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Libbey N, Gallagher L, Cantalino J, Weinberg BA, Noel MS, He AR, Radkani P, Marshall JL, Weiner LM, Jackson PG, Fishbein TM, Winslow ER, Haddad N, Rashid A, Unger KR. Patterns of Failure Following Preoperative Chemotherapy and Stereotactic Body Radiation Therapy and Resection for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer. J Gastrointest Cancer 2024; 55:852-861. [PMID: 38347342 DOI: 10.1007/s12029-023-00996-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 06/20/2024]
Abstract
BACKGROUND The role of neoadjuvant stereotactic body radiation therapy (SBRT) in the treatment of pancreatic adenocarcinoma (PDAC) is controversial and the optimal target volumes and dose-fractionation are unclear. The aim of this study is to report on treatment outcomes and patterns of failure of patients with borderline resectable (BL) or locally advanced (LA) pancreatic cancer following preoperative chemotherapy and SBRT. METHODS We conducted a single-institution, retrospective study of patients with BL or LA PDAC. Patients received neoadjuvant chemotherapy and SBRT was prescribed to 30 Gy over 5 fractions to the pancreas planning tumor volume (PTV). A subset of patients received a simultaneous integrated boost to the high risk vascular PTV and/or elective nodal irradiation (ENI). Following neoadjuvant chemoradiation, all patients underwent subsequent resection. Overall survival (OS), progression-free survival (PFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMPFS), and locoregional control (LRC) estimates were obtained using Kaplan-Meier analysis. RESULTS Twenty-two patients with BL (18) or LA (4) PDAC were treated with neoadjuvant chemotherapy and SBRT followed by resection from 2011-2022. Following neoadjuvant treatment, 5 patients (23%) achieved a pathologic complete response (pCR) and 16 patients (73%) had R0 resection. At 24 months, there were no isolated locoregional recurrences (LRRs), 9 isolated distant recurrences (DRs), and 5 combined LRRs and DRs. Two LRRs were in-field, 2 LRRs were marginal, and 1 LRR was both in-field and marginal. 2-year median LRC, LRRFS, DMPFS, PFS, and OS were 77.3%, 45.5%, 31.8%, 31.8%, and 59.1%, respectively. For BL and LA cancers, 2-year LRC, DMPFS, and OS were 83% vs. 75%, (p = 0.423), 39% vs. 0% (p = 0.006), and 61% vs. 50% (p = 0.202), respectively. ENI was associated with improved LRC (p = 0.032) and LRRFS (p = 0.033). Borderline resectability (p = 0.018) and lower tumor grade (p = 0.027) were associated with improved DMPFS. CONCLUSIONS Following preoperative chemotherapy and SBRT, locoregional failure outside of the target volume occurred in 3 of 5 recurrences; ENI was associated with improved LRC and LRRFS. Further studies are necessary to define the optimal techniques for preoperative radiation therapy.
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Affiliation(s)
- Nicole Libbey
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Jonathan Cantalino
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Benjamin A Weinberg
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Marcus S Noel
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Aiwu R He
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Pejman Radkani
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC, USA
| | - John L Marshall
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Louis M Weiner
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Patrick G Jackson
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC, USA
| | - Thomas M Fishbein
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC, USA
| | - Emily R Winslow
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University, Washington, DC, USA
| | - Nadim Haddad
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Abdul Rashid
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Keith R Unger
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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López JC, Ielpo B, Iglesias M, Pinilla FB, Sánchez-Velázquez P. The impact of vascular margin invasion on local recurrence after pancreatoduodenectomy in pancreatic adenocarcinoma. Langenbecks Arch Surg 2024; 409:122. [PMID: 38607450 PMCID: PMC11009726 DOI: 10.1007/s00423-024-03301-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PADC) still has nowadays a very impaired long-term survival. Most studies are focused on overall survival; however, local recurrence occurs about up to 50% of cases and seems to be highly related with margin resection status. We aim to analyze the impact of vascular resection margins on local recurrence (LR) and to assess its impact on overall and disease-free survival. METHODS Eighty out of 191 patients who underwent pancreatoduodenectomy in a university hospital between 2006 and 2021 with PDAC diagnosis were analyzed and vascular margin status specifically addressed. Univariate and multivariate were performed. Time to LR was compared by using the Kaplan-Meier method and prognostic factors assessed using Cox regression hazards model. RESULTS LR appeared in 10 (50%) of the overall R1 resections in the venous margin and 9 (60%) in the arterial one. Time to LR was significantly shorter when any margin was overall affected (23.2 vs 44.7 months, p = 0.01) and specifically in the arterial margin involvement (13.7 vs 32.1 months, p = 0.009). Overall R1 resections (HR 2.61, p = 0.013) and a positive arterial margin (HR 2.84, p = 0.012) were associated with local recurrence on univariate analysis, whereas arterial positive margin remained significant on multivariate analysis (HR 2.70, p = 0.031). CONCLUSIONS Arterial margin invasion is correlated in our cohort with local recurrence. Given the limited ability to modify this margin intraoperatively, preoperative therapies should be considered to improve local margin clearance.
