Role of adjuvant surgery in initially unresectable pancreatic cancer after long-term chemotherapy or chemoradiation therapy: survival benefit?

Significance of multiple tumor markers measurements in conversion surgery for unresectable locally advanced pancreatic cancer

BACKGROUND

This study aimed to evaluate the significance of multiple tumor markers (TMs) measurements in determining the indications for conversion surgery (CS) in the management of unresectable locally advanced pancreatic cancer (UR-LAPC).

METHODS

A total of 103 patients with UR-LAPC, treated between 2008 and June 2021, were enrolled in this study. Three TMs, including carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and Duke pancreatic monoclonal antigen type 2 (DUPAN-2), were measured.

RESULTS

Twenty-five patients (24%) underwent CS. The median preoperative treatment period was 9.5 months. The median survival time (MST) from the initial treatment for patients with CS was significantly longer than that for patients without surgery (34.6 vs. 18.9 months, P < 0.001). The number of elevated TMs before CS was one in five patients and two in five patients, while 15 patients had normal levels of all three TMs. Notably, the MST from the initial treatment for patients with all three preoperative normal TMs levels was favorable for 70.5 months. In contrast, patients with one or two preoperatively elevated TMs levels had a significantly worse prognosis (25.4 and 21.0 months, respectively, P < 0.001). Furthermore, the relapse-free survival of patients with three preoperative normal TMs levels was significantly longer than those with one or two elevated TMs levels (21.9 vs. 11.3 or 3.0 months, respectively, P < 0.001). Non-normal values of all TMs before CS were identified as independent poor prognostic factors.

CONCLUSIONS

Simultaneous measurement and assessment of the three TMs levels may help determine the surgical indications for UR-LAPC after systemic anticancer treatment.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.

Clinical Outcomes of Conversion Surgery after FOLFIRINOX in Patients with Unresectable Advanced Pancreatic Cancer: A Retrospective Cohort Study at a Single Center

Pancreatic cancer is one of the most lethal cancers. To improve its prognosis, conversion surgery for initially unresectable advanced pancreatic cancer (UAPC) after chemotherapy has been reported in recent years. Methods: A retrospective analysis of the patients with initially UAPC underwent conversion surgery after the first-line modified FOLFIRINOX (mFX) was conducted at a single tertiary care center between January 2014 and March 2020. Results: Among 79 patients with UAPC who had mFX, 8 patients with a median age of 63 years, including 5 males (3 with locally advanced and 5 metastatic lesions), underwent conversion surgery after a median of 20 cycles of mFX. Conversion surgery was performed in 10.1% of patients (8/79) and surgical resection was successful in all with R0 resection. Postoperative major adverse events were seen in 2 patients, but no perioperative deaths were recognized. Recurrence was confirmed in 3 patients, and these 3 patients died due to cancer recurrence in 17.7, 30.6 and 57.8 months after mFX initiation. 5 patients were still alive without recurrence. The median OS in the patients who underwent conversion surgery was estimated as 65.9 months and was significantly longer than that of the patients without conversion surgery or that in the patients who had a partial response for mFX but did not have conversion surgery. The median follow-up period for the patients who had conversion surgery was 35.2 months. Conclusion: Conversion surgery achieved long-term survival in patients with UAPC who were treated with the first-line mFX, although controversy still remained.

Clinical Benefits of Conversion Surgery for Unresectable Pancreatic Ductal Adenocarcinoma: A Single-Institution, Retrospective Analysis

BACKGROUND

Unresectable pancreatic ductal adenocarcinoma (UR-PDAC) has a poor prognosis. Conversion surgery is considered a promising strategy for improving the prognosis of UR-PDAC. This study aimed to investigate the clinical benefits of conversion surgery in patients with UR-PDAC.

METHODS

We retrospectively evaluated patients with PDAC who were referred to our department for possible surgical resection between January 2006 and December 2019. Conversion surgery was performed only in patients with UR-PDAC who could expect R0 resection. We analyzed the prognostic factors for overall survival among patients who underwent conversion surgery.

