

FINDINGS

ProCOL11A1+ cells present co-staining with mesenchymal, stellate and epithelial markers (EMT phenotype) in different proportions.

CONCLUSIONS/SIGNIFICANCE

Detection of proCOL11A1 through immunostaining with this newly-developed antibody allows for a highly accurate distinction between PDAC and CP. Unlike other available antibodies commonly used to detect CAFs, anti-proCOL11A1 is negative in stromal cells of the normal pancreas and almost absent in benign inflammation. These results strongly suggest that proCOL11A1 is a specific marker for CAFs, and thus, anti-proCOL11A1 is a powerful new tool for cancer research and clinical diagnostics.

Combination of the serum carbohydrate antigen 19-9 and carcinoembryonic antigen is a simple and accurate predictor of mortality in pancreatic cancer patients

PURPOSE

The aim of this study was to detect high-performance prognostic biomarkers of pancreatic cancer which would enable the identification of high-risk patients.

METHODS

The subjects were 324 patients who underwent radical surgery for pancreatic ductal adenocarcinoma without neoadjuvant therapy. We evaluated the prognostic impact of four perioperative serum tumor markers, including carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). We also evaluated the indices by multiplying the values of two tumor markers (e.g., CA19-9 × CEA).

RESULTS

The preoperative CA19-9 × CEA index had a strong correlation with the prognosis of patients with pancreatic cancer, even when the cut-off was set at the median value. CA19-9 × CEA ≥500 was an independent predictor of mortality (hazard ratio: 1.642, p = 0.021). In the ROC curve analysis of early mortality after surgery, the CA19-9 × CEA index had the highest goodness of fit. The presence of CA19-9 × CEA ≥500 had the largest attributable risk proportion because of its combined high predictive performance and prevalence. The postoperative CA19-9 × CEA index was also a significant predictive marker of mortality.

CONCLUSION

The CA19-9 × CEA index is a strong prognostic biomarker that could help identify pancreatic cancer patients expected to have a poor prognosis so that they can be administered appropriate multidisciplinary treatment.

microRNA-10b enhances pancreatic cancer cell invasion by suppressing TIP30 expression and promoting EGF and TGF-β actions

Increased microRNA-10b (miR-10b) expression in the cancer cells in pancreatic ductal adenocarcinoma (PDAC) is a marker of disease aggressiveness. In the present study, we determined that plasma miR-10b levels are significantly increased in PDAC patients by comparison with normal controls. By gene profiling, we identified potential targets downregulated by miR-10b, including Tat-interacting protein 30 (TIP30). Immunoblotting and luciferase reporter assays confirmed that TIP30 was a direct miR-10b target. Downregulation of TIP30 by miR-10b or siRNA-mediated silencing of TIP30 enhanced epidermal growth factor (EGF)-dependent invasion. The actions of miR-10b were abrogated by expressing a modified TIP30 cDNA resistant to miR-10b. EGF-induced EGF receptor (EGFR) tyrosine phosphorylation and extracellular signal-regulated kinase phosphorylation were enhanced by miR-10b, and these effects were mimicked by TIP30 silencing. The actions of EGF in the presence of miR-10b were blocked by EGFR kinase inhibition with erlotinib and by dual inhibition of PI3K (phosphatidylinositol 3'-kinase) and MEK. Moreover, miR-10b, EGF and transforming growth factor-beta (TGF-β) combined to markedly increase cell invasion, and this effect was blocked by the combination of erlotinib and SB505124, a type I TGF-β receptor inhibitor. miR-10b also enhanced the stimulatory effects of EGF and TGF-β on cell migration and epithelial-mesenchymal transition (EMT) and decreased the expression of RAP2A, EPHB2, KLF4 and NF1. Moreover, miR-10b overexpression accelerated pancreatic cancer cell (PCC) proliferation and tumor growth in an orthotopic model. Thus, plasma miR-10b levels may serve as a diagnostic marker in PDAC, whereas intra-tumoral miR-10b promotes PCC proliferation and invasion by suppressing TIP30, which enhances EGFR signaling, facilitates EGF-TGF-β cross-talk and enhances the expression of EMT-promoting genes, whereas decreasing the expression of several metastasis-suppressing genes. Therefore, therapeutic targeting of miR-10b in PDAC may interrupt growth-promoting deleterious EGF-TGF-β interactions and antagonize the metastatic process at various levels.

Redefining the R1 resection for pancreatic ductal adenocarcinoma: tumour lymph nodal burden and lymph node ratio are the only prognostic factors associated with survival

INTRODUCTION

The presence of positive nodal disease (LND) and the number of lymph nodes involved (LNB) are known to be significant prognostic markers for resected adenocarcinoma of the pancreas. In addition, the ratio of the number of involved nodes to the number of nodes resected known as the lymph node ratio (LNR) is emerging as an important prognostic marker. The role of the resection margin (RM) as presently defined (R1 ≤ 1 mm) is unclear as results differ based on the dataset. The aim of this study was to assess the impact of nodal disease and a redefined RM on outcome.

