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The effect of hospital volume on mortality, morbidity and dissected lymph nodes in pancreaticoduodenectomy for periampullary region tumors. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1076643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wang Z, Ke N, Wang X, Wang X, Chen Y, Chen H, Liu J, He D, Tian B, Li A, Hu W, Li K, Liu X. Optimal extent of lymphadenectomy for radical surgery of pancreatic head adenocarcinoma: 2-year survival rate results of single-center, prospective, randomized controlled study. Medicine (Baltimore) 2021; 100:e26918. [PMID: 34477122 PMCID: PMC8415937 DOI: 10.1097/md.0000000000026918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/23/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Radical pancreaticoduodenectomy is the only possible cure for pancreatic head adenocarcinoma, and although several RCT studies have suggested the extent of lymph node dissection, this issue remains controversial. This article wanted to evaluate the survival benefit of different lymph node dissection extent for radical surgical treatment of pancreatic head adenocarcinoma. METHODS A total of 240 patients were assessed for eligibility in the study, 212 of whom were randomly divided into standard lymphadenectomy group (SG) or extended lymphadenectomy group (EG), there were 97 patients in SG and 95 patients in EG receiving the radical pancreaticoduodenectomy. RESULT The demography, histopathology and clinical characteristics were similar between the 2 groups. The 2-year overall survival rate in the SG was higher than the EG (39.5% vs 25.3%; P = .034). The 2-year overall survival rate in the SG who received postoperative adjuvant chemotherapy was higher than the EG (60.7% vs 37.1%; P = .021). There was no significant difference in the overall incidence of complications between the 2 groups (P = .502). The overall recurrence rate in the SG and EG (70.7% vs 77.5%; P = .349), and the patterns of recurrence between 2 groups were no significant differences. CONCLUSION In multimodality therapy system, the efficacy of chemotherapy should be based on the appropriate lymphadenectomy extent, and the standard extent of lymphadenectomy is optimal for resectable pancreatic head adenocarcinoma. The postoperative slowing of peripheral blood lymphocyte recovery might be 1 of the reasons why extended lymphadenectomy did not result in survival benefits. CLINICAL TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov (NCT02928081) in October 7, 2016. https://clinicaltrials.gov/.
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Affiliation(s)
- Ziyao Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Nengwen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yonghua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hongyu Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jinheng Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Bole Tian
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ang Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weiming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Kezhou Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Magistrelli P, Antinori A, Crucitti A, La Greca A, Coppola R, Nuzzo G, Picciocchi A. Il Trattamento Chirurgico Resettivo Del Carcinoma Pancreatico. TUMORI JOURNAL 2018. [DOI: 10.1177/030089169908501s07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Paolo Magistrelli
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Armando Antinori
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Antonio Crucitti
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Antonio La Greca
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Roberto Coppola
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Gennaro Nuzzo
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Aurelio Picciocchi
- Istituto di Patologia Chirurgica, Università Cattolica del Sacro Cuore, Roma, Italia
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Zhao S, Ma D, Huang Y, Zhang L, Cao Y, Wang Y. STARD: How many lymph nodals needed to be dissected in corpus carcinoma? Medicine (Baltimore) 2018; 97:e0260. [PMID: 29668578 PMCID: PMC5916645 DOI: 10.1097/md.0000000000010260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
During corpus carcinoma surgery, there is uncertainty as to how many lymph nodes should be dissected and examined to determine lymph invasion.In this study, we evaluated a beta-binominal model in data extracted from the Surveillance, Epidemiology, and End Results (SEER) database, which contains 22,372 complete records. We quantified the relationship between examined node number and the probability of missing invaded nodes. Survival curves were used for further validation.We found that for stage T1-T4, 1, 10, 23, and 37 lymph nodes, respectively, needed to be examined to minimize the missing positive nodal probability (1-nodal staging score, NSS) to less than 5%. A hypothetical lymph node examination rate was calculated. Survival rate of T2 and T3 stage samples was significantly associated with NSS, but T1 and T4 sample survival rate was not.The currently dissected nodal should be reduced to 1 to 2 for T1, remains to 10 for T2, and increases to 23 for T3.