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Affiliation(s)
| | - Benedetto Ielpo
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, 08003, Barcelona, Spain
| | - Mar Iglesias
- Pompeu-Fabra University, Barcelona, Spain
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, 08003, Barcelona, Spain
- Department of Pathology, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu-Fabra, Barcelona, Spain
| | - Fernando Burdío Pinilla
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, 08003, Barcelona, Spain
| | - Patricia Sánchez-Velázquez
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, 08003, Barcelona, Spain.
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Nguyen TK, Nguyen HH, Luong TH, Dang KK, Le VD, Tran DD, Do VM, Pham HQ, Pham HM, Tran TL, Nguyen CT, Trinh HS, Inoue Y. Pancreaticoduodenectomy with superior mesenteric artery first-approach combined total meso-pancreas excision for periampullary malignancies: A high-volume single-center experience with short-term outcomes. Ann Hepatobiliary Pancreat Surg 2024; 28:59-69. [PMID: 38049111 PMCID: PMC10896681 DOI: 10.14701/ahbps.23-068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 12/06/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is the only radical treatment for periampullary malignancies. Superior mesenteric artery (SMA) first approach combined with total meso-pancreas (MP) excision was conducted to improve the oncological results. There has not been any previous research of a technique that combines the SMA first approach and total MP excision with a detailed description of the MP macroscopical shape. Methods We prospectively assessed 77 patients with periampullary malignancies between October 2020 and March 2022 (18 months). All patients had undergone PD with SMA first approach combined total MP excision. The perioperative indications, clinical data, intra-operative index, R0 resection rate of postoperative pathological specimens (especially mesopancreatic margin), postoperative complications, and follow-up results were evaluated. Results The median operative time was 289.6 min (178-540 min), the median intraoperative blood loss was 209 mL (30-1,600 mL). Microscopically, there were 19 (24.7%) cases with metastatic MP, and five cases (6.5%) with R1-resection of the MP. The number of lymph nodes (LNs) harvested and metastatic LNs were 27.2 (maximum was 74) and 1.8 (maximum was 16), respectively. Some (46.8%) patients had pancreatic fistula, but mostly in grade A, with 7 patients (9.1%) who required re-operations. Some 18.2% of cases developed postoperative refractory diarrhea. The rate of in-hospital mortality was 1.3%. Conclusions The PD with SMA first approach combined TMpE for periampullary malignancies was effective in achieving superior oncological statistics (rate of MP R0-resection and number of total resected LNs) with non-inferior short-term outcomes. It is necessary to evaluate survival outcomes with long-term follow-up.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Van Duy Le
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Duc Dung Tran
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
| | - Van Minh Do
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Hong Quang Pham
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
| | | | - Thi Lan Tran
- Pathology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Cuong Thinh Nguyen
- 108 Institute of Clinical Medical and Pharmaceutical Sciences, Hanoi, Vietnam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Ono Y, Inoue Y, Kato T, Kobayashi K, Takamatsu M, Atsushi O, Sato T, Ito H, Takahashi Y. New approach of circumferential lymph node dissection around the superior mesenteric artery for pancreatic cancer during pancreaticoduodenectomy (with video). Langenbecks Arch Surg 2023; 408:422. [PMID: 37910224 DOI: 10.1007/s00423-023-03159-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Various approaches have been reported for the resection of the nervous and lymphatic tissues around the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) for pancreatic cancer. We developed a new procedure for circumferential lymph node dissection around the SMA to minimize local recurrence. METHODS We included 24 patients who underwent PD with circumferential lymph node dissection around the SMA (circumferential dissection) and 94 patients who underwent classical mesopancreatic dissection (classical dissection) between 2019 and 2021. The technical details of this new method are described in the figures and videos, and the clinical characteristics and outcomes of this technique were compared with those of classical dissection. RESULTS The median follow-up durations in the circumferential and classical dissection groups were 39 and 36 months, respectively. The patients' characteristics, including tumor resectability, preoperative and adjuvant chemotherapy rates, postoperative complication rates, and tumor stage, were similar between the two groups. No differences were observed in recurrence-free survival and overall survival between the two groups; however, the classical dissection group tended to have more local recurrences than the circumferential dissection group (8.3% vs. 33.3%, P = 0.168). Although no case of nodular-type recurrence after circumferential dissection was observed, 61.1% of local recurrences after classical dissection were of the nodular-type, and 36.4% were located on the left side of the SMA. CONCLUSIONS Performing circumferential lymph node dissection around the SMA during PD can be conducted safely with minimal risks of local recurrence and may enhance the completeness of local resection.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Manabu Takamatsu
- Department of Pathology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Oba Atsushi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 1358550, Japan.