MATERIAL AND METHODS

Retrospective analysis of pancreatic head resections for adenocarcinomas from 2003-2009. The RM was re-analysed based on tumour clearance and categorized into: histopathological evidence of a tumour; ≤ 0.5 mm, ≤ 1 mm, ≤ 1.5 mm, or ≤ 2.0 mm of the actual surgical resection margin. The impact of histopathological variables on cancer-specific survival (CSS) and disease-free survival (DFS) was analysed.

RESULTS

LND, LNB and LNR were independent prognostic markers for CSS (P = 0.048, 0.003, 0.016) but, did not influence DFS. A LNR < 0.143 was associated with a higher CSS [38.16 ± 4.69 versus 20.59 ± 2.20 months, P = 0.0042, hazard ratio (HR) 3.74 (95% confidence interval (CI) 1.52-9.23)]. An R1 RM was not associated with CSS or DFS on multivariate analysis, irrespective of the distance. LNB and LNR maintained independent significance irrespective of the size of the RM.

CONCLUSION

LNB and LNR are the only prognostic factors for CSS in patients with pancreatic head adenocarcinoma, but do not predict recurrence. Microscopic RMs does not seem to influence the outcome even when redefined. Further prospective studies are indicated to substantiate these findings.

Impact of tumor grade on pancreatic cancer prognosis: validation of a novel TNMG staging system

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) patients demonstrate highly variable survival within each stage of the American Joint Committee on Cancer (AJCC) staging system. We hypothesize that tumor grade is partly responsible for this variation. Recently our group developed a novel tumor, node, metastasis, grade (TNMG) classification system utilizing Surveillance Epidemiology and End Results (SEER) data in which the presence of high tumor grade results in advancement to the next higher AJCC stage. This study's objective was to validate this TNMG staging system utilizing single-institution data.

METHODS

All patients with PDAC who underwent resection at UCLA between 1990 and 2009 were identified. Clinicopathologic data reviewed included age, sex, node status, tumor size, grade, and stage. Grade was redefined as a dichotomous variable. The impact of grade on survival was assessed by Cox regression analysis. Disease was restaged into the TNMG system and compared to the AJCC staging system.

RESULTS

We identified 256 patients who underwent resection for PDAC. Patients with low-grade tumors experienced a 13-month improvement in median survival compared to those with high-grade tumors. On multivariate analysis, tumor grade was the strongest predictor of survival with a hazard ratio of 2.02 (p = 0.0005). Restaging disease according to the novel TNMG staging system resulted in improved survival discrimination between stages compared to the current AJCC system.

CONCLUSIONS

We were able to demonstrate that grade is one of the strongest independent prognostic factors in PDAC. Restaging with our novel TNMG system demonstrated improved prognostication. This system offers an effective and convenient way of adding grade to the current AJCC staging system.

Number of examined lymph nodes and nodal status assessment in pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

The accuracy of the assessment of the nodal status in resected cephalic pancreatic adenocarcinoma (PA) depends on the number of examined lymph nodes (NELN). This study assesses the impact of the NELN on N staging and survival and propose a minimal number of examined lymph nodes (MNELN) ensuring reliability of the pN status determination.

METHODS

188 consecutive patients treated by pancreaticoduodenectomy (PD) for PA. Correlations between NELN and survivals of pN0 and pN1 groups and with the rate of pN1 patients were studied. A probability model based on the binomial law was built to estimate the MNELN able to detect pN1 patients with a sensitivity ≥ 95%.

RESULTS

Overall and disease free 5-year survivals were 27.2% and 24.6% respectively. 135 patients (71.8%) were staged pN1. The median NELN was 17 (range 0-68). Overall and disease free survivals of pN1 patients were not related to NELN. The influence of NELN on survival in pN0 patients due to stage migration did not reach significance. The probability model showed that a MNELN of 16 nodes was required to detect pN1 patients with a sensitivity of 95%.

CONCLUSION

A MNELN of 16 is required to assess pN status and should be considered as a quality criterion in future studies and trials on PD for PA.

