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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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Zhou Y, Liao S, You J, Wu H. Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma following induction therapy: a systematic review of the published literature. Updates Surg 2021; 74:43-53. [PMID: 34021484 DOI: 10.1007/s13304-021-01089-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
Patients with unresectable pancreatic ductal adenocarcinoma (UR-PDAC) are traditionally treated with palliative chemotherapy. The aim of this study was to evaluate the safety and efficacy of conversion surgery for initially UR-PDAC following induction therapy. The PubMed and Embase databases were systematically searched for eligible studies published between January 2000 and October 2020. Thirty-two series involving 1270 patients with 1056 locally advanced (LA) disease and 214 distant metastases were reviewed. The median mortality and morbidity was 0% (range 0-10%) and 47.1% (range 8.6-93.3%), respectively. Lymph-node negativity, negative resection margin and pathological complete response were observed in a median of 62.9% (38.5-90.9%), 84.4% (32.8-100%) and 6.7% (0-45.8%) of the specimens. The median survival was 32 (16.4-63.9) months with a 3-year survival rate of 47% (22-80%). Meta-analysis demonstrated that conversion surgery of initially UR-PDAC was associated with a significantly improved survival (hazard ratio [HR] = 0.55; 95% confidence intervals (CI) 0.45-0.66, P < 0.001). There was no significant difference in survival between the group with LA disease and that with distant metastases after conversion surgery (HR = 0.96; 95% CI 0.72-1.28, P = 0.790). Conversion surgery improved long-term survival of patients with initially UR-PDAC who had favorable response to induction therapy.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China.
| | - Shan Liao
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Jun You
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Huaxing Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
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Mataki Y, Kurahara H, Idichi T, Tanoue K, Hozaka Y, Kawasaki Y, Iino S, Maemura K, Shinchi H, Ohtsuka T. Clinical Benefits of Conversion Surgery for Unresectable Pancreatic Ductal Adenocarcinoma: A Single-Institution, Retrospective Analysis. Cancers (Basel) 2021; 13:1057. [PMID: 33801465 PMCID: PMC7958855 DOI: 10.3390/cancers13051057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Yuko Mataki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Tetsuya Idichi
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Kiyonori Tanoue
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Yuto Hozaka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Yota Kawasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Satoshi Iino
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
| | - Kosei Maemura
- Department of Digestive Surgery, Kagoshima Principal Hospital, Kagoshima 890-0055, Japan;
| | - Hiroyuki Shinchi
- Department of health sciences, School of Medicine, Kagoshima University, Kagoshima 890-8520, Japan;
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Kagoshima 890-8520, Japan; (H.K.); (T.I.); (K.T.); (Y.H.); (Y.K.); (S.I.); (T.O.)
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4
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Ishido K, Hakamada K, Kimura N, Miura T, Wakiya T. Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2021; 5:7-23. [PMID: 33532676 PMCID: PMC7832965 DOI: 10.1002/ags3.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Keinosuke Ishido
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Norihisa Kimura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Takuya Miura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Taiichi Wakiya
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
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5
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Saito T, Ebihara Y, Li L, Shirosaki T, Iijima H, Tanaka K, Nakanishi Y, Asano T, Noji T, Kurashima Y, Murakami S, Nakamura T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. A novel laparoscopic near-infrared fluorescence spectrum system for photodynamic diagnosis of peritoneal dissemination in pancreatic cancer. Photodiagnosis Photodyn Ther 2020; 33:102157. [PMID: 33348076 DOI: 10.1016/j.pdpdt.2020.102157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/04/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diagnosing peritoneal dissemination is essential for selecting the appropriate therapeutic strategy for patients with pancreatic cancer. Intraoperative laparoscopic diagnosis enables the selection of less invasive surgical strategies. Photodynamic diagnosis using 5-aminolevulinic acid may improve gastrointestinal cancer diagnostic accuracy, although weak