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Kuo YC, Kou HW, Hsu CP, Lo CH, Hwang TL. Identification and Clinical Significance of Pancreatic Cancer Stem Cells and Their Chemotherapeutic Drug Resistance. Int J Mol Sci 2023; 24:ijms24087331. [PMID: 37108495 PMCID: PMC10138402 DOI: 10.3390/ijms24087331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Pancreatic cancer ranks in the 10th-11th position among cancers affecting men in Taiwan, besides being a rather difficult-to-treat disease. The overall 5-year survival rate of pancreatic cancer is only 5-10%, while that of resectable pancreatic cancer is still approximately 15-20%. Cancer stem cells possess intrinsic detoxifying mechanisms that allow them to survive against conventional therapy by developing multidrug resistance. This study was conducted to investigate how to overcome chemoresistance and its mechanisms in pancreatic cancer stem cells (CSCs) using gemcitabine-resistant pancreatic cancer cell lines. Pancreatic CSCs were identified from human pancreatic cancer lines. To determine whether CSCs possess a chemoresistant phenotype, the sensitivity of unselected tumor cells, sorted CSCs, and tumor spheroid cells to fluorouracil (5-FU), gemcitabine (GEM), and cisplatin was analyzed under stem cell conditions or differentiating conditions. Although the mechanisms underlying multidrug resistance in CSCs are poorly understood, ABC transporters such as ABCG2, ABCB1, and ABCC1 are believed to be responsible. Therefore, we measured the mRNA expression levels of ABCG2, ABCB1, and ABCC1 by real-time RT-PCR. Our results showed that no significant differences were found in the effects of different concentrations of gemcitabine on CSCs CD44+/EpCAM+ of various PDAC cell line cultures (BxPC-3, Capan-1, and PANC-1). There was also no difference between CSCs and non-CSCs. Gemcitabine-resistant cells exhibited distinct morphological changes, including a spindle-shaped morphology, the appearance of pseudopodia, and reduced adhesion characteristics of transformed fibroblasts. These cells were found to be more invasive and migratory, and showed increased vimentin expression and decreased E-cadherin expression. Immunofluorescence and immunoblotting experiments demonstrated increased nuclear localization of total β-catenin. These alterations are hallmarks of epithelial-to-mesenchymal transition (EMT). Resistant cells showed activation of the receptor protein tyrosine kinase c-Met and increased expression of the stem cell marker cluster of differentiation (CD) 24, CD44, and epithelial specific antigen (ESA). We concluded that the expression of the ABCG2 transporter protein was significantly higher in CD44+ and EpCAM+ CSCs of PDAC cell lines. Cancer stem-like cells exhibited chemoresistance. Gemcitabine-resistant pancreatic tumor cells were associated with EMT, a more aggressive and invasive phenotype of numerous solid tumors. Increased phosphorylation of c-Met may also be related to chemoresistance, and EMT and could be used as an attractive adjunctive chemotherapeutic target in pancreatic cancer.
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Affiliation(s)
- Yu-Chi Kuo
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taoyuan 333, Taiwan
| | - Hao-Wei Kou
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taoyuan 333, Taiwan
| | - Chih-Po Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taoyuan 333, Taiwan
| | - Chih-Hong Lo
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taoyuan 333, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taoyuan 333, Taiwan
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The Timing of Surgery Following Stereotactic Body Radiation Therapy Impacts Local Control for Borderline Resectable or Locally Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15041252. [PMID: 36831594 PMCID: PMC9954439 DOI: 10.3390/cancers15041252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
We aimed to evaluate the impact of time from stereotactic body radiation therapy (SBRT) to surgery on treatment outcomes and post-operative complications in patients with borderline resectable or locally advanced pancreatic cancer (BRPC/LAPC). We conducted a single-institutional retrospective analysis of patients with BRPC/LAPC treated from 2016 to 2021 with neoadjuvant chemotherapy followed by SBRT and surgical resection. Covariates were stratified by time from SBRT to surgery. A Cox regression model was used to identify variables associated with survival outcomes. In 171 patients with BRPC/LAPC, the median time from SBRT to surgery was 6.4 (range: 2.7-25.3) weeks. Hence, patients were stratified by the timing of surgery: ≥6 and <6 weeks after SBRT. In univariable Cox regression, surgery ≥6 weeks was associated with improved local control (LC, HR 0.55, 95% CI 0.30-0.98; p = 0.042), pathologic node positivity, elevated baseline CA19-9, and inferior LC if of the male sex. In multivariable analysis, surgery ≥6 weeks (p = 0.013; HR 0.46, 95%CI 0.25-0.85), node positivity (p = 0.019; HR 2.09, 95% CI 1.13-3.88), and baseline elevated CA19-9 (p = 0.002; HR 2.73, 95% CI 1.44-5.18) remained independently associated with LC. Clavien-Dindo Grade ≥3B complications occurred in 4/63 (6.3%) vs. 5/99 (5.5%) patients undergoing surgery <6 weeks and ≥6 weeks after SBRT (p = 0.7). In summary, the timing of surgery ≥6 weeks after SBRT was associated with improved local control and low post-operative complication rates, irrespective of the surgical timing. Further investigation of the influence of surgical timing following radiotherapy is warranted.
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Lee HK, Yoon YS, Han HS, Lee JS, Na HY, Ahn S, Park J, Jung K, Jung JH, Kim J, Hwang JH, Lee JC. Clinical Impact of Unexpected Para-Aortic Lymph Node Metastasis in Surgery for Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13174454. [PMID: 34503264 PMCID: PMC8431119 DOI: 10.3390/cancers13174454] [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: 08/02/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Radiologically identified para-aortic lymph node (PALN) metastasis is contraindicated for pancreatic cancer (PC) surgery. There is no clinical consensus for unexpected intraoperative PALN enlargement. To analyze the prognostic role of unexpected PALN enlargement in resectable PC, we retrospectively reviewed data of 1953 PC patients in a single tertiary center. Patients with unexpected intraoperative PALN enlargement (group A1, negative pathology, n = 59; group A2, positive pathology, n = 13) showed median overall survival (OS) of 24.6 (95% CI: 15.2-33.2) and 13.0 (95% CI: 4.9-19.7) months, respectively. Patients with radiological PALN metastasis without other metastases (group B, n = 91) showed median OS of 8.6 months (95% CI: 7.4-11.6). Compared with group A1, groups A2 and B had hazard ratios (HRs) of 2.79 (95% CI, 1.4-5.7) and 2.67 (95% CI: 1.8-4.0), respectively. Compared with group A2, group B had HR of 0.96 (95% CI: 0.5-1.9). Multivariable analysis also showed positive PALN as a negative prognostic factor (HR 2.57, 95% CI: 1.2-5.3), whereas positive regional lymph node did not (HR 1.32 95% CI: 0.8-2.3). Thus, unexpected malignant PALN has a negative prognostic impact comparable to radiological PALN metastasis. This results suggests prompt pathologic evaluation for unexpected PALN enlargements is needed and on-site modification of surgical strategy would be considered.
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Affiliation(s)
- Ho-Kyoung Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Hee Young Na
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Soomin Ahn
- Samsung Medical Center, Department of Pathology and Translational Genomics, Seoul 06351, Korea;
| | - Jaewoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jae Hyup Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
- Correspondence:
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Lee CM, Yoon SY, Park S, Park SH. Laparoscopic Whipple's Operation for Locally Advanced Gastric Cancer Invading the Pancreas and Duodenum: a Case Report. J Gastric Cancer 2020; 19:484-492. [PMID: 31897350 PMCID: PMC6928087 DOI: 10.5230/jgc.2019.19.e24] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/24/2019] [Accepted: 07/10/2019] [Indexed: 12/15/2022] Open
Abstract
Few surgeons have adopted pancreaticoduodenectomy (PD) for the treatment of advanced gastric cancer (AGC) invading the pancreas or duodenum because it remains controversial whether its prognostic benefits outweigh the high morbidity rates in such advanced cases. However, recent technical advances have revived diverse surgical procedures in minimally invasive approaches. Inspired by this trend, laparoscopic PD procedures have been performed for AGC in our institute since 2014. We recently performed a laparoscopic Whipple's operation in a case of cT4b gastric cancer with invasion of the pancreatic head and duodenum.