RESULTS

Overall, 638 patients with advanced pancreatic cancer were enrolled in this study. According to resectability, resectable cancer (R) was present in 180 patients, borderline resectable cancer (BR) was present in 60 patients, unresectable locally advanced cancer (UR-LA) was present in 252 patients, and unresectable cancer with distant metastasis (UR-M) was present in 146 patients. Conversion surgery was performed in 20 of the 398 UR cases (5.1%). The median period between the initial therapy and conversion surgery was 15.5 months. According to the Response Evaluation Criteria in Solid Tumors (RECIST) evaluation, the treatment response was CR in one patient, PR in 13, SD in five, and PD in one. Downstaging was pathologically determined in all cases. According to the Evans grading system, grade I was observed in four patients (20%), grade IIb was observed in seven (35%), III was observed in seven (35%), and IV was observed in two (10%). We compared the overall survival period from initial treatment among patients undergoing conversion surgery; the median overall survival durations in the conversion surgery, R, BR, UR-LA, and UR-M groups were 73.7, 32.7, 22.7, 15.7, and 8.8 months, respectively. Multivariate analysis revealed that the presence or absence of chemoradiotherapy (CRT) and the RECIST partial response (PR)/complete response (CR) for the main tumor were statistically significant prognostic factors for overall survival among patients undergoing conversion surgery (p = 0.004 and 0.03, respectively).

CONCLUSION

In UR-PDAC, it is important to perform multidisciplinary treatment, including CRT with conversion surgery.

Role of Conversion Surgery for Unresectable Pancreatic Cancer After Long-Term Chemotherapy

BACKGROUND

Unresectable pancreatic cancer (UR-PC) has a poor prognosis. Although conversion surgery has been considered a promising strategy for improving prognosis in UR-PC, the clinical benefit offered to patients with UR-PC remains controversial. This study aimed to investigate the clinical benefits of conversion surgery in patients with UR-PC.

METHODS

We evaluated patients with UR-PC referred to our department for possible surgical resection between January 2008 and June 2017. Resectability was evaluated using multimodal imaging in patients who underwent chemotherapy for more than 6 months. Conversion surgery was performed only in patients who were judged eligible for R0 resection.

RESULTS

In total, 90 patients were evaluated. Among them, only 22 (24.4%) could actually undergo conversion surgery, and the R0 resection rate was 72.7% (16/22). Although Evans grade ≥ IIB was noted in six patients (27.3%), none achieved complete response (CR). The median survival time was significantly longer among patients who underwent conversion surgery than in the unresected patients who underwent chemotherapy (21.3 months vs. 12.6 months; p < 0.001). Multivariate and Kaplan-Meier analyses revealed microvascular invasion to have a significant adverse effect on recurrence-free survival (RFS: 7 months vs. not reached, p = 0.004) and overall survival (OS: 21 months vs. 85 months, p = 0.047).

CONCLUSIONS

After long-term chemotherapy, conversion surgery for UR-PC is associated with long-term survival. Microvascular invasion is predictive of poor prognosis in these patients; adjuvant protocols are therefore needed for patients with microvascular invasion.

Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is highly malignant. While cancers in other organs have shown clear improvements in 5-year survival, the 5-year survival rate of pancreatic cancer is approximately 10%. Early relapse and metastasis are not uncommon, making it difficult to achieve an acceptable prognosis even after complete surgical resection of the pancreas. Studies have been performed on various treatments to improve the prognosis of PDAC, and multidisciplinary approaches including non-surgical treatments have led to gradual improvement. In the present literature review, we have described the significance of anatomical and biological resectability criteria, the concept of R0 resection in surgical treatment, the feasibility of minimally invasive surgery, the remarkable development of perioperative chemotherapy, the effectiveness of conversion surgery for unresectable PDAC, and ongoing challenges in PDAC treatment. We also provide an essential update on these subjects by focusing on recent trends and topics.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

Background

Pancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.

Case presentation

A 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m²) plus nab-paclitaxel (125 mg/m²) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m²/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).