fluorescence is not easily detected. Here we aimed to improve this sensitivity using laparoscopic spectrophotometry. METHODS Photodynamic diagnosis was performed using serial dilutions of protoporphyrin IX, and its detectability using laparoscopic spectrophotometry was compared with that using naked-eye observation. Five-aminolevulinic acid-photodynamic diagnosis was performed for pancreatic cancer cell lines, and a murine peritoneal disseminated nodule model was established. We compared laparoscopic spectrophotometry and naked-eye observation results using white and fluorescent lights and compared them to routine histopathological examination results. Photodynamic diagnoses were made in 2017 and 2018 in eight patients with pancreatic cancer. RESULTS Weaker fluorescence of the diluted protoporphyrin IX samples was better detected with spectrophotometry than with naked-eye observation. Moreover, a spectrograph of protoporphyrin IX in multiple cell lines was detected by spectrophotometry. In the murine model, the detection rates were 62 %, 78 %, and 90 % for naked-eye observation with white light, fluorescent light, and spectrophotometry, respectively. Comparisons of fluorescent light-negative peritonea with and without pathological metastases showed significantly higher spectrophotometric intensities in the former (P < 0.010). In clinical studies, three fluorescent light-negative spectrophotometry-positive pathologically metastatic lesions were observed. CONCLUSIONS Laparoscopic spectrophotometry in the murine model and extraperitoneally photodynamic diagnoses using spectrophotometry in clinical practice are sensitive photodynamic diagnostic techniques.
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Affiliation(s)
- Takahiro Saito
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan.
| | - Liming Li
- Department of Bio-material, Chitose Institute of Science and Technology, Chitose, Japan
| | - Tomoya Shirosaki
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Hiroaki Iijima
- Department of Biostatistics, Hokkaido University Hospital, Sapporo, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
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Murase Y, Ban D, Maekawa A, Watanabe S, Ishikawa Y, Akahoshi K, Ogawa K, Ono H, Kudo A, Kudo T, Tanaka S, Tanabe M. 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. Surg Case Rep 2020; 6:302. [PMID: 33259017 PMCID: PMC7708555 DOI: 10.1186/s40792-020-01082-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Aya Maekawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shuichi Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kosuke Ogawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroaki Ono
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshifumi Kudo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shinji Tanaka
- Department of Molecular Oncology, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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7
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Wang M, Xu Y, Yang M, Jiang D, Chen Y, Jiang J, Chen Z, Yang L, Huang D. Conversion Therapy for Advanced Pancreatic Cancer: The Case Series and Literature Review. Front Pharmacol 2020; 11:579239. [PMID: 33117173 PMCID: PMC7573973 DOI: 10.3389/fphar.2020.579239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatic cancer has a high incidence and mortality. Most patients are in an advanced stage at the time of initial diagnosis and cannot be cured by a single surgery. The ASCO clinical practice guideline emphasized the overall management and multidisciplinary comprehensive treatment which put forward the concept of conversion therapy. In this paper, the real-world observation and study were carried out to explore the conversion effect of chemotherapy in patients with advanced pancreatic cancer and their long-term survival. Methods The subjects of this study are advanced pancreatic cancer patients who visited the oncology department of Zhejiang Provincial People’s Hospital from 2015 to 2019. Collected and summarized the cases, and selected 5 representative patients for analysis, all of them received standard treatment (FOLFIRINOX, AS, AG, or GS). The progress, clinical evaluation, adverse reactions, and prognosis of these patients after conversion therapy were analyzed and discussed in conjunction with relevant literature. Results Five patients with advanced pancreatic cancer received conversion therapy with an average survival time of 29.8 months, two of them received surgical treatment, and postoperative evaluations were pathological complete response (pCR). The tolerance of chemotherapy was good in five patients, and no serious adverse reactions of grade 3 or 4 occurred. Conclusion Conversion therapy for patients with advanced pancreatic cancer strives for surgical opportunities of radical resection, prolongs survival and improves quality of life.