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Evaluation of local recurrence after pancreaticoduodenectomy for borderline resectable pancreatic head cancer with neoadjuvant chemotherapy: Can the resection level change after chemotherapy? Surgery 2022; 173:1220-1228. [PMID: 36424197 DOI: 10.1016/j.surg.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/12/2022] [Accepted: 10/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Neoadjuvant treatment has significant survival benefits for patients with pancreatic cancer. However, local recurrence remains a serious issue, even after neoadjuvant treatment. This study investigated local recurrence after pancreaticoduodenectomy and determined the optimal resection level after neoadjuvant treatment. METHODS This retrospective study analyzed consecutive patients who underwent pancreaticoduodenectomy for borderline resectable pancreatic cancer after 4 cycles of neoadjuvant treatment-gemcitabine plus nab-paclitaxel between April 2015 and March 2020. Patients with borderline resectable-artery pancreatic cancer were classified according to the dissection level around the artery: level 3 group, hemi-, or whole circumferential arterial nerve plexus was dissected; and level 2 group, the nerve plexus was preserved. RESULTS Fifty-six patients with borderline resectable-artery pancreatic cancer underwent pancreaticoduodenectomy after neoadjuvant treatment (level 3 group, n = 40; level 2 group, n = 16). The resection level in the level 2 group was changed based on post-neoadjuvant treatment computed tomography images or intraoperative frozen section diagnosis. The overall and local recurrence rates were significantly higher in the level 2 group than in the level 3 group (overall recurrence, 93.8% vs 70.0%; P = .037) (local recurrence, 50.0% vs 5.0%; P < .001). Ten patients experienced local recurrence, of which 8 belonged to the level 2 group. Among them, 4 patients were confirmed as cancer-negative by surgical margin analysis or intraoperative frozen section diagnosis but experienced recurrence around the arteries. CONCLUSION For treating borderline resectable-artery pancreatic cancer, changing the resection level based on post-neoadjuvant treatment computed tomography images increased the risk of local recurrence. All patients with borderline resectable-artery should undergo level 3 dissection, regardless of the response to neoadjuvant treatment.
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Kang MJ, Han SS, Park SJ, Park HM, Kim SW. Do jejunal veins matter during pancreaticoduodenectomy? Ann Hepatobiliary Pancreat Surg 2022; 26:229-234. [PMID: 35934830 PMCID: PMC9428427 DOI: 10.14701/ahbps.22-013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
When planning pancreaticoduodenectomy for pancreatic head cancer, the prevalence of anatomical variation of the proximal jejunal vein (PJV), the associated short-term surgical outcomes, and the level of PJV convergence to the superior mesenteric vein must be carefully analyzed from both technical and oncological points of view. The prevalence of the first jejunal trunk (FJT) and PJV located ventral to the superior mesenteric artery is 58%–88% and 13%–37%, respectively. Patients with the FJT had a larger amount of intraoperative bleeding and a higher proportion of patients requiring transfusions compared to those without a common trunk. The risk of transfusion was higher in patients with ventral PJV compared to those with dorsal PJV. Although less frequent, sacrificing the FJT can result in fatal venous congestion of the jejunum. Therefore, a well-planned approach for pancreaticoduodenectomy, based on preoperative evaluation of anatomical variation in the PJV, may help reduce intraoperative bleeding and postoperative morbidity. Additionally, the importance of invasion into the PJVs should be revisited in terms of resectability and oncological clearance.