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Affiliation(s)
- Shuping Zhao
- Qingdao Women and Children Binomial Model from the SEER Database Strict
| | - Dehua Ma
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yu Huang
- Qingdao Women and Children Binomial Model from the SEER Database Strict
| | - Lei Zhang
- Qingdao Women and Children Binomial Model from the SEER Database Strict
| | - Yuan Cao
- Qingdao Women and Children Binomial Model from the SEER Database Strict
| | - Yawen Wang
- The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
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Asaoka T, Miyamoto A, Maeda S, Hama N, Tsujie M, Ikeda M, Sekimoto M, Nakamori S. CA19-9 level determines therapeutic modality in pancreatic cancer patients with para-aortic lymph node metastasis. Hepatobiliary Pancreat Dis Int 2018; 17:75-80. [PMID: 29428109 DOI: 10.1016/j.hbpd.2018.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 03/03/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND In general, para-aortic lymph node (LN16) metastasis has been considered as a contraindication for pancreatic resection. However, some pancreatic cancer patients with LN16 metastasis have been reported to survive for longer than expected after pancreatectomy. The purpose of this study was to determine whether pancreatic cancer patients with LN16 metastasis might benefit from surgery. METHODS We retrospectively reviewed 201 consecutive patients with invasive pancreatic ductal adenocarcinoma who underwent surgery at Osaka National Hospital between April 2003 and December 2012. These patients included 22 patients with LN16 metastasis who underwent an extended lymphadenectomy and 25 patients who underwent a palliative surgical biliary and gastric bypass. The clinicopathological data and outcomes were evaluated using univariate and multivariate analyses. RESULTS The overall survival of the patients with LN16 metastasis was poorer than that of the LN16-negative patients (P = 0.0014). An overall survival analysis of the LN16-positive patients stratified according to the preoperative CA19-9 level showed a significant difference between patients with a low preoperative CA19-9 level (≤360 U/mL) and those with a high preoperative CA19-9 level (>360 U/mL) (P = 0.0301). No significant difference in overall survival of patients was observed between those with LN16 positivity and those who underwent bypass surgery. However, the overall survival of the LN16-positive patients with a CA19-9 level ≤360 U/mL (n = 11) was significantly higher than that of those who underwent bypass surgery (P = 0.0452). CONCLUSION Surgical resection and extended lymphadenectomy remains an option for pancreatic cancer patients with LN16-positivity whose CA19-9 level is ≤360 U/mL.
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Affiliation(s)
- Tadafumi Asaoka
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Atsushi Miyamoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Sakae Maeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Naoki Hama
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Masanori Tsujie
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Masataka Ikeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Shoji Nakamori
- Department of Surgery, National Hospital Organization, Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan
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Surgical resection of pancreatic head cancer: What is the optimal extent of surgery? Cancer Lett 2016; 382:259-265. [DOI: 10.1016/j.canlet.2016.01.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/24/2015] [Accepted: 01/18/2016] [Indexed: 01/17/2023]
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Pedrazzoli S. Extent of lymphadenectomy to associate with pancreaticoduodenectomy in patients with pancreatic head cancer for better tumor staging. Cancer Treat Rev 2015; 41:577-87. [PMID: 26045226 DOI: 10.1016/j.ctrv.2015.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To define the extent of lymphadenectomy to associate with surgery for pancreatic head cancer. BACKGROUND Pancreaticoduodenectomy with extended lymphadenectomy fails to prolong patient survival. METHODS Prospective randomized and nonrandomized controlled trials (RCTs and NRCTs), meta-analyses, retrospective reviews, consensus conferences and pre- and intraoperative diagnoses of lymph node (LN) metastases were retrieved. Standard and extended lymphadenectomies were reviewed, including their effects on postoperative complications, mortality rate and long-term survival. The minimum total number of LN examined (TNLE) for adequate tumor staging, and the incidence of metastasis to each LN station were also considered. A pros and cons analysis was performed on the removal of each LN station. RESULTS Eleven retrospective studies (2514 patients), five prospective NRCTs (545 patients), and five prospective RCTs (586 patients) described different lymphadenectomies, which obtained similar long-term results. Five meta-analyses showed they did not influence long-term survival. However, N status is an important component of tumor staging. The recommended minimum TNLE is 15. The percent incidence of metastasis to each LN station was calculated considering at least 385 and up to 3725 patients. Preoperative imaging and intraoperative exploration frequently fail to identify metastatic nodes. A pros and cons analysis suggests that lymph node status is better established removing the following LN stations: 6, 8a-p, 12a-b-c, 13a-b, 14a-b-c-d, 16b1, 17a-b. Metastasis to 16b1 LNs significantly worsens prognosis. Their removal and frozen section examination, before proceeding with resection, may contraindicate resection. CONCLUSION A standard lymphadenectomy demands an adequate TNLE and removal of the LN stations metastasizing more frequently, without increasing the surgical risk.
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Sánchez Cabús S, Fernández-Cruz L. [Surgery for pancreatic cancer: Evidence-based surgical strategies]. Cir Esp 2015; 93:423-35. [PMID: 25957457 DOI: 10.1016/j.ciresp.2015.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
Abstract
Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed.