Conclusion

For locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

Liver resections in patients with prior bilioenteric anastomosis are predisposed to develop organ/space surgical site infections and biliary leakage: results from a propensity score matching analysis

PURPOSE

The aims of this study were to compare the perioperative outcomes after hepatectomy with prior bilioenteric anastomosis to those without prior anastomosis, and to elucidate the mechanisms and preventative measures of its characteristic complications.

METHODS

The demographic data and perioperative outcomes of 525 hepatectomies performed between January 2007 and December 2018, including 40 hepatectomies with prior bilioenteric anastomosis, were retrospectively analyzed.

RESULTS

A propensity score matching analysis demonstrated that hepatectomies with prior bilioenteric anastomosis were associated with a higher frequency of major complications (p = 0.015), surgical site infection (p = 0.005), organ/space surgical site infection (p = 0.003), and bile leakage (p = 0.007) compared to those without. A multivariate analysis also elucidated that prior bilioenteric anastomosis was one of the independent risk factors of organ/space surgical site infection. In the patients with prior bilioenteric anastomosis, bile leakage was associated with organ/space surgical site infection at a significantly higher rate than those without prior bilioenteric anastomosis (p < 0.001).

CONCLUSIONS

Prior bilioenteric anastomosis is a strong risk factor for organ/space surgical site infections, which might be induced by bile leakage. To prevent infectious complications after hepatectomy with prior bilioenteric anastomosis, meticulous liver transection to reduce bile leakage rate is thus considered to be mandatory.

Neoadjuvant Chemoradiation Therapy is Associated with Adverse Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Cancer

The use of neoadjuvant chemoradiation therapy in patients with pancreatic adenocarcinoma is emerg-ing as an acceptable therapy option. The effects of neoadjuvant therapy on 30 days’ outcomes in patients with pancreatic cancer are not well defined in the literature. NSQIP (2009–2012) was used. Only patients with a diagnosis of pancreatic cancer and those who underwent a Whipple were included in the analysis. Patient who underwent neoadjuvant chemoradiation therapy were compared with those who did not receive therapy. Main outcome measures were as follows: complications, ≥2 units of blood transfusions, length of stay, readmission rates, return to the operating room, and 30-day mortality. A total of 1445 patients (395: neoadjuvant chemoradiation and 1050: no neoadjuvant therapy) were identified. The mean age was 67 ± 12 years, and 51 per cent of the patients were male. Neoadjuvant chemoradiation therapy was associated with increase in readmission rates (18% vs 12.2%, P 0.02), unanticipated return to the operating room (2.3% vs 1.1%, P 0.03) with no difference in mortality rates. Neoadjuvant chemoradiation therapy is associated with increase in inhospital complications. These differences in outcomes may be explained by the more advance stage of pancreatic cancer in these subsets of patients. Resource utilization and preoperative rehabilitation are of utmost significance to overcome this rise in complications associated with neoadjuvant chemoradiation therapy.

Benefits of Conversion Surgery after Multimodal Treatment for Unresectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

Traditionally, the treatment options for unresectable locally advanced (UR-LA) and metastatic (UR-M) pancreatic ductal adenocarcinoma (PDAC) are palliative chemotherapy or chemoradiotherapy. The benefits of surgery for such patients remains unknown. The present study investigated clinical outcomes of patients undergoing conversion surgery (CS) after chemo(radiation)therapy for initially UR-PDAC.

METHODS

We recruited patients with UR-PDAC who underwent chemo(radiation)therapy for initially UR-PDAC between April 2006 and September 2017. We analyzed resectability of CS, predictive parameters for overall survival, and early recurrence (within six months).

RESULTS

A total of 468 patients (108 with UR-LA and 360 with UR-M PDAC) were enrolled in this study, of whom, 17 (15.7%) with UR-LA and 15 (4.2%) with UR-M underwent CS. The median survival time (MST) and five-year survival of patients who underwent CS was 37.2 months and 34%, respectively; significantly better than non-resected patients (nine months and 1%, respectively, p < 0.0001). MST did not differ according to UR-LA or UR-M (50.5 vs. 29.0 months, respectively, p = 0.53). Early recurrence after CS occurred in eight patients (18.8%). Lymph node metastasis, positive washing cytology, large tumor size (>35 mm), and lack of postoperative adjuvant chemotherapy were statistically significant predictive factors for early recurrence. Moreover, the site of pancreatic lesion and administration of postoperative adjuvant chemotherapy were statistically significant prognostic factors for overall survival in the patients undergoing CS.

