Cancer of the pancreas: palliative operation, Whipple procedure, or total pancreatectomy

Clinicopathological Evaluation of Postpancreaticoduonenectomy Hemorrhage with Endovascular Treatment

INTRODUCTION

Postpancreaticoduodenectomy hemorrhage (PPH) is a serious complication. Fatty or nonfibrous pancreas, or both, is a risk factor for pancreatic fistula. This study assessed various prognostic factors for interventional procedures for PPH, also focusing on the degree of pancreatic fatty infiltration/fibrosis evaluated histopathologically.

MATERIAL AND METHODS

The participants were 29 patients with PPH who underwent endovascular treatment from September 2001 to March 2020. Univariate analysis was performed to determine whether the histopathological degree of pancreatic fatty infiltration/fibrosis and other factors were associated with complications and mortality after endovascular treatment for PPH.

RESULTS

Of 39 treatment sessions overall, 38 (97%) achieved technical success and 34 (87%) had clinical success. In-hospital mortality occurred in five patients (17%). No association was found between the pancreatic fistula and the histopathological degree of pancreatic fatty infiltration/fibrosis. Fourteen patients with hemorrhagic shock before endovascular treatment included all five patients with in-hospital mortality, while the 15 patients without hemorrhagic shock survived (P = 0.017). A bleeding tendency was associated with complications after endovascular treatment for PPH (P = 0.033).

CONCLUSIONS

Although our results revealed no significant relation between the histopathological degree of pancreatic fatty infiltration/fibrosis and clinical success, including prognosis, endovascular treatment may be effective for PPH.

Preoperative ultrasound elastography for postoperative pancreatic fistula prediction after pancreatoduodenectomy: A prospective study

BACKGROUND

Postoperative pancreatic fistulas are the most frequent major complications after pancreatoduodenectomy. The soft pancreatic texture is a critical, independent risk factor for postoperative pancreatic fistulas after pancreatoduodenectomy. The current gold standard for postoperative pancreatic fistula risk evaluation consists of the surgeon's intraoperative palpation of the pancreatic texture and, thus, lacks objectivity. In this prospective study, we used ultrasound-based shear-wave elastography, image data analysis, and a fistula risk score calculator to correlate the stiffness of pancreatic tissue with the occurrence of clinically relevant postoperative pancreatic fistulas.

METHODS

We included 100 patients with pancreatic pathologies (71% pancreatic ductal adenocarcinoma) and 100 healthy individuals who were preoperatively assessed via real-time tissue ultrasound-based shear-wave elastography on a Philips EPIQ 7 ultrasound device and had pancreatic parenchyma histologically evaluated with manually stained images.

RESULTS

We found a significant difference in the mean elasticity between the soft (1.22 m/s) and the hard pancreas group (2.10 m/s; P < .0001). The mean elasticity significantly correlated with the pancreatic fibrosis rate and the appearance of a postoperative pancreatic fistula after pancreatoduodenectomy. Low elasticity (≤1.2 m/s, mean) correlated with soft and high elasticity (>2.0 m/s, mean) with hard pancreatic parenchyma, as assessed by pathologic evaluation. Multivariate analysis revealed a mean elasticity of <1.3 m/s as a significant cut-off predictor for clinically relevant postoperative pancreatic fistulas (P = .003; Youden-Index = 0.6945).

CONCLUSION

Preoperative ultrasound-based shear-wave elastography is a feasible and objective clinical diagnostic modality in evaluating pancreatic tissue stiffness. A mean pancreatic elasticity of <1.3 m/s was a significant independent risk predictor of clinically relevant postoperative pancreatic fistulas after pancreatoduodenectomy.

Surgeon vs Pathologist for Prediction of Pancreatic Fistula: Results from the Randomized Multicenter RECOPANC Study

BACKGROUND

Surgically assessed pancreatic texture has been identified as the strongest predictor of postoperative pancreatic fistula. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathologic parameters collected over the course of the Pancreatogastrostomy vs Pancreatojejunostomy for RECOnstruction (RECOPANC) study.