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Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Sam-Youl Yoon
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Sungsoo Park
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Seong-Heum Park
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
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Zhao N, Cui J, Yang Z, Xiong J, Wu H, Wang C, Peng T. Natural history and therapeutic strategies of post-pancreatoduodenectomy abdominal fluid collections: Ten-year experience in a single institution. Medicine (Baltimore) 2019; 98:e15792. [PMID: 31145305 PMCID: PMC6708627 DOI: 10.1097/md.0000000000015792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
TRIAL DESIGN The aim of this study was to identify independent risk factors for post-pancreatoduodenectomy (post-PD) abdominal fluid collections (AFCs) and evaluate our management protocol on it. METHODS A retrospective analysis of consecutive 2064 cases who underwent PD over the past decade in 1 single center was conducted. The patients were divided into AFCs and non-AFCs group. Univariable and multivariate logistic regression analysis was performed to identify independent risk factors of AFCs. The AFCs group was compared with the non-AFCs group with respect to the incidence of postoperative outcomes. The characteristics of AFCs were further analyzed in terms of clinical manifestations. RESULTS Two thousand sixty-four cases with pancreaticoduodenectomy were recruited and 15% of them were found AFCs. Diameter of main pancreatic duct ≤3 mm was found to be an independent predictor of AFCs (P < .001), along with soft pancreatic texture (P = .002), mesenterico-portal vein resection (P < .001), and estimated intraoperative blood loss >800 mL (P < .001). The incidence of mild complications was significantly higher in AFCs group than in non-AFCs group (34% vs 20%, P < .001), whereas no significant differences were noted in the rate of severe complications between these 2 groups (15% vs 15%, P = .939). CONCLUSION Enhanced drainage is recommended as an effective measure to decrease the incidence of severe complications caused by post-PD AFCs.
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Affiliation(s)
- Ning Zhao
- Department of Gastrointestinal Surgery
| | - Jing Cui
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Zhiyong Yang
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Jiongxin Xiong
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Heshui Wu
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
| | - Tao Peng
- Department of Pancreatic Surgery, Wuhan Union Hospital, Wuhan, Hubei, P.R. China
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Nishizawa N, Kumamoto Y, Katoh H, Ushiku H, Yokoi K, Tanaka T, Ishii S, Igarashi K, Tajima H, Kaizu T, Yoshida T, Saegusa M, Watanabe M, Yamashita K. Dissected peripancreatic tissue margin is a critical prognostic factor and is associated with a K-ras gene mutation in pancreatic ductal adenocarcinoma. Oncol Lett 2018; 17:2141-2150. [PMID: 30675280 PMCID: PMC6341795 DOI: 10.3892/ol.2018.9839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
We previously reported that the dissected pancreatic tissue margin (DPM) and the preoperative serum level of carbohydrate antigen 19-9 (preCA19-9) were independent prognostic factors in pancreatic ductal adenocarcinoma (PDAC). In the current study, the prognostic relevance of these factors, including their molecular associations, were validated. A total of 161 patients with PDAC underwent a pancreatectomy between 1986 and 2013, and a multivariate Cox proportional hazards model and a propensity score-based model validated the prognostic importance of DPM. The prognostic factors were compared with the mutation profiles of the K-ras and TP53 genes. Univariate prognostic analysis of disease-specific survival (DSS) demonstrated that DPM (P<0.0001), preCA19-9 (P<0.0001) and Union for International Cancer Control (UICC) stage (P<0.0001), were all significantly associated with poor outcome in PDAC. A multivariate Cox proportional hazards model confirmed that preCA19-9 (P=0.0002) and DPM (P=0.0002) remained as prognostic factors independent of UICC stage (P=0.0015). The combination of preCA19-9 and DPM to predict prognosis could accurately identify the long-term survivors of PDAC (70% 5-year DSS), and a multivariate logistic regression model identified that DPM was the most effective predictor of mortality. The prognostic relevance of DPM was also confirmed (P=0.0008) through propensity score-based background adjustment of patient bias. K-ras gene mutation was significantly associated with DPM (P=0.0002), and DPM-positive patients demonstrated recurrence of distant metastasis in 67% of cases. Therefore, DPM is a critical prognostic indicator in PDAC. In combination with preCA19-9, DPM may be useful to identify long-term survivors of PDAC. Furthermore, to the best of our knowledge, the current study was the first to discover that DPM can represent a poor prognosis based putatively on its association with the K-ras gene mutation.
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Affiliation(s)
- Nobuyuki Nishizawa
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Yusuke Kumamoto
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hiroshi Katoh
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hideki Ushiku
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Keigo Yokoi
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Toshimichi Tanaka
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Satoru Ishii
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Kazuharu Igarashi
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hiroshi Tajima
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Takashi Kaizu
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Tsutomu Yoshida
- Department of Pathology, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Makoto Saegusa
- Department of Pathology, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Keishi Yamashita
- Department of Surgery, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan.,Division of Advanced Surgical Oncology, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Kanagawa 252-0374, Japan
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Pathologic Evaluation of Surgical Margins in Pancreatic Cancer Specimens Using Color Coding With Tissue Marking Dyes. Pancreas 2018; 47:830-836. [PMID: 29975353 DOI: 10.1097/mpa.0000000000001106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Processing of pancreatoduodenectomy specimens is not standardized; the clinical impact of pathologic surgical margins remains controversial. We used the color-coding method using tissue-marking dyes to evaluate margin status of resected specimens to assess its association with postoperative recurrence. METHODS We developed a unified processing approach to assess pancreatoduodenectomy specimens. Five surgical margins of resected pancreatic specimens were marked with 5 colors. Microscopic resection margin distance (RMD) from margin closest to the tumor was evaluated for each surgical margin. Forty patients assessed using nonunified protocols, and 98 patients assessed using unified protocols were included. RESULTS The frequency of tumors with RMD of 1 mm or less in posterior margin was significantly lower and that in portal vein/superior mesenteric vein margin was significantly higher in unified protocol group than in nonunified protocol group (P < 0.001). In unified protocol group, tumors with RMD of 1 mm or less correlated with locoregional recurrence (P = 0.025) and recurrence-free survival (P = 0.030). Multivariate analysis revealed that tumor size and lymph node metastasis were independent indicators for disease recurrence. CONCLUSIONS Resection margin distance of 1 mm or less was a predictor for disease recurrence, particularly for locoregional recurrence. Early detection of small-sized tumors without lymph node metastasis is necessary for improved clinical outcomes in pancreas cancers.
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Courtin-Tanguy L, Turrini O, Bergeat D, Truant S, Darnis B, Delpero JR, Mabrut JY, Regenet N, Sulpice L. Multicentre study of the impact of factors that may affect long-term survival following pancreaticoduodenectomy for distal cholangiocarcinoma. HPB (Oxford) 2018; 20:405-410. [PMID: 29208352 DOI: 10.1016/j.hpb.2017.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/20/2017] [Accepted: 10/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the peri-operative mortality following pancreaticoduodenectomy (PD) for distal cholangiocarcinoma (DCC) has decreased, the post-operative morbidity remains high. The aim of this study was to evaluate the impact of factors that may affect the long term survival for patients with DCC following PD. METHODS All patients who underwent PD for DCC between January 2000 and December 2015 in 5 tertiary referral centers underwent retrospective medical record review. Factors likely to influence overall (OS) and disease-free (DFS) survivals were assessed by univariate and multivariate analysis. RESULTS A total of 201 on 217 patients who underwent PD for DCC were included for further analysis. The median OS was 39 months, with actuarial survival rates at 1, 3, and 5 years of 85%, 53% and 39%. Recurrence occurred in 123 (61%) patients. The median DFS was 16 months, with actuarial survival rates at 1, 3 and 5 years of 60%, 37% and 28%. Following multivariate analysis, peri-operative blood transfusions (PBT) were associated to worse OS (HR = 2.25 [1.31-3.85], P = 0.003) and DFS (HR = 2.08 [1.24-3.5], P = 0.005). CONCLUSION This study confirms the negative impact of PBT on the oncologic result following PD for DCC.
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Affiliation(s)
- Laëtitia Courtin-Tanguy
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INSERM U991, Foie Métabolismes et Cancer, Rennes, France
| | - Olivier Turrini
- Institut Paoli-Calmettes, Marseille, France; INSERM U1068, Centre de Recherche en Cancérologie, Marseille, France; CNRS U7258, Université Aix-Marseille et Institut Paoli-Calmettes, Parc Scientifique et Technologique de Luminy, Marseille, France
| | - Damien Bergeat
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INRA UR1341 ADNC, St Gilles, France
| | - Stéphanie Truant
- CHU Lille, Service de Chirurgie Digestive et Transplantation, Lille, France; INSERM U1172, Centre de Recherche Jean-Pierre Aubert, Lille, France
| | - Benjamin Darnis
- CHU Lyon, Département de Chirurgie Digestive et de Transplantation Hépatique, Lyon, France
| | | | - Jean Y Mabrut
- CHU Lyon, Département de Chirurgie Digestive et de Transplantation Hépatique, Lyon, France
| | - Nicolas Regenet
- CHU Nantes, Clinique de Chirurgie Digestive et Endocrinienne, Nantes, France
| | - Laurent Sulpice
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INSERM U991, Foie Métabolismes et Cancer, Rennes, France; INSERM U1414, Centre D'investigation Clinique, Rennes, France.