CONCLUSION

Conversion surgery offers benefits in terms of increase survival for initially UR-PDAC for patients who responded favorably to chemo(radiation)therapy when combined with postoperative adjuvant chemotherapy.

Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis

Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.

Surgical indication for and desirable outcomes of conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma

Aim of this review is to propose an acceptable surgical indication for conversion surgery in patients with initially unresectable (UR) pancreatic ductal adenocarcinoma (PDAC) by considering desirable outcomes, including resectability, overall survival (OS), and disease-free survival (DFS). A comprehensive literature search of PubMed was conducted through July 15, 2019. Eligible studies were those reporting on patients with UR-PDAC who underwent surgery. We excluded case reports with fewer than 10 patients, insufficient descriptions of survival data, and palliative surgery. When patients with UR-PDAC with no progression after chemo(radiation) therapy were offered surgical exploration, resectability and median survival time (MST) of those who underwent conversion surgery ranged from 20% to 69% (median, 52%) and from 19.5 to 33 months (median, 21.9 months), respectively. When conversion surgery was carried out in patients with expected margin-negative resection or with clinical response by Response Evaluation Criteria In Solid Tumors (RECIST), resectability and MST ranged from 18% to 27% (median, 20%) and from 21 to 35.3 months (median, 30 months), respectively. Among patients who underwent conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment, resectability and MST ranged from 2% to 24% (median, 4.1%) and from 24.1 to 64 months (median, 36 months), respectively. Decreased CA19-9 level was a predictor of resectability, OS and DFS by multivariate analysis. In conclusion, decision-making for conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment may be appropriate. With regard to desirable outcomes of OS and DFS, conversion surgery may provide improved survival for patients with initial UR-PDAC.

Conversion surgery for initially unresectable pancreatic cancer: current status and unresolved issues

Pancreatic cancer is one of the most lethal of all malignancies. One of the reasons for the dismal prognosis is that most diagnoses are made when the disease is either locally advanced or metastatic. Recent advances in chemotherapy and chemoradiotherapy (CRT) enable "conversion surgery" to be performed for selected patients with initially unresectable pancreatic cancer following favorable responses to preoperative treatment. Using FOLFIRINOX as preoperative treatment, the resection rate was reported as 6-44% of patients with locally advanced cancer and the prognosis of these patients was favorable. Even for metastasized cancer, recent reports show the effectiveness of conversion surgery, which has achieved 27-56 months of median overall survival. However, there are many unanswered questions about conversion surgery. The optimal regimen and duration of preoperative treatment remain unclear and there is still debate regarding the safety and effectiveness of vascular resection, which is often required for curative resection of locally advanced cancer. Accumulation of more data on conversion surgery is required to establish the safety and effectiveness of this treatment. In this review, we summarize the current status and unresolved issues about conversion surgery for initially unresectable pancreatic cancer.

FOLFIRINOX for locally advanced pancreatic cancer: Results and prognostic factors of subset analysis from a nation-wide multicenter observational study in Japan

BACKGROUND

FOLFIRINOX (oxaliplatin, irinotecan, 5-fluorouracil, leucovorin) treatment significantly improved overall survival in the recent phase III study and became a standard therapy for metastatic pancreatic cancer. However, treatment for locally advanced pancreatic cancer is still controversial. We conducted subset analyses from a nation-wide multicenter observational study in Japan to evaluate the tolerability and efficacy of FOLFIRINOX in patients with locally advanced pancreatic cancer and to investigate independent prognostic factors with pre-treatment variables.