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Affiliation(s)
- Mingxing Wang
- Department of Medical Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China.,Graduate School of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Yunyun Xu
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Min Yang
- The Qingdao University Medical College, Qingdao, China
| | - Dingyi Jiang
- The Qingdao University Medical College, Qingdao, China
| | - Yunwang Chen
- The Qingdao University Medical College, Qingdao, China
| | - Jiahong Jiang
- Department of Medical Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zheling Chen
- Department of Medical Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Liu Yang
- Department of Medical Oncology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Dongsheng Huang
- Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
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Kuribara T, Ichikawa T, Osa K, Inoue T, Ono S, Asanuma K, Kaneko S, Sano T, Shigeyoshi I, Matsubara K, Irie N, Iai A, Shinobi T, Ishizu H, Miura K. Combined resection of the hepatic artery without reconstruction in pancreaticoduodenectomy: a case report of pancreatic cancer with an aberrant hepatic artery. Surg Case Rep 2020; 6:228. [PMID: 32990830 PMCID: PMC7524997 DOI: 10.1186/s40792-020-00997-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background Pancreaticoduodenectomy (PD) is rarely performed for pancreatic cancer with hepatic arterial invasion owing to its poor prognosis and high surgical risks. Although there has been a recent increase in the reports of PD combined with hepatic arterial resection due to improvements in disease prognosis and operative safety, PD with major arterial resection and reconstruction is still considered a challenging treatment. Case presentation A 61-year-old man with back pain was diagnosed with pancreatic head and body cancer. Although distant metastasis was not confirmed, the tumor had extensively invaded the hepatic artery; therefore, we diagnosed the patient with locally advanced unresectable pancreatic cancer. After gemcitabine plus nab-paclitaxel (GnP) therapy, the tumor considerably decreased in size from 35 to 20 mm. Magnetic resonance imaging revealed a gap between the tumor and the hepatic artery. Tumor marker levels returned to their normal range, and we decided to perform conversion surgery. In this case, an artery of liver segment 2 (A2) had branched from the left gastric artery; therefore, we decided to preserve A2 and perform PD combined with hepatic arterial resection without reconstruction. After four cycles of GnP therapy, we performed hepatic arterial embolization to prevent postoperative ischemic complications prior to surgery. Immediately after embolization, collateral arterial blood flow to the liver was observed. Operation was performed 19 days after embolization. Although there was a temporary increase in liver enzyme levels and an ischemic region was found near the surface of segment 8 of the liver after surgery, no liver abscess developed. The postoperative course was uneventful, and S-1 was administered for a year as adjuvant chemotherapy. The patient is currently alive without any ischemic liver events and cholangitis and has not experienced recurrence in the past 4 years since the surgery. Conclusions In PD for pancreatic cancer with hepatic arterial invasion, if a part of the hepatic artery is aberrant and can be preserved, combined resection of the common and proper hepatic artery without reconstruction might be feasible for both curability and safety.
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Affiliation(s)
- Tadao Kuribara
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan.