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Morganti AG, Macchia G, Trodella L, Valentini V, Costamagna G, Mutignani M, Tringali A, Smaniotto D, Luzi S, Cellini N. Complete Response after Chemoradiation in Ampullary Carcinoma: A Case Report. TUMORI JOURNAL 2018; 89:82-4. [PMID: 12729368 DOI: 10.1177/030089160308900117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Aims and Background The case of a 70-year-old patient with resectable, poorly differentiated adenocarcinoma of the ampulla of Vater is presented. Patient and Methods Due to intraoperative hemorrhagic complications, surgical resection was not feasible. The patient was treated with radiochemotherapy consisting of external beam radiotherapy (50.4 Gy; 1.8 Gy/fraction; 5 fractions/week) plus 5-FU (1000 mg/m2/day, continuous IV infusion, days 2–5, week 1 and 5 of radiotherapy) and mitomycin C (10 mg/m2 IV, day 2, week 1 of radiotherapy). Results At five years’ follow-up the patient was in good general condition, without any signs of disease according to CT scan, endoscopic retrograde cholangiopancreatography and tumor marker determination. Multiple random biopsies performed in the ampullary region were negative for tumor growth. Conclusions In patients with ampullary carcinoma the use of concurrent chemoradiation should be considered, particularly when surgical resection is unfeasible due to medical contraindications or locally advanced disease.
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Affiliation(s)
- Alessio G Morganti
- Radiation Therapy Department, Università Cattolica del Sacro Cuore, Rome, Italy
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Tringale KR, Pang J, Nguyen QT. Image-guided surgery in cancer: A strategy to reduce incidence of positive surgical margins. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2018; 10:e1412. [PMID: 29474004 DOI: 10.1002/wsbm.1412] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/13/2017] [Accepted: 11/03/2017] [Indexed: 12/16/2022]
Abstract
Primary treatment for many solid cancers includes surgical excision or radiation therapy, with or without the use of adjuvant therapy. This can include the addition of radiation and chemotherapy after primary surgical therapy, or the addition of chemotherapy and salvage surgery to primary radiation therapy. Both primary therapies, surgery and radiation, require precise anatomic localization of tumor. If tumor is not targeted adequately with initial treatment, disease recurrence may ensue, and if targeting is too broad, unnecessary morbidity may occur to nearby structures or remaining normal tissue. Fluorescence imaging using intraoperative contrast agents is a rapidly growing field for improving visualization in cancer surgery to facilitate resection in order to obtain negative margins. There are multiple strategies for tumor visualization based on antibodies against surface markers or ligands for receptors preferentially expressed in cancer. In this article, we review the incidence and clinical implications of positive surgical margins for some of the most common solid tumors. Within this context, we present the ongoing clinical and preclinical studies focused on the use of intraoperative contrast agents to improve surgical margins. This article is categorized under: Laboratory Methods and Technologies > Imaging.
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Affiliation(s)
- Kathryn R Tringale
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - John Pang
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - Quyen T Nguyen
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California.,Department of Pharmacology, University of California, San Diego, La Jolla, California.,Moores Cancer Center, University of California, San Diego, La Jolla, California
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Abstract
Pancreatic adenocarcinoma is a common malignancy that has a poor prognosis. Imaging is vital in its detection, staging, and management. Although a variety of imaging techniques are available, MDCT is the preferred imaging modality for staging and assessing the resectability of pancreatic adenocarcinoma. MR also has an important adjunct role, and may be used in addition to CT or as a problem-solving tool. A dedicated pancreatic protocol should be acquired as a biphasic technique optimized for the detection of pancreatic adenocarcinoma and to allow accurate local and distant disease staging. Emerging techniques like dual-energy CT and texture analysis of CT and MR images have a great potential in improving lesion detection, characterization, and treatment monitoring.
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Torgeson A, Garrido-Laguna I, Tao R, Cannon GM, Scaife CL, Lloyd S. Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins. ESMO Open 2018; 3:e000282. [PMID: 29387477 PMCID: PMC5786921 DOI: 10.1136/esmoopen-2017-000282] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/11/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022] Open
Abstract
Background Surgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB). Patients and methods Patients with stage IIA–III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage. Results We analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001). Conclusion R1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.
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Affiliation(s)
- Anna Torgeson
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Ignacio Garrido-Laguna
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Randa Tao
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - George M Cannon
- Department of Radiation Oncology, Intermountain Medical Center, Murray, Utah, USA
| | - Courtney L Scaife
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Alberghina N, Sánchez-Montes C, Tuñón C, Maurel J, Araujo IK, Ferrer J, Sendino O, Córdova H, Vaquero EC, González-Suárez B, Martínez-Palli G, Ginès À, Fernández-Esparrach G. Endoscopic ultrasonography can avoid unnecessary laparotomies in patients with pancreatic adenocarcinoma and undetected peritoneal carcinomatosis. Pancreatology 2017; 17:858-864. [PMID: 28844696 DOI: 10.1016/j.pan.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/01/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE To assess the relationship between the presence of ascites detected by endoscopic ultrasonography (EUS) and peritoneal carcinomatosis (PC) in patients with pancreatic adenocarcinoma. METHODS Consecutive patients who underwent a EUS for preoperative staging of a pancreatic adenocarcinoma between 1998 and 2014 were retrospectively reviewed. The diagnosis of PC was confirmed by histopathology or peritoneal fluid cytology. The main outcome of the study was the relationship of ascites at EUS and PC in patients with pancreatic cancer. Secondarily, to evaluate the relationship between this finding and survival as well as the development of PC during follow-up. RESULTS A total of 136 patients were included: 30 patients with local unresectable tumor or metastatic disease and 106 potentially-resectable candidates based on CT staging. EUS showed ascites in 27 (20%) patients, of whom 8 (29.6%) had PC. The sensitivity, specificity, PPV, NPV and accuracy of ascites by EUS in the detection of PC in this group of patients were 67%, 85%, 30%, 96% and 83%, respectively. Ascites detected by EUS was the only independent predictive factor of PC with an OR of 11 (CI 95%: 3-40). The detection of ascites by EUS was associated with a shorter survival (median survival time 7,3 months; range 0-60 vs 14.2 months; range 0-140) (p = 0.018) and earlier development of PC during follow-up (median 3.2 months, range 1.4-18.1 vs 12.7 months, range 5.4-54.8; p = 0.003). CONCLUSION The finding of ascites at EUS in patients with pancreatic adenocarcinoma is highly associated with PC and a poor outcome.
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Affiliation(s)
- Nadia Alberghina
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Cristina Sánchez-Montes
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Carlos Tuñón
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Joan Maurel
- Oncology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Isis K Araujo
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Joana Ferrer
- Surgical Department, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Oriol Sendino
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Henry Córdova
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Eva C Vaquero
- Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Begoña González-Suárez
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Graciela Martínez-Palli
- Anesthesiology Department, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Àngels Ginès
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalunya, Spain.
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14
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Tampi CS, Nilkanth S, Jagannath P. Reporting the margin in pancreaticoduodenectomies: R0 versus R1. Indian J Gastroenterol 2017; 36:81-87. [PMID: 28417289 DOI: 10.1007/s12664-017-0742-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 03/10/2017] [Indexed: 02/04/2023]
Abstract
AIM This study was conducted to analyze the changes in margin positivity in pancreaticoduodenectomies, on using a standardized protocol, which bread loafs the pancreas and duodenum in the axial plane for adenocarcinomas arising in the pancreatic head, ampulla, terminal common bile duct (CBD), and duodenum, and then to assess whether these tumor subsets involve the margins in different ways. METHODS The analysis was performed on 70 consecutive specimens, the pre-protocol specimens serving as the control group. RESULTS AND CONCLUSIONS Tumors originating from the pancreatic head, ampulla, terminal CBD, and duodenum showed a consistent increase in their R1 incidence, post-protocol. Ampullary tumors showed the greatest upward change in R1 positivity. The highest incidence of margin positivity was seen in pancreatic head adenocarcinomas (80%), then distal CBD tumors (60%), and finally the ampullary tumors (39%). In pancreatic head adenocarcinomas, R1 increased from 55% to 80%, distal CBD from 50% to 60%, and ampullary from 17% to 39%. Duodenal adenocarcinomas had no R1 in both pre- and post-protocol groups. The tumors also had different patterns of margin involvement. Ampullary tumors involved only the posterior margin, pancreatic adenocarcinomas involved the superior mesenteric vein (SMV) groove more often than the posterior margin, and distal CBD tumors involved the posterior margin and SMV groove equally. The size of the tumor made a significant difference in pancreatic head carcinomas with tumor size less than or equal to 2 cm, showing an R1 incidence of 38%, while those above 2 cm had an R1 incidence of 68%.