METHODS

The study included 66 patients with unresectable locally advanced pancreatic cancer from 27 institutions in Japan who received FOLFIRINOX as first-line treatment between December 20, 2013 and December 19, 2014 and surveyed until December 2015.

RESULTS

The median age was 63 with the Eastern Cooperative Oncology Group performance status of 0 or 1. Major Grade 3 or 4 adverse events included neutropenia (64%), leukopenia (33%), febrile neutropenia (15%), and diarrhea (15%). Severe adverse event occurred in 14 patients (11%) without fatal event. The median overall survival and progression-free survival times were 18.5 and 7.6 months, respectively. The objective response rate 15.2% and the disease control rate was 81.9%. A high modified Glasgow prognostic score (mGPS, ≥1) (95%CI 1.96-12.5) and female (95%CI 0.20-0.97) were identified as independent poor prognostic factors.

CONCLUSIONS

First-line FOLFIRINOX treatment for locally advanced pancreatic cancer seems to be effective with acceptable toxicities. A high mGPS may be associated with poor survival in patients with locally advanced pancreatic cancer who receive FOLFIRINOX. This study was registered at the UMIN Clinical Trials Registry (UMIN000014658).

Conversion surgery only for highly selected patients with unresectable pancreatic cancer: a satisfactory outcome in exchange for a lower resection rate

PURPOSE

The purpose of this study is to clarify the resection rate, safety, and significance of conversion surgery for highly selected patients with unresectable pancreatic cancer (URPca).

METHODS

We studied 434 URPca patients. Conversion surgery was permitted only for patients who met following requirements: responders to first-line therapy, showing sufficient reduction of the local tumor to enable complete resection, at least 6 months of disease control, and no metastatic lesions detected on radiological examinations (for patients with metastatic disease). The overall survival (OS) was compared between patients who underwent surgery and those who did not. Furthermore, a multivariate analysis was performed to identify possible predictive factors for both total patients with URPca and responders.

RESULTS

Conversion surgery was performed in 18 patients (4.1%). The pathologically complete resection rate was 88.9% (16/18). The median operative time, blood loss, and hospitalization duration were 450 min, 780 ml, and 29 days, respectively. The OS was significantly better in patients who underwent surgery than in those who did not. In a multivariate analysis, conversion surgery was shown to be significantly correlated with the OS both in total patients and responders.

CONCLUSIONS

A satisfactory outcome was achieved for highly selected patients with URPca in exchange for a lower resection rate (4.1%).

The preoperative modified Glasgow prognostic score for the prediction of survival after pancreatic cancer resection following non-surgical treatment of an initially unresectable disease

AIM OF THE STUDY

Recent advances in chemotherapy have increasingly enabled conversion surgery (CS) in patients with initially unresectable pancreatic cancer (PC), but patient selection remains controversial. We examined the characteristics of patients who would benefit from this procedure.

MATERIAL AND METHODS

The clinical and pathological data of 38 patients with unresectable PC, who underwent CS after a favourable response to chemo(radio)therapy at our institute, were investigated. Univariate and multivariate analyses were performed to identify predictors for overall survival (OS). Several inflammation-based scores, such as the modified Glasgow prognostic score (mGPS), were also evaluated.

RESULTS

The patients included 13 with locally advanced disease and 25 with metastatic disease. After non-surgical treatment with a median duration of six months, 27 patients (71%) underwent R0/1 resection, and the remainder underwent R2 resection. The two-year and five-year OS from the initial treatment for all patients were 64% and 29%, respectively, and the median survival was 29.1 months. Univariate analysis showed that age < 62 years, preoperative CA19-9 decrease rate ≥ 89%, preoperative mGPS-0, and R0/1 resection were related to a favourable OS. R0/1 resection and mGPS-0 were independent prognostic factors according to multivariate analysis.

CONCLUSIONS

Preoperative mGPS is a potential predictor of survival and can aid selection of patients for whom CS could yield promising prognosis for initially unresectable PC.