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Svoronos C, Tsoulfas G, Katsourakis A, Noussios G, Chatzitheoklitos E, Marakis NG. Role of extended lymphadenectomy in the treatment of pancreatic head adenocarcinoma: review and meta-analysis. ANZ J Surg 2014; 84:706-11. [PMID: 24165093 DOI: 10.1111/ans.12423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Extended lymph node dissection has been established as the method of choice in the treatment of many digestive malignancies, but its role in the treatment of adenocarcinoma of the pancreas remains controversial. OBJECTIVES The goal is to evaluate the role of extended lymph node dissection in pancreatic head adenocarcinoma and to review how it affects survival, morbidity, mortality and post-operative quality of life. METHODS A computerized search was made of the Medline database from January 1973 to October 2012. Fifteen non-duplicated studies, four randomized and 11 non-randomized, comparing extended radical pancreaticoduodenectomy (ERP) and standard pancreaticoduodenectomy were reviewed. Five-year overall survivals were compared using the MetaXL software in eight of these studies, where the necessary data were available. RESULTS The 5-year survival after ERP ranged from 6 to 33.4% and the local recurrence incidence from 8 to 36.1%, while the incidence of severe diarrhoea, one of the main complications, ranged from 10.8 to 42.4%. Meta-analysis showed that there was no significant difference in the 5-year overall survival (95% confidence interval (CI): -0.21-0.20, Z=0.07, P=0.94) for randomized control trials, (95% CI: -0.51-0.02, Z=1.85, P=0.07) for non-randomized control trials and (95% CI: -0.26-0.06, Z=1.20, P=0.23) for all the studies. CONCLUSIONS Although ERP is a safe procedure, it did not offer a significant improvement in survival, while at the same time leading to an increased incidence of severe diarrhoea for at least 1 year, thus leaving the standard pancreaticoduodenectomy as the surgical method of choice for the treatment of pancreatic head adenocarcinoma.
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Affiliation(s)
- Christos Svoronos
- Department of Surgery, General Hospital of Thessaloniki, Agios Dimitrios, Thessaloniki, Greece
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10
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Prognostic significance of XB130 expression in surgically resected pancreatic ductal adenocarcinoma. World J Surg Oncol 2014; 12:49. [PMID: 24581082 PMCID: PMC3996025 DOI: 10.1186/1477-7819-12-49] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 02/19/2014] [Indexed: 01/09/2023] Open
Abstract
Background XB130 is a newly discovered adaptor protein for intracellular signal transduction; it is involved in gene regulation, cell proliferation, cell survival, cell migration, and tumorigenesis. However, its expression and role in pancreatic ductal adenocarcinoma (PDAC) have not been investigated. The present study was designed to clarify the prognostic significance of XB130 expression in PDAC. Methods A total of 76 consecutive patients with surgically resected PDAC were retrospectively reviewed. XB130 expression was detected by immunohistochemical analysis on the paraffin-embedded tumour sections. Correlation between the expression of XB130 and clinicopathological parameters was analyzed. Results XB130 expression was significantly upregulated in PDAC(56.5%, 43/76) compared to normal pancreas (0%, 0/15; P < 0.05). Increased XB130 expression was correlated with lymph node metastasis (P = 0.017), distant metastasis (P = 0.0024), high tumour-node-metastasis (TNM) stage (P =0.001), and high tumour grade (P = 0.013). The survival of 43 patients with high XB130 expression was significantly worse than that of the 33 patients with low XB130 expression (P = 0.001). Univariate analysis showed that high XB130 expression (P = 0.0045), tumour size (P = 0.024), distant metastasis (P = 0.003), TNM stage (P = 0.002) and lymphatic metastasis (P = 0.016) were independent prognostic factors of postoperative survival. Multivariate analysis using the Cox proportional hazards model showed that high XB130 expression and distant metastasis (P = 0.0239) were significant independent risk factors. Conclusions XB130 was overexpressed in the PDAC. XB130 is a promising pathological marker for the prediction of outcome in patients with PDAC.