STUDY DESIGN

The RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. There were 261 hematoxylin and eosin-stained slides allocated for histopathologic analyses. Pancreatic fibrosis was scored from 0 to III (no fibrosis up to severe fibrosis) by 2 blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis.

RESULTS

The fibrosis grade and pancreatic texture were scored in all 261 patients. In POPF B/C (postoperative pancreatic fistula grade B or C) patients, 71% had a soft pancreas, and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II, and 7% with score III, respectively. Fibrosis grading showed substantial inter-rater reliability (kappa = 0.74) and correlated positively with hard pancreatic texture (p < 0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture, and fibrosis grade. However, the addition of pancreatic texture only led to an incremental improvement (AUC 0.794 vs 0.819).

CONCLUSIONS

Histologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.

Association Between the Incidence of Pancreatic Fistula After Pancreaticoduodenectomy and the Degree of Pancreatic Fibrosis

OBJECTIVE

The objective of this study is to investigate the association between the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) and the degree of pancreatic fibrosis.

METHOD

Between January 2013 and December 2016, the analysis of the clinical data of 529 cases of pancreaticoduodenectomy patients of our hospital was performed in a retrospective fashion. The univariate analysis and multivariate analysis were done using the Pearson chi-squared test and binary logistic regression analysis model; correlations were analyzed by Spearman rank correlation analysis. The value of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy was evaluated by the area under the receiver operating characteristic (ROC) curve.

RESULTS

The total incidence of pancreatic fistula after pancreaticoduodenectomy was 28.5% (151/529). Univariate analysis and multivariate analysis showed that BMI ≥ 25 kg/m², pancreatic duct size ≤ 3 mm, pancreatic CT value< 30, the soft texture of the pancreas (judged during the operation), and the percent of fibrosis of pancreatic lobule ≤ 25% are prognostic factors of pancreatic fistula after pancreaticoduodenectomy (P < 0.05); the pancreatic CT value and the percent of fibrosis of pancreatic lobule in pancreatic fistula group were both lower than those in non-pancreatic fistula group (P < 0.05). Results indicated that there is a negative correlation between the severity of pancreatic fistula and the pancreatic CT value or the percent of fibrosis of pancreatic lobule (r = - 0.297, - 0.342, respectively). The areas under the ROC curve of the percent of fibrosis of pancreatic lobule and the pancreatic CT value were 0.756 and 0.728, respectively.

CONCLUSION

The degree of pancreatic fibrosis is a prognostic factor which can influence the pancreatic texture and the incidence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic CT value can be used as a quantitative index of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy.

Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes

INTRODUCTION

The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM.

OBJECTIVE

The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD.

METHODS

An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized.

RESULTS

POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity.

CONCLUSION

The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.

Results of extensive surgery for pancreatic carcinoma

BACKGROUND

Since 1973, 210 patients with pancreatic carcinoma have undergone surgery in our clinic, including 144 with carcinoma of the head of the pancreas. Of these 144 patients, macroscopic curative resections were performed on 53 (36.8%). Five patients (9.4%) died within 30 postoperative days, and an additional 3 (5.7%) died within 60 days. The overall median survival was 13 months. Eight of the patients who underwent macroscopic curative resection survived 5 years, giving a 5-year survival rate of 27.4% using the Kaplan-Meier method. The 5-year survival rate was 39.7% after a microscopically curative resection and 0% after a microscopically noncurative resection.

METHODS

Outcome was compared based on the extent of pancreatic cancer by constructing survival curves according to the general rules published by the Japan Pancreas Society.

RESULTS

There was no statistically significant difference in survival based on tumor size or stage. However, there was a significant difference in the survival of patients with the absence (so) or presence (se) of invasion to the anterior capsule of the pancreas, the absence (rpo) or presence (rpe) of invasion of the retroperitoneal tissue, the absence (ew0) or presence (ew2) of invasion at the surgical margin of resection, and the extent (n0 to n2) of lymph node metastasis.