| | - Tatsuo Ichikawa
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kiyoshi Osa
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Takeshi Inoue
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Satoshi Ono
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kozo Asanuma
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Shiori Kaneko
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Takayuki Sano
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Itaru Shigeyoshi
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kouta Matsubara
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Naoko Irie
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Akira Iai
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Tetsuya Shinobi
- Department of Internal Medicine, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan
| | - Hideki Ishizu
- Department of Pathology, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan
| | - Katsuhiro Miura
- Department of Internal Medicine, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan.,Tumor Center, Nihon University Itabashi Hospital, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo, Japan.,Department of Hematology and Rheumatology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo, Japan
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9
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Loch FN, Asbach P, Haas M, Seeliger H, Beyer K, Schineis C, Degro CE, Margonis GA, Kreis ME, Kamphues C. Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging. World J Surg Oncol 2020; 18:213. [PMID: 32811523 PMCID: PMC7436989 DOI: 10.1186/s12957-020-01951-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymph node staging of ductal adenocarcinoma of the pancreatic head (PDAC) by cross-sectional imaging is limited. The aim of this study was to determine the diagnostic accuracy of expanded criteria in nodal staging in PDAC patients. METHODS Sixty-six patients with histologically confirmed PDAC that underwent primary surgery were included in this retrospective IRB-approved study. Cross-sectional imaging studies (CT and/or MRI) were evaluated by a radiologist blinded to histopathology. Number and size of lymph nodes were measured (short-axis diameter) and characterized in terms of expanded morphological criteria of border contour (spiculated, lobulated, and indistinct) and texture (homogeneous or inhomogeneous). Sensitivities and specificities were calculated with histopathology as a reference standard. RESULTS Forty-eight of 66 patients (80%) had histologically confirmed lymph node metastases (pN+). Sensitivity, specificity, and Youden's Index for the criterion "size" were 44.2%, 82.4%, and 0.27; for "inhomogeneous signal intensity" 25.6%, 94.1%, and 0.20; and for "border contour" 62.7%, 52.9%, and 0.16, respectively. There was a significant association between the number of visible lymph nodes on preoperative CT and lymph node involvement (pN+, p = 0.031). CONCLUSION Lymph node staging in PDAC is mainly limited due to low sensitivity for detection of metastatic disease. Using expanded morphological criteria instead of size did not improve regional nodal staging due to sensitivity remaining low. Combining specific criteria yields improved sensitivity with specificity and PPV remaining high.
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Affiliation(s)
- Florian N Loch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Patrick Asbach
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Matthias Haas
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hendrik Seeliger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Katharina Beyer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Schineis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Claudius E Degro
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Georgios A Margonis
- The Johns Hopkins University School of Medicine, Department of Surgery, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
| | - Martin E Kreis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Carsten Kamphues
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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10
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Yanagimoto H, Satoi S, Yamamoto T, Yamaki S, Hirooka S, Kotsuka M, Ryota H, Ishida M, Matsui Y, Sekimoto M. Benefits of Conversion Surgery after Multimodal Treatment for Unresectable Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2020; 12:cancers12061428. [PMID: 32486418 PMCID: PMC7352934 DOI: 10.3390/cancers12061428] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
- Correspondence: ; Tel.: +81-72-804-0101; Fax: +81-72-804-2578
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - So Yamaki
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Mitsuaki Ishida
- Department of Pathology and Laboratory Medicine, Kansai Medical University, Hirakata 573-1010, Japan;
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Hirakata 573-1010, Japan; (H.Y.); (T.Y.); (S.Y.); (S.H.); (M.K.); (H.R.); (Y.M.); (M.S.)
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11
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Noji T, Nagayama M, Imai K, Kawamoto Y, Kuwatani M, Imamura M, Okamura K, Kimura Y, Hirano S. Conversion surgery for initially unresectable biliary malignancies: a multicenter retrospective cohort study. Surg Today 2020; 50:1409-1417. [PMID: 32468112 DOI: 10.1007/s00595-020-02031-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Few studies have focused on conversion surgery for biliary malignancy; thus, it is not clear if this treatment modality can extend the survival of patients with unresectable biliary malignancy. We conducted a multicenter retrospective cohort study to evaluate the surgical outcomes of conversion surgery in this setting and analyze long-term survival. METHODS We collected clinical data retrospectively on patients who underwent conversion surgery for biliary malignancy. RESULTS Twenty-four patients met our inclusion criteria. Preoperative chemotherapy regimens or chemoradiation therapy regimens were administered based on the institutional criteria, and surgical procedures were chosen based on tumor location. Morbidity occurred in 16 patients (66.7%), and 1 patient died of liver failure after surgery. The overall 5-year survival rate following initial therapy was 43.2%, and the median survival time was 57.4 months. The corresponding values following surgery were 38.2% and 34.3 months, respectively. The 5-year survival rate of the 24 patients who received both chemotherapy and surgery was significantly better than that of 110 patients treated with chemotherapy only (p < 0.001). CONCLUSION Conversion surgery for initially unresectable biliary malignancies may be feasible and achieve long-term survival for selected patients.