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Affiliation(s)
- Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Sang-Jae Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Hyeong Min Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Sun-Whe Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
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Khiem T, Hoi H, Hiep T, Khue K, Duy V, Inoue Y, Son H, Dung D. Total laparoscopic pancreaticoduodenectomy with left posterior superior mesenteric artery first-approach and plexus-preserving circumferential lymphadenectomy: step-by-step technique with a surgical case report (with video). World J Surg Oncol 2022; 20:269. [PMID: 36028841 PMCID: PMC9419321 DOI: 10.1186/s12957-022-02730-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Total laparoscopic pancreaticoduodenectomy (tLPD) for cancer of the Vater remains a challenging procedure. Recently, several meta-analyses showed the superior aspects of “superior mesenteric artery (SMA)-first approach,” “systematic mesopancreas dissection,” and “circumferential lymphadenectomy around SMA” in increasing R0 resection rate and reducing postoperative complications including pancreatic fistula and bleeding as well as improving overall survival particularly. Case presentation Our patient is a 70-year-old female with a no special medical history, recruited because of jaundice. She was referred for pancreaticoduodenectomy because of a 10-mm-sized mass in distal bile duct referred to as Vater’s tumor. We used 5 trocars, and the patient was placed in a Trendelenburg position. The transverse colon was lifted, the first loop of the jejunum was pulled to the left, and lymph node groups 14th and 15th were removed en bloc and then exposed the SMA from the anterior to the left posterior side from the caudal side to the origin. The first jejunal vessels and the posterior inferior pancreaticoduodenal artery were ligated as well as the extensive mobility of the duodenum and head of the pancreas from the left side. The systematic mesopancreas dissection from the right site of the SMA will be easily and conveniently done afterwards. Histopathological examination of ypT2N1 indicated that 1 of the 22 lymph nodes was positive, which was 1 of 7 LN no. 14. Pathological results showed a Vater adenocarcinoma with all margins being negative. Conclusions This technique was safe and effective to perform precise level 2 mesopancreas dissection and complete lymphadenectomy around SMA without dissection of pl-SMA in laparoscopic field. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-022-02730-y.
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Affiliation(s)
- Thanh Khiem
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep
- Department of Surgery, Hanoi Medical University, 1st Ton That Tung Street, Dong Da, Ha Noi, 11521, Vietnam.
| | - Kim Khue
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Van Duy
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hong Son
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Duc Dung
- Department of Surgery, Thai Binh Medical University, Thai Binh, Vietnam
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Nakajima T, Ikuta S, Nakamura I, Aihara T, Kasai M, Iwama H, Fujimoto Y, Hatano E, Yamanaka N. Impact of the aberrant right hepatic artery on local recurrence of pancreatic ductal adenocarcinoma after pancreaticoduodenectomy. Surgery 2022; 172:691-699. [PMID: 35337684 DOI: 10.1016/j.surg.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/12/2022] [Accepted: 02/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The influence and risk associated with an aberrant right hepatic artery, a common anatomical variation, during pancreatoduodenectomy for pancreatic ductal adenocarcinoma has not been fully investigated. The present study analyzed the impact of an aberrant right hepatic artery on local recurrence after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. METHODS A total of 169 patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy at 2 separate Japanese medical institutions were retrospectively analyzed. RESULTS Thirty of 169 patients (17.7%) presented with an aberrant right hepatic artery. The incidence of local recurrence was higher in the aberrant right hepatic artery group than in the normal right hepatic artery group (43.3 vs 21.5%, P = .017). The local recurrence-free survival was significantly poorer in the aberrant right hepatic artery group than in the normal right hepatic artery group (P = .011). A multivariate analysis found that the aberrant right hepatic artery was an independent risk factor for local recurrence (hazard ratio: 3.74, P = .017). In the aberrant right hepatic artery group, more frequent local recurrence was observed in patients with tumors situated ≤10 mm from the aberrant right hepatic artery root. However, local recurrence was not observed in 2 out of 3 patients with tumors ≤10 mm from the aberrant right hepatic artery root who underwent pancreatoduodenectomy with combined resection of the aberrant right hepatic artery. CONCLUSION The presence of an aberrant right hepatic artery in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma may be associated with an increased risk of postoperative local recurrence. Combined resection of the aberrant right hepatic artery may reduce local recurrence, especially for tumors near the root of the aberrant right hepatic artery.