CONCLUSIONS

The results of this study suggest that extended radical pancreatectomy may be indicated for patients with pancreatic carcinoma because standard dissection may fail when the tumor has spread to the retroperitoneum or extrapancreatic nerve plexus.

Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage

BACKGROUND

A soft pancreas with a main pancreatic duct (MPD) with normal diameter has been considered a high risk for pancreatic anastomotic leakage because of a relatively high output of pancreatic juice, but data are lacking.

METHODS

An attempt was made to assess the relationship between the consistency of the pancreas, MPD diameter, pancreatic juice output, and pancreatic leakage after partial pancreatoduodenectomy. The pancreatic parenchyma was classified as of soft, intermediate, and hard consistency in 70 consecutive patients undergoing operation (groups 1, 2, and 3, respectively) by one surgeon. The MPD diameter was determined by means of endoscopic pancreatography or abdominal ultrasonography. Pancreatic juice output was measured for 21 days after operation by using a catheter inserted into the MPD. Anastomotic leakage was identified radiologically by using contrast medium.

RESULTS

The mean (SD) pancreatic juice output during a period of 10 days (postoperative days 5 to 14) was 1554 (1073) ml in group 1 (n = 29), 1513 (1060) ml in group 2 (n = 13), and 187 (220)ml in group 3 (n = 28) (groups 1 and 2 versus group 3, p < 0.0001). The MPD diameter was 3.0 (1.6) mm in group 1, 5.9 (2.5) mm in group 2, and 6.6 (2.6) mm in group 3 (group 1 versus groups 2 and 3, p = 0.0001). Anastomotic leaks occurred in four (14%) patients in group 1, three (23%) in group 2, and none in group 3 (p < 0.05).

CONCLUSIONS

Patients with a pancreatic parenchyma with an intermediate or normal consistency produced more pancreatic juice and had a higher leak rate.

Outcome of microscopically nonradical, subtotal pancreaticoduodenectomy (Whipple's resection) for treatment of pancreatic head tumors

From 1983 to 1992 a total of 240 patients with a pancreatic head tumor underwent laparotomy to assess the resectability of the tumor. In 44 patients the tumor was not resected because of distant metastases (n = 20) or major vascular involvement or local tumor infiltration (n = 24) not detected during the preoperative workup. A palliative biliary and gastric bypass was performed in these patients. All other patients underwent a subtotal (Whipple's resection, n = 164) or total (n = 32) pancreaticoduo-denectomy. However, in 56 cases after Whipple's resection, microscopic examination of the specimen showed tumor invasion in the dissection margins. For this reason, these resections were considered palliative. We compared hospital mortality, morbidity, and long-term survival of patients who had undergone a biliary and gastric bypass for a locally advanced tumor (group A, n = 24) with a matched group of patients who had undergone a macroscopically radical Whipple's resection that on microscopic examination proved to be nonradical (group B, n = 36). Both groups were comparable with regard to age (mean 61 years in both groups), duration of symptoms (8 weeks in group A and 10 weeks in group B), and tumor size (mean 4.25 cm in group A and 4.30 cm in group B). Median postoperative hospital stay was 18 days in group A and 25 days in group B. Postoperative complications (intraabdominal abscess, gastrointestinal hemorrhage, anastomotic leakage, delayed gastric emptying) occurred in 33% of patients in group A and in 44% of patients in group B. Hospital mortality was 0% and 3% in group A and group B, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A reappraisal of total pancreatectomy for pancreatic cancer: results from U.S. Veterans Affairs hospitals, 1987-1991

BACKGROUND

After enthusiasm for total pancreatectomy for pancreatic adenocarcinoma peaked in the 1970s, a failure to improve outcomes in the 1980s led to fewer reports of this procedure.