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Affiliation(s)
- Takehiro Noji
- Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Minoru Nagayama
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Koji Imai
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuyuki Kawamoto
- Gastroenterology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masaki Kuwatani
- Gastroenterology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masafumi Imamura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Keikuke Okamura
- Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yastoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Satoshi Hirano
- Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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12
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Motoi F, Unno M. Neoadjuvant treatment for resectable pancreatic adenocarcinoma: What is the best protocol? Ann Gastroenterol Surg 2020; 4:100-108. [PMID: 32258974 PMCID: PMC7105839 DOI: 10.1002/ags3.12311] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/27/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Although upfront surgery has been the gold standard for pancreatic adenocarcinoma that is planned for resection, it should be compared with the alternative strategy of neoadjuvant therapy. Despite the many reports of the efficacy of neoadjuvant therapy, most of them were not comparative. Recently Prep-02/JSAP05 study clearly demonstrated the significant survival benefit of neoadjuvant chemotherapy over upfront surgery for pancreatic adenocarcinoma that is planned for resection. These findings opened a new chapter of neoadjuvant therapy. Ongoing trials are expected to confirm the evidence. This review summarizes the past, present, and future perspectives of neoadjuvant therapy and its optimization.
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Affiliation(s)
- Fuyuhiko Motoi
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
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13
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Satoi S, Yamamoto T, Yamaki S, Sakaguchi T, Sekimoto M. Surgical indication for and desirable outcomes of conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2020; 4:6-13. [PMID: 32021953 PMCID: PMC6992681 DOI: 10.1002/ags3.12295] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 09/30/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sohei Satoi
- Department of SurgeryKansai Medical UniversityHirakata‐CityJapan
| | | | - So Yamaki
- Department of SurgeryKansai Medical UniversityHirakata‐CityJapan
| | | | - Mitsugu Sekimoto
- Department of SurgeryKansai Medical UniversityHirakata‐CityJapan
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14
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Mitachi K, Ariake K, Motoi F, Unno M. Conversion surgery for positive peritoneal washing cytology in pancreatic cancer. BMJ Case Rep 2019; 12:e229993. [PMID: 31753819 PMCID: PMC6887384 DOI: 10.1136/bcr-2019-229993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 01/05/2023] Open
Abstract
Positive peritoneal washing cytology (PPC) of pancreatic carcinoma is defined as distant metastasis in the American Joint Committee on Cancer or Union for International Cancer Control's tumour, node, metastases classification. However, surgical resection was believed to be the only method that prolong survival; thus, many institutions perform pancreatectomy for PPC, despite the unfavourable prognosis. Therefore, a more preferable alternative treatment for PPC is required. A 64-year-old man with resectable pancreatic tail cancer presented to our hospital. PPC was detected at first laparotomy; thus, pancreatectomy was avoided and gemcitabine with nabpaclitaxel (GnP) was administered. After four courses of GnP treatment, PPC converted to negative, as evaluated by abdominal port cytology. Thus, distal pancreatectomy was performed, and R0 resection was achieved. He has been healthy for more than 24 months since the first laparotomy. Initial chemotherapy with the intention of converting the cytological status followed by surgical treatment might become a useful treatment strategy for PPC.