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Affiliation(s)
| | - Somesh Nilkanth
- Department of Histopathology, Lilavati Hospital and Research Centre, A-791, Bandra Reclamation, Mumbai, 400 050, India
| | - Palepu Jagannath
- Department of Surgical Oncology, Lilavati Hospital and Research Centre, A-791, Bandra Reclamation, Mumbai, 400 050, India
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Hsu CP, Hsu JT, Liao CH, Kang SC, Lin BC, Hsu YP, Yeh CN, Yeh TS, Hwang TL. Three-year and five-year outcomes of surgical resection for pancreatic ductal adenocarcinoma: Long-term experiences in one medical center. Asian J Surg 2016; 41:115-123. [PMID: 28010955 DOI: 10.1016/j.asjsur.2016.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 08/31/2016] [Accepted: 11/15/2016] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Pancreatic ductal adenocarcinoma is one of the most malignant types of cancer. This study evaluated the 3-year and 5-year surgical outcomes associated with the cancer and determined whether statistically identified factors can be used to predict survival. METHODS This retrospective review was conducted from 1995 to 2010. Patients who had resectable pancreatic ductal adenocarcinoma and received surgical treatment were included. Cases of hospital mortality were excluded. The relationships between several clinicopathological factors and the survival rate were analyzed. RESULTS A total of 223 patients were included in this study. The 3-year and 5-year survival rates were 21.4% and 10.1%, respectively, and the median survival was 16.1 months. Tumor size, N status, and resection margins were independent predictive factors for 3-year survival. Tumor size independently predicted 5-year survival. CONCLUSION Tumor size is the most important independent prognostic factor for 3-year and 5-year survival. Lymph node status and the resection margins also independently affected the 3-year survival. These patient outcomes might be improved by early diagnosis and radical resection. Future studies should focus on the tumor biology of this aggressive cancer.
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Affiliation(s)
- Chih-Po Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Being-Chuan Lin
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Pancreatic cancer metastatic to a limited number of lymph nodes has no impact on outcome. HPB (Oxford) 2016; 18:523-8. [PMID: 27317957 PMCID: PMC4913131 DOI: 10.1016/j.hpb.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 02/14/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to determine the association of the extent of metastatic lymph node involvement with survival in pancreatic cancer. METHODS This is a retrospective review of a prospectively maintained database of patients who underwent resection for pancreatic adenocarcinoma, 1999-2011. RESULTS 165 patients were identified and divided into 3 groups based on the number of positive lymph nodes - 0 (group A), 1-2 (B), >3 (C). Each group had 55 patients. Those in group C were more likely to have a higher T stage, poorly differentiated grade, lymphovascular invasion (LVI), higher mean intraoperative blood loss, positive margins, tumor location involving the uncinate process, and a higher likelihood of undergoing a pancreaticoduodenectomy. Median overall survival (OS) for group A, B and C was 25.5 months (mo), 21 mo and 12.3 mo, respectively (p < 0.001). No survival difference was noted for survival between groups A and B (p = 0.86). The ratio of involved lymph nodes <0.2 was predictive of improved survival (p < 0.001). CONCLUSIONS Resected pancreatic cancer patients with only 1-2 positive lymph nodes or less than 20% involvement have a similar prognosis to patients without nodal disease. Current staging should consider stratification based on the extent of nodal involvement.
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Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2015; 103:179-91. [PMID: 26663252 DOI: 10.1002/bjs.9969] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 08/27/2015] [Accepted: 09/15/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection. METHODS A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes. RESULTS Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results. CONCLUSION This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.
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Affiliation(s)
- F Giovinazzo
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - G Turri
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - M H Katz
- MD Anderson Cancer Center, Houston, Texas, USA
| | - N Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - I Ahmed
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
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18
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Ahmad Z, Din NU, Minhas K, Moeen S, Ahmed A. Epidemiologic Data, Tumor Size, Histologic Tumor Type and Grade, Pathologic Staging and Follow Up in Cancers of the Ampullary Region and Head of Pancreas in 311 Whipple Resection Specimens of Pakistani Patients. Asian Pac J Cancer Prev 2015; 16:7541-6. [PMID: 26625759 DOI: 10.7314/apjcp.2015.16.17.7541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AIM To report the histologic findings on Whipple resection specimens and thus determine the extent and spread of carcinomas of ampullary region and head of pancreas in our population. SETTING Section of Histopathology, Department of Pathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan. MATERIALS AND METHODS A case series of 311 consecutive Whipple resection specimens received between January 1,2003 and December 31, 2014. Specimens processed for histologic sections and representative sections submitted and histologically examined as per established and standard protocols. All relevant tumor parameters including histologic type, histologic grade, pathologic T and N stage and tumor size were assessed. Epidemiologic data were also recorded. All findings were analysed using SPSS 19.0 software. RESULTS Ampullary (periampullary) carcinomas were much more common than carcinomas of the head of the pancreas, especially in males, with an average age of 53 years. Mean tumor size was 2.5 cms, over 54% were well differentiated. A large majority were pT2 or pT3 and N0. Carcinomas of pancreatic head were also more common in males, mean age was 55 years, mean tumor size was 3.5 cms, and over 65% were moderately differentiated. The majority were T2 or T3 and pN1. Prognostically, significant statistical correlation was seen with tumor grade and pathologic T and N stage (p values statistically significant). However, tumor size was not statistically significant. CONCLUSIONS Ampullary carcinomas are more common compared to pancreatic carcinomas. Majority of ampullary carcinomas were well differentiated while majority of pancreatic carcinomas were moderately differentiated. Large majority of both types of cases were pT2 or T3. Histologic tumor grade and pathologic T and N stage are significantly related to prognosis in Pakistani patients with ampullary and pancreatic cancers.
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Affiliation(s)
- Zubair Ahmad
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan E-mail :
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Téoule P, Distler M, Niedergethmann M, Gaiser T, Rückert F, Grützmann R, Wilhelm TJ. Retrospective analysis of prognostic factors in patients with duodenal adenocarcinoma. Eur Surg 2015. [DOI: 10.1007/s10353-015-0374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Mavros MN, Xu L, Maqsood H, Gani F, Ejaz A, Spolverato G, Al-Refaie WB, Frank SM, Pawlik TM. Perioperative Blood Transfusion and the Prognosis of Pancreatic Cancer Surgery: Systematic Review and Meta-analysis. Ann Surg Oncol 2015; 22:4382-91. [PMID: 26293837 DOI: 10.1245/s10434-015-4823-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative blood transfusion (PBT) is common in pancreatic surgery. Recent studies have suggested that PBT may be associated with worse long-term outcomes. METHODS A systematic review and meta-analysis of studies comparing long-term clinical outcomes of cancer patients undergoing curative-intent pancreatic surgery with regard to occurrence of PBT was performed. RESULTS A total of 23 studies (4339 patients) were included in the systematic review, and 19 studies (3646 patients) were included in the meta-analysis. Nearly half (45.8 %) of all patients were female (range 25-60 %), and median age ranged from 59 to 72 years. About half (46.5 %, range 19-72 %) of the patients were transfused. Most had pancreatic ductal adenocarcinoma (69.5 %), while others had ampullary carcinoma (15.0 %), cholangiocarcinoma (7.4 %), or exocrine tumors of pancreas (8.1 %). Most (91.1 %) underwent pancreaticoduodenectomy, while the remaining patients underwent a total or distal pancreatectomy. The 5-year overall survival for all patients ranged from 0 to 65 %. Thirteen and nine of 19 studies reported a detrimental effect of PBT on survival on univariable and multivariable analysis, respectively. Overall, PBT was associated with shorter overall survival (pooled odds ratio 2.43, 95 % confidence interval 1.90-3.10); this finding was reproduced in sensitivity analysis. CONCLUSIONS Patients receiving PBT had significantly lower 5-year survival after curative-intent pancreatic surgery. Further research should focus on implementing guidelines for and discerning factors associated with the poor outcomes after PBT.
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Affiliation(s)
- Michael N Mavros
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Alfa Institute of Biomedical Sciences, Marousi, Athens, Greece
| | - Li Xu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China
| | - Hadia Maqsood
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aslam Ejaz
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Gaya Spolverato
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Waddah B Al-Refaie
- Department of Surgery, MedStar Georgetown University Hospital Center, Washington, DC, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tol JAMG, Brosens LAA, van Dieren S, van Gulik TM, Busch ORC, Besselink MGH, Gouma DJ. Impact of lymph node ratio on survival in patients with pancreatic and periampullary cancer. Br J Surg 2014; 102:237-45. [DOI: 10.1002/bjs.9709] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/18/2014] [Accepted: 10/17/2014] [Indexed: 12/17/2022]
Abstract
Abstract
Background
According to some studies, the number of lymph nodes with metastases in relation to the total number of removed lymph nodes, the lymph node ratio (LNR), is one of the most powerful predictors of survival after resection in patients with pancreatic cancer. However, contradictory results have been reported, and small sample sizes of the cohorts and different definitions of a microscopic positive resection margin (R1) hamper the interpretation of data.