METHODS

We retrieved records from 252 Whipple and 47 total pancreatectomies for pancreatic cancer performed at U.S. Department of Veterans Affairs hospitals from 1987 to 1991.

RESULTS

Thirty-day mortality was 8% with both procedures. There was no significant difference in morbidity at 30 days (Whipple 36%, total pancreatectomy 39%). The mean survival after total pancreatectomy was 526 days compared to 376 days following Whipple (P = 0.03). Staging information was retrieved from tumor registrars for 117 patients with pancreatic adenocarcinoma, 21 of whom underwent total pancreatectomy and 96 the Whipple procedure. In patients with stage I and stage II localized pancreatic adenocarcinoma, mean survival was 772 days in 11 patients after total pancreatectomy, and 446 days in 55 patients after Whipple resection (P = 0.057).

CONCLUSION

The type of resection did not affect the mean survival of patients with stage III (nodal metastases) or stage IV (distant metastases) cancer.

Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head

Of 176 patients with carcinoma of the pancreatic head region 156 underwent standard pancreatoduodenectomy (group 2) and 20 with macroscopic suspicion of invasion of the portal vein or superior mesenteric vein (SMV) underwent pancreatoduodenectomy with partial resection of the portal vein or SMV (group 1). In 16 patients in group 1 end-to-end anastomosis was used for reconstruction of the vein. The morbidity rate in groups 1 and 2 was similar (55 versus 63 per cent). The hospital mortality rate was 15 per cent in group 1 and 7 per cent in group 2 (P = 0.22). Histological examination confirmed tumour invasion of the portal vein or SMV in ten patients in group 1. Invasion of the portal vein or SMV was significantly more frequent in patients with pancreatic cancer than in those with distal bile duct or ampullary carcinoma. Of the 20 patients in group 1 only three underwent curative resection with tumour-free margins. The median survival time after resection of the portal vein or SMV was 8 months; the 2-year survival rate was 19 per cent. Comparison of survival in group 1 with survival in subgroups of patients undergoing standard pancreatoduodenectomy, matched for all histological parameters, showed no significant difference. It is concluded that partial resection of the portal vein or SMV in patients undergoing pancreatoduodenectomy who are suspected of having tumour invasion of the portal vein or SMV does not improve either the rate of curative resection or survival.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

Carcinoma of the pancreas and periampullary region: palliation versus cure

A retrospective study of 310 patients with carcinoma of the head of the pancreas or periampullary region was performed. Preoperative bile drainage by placement of a stent reduced the number of postoperative complications, especially bleeding (P = 0.03). The operative mortality rate was nil in patients with periampullary cancer aged under 70 years and 23 per cent in those over 70 years of age (P < 0.001). In the last 2 years of the study, the mortality rate following resection decreased to 2 per cent. Tumour-containing resection margins did not influence survival after resection (P = 0.48). Tumour dimension of pancreatic and periampullary cancer and the presence of tumour in locoregional lymph nodes (N1a) resected with the primary tumour in cancer of the head of the pancreas were of no prognostic value. Following palliative resection of carcinoma of the pancreatic head, median survival was significantly better than when no resection was performed (10.1 versus 3.9 months, P < 0.001). In conclusion, even palliative resection may benefit some patients. Preoperative bile drainage is indicated in those with jaundice. Resection should be performed, irrespective of tumour size, provided that the unit's operative mortality rate is sufficiently low.