Surgical palliation of pancreatic cancer

The surgical palliation of pancreatic cancer remains an important component of the treatment of this disease. The introduction of a new aggressive and effective chemotherapy regimen (FOLFIRINOX), interdisciplinary palliative care, and minimally invasive approaches for providing palliation are all factors that expand the role of the surgeon in the care of patients with unresectable disease. Currently, the role of the surgeon in the palliation of pancreatic cancer is (1) to identify patients with incurable disease (either preoperatively or intraoperatively), (2) to determine the optimal palliative technique to optimize results and preserve resources, and (3) to perform palliation of symptoms with low morbidity and mortality. The 3 most common symptoms of pancreatic cancer requiring surgical palliation are obstructive jaundice, gastric outlet obstruction, and tumor-associated pain. It is important that the surgeon recognizes the full range of surgical and nonoperative techniques available and contributes to the decision making as to the most appropriate method for each individual patient.

Tumor recurrence is independent of pancreatic fistula in patients after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

BACKGROUND

Recurrence of pancreatic adenocarcinoma after pancreaticoduodenectomy (PD) can be increased in patients with pancreatic fistula (PF). The purpose of our study was to determine if a relationship exists between PF and tumor recurrence (both peritoneal and local) in patients after PD for pancreatic ductal adenocarcinoma.

STUDY DESIGN

A single-institution, retrospective analysis of 221 patients who underwent PD from January 2001 to December 2009 was conducted. Electronic charts and medical records were queried for tumor characteristics, recurrence, and complications. Presence and grading of PF was determined using the criteria of the International Study Group on Pancreatic Fistula. Data were analyzed using chi-square and Kaplan-Meier survival statistics.

RESULTS

There were 114 male and 107 female patients. Mean age was 66 years (range 35 to 91 years). The vast majority (84%) of patients had stage II disease; 143 (65%) had positive lymph nodes (median 2 positive nodes; range 1 to 17 positive nodes). Pancreatic fistula developed in 23 patients (grade A, n = 9; grade B, n = 13; grade C, n = 1; 10.2%). Peritoneal recurrence was noted in 20 patients (9%). Of the 23 patients with PF, peritoneal recurrence developed in 3 (13%). Of the 198 patients without PF, peritoneal recurrence developed in 17 (10%). Local recurrence occurred in 47 patients (21%), 5 (2%) in patients with PF and 42 (21%) in those without PF (p = NS). In Kaplan-Meier survival analysis, there was no significant difference in recurrence-free survival (p = 0.4) and overall survival (p = 0.3) for those with PF vs those without PF.

CONCLUSIONS

Patients with PF after PD were not found to have a significant increase in local or peritoneal recurrence. Therefore, in this analysis, postoperative PF does not appear to serve as an adverse prognostic marker.

An evaluation of neoadjuvant chemoradiotherapy for patients with resectable pancreatic ductal adenocarcinoma

Aims. The aim of this study is to compare our results of preoperative chemotherapy followed by pancreaticoduodenectomy (PD) with those of surgery alone in patients with localized resectable pancreatic ductal adenocarcinoma (PDAC). Methods. Outcome data for 112 patients of resectable PDAC who received preoperative chemoradiotherapy followed by PD (group I) between January 2004 and April 2010 were retrospectively analyzed and were compared with selected 120 patients who underwent PD alone (group II) in the same period. Results. Patients in group I had an incidence of locoregional recurrence of 17.1% compared to 30.8% in group II (P = 0.03). There were no statistically significant differences in postoperative morbidity (27.7% versus 30.8%) and mortality (2.67% versus 3.33%). The 1-, 2-, and 3-year survival rates were estimated at 82.1%, 54%, and 28%, respectively, with NCRT and 65.8%, 29.1%, and 10% without (P = 0.006). Nevertheless, preoperative chemotherapy did not reduce the 1-, 3-, and 5-year disease-free survival rates, which were estimated at 58%, 36.6%, and 12.5% with NCRT and 51.7%, 18.3%, and 7.5% without (P = 0.058). Conclusions. The treatment of NCRT followed by PD in patients with PDAC has a significantly lower rate of locoregional recurrence and a longer overall survival than those with surgery alone.

[New insights into the origin of pancreatic cancer. Role of atypical flat lesions in pancreatic carcinogenesis]

The identification and characterization of precursor lesions is fundamental to develop screening programs for early diagnosis and treatment, aiming at reducing cancer-related mortality. Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease that becomes clinical apparent only in advanced stages. In order to enable screening procedures for early detection of PDAC, an exact characterization of precursor lesions is of utmost importance. Pancreatic intraepithelial neoplasias (PanIN) are the most frequent and best characterized precursors of PDAC and are lesions with a ductal phenotype thus indicating a ductal cell origin of PDAC. However, evidence from genetically engineered mouse models suggests that tubular complexes (TC) originating through a process of acinar-ductal metaplasia (ADM) form atypical flat lesions (AFL) that may represent an alternative pathway of pancreatic carcinogenesis. Based on a thorough morphological and genetic analysis of murine TC, AFL and PanIN and their human counterparts, a new dual model of pancreatic carcinogenesis is proposed taking into account the role of AFL as possible new precursors of PDAC.