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Affiliation(s)
| | - Kyohei Ariake
- Department of Surgery, Tohoku University, Sendai, Japan
| | | | - Michiaki Unno
- Department of Surgery, Tohoku University, Sendai, Japan
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15
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Kimura Y, Nakamura T, Hayashi T, Kuwatani M, Motoya M, Yoshida M, Imamura M, Nagayama M, Yamaguchi H, Yamakita K, Goto T, Sakuhara Y, Takahashi K, Maguchi H, Hirano S, Takemasa I. Clinical usefulness of conversion surgery for unresectable pancreatic cancer diagnosed on multidetector computed tomography imaging: Results from a multicenter observational cohort study by the Hokkaido Pancreatic Cancer Study Group (HOPS UR-01). Ann Gastroenterol Surg 2019; 3:523-533. [PMID: 31549012 PMCID: PMC6749954 DOI: 10.1002/ags3.12272] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/26/2019] [Accepted: 06/04/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND AIM Effective multidisciplinary approaches for unresectable pancreatic cancer (UR-PC) that include modern chemotherapeutic regimens and subsequent conversion surgery (CS) are being developed. The aim of this study was to evaluate outcomes of patients clinically diagnosed with UR-PC, focusing on the efficacy of CS. METHODS Patients ineligible for two multicenter phase II studies conducted by the Hokkaido Pancreatic Cancer Study Group (HOPS) were recruited. Sequential treatment regimens, conversion to radical surgery, and overall survival (OS) were analyzed by multidetector computed tomography (MDCT)-based UR factors. Univariate and multivariate analyses were performed to identify predictors of OS. RESULTS Sixty-six of 247 intended recruits for HOPS studies from October 2013 to April 2016 were included. Unresectability was due to locally advanced (LA) disease and metastasis (M) in 42 and 24 patients, respectively. Induction therapy began with chemotherapy (CT) and chemoradiotherapy (CRT) in 44 and 17 patients, respectively, of whom 23 received modern CT regimens. Radical surgery was completed in 12 (LA, 10; M, two) with a median treatment interval of 10.3 months (range, 2-32). Eleven patients (91.6%) achieved pathological R0 resection. Median OS was significantly longer in patients who underwent CS than those who did not (44.1 vs 14.5 months, P < 0.0001). CS was an independent predictor of OS (hazard ratio, 0.078; 95% confident interval, 0.017-0.348; P = 0.001). CONCLUSION Conversion surgery after a favorable response to sequential treatment might prolong survival in patients with UR-PC. Precise diagnosis on MDCT followed by sequential multimodal anticancer treatment is essential.
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Affiliation(s)
- Yasutoshi Kimura
- Department of SurgerySurgical Oncology and ScienceSapporo Medical University School of MedicineSapporoJapan
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
| | - Toru Nakamura
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of Gastroenterological Surgery IIHokkaido UniversityFaculty of MedicineSapporoJapan
| | - Tsuyoshi Hayashi
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Center for GastroenterologyTeine‐Keijinkai HospitalSapporoJapan
| | - Masaki Kuwatani
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of Gastroenterology and HepatologyHokkaido University Graduate School of MedicineSapporoJapan
| | - Masayo Motoya
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of Gastroenterology and HepatologySapporo Medical University School of MedicineSapporoJapan
| | - Makoto Yoshida
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of Medical OncologySapporo Medical University School of MedicineSapporoJapan
| | - Masafumi Imamura
- Department of SurgerySurgical Oncology and ScienceSapporo Medical University School of MedicineSapporoJapan
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
| | - Minoru Nagayama
- Department of SurgerySurgical Oncology and ScienceSapporo Medical University School of MedicineSapporoJapan
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
| | - Hiroshi Yamaguchi
- Department of SurgerySurgical Oncology and ScienceSapporo Medical University School of MedicineSapporoJapan
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
| | - Keisuke Yamakita
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Division of Metabolism and Biosystemic ScienceDepartment of MedicineAsahikawa Medical UniversitySapporoJapan
| | - Takuma Goto
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Division of Gastroenterology and Hematology/OncologyDepartment of MedicineAsahikawa Medical UniversitySapporoJapan
| | - Yusuke Sakuhara
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of RadiologyTonan HospitalSapporoJapan
| | - Kuniyuki Takahashi
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Center for GastroenterologyTeine‐Keijinkai HospitalSapporoJapan
| | - Hiroyuki Maguchi
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Center for GastroenterologyTeine‐Keijinkai HospitalSapporoJapan
| | - Satoshi Hirano
- Hokkaido Pancreatic Cancer Study Group; HOPSSapporoJapan
- Department of Gastroenterological Surgery IIHokkaido UniversityFaculty of MedicineSapporoJapan
| | - Ichiro Takemasa
- Department of SurgerySurgical Oncology and ScienceSapporo Medical University School of MedicineSapporoJapan
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16
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Conversion surgery for initially unresectable pancreatic cancer: current status and unresolved issues. Surg Today 2019; 49:894-906. [PMID: 30949842 DOI: 10.1007/s00595-019-01804-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/17/2019] [Indexed: 12/16/2022]
Abstract
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.