Conversion surgery for an initially unresectable, locally advanced pancreatic cancer after induction chemotherapy and carbon-ion radiotherapy: a case report

Background

Pancreatic cancer has a very high mortality rate worldwide, and about 30–40% of all patients have extensive vascular involvement at initial diagnosis that precludes surgical intervention. Here, we describe our experience in a patient with locally advanced pancreatic cancer (LAPC) who underwent R0 conversion surgery after undergoing a combination of chemotherapy and carbon-ion radiotherapy (CIRT), which led to long-term relapse-free survival (23 months).

Case presentation

A 41-year-old woman presented a month ago with epigastralgia referred to our facility and was subsequently diagnosed with pancreatic cancer cStage III (Ph, TS2 (35 mm), cT4, cCH1, cDU1, cS1, cRP1, cPL1, cVsm0, cAsm1, cN0, cM0) that was also categorized as an unresectable LAPC. She immediately underwent 3 cycles of induction chemotherapy (gemcitabine + nanoparticle albumin-bound (nab-) paclitaxel) followed by CIRT with concurrent gemcitabine. Although significant shrinkage of the primary tumor occurred, frequent cholangitis due to duodenal stenosis of unknown etiology prevented continued chemotherapy, and 9 months after the first visit, she underwent a radical, subtotal, stomach-preserving, pancreaticoduodenectomy (SSPPD). Histopathologic examination of the resected tissue revealed a R0 resection with a histological response of Evans grade IIB. She was administered an almost full dose of S-1 as adjuvant chemotherapy for 6 months and has shown no signs of recurrence in 23 months.

Conclusions

We report a first case of successful conversion surgery for an initially unresectable LAPC after rapid induction GEM + nab-PTX chemotherapy followed by CIRT. Rapid induction GEM + nab-PTX chemotherapy followed by CIRT for LAPC might be a safe and effective treatment option.

Survival benefit of conversion surgery for patients with initially unresectable pancreatic cancer who responded favorably to nonsurgical treatment

BACKGROUND

Conversion surgery (CS) is expected as a new therapeutic strategy for patients with unresectable pancreatic cancer (UR-PC). We analyzed outcomes of CS for patients with UR-PC and evaluated the survival benefit of CS.

METHODS

Thirty-four patients diagnosed with UR-PC according to the National Comprehensive Cancer Network guideline underwent CS in our hospital. Resectability was considered by multimodal images in patients who underwent nonsurgical treatment (NST) for more than 6 months. CS was performed only in patients who were judged to be able to undergo R0 resection.

RESULTS

Twenty-six patients had locally advanced PC, and eight had distant metastases. The median duration of NST was 9 (range 5-44) months. R0 resection was achieved in 30 patients (88.2%). Six patients (17.6%) showed Evans grade ≥III. Three- and 5-year overall survival (OS) rates from initial treatment were 74% and 56.9%, respectively, with median survival time (MST) of 5.3 years. The actual 5-year OS rate in 19 patients was 47.4% with an MST of 4.0 years. Patients with Evans grade ≥III had a better prognosis than those with Evans grade <III (P = 0.0092, log-rank test).

CONCLUSIONS

Conversion surgery might have survival benefits to patients with UR-PC who responded favorably to NST.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Clinical Significance of Histological Effect and Intratumor Stromal Expression of Tenascin-C in Resected Specimens After Chemoradiotherapy for Initially Locally Advanced Unresectable Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Tenascin-C (TN-C) is an extracellular matrix protein that is up-regulated in pancreatic ductal adenocarcinoma (PDAC) stroma and associated with tumor invasion. We examined intratumor stromal expression of TN-C in resected specimens and the histologic effect of chemoradiotherapy (CRT) as prognostic indicators in initially locally advanced unresectable (UR-LA) PDAC.

METHODS

Among 110 UR-LA PDAC patients enrolled in the CRT protocol from February 2005 to December 2015, 46 who underwent curative-intent resection were classified as high (tumor destruction >50%) and low (≤50%) responders according to the Evans grading system. Tenascin-C expression was immunohistologically evaluated in all patients except one with complete response.