Total pancreatectomy for ductal adenocarcinoma of the pancreas with special reference to resection of the portal vein and multicentric cancer

Between March 1, 1968 and March 1, 1986, 323 patients underwent surgery for cancer of the pancreas or the periampullary region. Extirpative procedures were performed in 91 patients, of whom 51 had ductal carcinoma of the pancreas. Forty-seven patients had total pancreatectomy, 9 associated with resection of the portal vein and 1 with total gastrectomy. Operative mortality was 15% but fell to zero for the 19 total pancreatectomies performed after 1981. With the introduction of total pancreatectomy, the resectability rate increased from 15% to 32%. Overall mean survival was 14.4 months. Actuarial survival was 42.4% at 1 year, 25.6% at 2 years, 11.9% at 3 years, and 8% at 5 years. Six patients are alive 7, 11, 14, 30, 30, and 73 months, respectively, after operation. Survival was calculated according to the classifications of Hermreck, Tryka and Brooks, and the TNM system. Ductal carcinoma was multifocal in 32% of patients, and 25% had epithelial dysplasia of the pancreatic duct. When portal vein resection was necessary, mean survival was 6.1 months, compared with 18.25 months when it was not performed. We conclude that total pancreatectomy has increased our resectability rate, mainly in patients with tumor spread beyond the usual margins of division for Whipple's procedure. However, the procedure does not appear worthwhile when portal vein resection is necessary or when multicentric cancer or neoplastic emboli are observed in the operative specimen.

Conventional external irradiation alone as adjuvant treatment in resectable pancreatic cancer: results of a prospective study

Between 1/85 and 1/90, 14 consecutive patients were entered into a prospective study of conventional adjuvant post-operative external beam radiotherapy after complete resection for a pancreatic adenocarcinoma. The surgical procedure was a Whipple resection in nine patients, a distal pancreatectomy in four patients and a total pancreatectomy in one patient. There were three T1b, eight T2 and three T3 tumours (UICC 1987); nodal involvement was present in five cases. The radiotherapy was delivered using a four-field box technique with a 23 x MV photon beam. All patients received a total dose of 54 Gy to the tumour bed. The mean treated volume was 900 cm3. Acute toxicities consisted mainly of weight loss (mean: 2 kg). Two patients had a grade 2 diarrhoea and two patients a grade 2 gastritis. Late effects were minimal and only observed in two patients. The overall locoregional recurrence (LR) rate was 50%. The median disease-free survival was 12 months, and the median survival was 23 months. This post-operative conventional radiotherapy treatment gives results that are comparable to the results of the GITSG-adjuvant study using a combination of split-course radiotherapy and 5-fluorouracil (5-FU).

Clinical evaluation of a new serum tumour marker CA 242 in pancreatic carcinoma

The aim of this study was to evaluate the new monoclonal tumour marker CA 242 in the diagnosis of pancreatic carcinoma and to compare it with the established markers CA 50 and CEA. Serum concentrations were determined in 113 patients with jaundice, in 20 patients with laboratory values suggesting cholestasis, and in 60 patients with a suspicion to have chronic pancreatitis. Twenty-four of these 193 patients had pancreatic carcinoma and two patients had carcinoma of papilla of Vater. The sensitivities of CA 242, CA 50 and CEA were 80.7%, 96.1%, and 92.3%, respectively. The specificities were 79.0%, 58.0%, and 59.2%. The sensitivities of combinations of CA 50 and CEA with CA 242 did not exceed the sensitivity of CA 50 alone. The specificity of CA 242 was improved by combining it with CEA (92.2%). The serum marker CA 242 seems to be less sensitive than CEA and CA 50 in the detection of pancreatic carcinoma, but it may prove useful because of its high specificity.

DNA ploidy, S-phase fraction, and G2 fraction as prognostic determinants in human pancreatic cancer