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Affiliation(s)
| | | | - Ikuo Nakamura
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Japan
| | | | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Hideaki Iwama
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Japan
| | - Yasuhiro Fujimoto
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Japan
| | - Etsuro Hatano
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Japan
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Healy GM, Salinas-Miranda E, Jain R, Dong X, Deniffel D, Borgida A, Hosni A, Ryan DT, Njeze N, McGuire A, Conlon KC, Dodd JD, Ryan ER, Grant RC, Gallinger S, Haider MA. Pre-operative radiomics model for prognostication in resectable pancreatic adenocarcinoma with external validation. Eur Radiol 2021; 32:2492-2505. [PMID: 34757450 DOI: 10.1007/s00330-021-08314-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/05/2021] [Accepted: 08/31/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES In resectable pancreatic ductal adenocarcinoma (PDAC), few pre-operative prognostic biomarkers are available. Radiomics has demonstrated potential but lacks external validation. We aimed to develop and externally validate a pre-operative clinical-radiomic prognostic model. METHODS Retrospective international, multi-center study in resectable PDAC. The training cohort included 352 patients (pre-operative CTs from five Canadian hospitals). Cox models incorporated (a) pre-operative clinical variables (clinical), (b) clinical plus CT-radiomics, and (c) post-operative TNM model, which served as the reference. Outcomes were overall (OS)/disease-free survival (DFS). Models were assessed in the validation cohort from Ireland (n = 215, CTs from 34 hospitals), using C-statistic, calibration, and decision curve analyses. RESULTS The radiomic signature was predictive of OS/DFS in the validation cohort, with adjusted hazard ratios (HR) 2.87 (95% CI: 1.40-5.87, p < 0.001)/5.28 (95% CI 2.35-11.86, p < 0.001), respectively, along with age 1.02 (1.01-1.04, p = 0.01)/1.02 (1.00-1.04, p = 0.03). In the validation cohort, median OS was 22.9/37 months (p = 0.0092) and DFS 14.2/29.8 (p = 0.0023) for high-/low-risk groups and calibration was moderate (mean absolute errors 7%/13% for OS at 3/5 years). The clinical-radiomic model discrimination (C = 0.545, 95%: 0.543-0.546) was higher than the clinical model alone (C = 0.497, 95% CI 0.496-0.499, p < 0.001) or TNM (C = 0.525, 95% CI: 0.524-0.526, p < 0.001). Despite superior net benefit compared to the clinical model, the clinical-radiomic model was not clinically useful for most threshold probabilities. CONCLUSION A multi-institutional pre-operative clinical-radiomic model for resectable PDAC prognostication demonstrated superior net benefit compared to a clinical model but limited clinical utility at external validation. This reflects inherent limitations of radiomics for PDAC prognostication, when deployed in real-world settings. KEY POINTS • At external validation, a pre-operative clinical-radiomics prognostic model for pancreatic ductal adenocarcinoma (PDAC) outperformed pre-operative clinical variables alone or pathological TNM staging. • Discrimination and clinical utility of the clinical-radiomic model for treatment decisions remained low, likely due to heterogeneity of CT acquisition parameters. • Despite small improvements, prognosis in PDAC using state-of-the-art radiomics methodology remains challenging, mostly owing to its low discriminative ability. Future research should focus on standardization of CT protocols and acquisition parameters.
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Affiliation(s)
- Gerard M Healy
- Joint Department of Medical Imaging, University Health Network, Sinai Health System and Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | | | - Rahi Jain
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Xin Dong
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Dominik Deniffel
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Department of Diagnostic and Interventional Radiology, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Ayelet Borgida
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David T Ryan
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
| | - Nwabundo Njeze
- National Surgical Centre for Pancreatic Cancer, St. Vincent's University Hospital, Dublin, Ireland
| | - Anne McGuire
- National Surgical Centre for Pancreatic Cancer, St. Vincent's University Hospital, Dublin, Ireland
| | - Kevin C Conlon
- National Surgical Centre for Pancreatic Cancer, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Jonathan D Dodd
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Edmund Ronan Ryan
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
- National Surgical Centre for Pancreatic Cancer, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Robert C Grant
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Steven Gallinger
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada
- Surgical Oncology Program, Hepatobiliary Pancreatic, University Health Network, Toronto, ON, Canada
| | - Masoom A Haider
- Joint Department of Medical Imaging, University Health Network, Sinai Health System and Women's College Hospital, University of Toronto, Toronto, ON, Canada.