RESULTS

The 12 high responders achieved a significantly higher R0 rate than did the 34 low responders (83.3 vs 47.1%), but disease-specific survival (DSS) time was not significantly different (median survival time, 29.8 vs 21.0 months). Tenascin-C expression was inversely correlated with histologic effect of CRT. The 22 patients with negative TN-C had significantly longer DSS time than did the 23 with positive TN-C (29.3 vs 17.1 months). In multivariate analysis, only TN-C expression was a significant prognostic factor for DSS.

CONCLUSIONS

Intratumor stromal expression of TN-C is a strong prognostic indicator in UR-LA PDAC patients with resection after CRT.

Multicenter Phase II Study of Intravenous and Intraperitoneal Paclitaxel With S-1 for Pancreatic Ductal Adenocarcinoma Patients With Peritoneal Metastasis

OBJECTIVE

To evaluate the clinical efficacy and tolerability of intravenous (i.v.) and intraperitoneal (i.p.) paclitaxel combined with S-1, "an oral fluoropyrimidine derivative containing tegafur, gimestat, and otastat potassium" in chemotherapy-naive pancreatic ductal adenocarcinoma (PDAC) patients with peritoneal metastasis.

BACKGROUND

PDAC patients with peritoneal metastasis (peritoneal deposits and/or positive peritoneal cytology) have an extremely poor prognosis. An effective treatment strategy remains elusive.

METHODS

Paclitaxel was administered i.v. at 50 mg/m and i.p. at 20 mg/m on days 1 and 8. S-1 was administered at 80 mg/m/d for 14 consecutive days, followed by 7 days of rest. The primary endpoint was 1-year overall survival (OS) rate. The secondary endpoints were antitumor effect and safety (UMIN000009446).

RESULTS

Thirty-three patients who were pathologically diagnosed with the presence of peritoneal dissemination (n = 22) and/or positive peritoneal cytology (n = 11) without other organ metastasis were enrolled. The tumor was located at the pancreatic head in 7 patients and the body/tail in 26 patients. The median survival time was 16.3 (11.47-22.57) months, and the 1-year survival rate was 62%. The response rate and disease control rate in assessable patients were 36% and 82%, respectively. OS in 8 patients who underwent conversion surgery was significantly higher than that of nonsurgical patients (n = 25, P = 0.0062). Grade 3/4 hematologic toxicities occurred in 42% of the patients and nonhematologic adverse events in 18%. One patient died of thrombosis in the superior mesenteric artery.

CONCLUSIONS

This regimen has shown promising clinical efficacy with acceptable tolerability in chemotherapy-naive PDAC patients with peritoneal metastasis.

Survival benefit of intravenous and intraperitoneal paclitaxel with S-1 in pancreatic ductal adenocarcinoma patients with peritoneal metastasis: a retrospective study in a single institution

BACKGROUND

We evaluated the clinical efficacy of intravenous (i.v.) and intraperitoneal (i.p.) paclitaxel (PTX) combined with S-1 in patients with chemotherapy-naïve pancreatic ductal adenocarcinoma (PDAC) with peritoneal metastasis.

METHODS

Forty-nine patients were diagnosed with peritoneal metastasis during 2007-2014; 29 received gemcitabine or S-1-based chemo(radio)therapy from 2007 to 2011 (control group), and the remaining 20 received i.v. (50 mg/m² ) and i.p. (20 mg/m² ) PTX on days 1 and 8, and S-1 at 80 mg/m² per day for 14 consecutive days, followed by 7 days of rest from 2012 to 2014 (study group).

RESULTS

The median survival time in the study group was significantly longer than that in the control group (20 vs. 10 months, respectively; P = 0.004). At 1 year after initial treatment, a significant difference in ascites development on CT was found between the study (5/20 patients) and the control group (18/29 patients, P = 0.009). The frequency of objective response (9/20 patients) and conversion surgery (6/20 patients) in the study group was higher than those in the control group (8/29 and 2/29, respectively). Patients who underwent conversion surgery had improved survival in both groups.

CONCLUSION

Implementation of the S-1+i.v./i.p. PTX regimen was closely associated with improved overall survival in PDAC patients with peritoneal metastasis.