The DNA ploidy, S-phase fraction (SPF), and G2 fraction of pancreatic cancer tissue was measured by flow cytometry in 95 patients. Forty-nine per cent (n = 47) had a diploid DNA index, and 51% (n = 48) of tumours were aneuploid. Aneuploid tumours and high-grade tumours had significantly higher S-phase and G2-fraction values than diploid tumours or low-grade tumours. Diploid and tetraploid tumours had a more favourable prognosis than non-tetraploid aneuploid tumours (p = 0.0020) during the mean follow-up of 6 years. The type of therapy (p = 0.07), histologic grade (p = 0.06), SPF (p = 0.1), and G2 fraction (p = 0.02) had predictive value in survival analysis as well. In multivariate survival analysis, including flow-cytometric, histologic, and clinical variables, diploidy and tetraploidy had independent predictive value. The results suggest that flow cytometry might be used in grading of pancreatic cancer. Such a grading would have practical value if new modes of therapy are being developed. Forty-one per cent of multiple samples had a heterogeneous DNA index when multiple samples were used. Consequently, flow cytometric analysis of pancreatic cancer using multiple samples is recommended.

Common difficulties and complications in pancreatic surgery

Pancreatic surgery requires dedicated surgeons to optimize results. Difficult operative situations faced during the course of pancreatic procedures and ways of dealing with them are suggested. The horizons of surgery on the pancreas will expand as the morbidity and mortality rates fall.

Surgical treatment of pancreatic cancer. The Japanese experience

Since 1973, 194 patients with pancreatic carcinoma have undergone surgery in our clinic, including 134 with carcinoma of the head of the pancreas. Of these 134 patients, resections were performed on 61 (45.5%), 49 (36.6%) of whom underwent a curative resection based on macroscopic evidence. Seven of the patients who underwent macroscopic curative resection survived for five years, giving a five-year survival rate of 26.4% by the Kaplan-Meier method after excepting seven operative deaths. We compared the extent of pancreatic cancer by constructing survival curves according to the General Rules published by the Japan Pancreas Society. There was no statistical difference in survival based on tumor size or stage; however, there was a significant difference in the survival curves of so and se, being the absence or presence of the anterior capsule of the pancreas; rpo and rpe, being the absence or presence of invasion of the retroperitoneal tissue; ew(-) and ew(+), being the absence or presence of invasion at the surgical margin of resection; and n0 and n1, being the extent of lymph node metastasis. The results of this comparison suggest that extended radical pancreatectomy may be indicated for the treatment of pancreatic cancer, since the standard radical operation for pancreatic cancer may miss tumors that have spread to the retroperitoneum and extrapancreatic nerve plexus.

The results and problems of extensive radical surgery for carcinoma of the head of the pancreas

Since 1973, 152 patients with pancreatic carcinoma have undergone surgery in our clinic, including 110 with carcinoma of the head of the pancreas. Of these 110 patients, resections were performed on 43 (39.1 per cent), 33 (30 per cent) of whom underwent a curative resection based on macroscopic evidence. Six of the patients who underwent macroscopic curative resection survived for five years, giving a five-year survival rate of 36.5 per cent by the Kaplan-Meier method after excepting 6 operative deaths. We compared the extent of pancreatic cancer by constructing survival curves according to the General Rules published by the Japan Pancreas Society. There was no statistical difference in survival based on tumor size or stage, however, there was a significant difference in the survival curves of so and se, being the absence or presence of the anterior capsule of the pancreas, rpo and rpe, being the absence or presence of invasion of the retroperitoneal tissue; ew(-) and ew(+) being the absence or presence of invasion at the surgical margin of resection, or n0 and n1 being the extent of lymph node metastasis. The results of this comparison suggest that extended radical pancreatectomy may be indicated for the treatment of pancreatic cancer as the standard radical operation for pancreatic cancer may miss tumors which have spread to the retroperitoneum and extrapancreatic nerve plexus.

Carcinoma of the pancreas: a retrospective review

Eighty-five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment. The most useful diagnostic test was percutaneous transhepatic cholangiography (PTC) with a diagnostic rate of 96%. Pancreaticoduodenectomy (Whipple procedure) and total pancreatic resection were performed in 13 and 2 patients, respectively. The remaining 50 patients underwent various palliative drainage procedures. Twenty patients did not undergo operation for various reasons. The primary tumor was found in the head of the pancreas in 50 patients (59%), the body in 6 patients (7%), and in the tail in 8 patients (9%). Postoperative complications, including sepsis, bleeding, intra-abdominal abscesses, and anastomotic leaks, occurred in 37% of the patients. There were one operative and 9 postoperative deaths. The average survival for those patients undergoing surgical intervention was 6 months. There were no 5-year survivors.