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Yokota T, Takano S, Yoshitomi H, Kagawa S, Furukawa K, Takayashiki T, Kuboki S, Suzuki D, Sakai N, Nojima H, Mishima T, Nakadai E, Ohtsuka M. Successful treatment of a locally advanced unresectable pancreatic cancer patient with interstitial pneumonitis by conversion surgery following gemcitabine plus nab-paclitaxel chemotherapy: A case report. Mol Clin Oncol 2019; 10:419-424. [PMID: 30931110 PMCID: PMC6425509 DOI: 10.3892/mco.2019.1807] [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: 12/11/2018] [Accepted: 01/30/2019] [Indexed: 12/24/2022] Open
Abstract
Conversion surgery is an attractive strategy to improve the outcomes for locally advanced unresectable (UR-LA) pancreatic ductal adenocarcinoma (PDAC). The present case report, presents a case of successful conversion surgery following the treatment of a patient with UR-LA PDAC, suffering from interstitial pneumonitis (IP), using a combination of gemcitabine and nab-paclitaxel (GnP). A 67-year-old woman presented at the hospital with a high level of carbohydrate antigen 19-9 (CA19-9; 1,713 U/ml). Radiological examination revealed a pancreatic tumor in contact with the superior mesenteric artery, with invasion extending to the most proximal draining jejunal branch into the superior mesenteric vein. The patient was diagnosed with UR-LA PDAC. Following 6 courses of GnP therapy, the tumor size markedly decreased from 50 to 18 mm, and the level of CA19-9 also decreased from 1,713 to 60.1 U/ml. Due to the progression of IP, the patient was administered steroid medication along with a restart of tacrolimus for the treatment of dermatomyositis and IP. After recovery from her lung condition, an additional 3 courses of GnP therapy were administered, and then pancreatoduodenectomy was performed. The patient was still alive 14 months post-surgery with no recurrence. Between July 2009 and September 2017, conversion surgery was performed for 18 cases of UR-LA PDAC treated with gemcitabine plus S-1 (GS) therapy, and 11 cases with GnP therapy. The percentage of median CA19-9 and median tumor volume reductions were 73.7 and 51.6%, respectively, following GS therapy, and 86.7 and 68.8%, respectively, following GnP therapy. Tumor reduction following GnP therapy was significantly higher than that after GS therapy (P=0.02). GnP therapy is a suitable regimen to shrink the tumor mass in patients with UR-LA PDAC. Careful management of systemic conditions is required to treat patients with PDAC and IP when using GnP therapy. Conversion surgery should be considered for recognizing radiological responses (tumor shrinkage adjacent to major arteries) and reductions in CA19-9 levels.
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Affiliation(s)
- Tetsuo Yokota
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Shingo Kagawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Hiroyuki Nojima
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Takashi Mishima
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Eri Nakadai
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan
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Ikuta S, Sonoda T, Aihara T, Nakajima T, Yamanaka N. The preoperative modified Glasgow prognostic score for the prediction of survival after pancreatic cancer resection following non-surgical treatment of an initially unresectable disease. Contemp Oncol (Pozn) 2018; 22:229-235. [PMID: 30783386 PMCID: PMC6377419 DOI: 10.5114/wo.2018.81344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/16/2018] [Indexed: 12/24/2022] Open
Abstract
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.
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Conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma: where do we stand in 2018? JOURNAL OF PANCREATOLOGY 2018. [DOI: 10.1097/jp9.0000000000000001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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