Methods
The predictive value of LNR for 3-year survival was assessed using a Cox proportional hazards model. From 1992 to 2012, all patients with pancreatic and periampullary cancer operated on with pancreatoduodenectomy were selected from a database. Clinicopathological characteristics were analysed. Microscopic positive resection margin was defined as the microscopic presence of tumour cells within 1 mm of the margins. A nomogram was created.
Results
Some 760 patients were included. Predictive factors for death in 350 patients with pancreatic ductal adenocarcinoma included in the nomogram were: R1 resection (hazard ratio (HR) 1·55, 95 per cent c.i. 1·07 to 2·25), poor tumour differentiation (HR 2·78, 1·40 to 5·52), LNR above 0·18 (HR 1·75, 1·13 to 2·70) and no adjuvant therapy (HR 1·54, 1·01 to 2·34). The C statistic was 0·658 (0·632 to 0·698), and calibration was good (Hosmer–Lemeshow χ2 = 5·67, P =0·773). LNR and poor tumour differentiation (HR 4·51 and 3·30 respectively) were also predictive in patients with distal common bile duct (CBD) cancer. LNR, R1 resection and jaundice were predictors of death in patients with ampullary cancer (HR 7·82, 2·68 and 1·93 respectively).
Conclusion
LNR is a common predictor of poor survival in pancreatic, distal CBD and ampullary cancer.
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Affiliation(s)
- J A M G Tol
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - L A A Brosens
- Departments of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Departments of Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G H Besselink
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - D J Gouma
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Long-term survival following total pancreatectomy and superior mesenteric-portal vein resection for pancreatic ductal adenocarcinoma: A case report. Oncol Lett 2014; 9:318-320. [PMID: 25435983 PMCID: PMC4246678 DOI: 10.3892/ol.2014.2628] [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: 04/17/2014] [Accepted: 10/02/2014] [Indexed: 11/05/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with few therapeutic options. At present, surgical resection remains the only potential curative treatment for PDAC. However, only 15–20% of patients with PDAC are eligible for lesion resection. Total pancreatectomy (TP) and superior mesenteric-portal vein resection (SMPVR) may increase the rate of resection of PDCA, but the effect of this approach on improving long-term patient outcomes remains controversial. The present study investigated a case of PDAC in the pancreatic neck of a male patient. The patient underwent a TP, combined with SMPVR, for a margin-negative resection. Following an uneventful post-operative recovery, the patient received adjuvant chemoradiotherapy. The patient is currently alive at six years post-surgery, with a high quality of life. Given the clinical outcome of this patient, TP combined with SMPVR may provide PDAC patients with an opportunity for long-term survival. Therefore, patients with PDAC that is believed to be unresectable based on pre-operative assessment, may benefit from TP and SMPVR.
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CA 19-9 Nonproduction Is Associated With Poor Survival After Resection of Pancreatic Adenocarcinoma. Am J Clin Oncol 2014; 37:550-4. [DOI: 10.1097/coc.0b013e318280d5f0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sugawara A, Kunieda E. Effect of adjuvant radiotherapy on survival in resected pancreatic cancer: a propensity score surveillance, epidemiology, and end results database analysis. J Surg Oncol 2014; 110:960-6. [PMID: 25146251 DOI: 10.1002/jso.23752] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 07/25/2014] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Akitomo Sugawara
- Department of Radiation Oncology, Tokai University Hachioji Hospital, Hachioji, Japan
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Lim SJ, Park KB, Hyun DH, Do YS, Park HS, Shin SW, Cho SK, Choi DW. Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings. J Vasc Interv Radiol 2014; 25:1539-48. [PMID: 25149115 DOI: 10.1016/j.jvir.2014.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the clinical results and imaging follow-up findings of stent grafts placed for hemorrhage from hepatic arteries following surgery. MATERIALS AND METHODS The investigation included 17 patients (14 men and 3 women) who underwent endovascular stent graft placement for hepatic arterial hemorrhage following surgery. Bleeding occurred from the common hepatic artery (n = 1; 6%), right hepatic artery (n = 1; 6%), proper hepatic artery (n = 6; 35%), and gastroduodenal artery stump (n = 9; 53%). Stent graft patency, thrombus at the graft, target hepatic artery diameter, and liver perfusion status were analyzed by comparing computed tomography (CT) scans performed before the procedure with follow-up CT scans. Laboratory data were also analyzed before the procedure and at follow-up intervals. RESULTS There were 17 stent grafts placed in 17 patients. The mean follow-up period was 356 days (range, 1-2,119 d). The stent graft primary patency rate was 79.5% at 1 month, 69.6% at 6 months, and 69.6% at 1 year. The clinical success rate was 82% (14 of 17 patients), and the technical success rate was 94% (16 of 17 patients). Mortality related to the stent graft was 12% (2 of 17 patients). Occlusion occurred in 4 of 16 stent grafts (25%). There was one technical failure. The mean stent graft diameter was 6.2 mm (range, 3.5-8.0 mm), and the degree of stent graft oversizing was 38% of the hepatic artery diameter on CT scans and 58% on angiography. Hepatic parenchymal perfusion was preserved in 80% of patients (12 of 15). CONCLUSIONS Hepatic artery hemorrhage following surgery can be treated effectively with stent graft placement.
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Affiliation(s)
- Seong Joo Lim
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea.
| | - Dong Ho Hyun
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Young Soo Do
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Hong Suk Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Wook Shin
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Ki Cho
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Dong Wook Choi
- Division of Hepato-Biliary and Pancreas, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
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Hwang TL, Lee LY, Chen TC, Thorat A, Hsu JT, Yeh CN, Yeh TS, Jan YY. Prognosis of ductal adenocarcinoma of pancreatic head with overexpression of CD44. FORMOSAN JOURNAL OF SURGERY 2014. [DOI: 10.1016/j.fjs.2014.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Elebro J, Jirström K. Use of a standardized diagnostic approach improves the prognostic information of histopathologic factors in pancreatic and periampullary adenocarcinoma. Diagn Pathol 2014; 9:80. [PMID: 24731283 PMCID: PMC3999361 DOI: 10.1186/1746-1596-9-80] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/01/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Variability in reported histopathology parameters in operated periampullary adenocarcinomas may affect the prognostic weight of the parameters. Standardized axial sectioning produces a higher incidence of involved margins and also seems to produce a lower relative incidence of pancreatic compared with distal bile duct origin and a higher incidence of involved lymph nodes, compared with non-standardized procedure. The aims of this study were to 1) assess how a previously not described standardized pathology procedure, with longitudinal sectioning along the distal bile duct, affects reported tumour origin, margin status and involved lymph nodes, compared with non-standardized procedure, 2) assess if re-evaluation of microscopic slides affects the prognostic value of margin status and 3) compare the results of this standardized procedure with reported results of other standardized and non-standardized procedures. METHODS One hundred seventy-five consecutive pancreaticoduodenectomy specimens with primary adenocarcinomas, operated during 2001 - 2011 at the University hospitals of Lund and Malmö, Sweden, were re-evaluated histologically, and parameters relevant for classification and prognosis were assessed, with 1 mm as a threshold for involved or uninvolved margins. Follow-up lasted until 31 December 2013. Five-year overall survival (OS) and hazard ratios (HR) were calculated for the margin status stated in the original reports and margin status after re-evaluation. RESULTS Compared with non-standardized cases (n = 129), standardized cases (n = 46) had more involved lymph nodes in the specimens (median 3 vs 1), a higher fraction of distal bile duct origin (39% vs 21%) and a higher fraction of involved margins (74% vs 47%). The prognostic value of uninvolved margins increased by re-evaluation of slides (p < 0.001) and the adjusted HR for involved margins increased from 1.6 (95% CI 1.1 - 2.4) to 3.3 (95% CI 1.5 - 7.0). Uninvolved margins remained a significant predictor of OS in adjusted analysis. CONCLUSIONS Both the method of sectioning the specimen and the microscopic assessment affect prognostic pathology parameters significantly. The results of the herein described standardized method are similar to the results of other standardized procedures. The 1-mm threshold for involved margins in pancreaticoduodenectomies is relevant for OS, and margin status is an independent prognostic parameter. VIRTUAL SLIDES The virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1056639379120615.
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Affiliation(s)
- Jacob Elebro
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Skåne University Hospital, Lund SE-221 85, Sweden.