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, Toronto, ON, Canada.
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10
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Hirono S, Kawai M, Okada KI, Miyazawa M, Kitahata Y, Kobayashi R, Hayami S, Ueno M, Yamaue H. Complete circumferential lymphadenectomy around the superior mesenteric artery with preservation of nerve plexus reduces locoregional recurrence after pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2021; 47:2586-2594. [PMID: 34127329 DOI: 10.1016/j.ejso.2021.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/26/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Evaluation of recurrence pattern and risk factors for recurrence are essential for good rates of survival after upfront pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS This retrospective study included 167 consecutive patients who underwent upfront PD for resectable PDAC between 2000 and 2018. Postoperative recurrences were classified into three patterns according to initial recurrence site: isolated locoregional, isolated distant, and simultaneous locoregional and distant recurrences. RESULTS This study found 114 patients who developed postoperative recurrence (68.3%), including 37 patients with isolated locoregional recurrence (32.5%), 67 patients with isolated distant recurrence (58.8%), and 10 patients with simultaneous locoregional and distant recurrences (6.0%). When locoregional recurrence was classified based on the location of recurrent lesions, locoregional recurrence most commonly occurred around the superior mesenteric artery (SMA) (70.2%), followed by around the hepatic artery (25.5%) and in the paraaortic region (14.9%). Multivariate analyses showed that complete circumferential lymphadenectomy around the SMA, including not only the right side, but also the left side, was an independent factor for reduction of locoregional recurrence (P = 0.019, odds ratio [OR]: 2.217). Lymph node metastasis was an independent risk factor for both locoregional (P < 0.001, OR: 3.686) and distant recurrences (P < 0.001, OR: 4.315). Non-completion of postoperative adjuvant therapy was a risk factor for distant recurrence (P < 0.001, OR: 3.748). CONCLUSION Based on our data, complete circumferential lymphadenectomy around the SMA might contribute to local control, and multidisciplinary treatment including neoadjuvant therapy might be needed for resectable PDAC with high risk for recurrence.
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Affiliation(s)
- Seiko Hirono
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan.
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Motoki Miyazawa
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Yuji Kitahata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Rryohei Kobayashi
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Shinya Hayami
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Japan
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11
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Kang MJ, Kim SW. En bloc proximal peri-mesenteric clearance for pancreatic head cancer surgery. Ann Hepatobiliary Pancreat Surg 2020; 24:389-395. [PMID: 33234741 PMCID: PMC7691194 DOI: 10.14701/ahbps.2020.24.4.389] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 01/02/2023] Open
Abstract
The superior mesenteric artery (SMA) first approach and meso-pancreas excision (MPE) during pancreatoduodenectomy (PD) for pancreatic head cancer have been suggested for complete local tumor control, less operative blood loss, and early determination of resectability. However, SMA-first approach is merely a mode of approach and the concept of MPE has been challenged due to its anatomical obscurity. Dissection around proximal mesenteric vessels, superior mesenteric vein and SMA, is a critical procedure point for local tumor control as tumor infiltration is frequently observed both at the time of initial diagnosis and recurrence. The meso-pancreas, which encompasses the soft tissue between the uncinated process and SMA, does not include all the aforementioned points of proximal mesenteric areas. Therefore, the authors propose a new terminology named, “en bloc proximal peri-mesenteric clearance (PPMC)”, to describe the removal of all the lymph nodes including soft tissue around proximal mesenteric vessels, especially the SMA, to ensure complete local tumor control of pancreatic head cancer. The SMA-first approach applied either by the mesenteric approach or supra-colic approach can make this procedure more feasible. The extent of the circumferential dissection of the peri-SMA nerve plexus can be adjusted according to the primary disease. PPMC including the removal of all lymph nodes around the proximal SMA may be considered as a standard extent of PD for pancreatic head cancer.
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Affiliation(s)
- Mee Joo Kang
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Sun-Whe Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
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