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Igarashi T, Fukasawa M, Watanabe T, Kimura N, Itoh A, Tanaka H, Shibuya K, Yoshioka I, Hirabayashi K, Fujii T. Evaluating staging laparoscopy indications for pancreatic cancer based on resectability classification and treatment strategies for patients with positive peritoneal washing cytology. Ann Gastroenterol Surg 2024; 8:124-132. [PMID: 38250680 PMCID: PMC10797817 DOI: 10.1002/ags3.12719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/17/2023] [Accepted: 07/04/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction The prognosis of pancreatic ductal adenocarcinoma (PDAC) in patients with positive peritoneal washing cytology (CY1) is poor. We aimed to evaluate the results of staging laparoscopy (SL) and treatment efficacy in CY1 patients based on a resectability classification. Methods We retrospectively reviewed 250 patients with PDAC who underwent SL before the initial treatment between 2017 and 2023 at the University of Toyama. Results The breakdown of cases by resectability classification was resectable (R):borderline resectable (BR):unresectable locally advanced (UR-LA) = 131:48:71 cases. The frequency of CY1 increased in proportion to the degree of local progression (R:BR:UR-LA = 20:23:34%), but the frequencies of liver metastasis or peritoneal dissemination were comparable (R:BR:UR-LA = 6.9:6.3:8.5%). Most CY1 patients received gemcitabine along with nab-paclitaxel therapy. The CY-negative conversion rates (R:BR:UR-LA = 70:64:52%) and conversion surgery rates (R:BR:UR-LA = 40:27:9%) were inversely proportional to the degree of local progression.Comparing H0P0CY1 factors for each classification, patients with H0P0CY1 had significantly more pancreatic body or tail carcinoma and tumor size ≥32 mm in R patients, whereas in BR patients, duke pancreatic monoclonal antigen type 2 (DUPAN-2) ≥ 230 U/mL was a significant factor. In contrast, no significant factors were observed in UR-LA patients. Conclusion The CY1 rates, CY-negative conversion rates, and conversion surgery rates varied according to local progression. In the case of R and BR, SL could be considered in patients with pancreatic body or tail carcinoma, large tumor size, or high DUPAN-2 level. In UR-LA, SL might be considered for all patients.
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Affiliation(s)
- Takamichi Igarashi
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Mina Fukasawa
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Nana Kimura
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Ayaka Itoh
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Haruyoshi Tanaka
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Kenichi Hirabayashi
- Department of Diagnostic Pathology, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of MedicineAcademic Assembly, University of ToyamaToyamaJapan
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Kuriyama N, Maeda K, Shinkai T, Ito T, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Nagata M, Ichikawa S, Mizuno S. Anterior versus posterior radical antegrade modular pancreatosplenectomy for pancreatic body and tail cancer: an inverse probability of treatment weighting with survival analysis. Surg Today 2023:10.1007/s00595-023-02651-7. [PMID: 36943448 DOI: 10.1007/s00595-023-02651-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 12/08/2022] [Indexed: 03/23/2023]
Abstract
PURPOSE Radical antegrade modular pancreatosplenectomy (RAMPS) is a standard procedure for patients with pancreatic body and tail cancer. There are two types of RAMPS: anterior and posterior, but their indications and surgical outcomes remain unclear. We compared the surgical outcomes, postoperative course, and prognosis between anterior and posterior RAMPS. METHODS Between 2007 and 2020, 105 consecutive patients who underwent RAMPS for pancreatic body and tail cancers were divided into an anterior RAMPS group (n = 30) and a posterior RAMPS group (n = 75). To adjust for differences in preoperative characteristics and intraoperative procedures, an inverse probability of treatment weighting (IPTW) analysis was done, using propensity scores. RESULTS After IPTW adjustment, the postoperative body temperature of the posterior RAMPS group and the amount of drain discharge in the anterior RAMPS group were significantly lower, from postoperative days (PODs) 1 to 3, but there were no differences in postoperative complications, recurrence patterns, or prognosis between the two groups. Regarding the diagnostic ability of multidetector-row computed tomography (MD-CT) for direct tumor involvement of the left adrenal gland, the sensitivity and specificity were 100% and 90.0%, respectively. CONCLUSION Pancreatic body and tail cancer without apparent preoperative direct tumor involvement of the left adrenal gland on MD-CT may be sufficient indication for anterior RAMPS.
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Affiliation(s)
- Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toru Shinkai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Motonori Nagata
- Department of Radiology, Mie University School of Medicine, Tsu, Mie, Japan
| | - Shuhei Ichikawa
- Department of General Medicine, Mie University School of Medicine, Tsu, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Kang MJ, Kim SW. Paradigm shift for defining the resectability of pancreatic cancer. Ann Hepatobiliary Pancreat Surg 2021; 25:451-455. [PMID: 34845115 PMCID: PMC8639311 DOI: 10.14701/ahbps.2021.25.4.451] [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: 07/09/2021] [Accepted: 09/02/2021] [Indexed: 12/11/2022] Open
Abstract
Supported by the expanding indications for neoadjuvant therapy (NAT) for advanced pancreatic cancer (PC), the concept of resectability has evolved from being mostly based on the anatomical tumor extent to considering the biological and conditional factors relevant to prognosis. Therefore, it is more reasonable to define the “criteria for surgical resection” instead of using the “(technical) resectability criteria.” NAT has been used in resectable PCs (RPC) with a high risk of early systemic recurrence, as predicted by various biological or anatomical markers. Moreover, the indications for NAT followed by conversion surgery or adjuvant surgery for borderline resectable or locally advanced PC (LAPC) are gradually expanding. Therefore, it is important to define the RPC group that will benefit from NAT and the LAPC group that will benefit from post-NAT surgery. At diagnosis, population-based approaches, such as prognostic stratification and staging systems and personalized outcome-based approaches using prognostic prediction models can be used to determine the criteria for treatment options. Standardized indications for conversion surgery are needed for patients who are initially treated with NAT. In addition to imaging-based morphological criteria, biological criteria, including CA19-9, and various metabolic criteria can be used to establish predicted outcome-based criteria. Multicenter collaboration is required to develop a large database with standardized data collection for various biomarkers and response data after NAT to establish more accurate outcome prediction models to define the new resectability criteria.
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Affiliation(s)
- Mee Joo Kang
- Department of Surgery, Center for Liver and Pancreato-Biliary Cancer, National Cancer Center, Goyang, Korea
| | - Sun-Whe Kim
- Department of Surgery, Center for Liver and Pancreato-Biliary Cancer, National Cancer Center, Goyang, Korea
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Kang MJ, Kim S. Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science". Ann Gastroenterol Surg 2021; 5:738-746. [PMID: 34755005 PMCID: PMC8560610 DOI: 10.1002/ags3.12494] [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: 05/20/2021] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 12/18/2022] Open
Abstract
Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long-term survival outcomes, and various challenges in obtaining high-level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long-term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high-level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico-enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called "art" when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered "surgical artists," "surgical scientists," and "surgical practitioners." We look forward to more "surgical artists" educating future "surgical artists and scientists" to create a richer "spirit of innovation," leading to a more beautiful integration of art and science in the field of pancreatic surgery.
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Affiliation(s)
- Mee Joo Kang
- Department of SurgeryCenter for Liver and Pancreato‐Biliary CancerNational Cancer CenterGoyang‐siKorea
| | - Sun‐Whe Kim
- Department of SurgeryCenter for Liver and Pancreato‐Biliary CancerNational Cancer CenterGoyang‐siKorea
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