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Palta M, Willett C, Czito B. The Role of Intraoperative Radiation Therapy in Patients With Pancreatic Cancer. Semin Radiat Oncol 2014; 24:126-31. [DOI: 10.1016/j.semradonc.2013.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yu YP, Yu Q, Guo JM, Jiang HT, Di XY, Zhu Y. (125)I particle implantation combined with chemoradiotherapy to treat advanced pancreatic cancer. Br J Radiol 2014; 87:20130641. [PMID: 24625042 PMCID: PMC4067019 DOI: 10.1259/bjr.20130641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/17/2014] [Accepted: 01/27/2014] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To evaluate the therapy effects of (125)I implantation combined with chemoradiotherapy on pancreatic cancer patients. METHODS 30 patients with Stage III or IV pancreatic cancer were equally divided into two groups (control and treatment group). The patients in the treatment group (nine males, six females) received chemotherapy in the first week and (125)I implantation in the third week, followed by combined chemoradiotherapy in the fifth week. The patients in the control group (10 males, 5 females) received the same treatment except (125)I implantation. The therapy in the control group and treatment group was repeated every 4 weeks. RESULTS The median conformal radiotherapy dose in the treatment group (30.62 Gy) was significantly lower than that in the control group (47.86 Gy). The total radiation dose was 88.71 ± 27.39 Gy, and the surface activity was 0.6 mCi in the treatment group. After treatment, the average tumour size decreased both in the treatment group [9.17 cm(2), 95% confidence interval (CI): 5.60-12.74, p < 0.001] and in the control group (4.54 cm(2), 95% CI: 2.74-6.35, p < 0.001). The median survival time in the treatment group was 14 months (95% CI: 12.215-14.785) and in the control group was 12 months (95% CI: 10.884-13.116). There was no statistical significance in survival rates between the two groups (χ(2) = 0.908, p = 0.341). CONCLUSION (125)I implanted into tumour combined with chemoradiotherapy has higher local control rate of advanced pancreatic cancer than chemoradiotherapy. ADVANCES IN KNOWLEDGE We combined chemoradiotherapy with (125)I implantation to treat advanced pancreatic cancer and obtained a higher local control rate and better quality of life than when using chemoradiatherapy alone.
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Affiliation(s)
- Y-P Yu
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
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Endovascular Management of Severe Bleeding After Major Abdominal Surgery. Ann Vasc Surg 2013; 27:1098-104. [DOI: 10.1016/j.avsg.2012.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 12/19/2022]
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31
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Saira Chowdhury, Orla Hynes. Nutrition in Upper Gastrointestinal Cancer. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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An evaluation of neoadjuvant chemoradiotherapy for patients with resectable pancreatic ductal adenocarcinoma. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2013; 2013:298726. [PMID: 23864756 PMCID: PMC3705743 DOI: 10.1155/2013/298726] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 05/25/2013] [Accepted: 06/02/2013] [Indexed: 01/13/2023]
Abstract
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.
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Graham JA, Kayser R, Smirniotopoulos J, Nusbaum JD, Johnson LB. Probability prediction of a postoperative pancreatic fistula after a pancreaticoduodenectomy allows for more transparency with patients and can facilitate management of expectations. J Surg Oncol 2013; 108:137-8. [PMID: 23775846 DOI: 10.1002/jso.23362] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 05/20/2013] [Indexed: 12/27/2022]
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Fong ZV, Tan WP, Lavu H, Kennedy EP, Mitchell DG, Koniaris LG, Sauter PK, Rosato EL, Yeo CJ, Winter JM. Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings. J Gastrointest Surg 2013; 17:1098-106. [PMID: 23553385 DOI: 10.1007/s11605-013-2181-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 03/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. METHODS We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. RESULTS There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). DISCUSSION While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
OBJECTIVE Image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers. To enable appropriate tracking, it is recommended to place fiducials with "ideal fiducial geometry" (IFG). Our objectives were to determine the proportion of patients in whom IFG can be achieved when fiducials are placed by endoscopic ultrasound (EUS) and surgery and to determine if attaining IFG is necessary for delivering radiation. METHODS This single-center retrospective cohort study included 77 patients with biopsy-proven advanced pancreatic cancer who underwent either EUS-guided or laparotomy/laparoscopy-assisted fiducial placement between September 2005 and July 2009. RESULTS Gold fiducials were implanted by EUS in 39 patients (51%) and by surgery in 38 patients (49%). The proportion of patients with IFG was significantly higher for surgical placement [18/38, 47%; 95% confidence interval (CI), 32%-63%] compared with EUS-guided placement (7/39, 18%; 95% CI, 8%-32%), P = 0.0011. However, fiducial tracking was successfully used for Cyberknife therapy in 35 (90%) of 39 (95% CI, 77%-97%) patients in the EUS group compared with 31 (82%) of 38 (95% CI, 67%-92%) patients in the surgery group. There were 5 procedure-related complications in the EUS group. CONCLUSIONS Achieving IFG appears unnecessary for successful tracking and delivery of radiation.
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Egorov VI, Petrov RV, Lozhkin MV, Maynovskaya OA, Starostina NS, Chernaya NR, Filippova EM. Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy. World J Gastrointest Surg 2013; 5:51-61. [PMID: 23556062 PMCID: PMC3615305 DOI: 10.4240/wjgs.v5.i3.51] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/02/2012] [Accepted: 12/20/2012] [Indexed: 02/06/2023] Open
Abstract
Reported here are two cases of a modified Appleby operation for borderline resectable ductal adenocarcinoma of the pancreatic body, in one of which a R0 distal resection was attended to by excision, not only of the celiac axis, but also of the common and left hepatic arteries in the presence of arterial anatomic variation Michels, type VIIIb. The possibility and avenues of the maintenance of the blood supply to the left hepatic lobe after surgical aggression of this kind are demonstrated employing computed tomography (CT) and 3-D CT angiography. Furthermore, both cases highlight all important worrisome aspects of pancreatic cancer resectability prediction.
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Affiliation(s)
- Vyacheslav I Egorov
- Vyacheslav I Egorov, Ostroumov 14 City Hospital, Department of Surgical Oncology, Sechenov First State Medical University, 117997 Moscow, Russia
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Lymph node involvement beyond peripancreatic region in pancreatic head cancers: when results belie expectations. Pancreas 2013; 42:239-48. [PMID: 23038054 DOI: 10.1097/mpa.0b013e31825f80a9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Surgery remains the standard therapy for curative management of pancreatic duct adenocarcinoma (PDA) involving the head of pancreas. This study aimed to report our experience in PDA about the prognostic value of lymph node (LN) invasion (N⁺) at the root of the superior mesenteric artery (SMA) and in N2 subgroup. METHODS From January 2005 to September 2009, 110 patients were included for pancreaticoduodenectomy or total pancreatectomy. RESULTS Etiologies were PDA (n = 87) or ampullary carcinomas (n = 23). Sixty-five percent of patients were N⁺, with N1/N2/N3 location, respectively, 63.6%, 9.1%, and 2.7%. Forty-four percent had a LN identified intraoperatively at the origin of the SMA, of whom only 12% were N⁺. In multivariate analysis (whole series), complication grade greater than II, location of positive LN (N1 to N3) and vascular resection were associated with a poorer survival. In the exocrine PDA subgroup, only location of positive LN and vascular resection were associated with a poorer survival. N⁺ SMA was not statistically correlated with survival, recurrence, or disease-free survival. CONCLUSIONS N⁺ at the origin of the SMA was not a significant prognostic factor for PDA and should no longer be considered as a formal contraindication for curative surgery. Conversely, N2 invasion remains an unfavorable prognostic.
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Pomianowska E, Grzyb K, Westgaard A, Clausen OPF, Gladhaug IP. Reclassification of tumour origin in resected periampullary adenocarcinomas reveals underestimation of distal bile duct cancer. Eur J Surg Oncol 2012; 38:1043-50. [PMID: 22883964 DOI: 10.1016/j.ejso.2012.07.113] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 07/05/2012] [Accepted: 07/19/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Primary adenocarcinomas removed by pancreatoduodenectomy originate from the duodenum (DC), ampulla (AC), distal bile duct (DBC), or pancreas (PC). Pathobiology, staging, survival, and adjuvant chemotherapy vary among these cancers. The proximity of the structures of possible origin renders it difficult to obtain a correct diagnosis, which might lead to inconsistencies in reported data and inappropriate adjuvant treatment. METHODS Records of 207 patients undergoing pancreatoduodenectomy (1998-2009) for periampullary adenocarcinoma were reviewed. Routine histopathology reports of tumour origin performed by multiple pathologists were independently re-evaluated based on predetermined criteria by two experienced pancreatic pathologists. RESULTS Slide review changed the diagnosis in 55 (27%) patients. After reclassification, final distribution was 29 (14%) DC, 52 (25%) AC, 57 (28%) DBC, and 69 (33%) PC. The diagnosis was revised in 4 (14%) DC, 7 (17%) AC, 30 (53%) DBC and 14 (19%) PC. The underestimation of DBC during routine histopathology was caused by misinterpretation of DBC either PC or AC. Misclassification of PC was mainly due to erroneous diagnosis of AC. Reassignment of tumour origin caused no significant changes in survival within cancer type, but resulted in a significant difference in survival between DBC and PC (p = 0.004). CONCLUSION Specialist slide review resulted in reassignment of tumour origin in 27% of periampullary adenocarcinomas. Distal bile duct cancer was found to be most frequently misdiagnosed (53%). Correct diagnosis of tumour origin is crucial for data quality, appropriate adjuvant therapy, and patient inclusion in clinical trials.