Factors influencing prognosis and indications for curative pancreatectomy for ductal adenocarcinoma of the head of the pancreas

The factors influencing prognosis and the indications for curative resection by radical pancreatectomy were evaluated in 74 patients treated with pancreatectomy for ductal cell carcinoma of the head of the pancreas. The 5-yr survival rates for patients without lymph node metastasis, capsular invasion, portal system involvement, or retroperitoneal invasion were 21.2, 20.2, 25.5, and 19.6%, respectively; the 5-yr survival rate for patients with lymph node metastasis or capsular invasion was 5.3% and 6.4%, respectively, and the 2-yr survival rate for patients with portal system involvement or retroperitoneal invasion was 0%. The 5-yr survival rate for 32 patients treated with radical pancreatectomy was 33.4%, and the 3-yr survival rate for 42 patients treated with nonradical pancreatectomy was 0%. Our results suggest that, in patients with ductal adenocarcinoma of the pancreas without factors limiting prognosis, curative resection by radical pancreatectomy is feasible; however, in patients with positive factors, particularly portal system involvement or retroperitoneal invasion, a comprehensive therapeutic program combining extensive surgery, radiation, chemotherapy and/or immunotherapy is necessary to obtain better results.

Combination of intraoperative radiation with resection of cancer of the pancreas

The utility of intraoperative radiation therapy (IORT) as an adjuvant to the surgical resection of pancreatic cancer was studied. In 1976, as our first trial with this combined therapy, we applied IORT with 30 Gy of electron beam with 8 MeV to 15 patients to prevent local recurrence around the celiac axis and superior mesenteric artery after standard pancreatectomy. However, the combined therapy did not show an improvement in survival rate as compared to that of 19 patients with standard operation alone. Autopsies of three patients with the combined therapy did not show involved lymph nodes in the radiation field, but did show local recurrence around the aorta outside the radiation field. By comparison, we performed extended operation without IORT on nine patients, with almost complete dissection of the lymph nodes around the aorta, from the diaphragm to the level of the inferior mesenteric artery. This extended surgery did not improve survival time, and autopsy showed local recurrence in spite of the dissection of lymph nodes. Therefore, since 1984, we have performed IORT with a dose of 30 Gy, 9 MeV, and an extended radiation field from the diaphragm above to the inferior mesenteric artery below, following extended operation on 14 patients. The five-year cumulative survival rate of these cases was 33.3%. Four autopsies showed improvement of local control rate. No radiation-related complications were noticed postoperatively in patients who underwent extended IORT following pancreatectomy. We were encouraged to continue this approach for the cure of pancreatic cancer.

Patterns of failure after curative resection of pancreatic carcinoma

Thirty-six patients underwent curative resection of a primary pancreatic carcinoma from January 1977 to September 1987; 26 had Whipple resections, seven had total pancreatectomies, and three had distal pancreatectomies. Twenty-six patients manifested recurrent disease, four died of intercurrent disease, and six were apparently cured. Median survival was 11.5 months with actuarial survival at 2 and 5 years of 32% and 17%, respectively. Of the eventual recurrences, 19% were local only (pancreatic bed, regional nodes, adjacent organs, and immediately adjacent peritoneum) and 73% had a component of local failure. All patients failing did so with a component in the intraabdominal cavity. Peritoneal (42%) and hepatic failures (62%) were common. Extraabdominal metastases were documented in only 27%, but never as a sole site. Fourteen patient and tumor characteristics were evaluated for any relationships with failure or survival. No single variable independently predicted for local failure. However, a group of three (age greater than 60 years, T2 or T3 stage, and location of tumor in the body or tail) was associated with a substantial local failure risk (85% of all patients with local failure). Multivariate analysis showed that low tumor grade (P = 0.002), female sex (P = 0.002), and adjuvant radiation (P = 0.02) were all independent predictors of prolonged survival. Ten patients were treated in an adjacent setting. Those given 55 Gy or greater had improved local control (50% versus 25%) and cure (33% versus none) when compared with patients treated to lower doses. The authors conclude that local failure after curative resection remains a significant problem and further efforts to improve local control are warranted. However, peritoneal and hepatic relapses occur frequently. Thus, adjuvant treatment strategies using wide-field radiation techniques or intraperitoneal therapy, in combination with local tumor bed irradiation and chemotherapy, should be explored.

Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas

Seventy-four patients were treated with a radical or a nonradical pancreatectomy for ductal cell carcinoma of the head of the pancreas. Their survival rates and the selection of the operative procedure were evaluated. In 32 patients, a radical pancreatectomy was attempted where there was sufficient clearance of regional or juxta-regional lymph nodes beyond the group of suspected metastatic nodes, as well as a resection of a greater margin of soft tissue around the pancreas. These patients' cumulative 5-year survival rate was 33.4%. In 14 Stage I or Stage II patients, the cumulative 5-year survival rate was 46.4%. In 18 Stage III or Stage IV patients, the cumulative 5-year survival rate was 20.7%. For 42 patients treated with a nonradical pancreatectomy with the dissection of lymph nodes adjacent to the pancreas or of regional lymph nodes but with insufficient clearance of the soft tissue around the pancreas, the cumulative 2-year and 3-year survival rates were 5.4% and 0%, respectively. In seven patients with Stage II carcinoma, the survival rate was 16.7% after 2 years and 0% after three years. In 35 Stage III or Stage IV patients, the survival rate was 3.2% after 2 years and 0% after 3 years. Thus, the survival rates were significantly higher in patients treated with radical operation than in patients who had nonradical operation. These results indicate that a radical pancreatectomy with sufficient lymph node clearance with the surrounding connective tissue around the pancreas is indispensable to cure patients with ductal cell carcinoma of the pancreas.

Pancreatic resection for pancreatic cancer

In the majority of patients, pancreatic resection is performed for a proved carcinoma or for a mass in the pancreas with clinical features of carcinoma. Preoperative preparation is similar to that for other cancer operations, and good nutritional status and normal clotting factors are important. In many patients with resectable lesions, preoperative histologic diagnosis is not possible.

Long-term survivors after operation on carcinoma of the pancreas

Reports of 35 long-term more than five years survivors after resectional surgery which was performed for carcinoma of the pancreas from 1966 to 1980 were collected from major institutions in Japan and analyzed. Male to female ratio was 0.94:1 and average age was 56 years old. In 34 of the 35, the tumor was located at the head of the pancreas, 32 received pancreatoduodenectomy and two underwent total pancreatectomy. One patient with carcinoma of the tail received distal pancreatectomy. There was no correlation between the size of tumor and the postoperative prognosis. It seems that lymph node metastasis is not an obstacle to long postoperative survivals when they are removed, and also invasion to the pancreatic capsule shows no relationship to prognosis. However, there were no definite or severe invasions to the retroperitoneal tissue, nor to the portal venous system in the 35 patients at all. It is considered that invasion to the retroperitoneal tissues and to the portal venous system may be the most influential factor to the postoperative prognosis.

Pancreatic cancer in 1988. Possibilities and probabilities

Pancreatic adenocarcinoma is increasing in frequency, generally grows without symptoms until late in its natural history, and presents many discouraging unresolved problems in management. This review analyzes the status of current modalities of diagnosis, staging, and treatment. The limitations of those methods are defined, and possible improvements and new directions are suggested. A strategy for a rational and humane approach to pancreatic cancer is developed with the goal of maximizing quality as well as quantity of life.