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Affiliation(s)
- E Pomianowska
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.
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Clinicopathologic assessment of pancreatic ductal carcinoma located at the head of the pancreas, in relation to embryonic development. Pancreas 2012; 41:582-8. [PMID: 22228049 DOI: 10.1097/mpa.0b013e318239d233] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pancreaticoduodenectomy is performed for pancreatic head cancer that originated from the dorsal or ventral primordium. Although the extent of lymph node (LN) dissection is the same irrespective of the origin, the lymphatic continuities may differ between the 2 primordia. METHODS Between March 2003 and September 2010, 152 patients underwent pancreaticoduodenectomy for pancreatic cancer. One hundred six patients were assigned into 2 groups according to tumor location on preoperative computed tomography, and their clinical and pathological features were retrospectively analyzed in view of the embryonic development of the pancreas. RESULTS Sixty of 106 patients were classified with tumors that were derived from the dorsal pancreas (D group) and 46 from the ventral pancreas (V group). The frequency of LN involvement around the middle colic artery (LN 15) in the D group was higher than in the V group (P = 0.008). The rate of additional resection of the pancreas tended to be higher in the D group (P = 0.067). CONCLUSIONS The present study showed the detailed pattern of spread of pancreatic ductal carcinoma to the LNs and provided important information for determining the optimal surgical strategy.
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Verbeke CS, Gladhaug IP. Resection margin involvement and tumour origin in pancreatic head cancer. Br J Surg 2012; 99:1036-49. [PMID: 22517199 DOI: 10.1002/bjs.8734] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Assessment of the origin of adenocarcinoma in pancreatoduodenectomy specimens (pancreatic, ampullary or biliary) and resection margin status is not performed in a consistent manner in different centres. The aim of this review was to identify the impact of such variations on patient outcome. METHODS A systematic literature search for articles on pancreatic, ampullary, distal bile duct and periampullary cancer was performed, with special attention to data on resection margin status, pathological examination and outcome. RESULTS The frequent reclassification of tumour origin following slide review, and the wide variation in published incidence of pancreatic (33-89 per cent), ampullary (5-42 per cent) and distal bile duct (5-38 per cent) cancers indicate that the histopathological distinction between the three cancer groups is less accurate than generally believed. Recent studies have shown that the wide range of rates of microscopic margin involvement (R1) in pancreatoduodenectomy specimens (18-85, 0-27 and 0-72 per cent respectively for pancreatic, ampullary and distal bile duct cancers) is mainly caused by differences in pathological assessment rather than surgical practice and patient selection. As a consequence of the existing inconsistency in reporting of these data items, the clinical significance of microscopic margin involvement in each of the three cancer groups remains unclear. CONCLUSION Inaccurate and inconsistent distinction between pancreatic, ampullary and distal bile duct cancer, combined with inaccuracies in resection margin assessment, results in obfuscation of key clinicopathological data. Specimen dissection technique plays a key role in the quality of the assessment of both tumour origin and margin status. Unless the pathological examination is meticulous and standardized, comparison of results between centres and observations in multicentre trials will remain of limited value.
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Affiliation(s)
- C S Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Marangoni G, O’Sullivan A, Faraj W, Heaton N, Rela M. Pancreatectomy with synchronous vascular resection – An argument in favour. Surgeon 2012; 10:102-6. [DOI: 10.1016/j.surge.2011.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 11/23/2011] [Accepted: 12/06/2011] [Indexed: 12/22/2022]
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Vascular invasion in infiltrating ductal adenocarcinoma of the pancreas can mimic pancreatic intraepithelial neoplasia: a histopathologic study of 209 cases. Am J Surg Pathol 2012; 36:235-41. [PMID: 22082604 DOI: 10.1097/pas.0b013e3182376e36] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Although vascular invasion is a well-established indicator of poor prognosis for patients with infiltrating ductal adenocarcinoma of the pancreas (PDAC), the histopathologic characteristics of vascular invasion are not well described. Hematoxylin and eosin-stained slides from 209 surgically resected infiltrating PDACs were systematically evaluated for the presence or absence of microscopic vascular invasion. For the cases with vascular invasion, we further categorized the histologic pattern of invasion into conventional and pancreatic intraepithelial neoplasia-like (PanIN-like). In addition, several histopathologic factors in the surrounding blood vessels, including lymphocytic infiltration and luminal fibrosis, were carefully assessed. Data were compared with clinicopathologic variables, including patient survival. Microscopic vascular invasion was observed in 136 of the 209 PDACs (65.1%). Vascular invasion mimicking pancreatic intraepithelial neoplasia (PanIN-like invasion) was observed in 94 of the 136 cases (69.1%) with vascular invasion. Microscopic vascular invasion was associated with increased tumor size (P=0.04), higher pT classification (P=0.003), lymph node metastasis (P<0.0001), and perineural invasion (P=0.005). Vascular invasion was inversely correlated with neo-adjuvant therapy (P<0.0001). Examination of adjacent blood vessels revealed that peritumoral blood vessels with intimal lymphocytes (P=0.002), intimal (P=0.007) and medial (P=0.001) fibrosis, and cancer cells in vascular wall (P<0.0001) were all highly associated with the intraluminal vascular invasion. In univariate analysis, patients whose cancers had microscopic vascular invasion (median survival, 15.3 mo) had a significantly worse survival than did patients with carcinomas without vascular invasion (25.1 mo; P=0.01, log-rank test). Microscopic vascular invasion is a poor prognostic indicator and can histologically mimic PanIN.
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Gray PJ, Wang J, Pawlik TM, Edil BH, Schulick R, Hruban RH, Dao H, Cameron J, Wolfgang C, Herman JM. Factors influencing survival in patients undergoing palliative bypass for pancreatic adenocarcinoma. J Surg Oncol 2012; 106:66-71. [PMID: 22308098 DOI: 10.1002/jso.23047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Accepted: 01/03/2012] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study is to identify factors predictive of early mortality following palliative bypass in patients with previously unsuspected advanced pancreatic adenocarcinoma to provide a basis for the selection of appropriate therapies. METHODS All patients with pancreatic adenocarcinoma who underwent a bypass procedure at our institution between 9/30/1994 and 1/31/2006 were reviewed. Patients with peri-operative mortality were excluded from the analysis. Univariate analysis was performed on peri-operative data to identify factors associated with early mortality (death within 6 months of surgery). Patients having multiple risk factors were assigned an overall prognostic score based on the sum of these factors. RESULTS Of the 397 patients with pancreatic adenocarcinoma analyzed, four factors were found to predict early mortality following palliative bypass: Presence of distant metastatic disease (HR 2.59, P < 0.0001), poor tumor differentiation (HR 1.71, P = 0.009), severe pre-operative nausea and vomiting (HR 1.48, P = 0.013), and lack of previous placement of a biliary stent (HR 1.36, P = 0.048). Patients with a prognostic score of 0 were significantly more likely to survive past 6 months than patients with a prognostic score of 1 (HR 2.71, P < 0.0001), 2 (HR 3.70, P < 0.0001), or ≥3 (HR 5.63, P < 0.0001). CONCLUSIONS In a cohort of patients undergoing a palliative bypass procedure, specific peri-operative factors can be used to identify patients who are at risk of early mortality. These factors may be helpful in selecting appropriate interventions for this group of patients.
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A modified technique of pancreaticojejunostomy after pancreatoduodenectomy: a preliminary experience. Updates Surg 2011; 63:287-91. [DOI: 10.1007/s13304-011-0120-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 05/25/2011] [Indexed: 12/29/2022]
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Abstract
Pancreatic cancer patients present late in their course and surgical resection as a modality of treatment is of limited value. Majority develop loco-regional failure and distant metastasis, therefore, adjuvant therapy comprising of radiotherapy and chemotherapy are useful treatment options to achieve higher loco-regional control. Specialized irradiation techniques like intra-operative radiotherapy that help to increase the total tumor dose have been used, however, controvertible survival benefit was observed. Various studies have shown improved median and overall survival with chemoradiotherapy for advanced unresectable pancreatic carcinoma. The role of new agents such as topoisomerase I inhibitors also needs further clinical investigations.
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Affiliation(s)
- Sushmita Pathy
- Department of Radiation Oncology, All India Institute Of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India
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Lazaryan A, Kalmadi S, Almhanna K, Pelley R, Kim R. Predictors of clinical outcomes of resected ampullary adenocarcinoma: a single-institution experience. Eur J Surg Oncol 2011; 37:791-7. [PMID: 21741199 DOI: 10.1016/j.ejso.2011.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 05/25/2011] [Accepted: 06/14/2011] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In the absence of prospective data, the use of adjuvant therapy in ampullary adenocarcinoma is contingent upon the clinicopathological features which can correlate to 5-year post-operative survival and disease relapse. METHODS We investigated the factors associated with clinical outcomes among 72 patients who underwent pancreatoduodenectomy at the Cleveland Clinic from 1995 to 2007 for histologically confirmed adenocarcinoma of the ampulla of Vater. RESULTS R0 resection was achieved in 96% of patients (median age, 72 years; 58% males, 89% Caucasians). Nineteen patients experienced disease relapse after surgery and 61% were alive within 5 years of follow up. Thirty five percent of patients received some form of adjuvant therapy. Perineural tumor invasion (p < 0.01) and presence of ulcerated tumor on histopathology (p < 0.01) were associated with higher rates of tumor relapse and poor 5-year overall survival in multivariable analysis. Lymph node involvement (p = 0.02) also portended poor overall survival after adjustment for other covariates. Although adjuvant therapy was associated with poor clinical outcomes in univariate analysis, it demonstrated a favorable albeit non-significant trend in multivariable analysis. CONCLUSIONS Factors associated with poor clinical outcomes in this contemporary single-institution study, included perineural invasion, tumor ulceration, and lymph node involvement. No definite conclusion could be made in regards to adjuvant treatment.
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Affiliation(s)
- A Lazaryan
- Cleveland Clinic Taussig Cancer Institute, R35, Cleveland OH 44195, USA
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Graham JA, Johnson LB, Haddad N, Al-Kawas F, Carroll J, Jha R, Wong J, Maglaris D, Mertens S, Fishbein T. A prospective study of prophylactic long-acting octreotide in high-risk patients undergoing pancreaticoduodenectomy. Am J Surg 2011; 201:481-5. [PMID: 21421102 DOI: 10.1016/j.amjsurg.2010.06.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Revised: 06/04/2010] [Accepted: 06/07/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (postoperative pancreatic fistula [POPF]) is the most common complication after pancreaticoduodenectomy. Despite some studies showing little effect of octreotide in unselected patients, we hypothesized that in high-risk patients depot octreotide may reduce the risk of POPF. METHODS Sixty-eight patients were prospectively evaluated for inclusion in the current study. Two groups were identified: pancreatic ducts ≤3 mm (high risk) and those with ducts >3 mm (low risk). Thirty-two patients were low risk, whereas 36 patients were high risk. High-risk patients were treated preoperatively with depot octreotide and begun on an intravenous drip for 24 hours. Low-risk patients underwent pancreaticoduodenectomy without pharmacologic intervention. In contrast, the control cohort represents 106 retrospectively analyzed patients who underwent a pancreaticoduodenectomy without depot octreotide injection without regard to low- or high-risk status. RESULTS Overall, POPF was 11 of 68 (16%). Nine of 36 high risk patients treated with depot octreotide developed POPF (25%), and 2 of 32 low risk patients developed POPF (6%). In the control cohort of high-risk patients, 9 of 44 (20%) and 3 of 62 (5%) low-risk patients developed POPF (P = .628 when comparing the development of POPF in high-risk patients with or without pharmacologic intervention). CONCLUSIONS Prophylactic use of depot octreotide in high-risk patients does not result in reduced incidence of POPF. Duct size has a significant impact on the occurrence of POPF.
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Affiliation(s)
- Jay A Graham
- Department of Surgery, Georgetown University, Washington, DC 20007, USA
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Karapanos K, Nomikos IN. Current surgical aspects of palliative treatment for unresectable pancreatic cancer. Cancers (Basel) 2011; 3:636-51. [PMID: 24212633 PMCID: PMC3756381 DOI: 10.3390/cancers3010636] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 01/19/2011] [Accepted: 02/05/2011] [Indexed: 02/06/2023] Open
Abstract
Despite all improvements in both surgical and other conservative therapies, pancreatic cancer is steadily associated with a poor overall prognosis and remains a major cause of cancer mortality. Radical surgical resection has been established as the best chance these patients have for long-term survival. However, in most cases the disease has reached an incurable state at the time of diagnosis, mainly due to the silent clinical course at its early stages. The role of palliative surgery in locally advanced pancreatic cancer mainly involves patients who are found unresectable during open surgical exploration and consists of combined biliary and duodenal bypass procedures. Chemical splanchnicectomy is another modality that should also be applied intraoperatively with good results. There are no randomized controlled trials evaluating the outcomes of palliative pancreatic resection. Nevertheless, data from retrospective reports suggest that this practice, compared with bypass procedures, may lead to improved survival without increasing perioperative morbidity and mortality. All efforts at developing a more effective treatment for unresectable pancreatic cancer have been directed towards neoadjuvant and targeted therapies. The scenario of downstaging tumors in anticipation of a future oncological surgical resection has been advocated by trials combining gemcitabine with radiation therapy or with the tyrosine kinase inhibitor erlotinib, with promising early results.
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Affiliation(s)
- Konstantinos Karapanos
- Department of Surgery (B′ Unit), “METAXA” Cancer Memorial Hospital, Piraeus, Greece; E-Mail:
| | - Iakovos N. Nomikos
- Department of Surgery (B′ Unit), “METAXA” Cancer Memorial Hospital, Piraeus, Greece; E-Mail:
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Kneuertz PJ, Patel SH, Chu CK, Maithel SK, Sarmiento JM, Delman KA, Staley CA, Kooby DA. Effects of perioperative red blood cell transfusion on disease recurrence and survival after pancreaticoduodenectomy for ductal adenocarcinoma. Ann Surg Oncol 2011; 18:1327-34. [PMID: 21369744 DOI: 10.1245/s10434-010-1476-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND The premise that allogeneic red blood cell transfusion (RBCT) contributes to adverse oncologic outcomes after surgery remains controversial. We examined the effects of RBCT during and after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) on disease recurrence and survival. METHODS A prospective database of 220 patients undergoing PD for PDAC from 2000 to 2008 was reviewed and transfusion data collected. Univariate and multivariate analyses were performed for factors influencing RBCT, recurrence-free survival (RFS), and overall survival (OS). The effect of amount and timing (intraoperative vs. postoperative) of RBCT was analyzed. RESULTS One hundred forty-seven patients (67%) received RBCT: 70 (32%) received 1 to 2 units, and 77 (35%) received >2 units. Median RFS and OS for the entire cohort was 12 and 16 months, respectively. RBCT of >2 units was associated with reduced RFS (9 vs. 15 months; P = 0.033) and OS (14 vs. 20 months; P = 0.003). Stratified by timing of transfusion, postoperative RBCT was associated with shortened RFS and OS. Controlling for age, body mass index, comorbidities, tumor factors, and major complications, each incremental unit of postoperative RBCT was associated with reduced RFS (hazard ratio 1.10, 95% confidence interval 1.02-1.18) and OS (hazard ratio 1.08, 95% confidence interval 1.03-1.12). Low hemoglobin and presence of comorbidities were the only preoperative factors independently associated with RBCT. CONCLUSIONS Allogeneic red blood cell transfusion after PD for PDAC is independently associated with earlier cancer recurrence and reduced survival, in particular when administered postoperatively and in larger quantities. Blood-conservation methods are especially indicated for patients with preoperative anemia and medical comorbidities.
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Affiliation(s)
- Peter J Kneuertz
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
OBJECTIVES In patients with unresectable pancreatic cancer, estimation of individual prognosis is essential to provide the most suitable biliary stent (self-expanding metal stent or plastic stent). The aim of the current study was to determine prognostic factors for survival in patients with unresectable pancreatic cancer after initial biliary drainage. PATIENTS AND METHODS The current study included 278 patients with unresectable pancreatic cancer. Prognostic factors for survival were analyzed using the Cox proportional hazards model, the Kaplan-Meier survival estimator, and the Wilcoxon test for difference in survival. RESULTS In univariate analysis, advanced T stage according to the TNM classification (P = 0.021, Wald test) and the presence of distant metastases (P = 0.001, Wald test) were predictive factors for shorter survival. However, in multivariate analysis, the presence of distant metastasis was the only independent prognostic factor. The median survival time after initial biliary drainage was 3.1 and 6.6 months in patients with and without the presence of distant metastases, respectively. CONCLUSIONS The presence of distant metastases was identified as the only independent prognostic factor for survival after initial biliary drainage. A self-expanding metal stent should be systematically chosen for patient without distant metastases, whereas polyethylene plastic stents should be preferred in patients with distant metastases.
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