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Xu X, Zhang H, Zhou P, Chen L. Meta-analysis of the efficacy of pancreatoduodenectomy with extended lymphadenectomy in the treatment of pancreatic cancer. World J Surg Oncol 2013; 11:311. [PMID: 24321394 PMCID: PMC4029310 DOI: 10.1186/1477-7819-11-311] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/18/2013] [Indexed: 01/13/2023] Open
Abstract
Background The purpose of this meta-analysis is to compare the efficacy of pancreatoduodenectomy (PD) with extended lymphadenectomy (PD/ELND) versus standard PD in the treatment of pancreatic cancer, with the hope of providing evidence for clinical practice. Methods The retrieval of relevant literature published before September 2012 was carried out on PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) by computer. Information was extracted according to Cochrane systematic review methods, and analyzed using software Stata 11.0. Results Five prospective randomized controlled trials (RCTs) were included in this meta-analysis of 555 cases (278 in the PD/ELND group and 277 in the standard PD group). The PD/ELND group showed a significantly lower 3-year survival rate (relative risk (RR) = 1.46, 95% confidence interval (CI) 1.03 to approximately 2.06, P = 0.034), prolonged operative time (weighted mean difference WMD = −1.03, 95% CI −1.96 to approximately −0.10, P = 0.029) and higher incidence of postoperative complications (RR = 0.56, 95% CI 0.42 to approximately 0.77, P = 0.000) by comparing with standard PD group. Besides, no significant difference was observed in the 1-year survival rate (RR = 0.87, 95% CI 0.60 to approximately 1.25, P = 0.69), 5-year survival rate (RR = 1.04, 95% CI 0.68 to approximately 1.58, P = 0.854), postoperative mortality (RR = 1.14, 95% CI 0.43 to approximately 3.00, P = 0.789), length of stay (WMD = −0.32, 95% CI −2.57 to approximately 1.94 , P = 0.784) and the amount of blood transfusions (WMD = −0.14, 95% CI −0.36 to approximately 0.08, P = 0.213). Conclusions PD/ELND does not have an advantage over standard PD in the survival rate for patients with pancreatic cancer, but does increase operative time and incidences of postoperative complications.
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Affiliation(s)
- Xinbao Xu
- Department of Hepatobiliary Surgery, Airforce General Hospital of Chinese People's Liberation Army, Beijing 100142, China.
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Toomey PG, Vohra NA, Ghansah T, Sarnaik AA, Pilon-Thomas SA. Immunotherapy for gastrointestinal malignancies. Cancer Control 2013; 20:32-42. [PMID: 23302905 DOI: 10.1177/107327481302000106] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gastrointestinal (GI) cancers are the most common human tumors encountered worldwide. The majority of GI cancers are unresectable at the time of diagnosis, and in the subset of patients undergoing resection, few are cured. There is only a modest improvement in survival with the addition of modalities such as chemotherapy and radiation therapy. Due to an increasing global cancer burden, it is imperative to integrate alternative strategies to improve outcomes. It is well known that cancers possess diverse strategies to evade immune detection and destruction. This has led to the incorporation of various immunotherapeutic strategies, which enable reprogramming of the immune system to allow effective recognition and killing of GI tumors. METHODS A review was conducted of the results of published clinical trials employing immunotherapy for esophageal, gastroesophageal, gastric, hepatocellular, pancreatic, and colorectal cancers. RESULTS Monoclonal antibody therapy has come to the forefront in the past decade for the treatment of colorectal cancer. Immunotherapeutic successes in solid cancers such as melanoma and prostate cancer have led to the active investigation of immunotherapy for GI malignancies, with some promising results. CONCLUSIONS To date, monoclonal antibody therapy is the only immunotherapy approved by the US Food and Drug Administration for GI cancers. Initial trials validating new immunotherapeutic approaches, including vaccination-based and adoptive cell therapy strategies, for GI malignancies have demonstrated safety and the induction of antitumor immune responses. Therefore, immunotherapy is at the forefront of neoadjuvant as well as adjuvant therapies for the treatment and eradication of GI malignancies.
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Affiliation(s)
- Paul G Toomey
- Department of Surgery, USF Health Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Ghansah T, Vohra N, Kinney K, Weber A, Kodumudi K, Springett G, Sarnaik AA, Pilon-Thomas S. Dendritic cell immunotherapy combined with gemcitabine chemotherapy enhances survival in a murine model of pancreatic carcinoma. Cancer Immunol Immunother 2013; 62:1083-91. [PMID: 23604104 DOI: 10.1007/s00262-013-1407-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 02/15/2013] [Indexed: 01/27/2023]
Abstract
Pancreatic cancer is an extremely aggressive malignancy with a dismal prognosis. Cancer patients and tumor-bearing mice have multiple immunoregulatory subsets including regulatory T cells (Tregs) and myeloid-derived suppressor cells (MDSC) that may limit the effectiveness of anti-tumor immunotherapies for pancreatic cancer. It is possible that modulating these subsets will enhance anti-tumor immunity. The goal of this study was to explore depletion of immunoregulatory cells to enhance dendritic cell (DC)-based cancer immunotherapy in a murine model of pancreatic cancer. Flow cytometry results showed an increase in both Tregs and MDSC in untreated pancreatic cancer-bearing mice compared with control. Elimination of Tregs alone or in combination with DC-based vaccination had no effect on pancreatic tumor growth or survival. Gemcitabine (Gem) is a chemotherapeutic drug routinely used for the treatment for pancreatic cancer patients. Treatment with Gem led to a significant decrease in MDSC percentages in the spleens of tumor-bearing mice, but did not enhance overall survival. However, combination therapy with DC vaccination followed by Gem treatment led to a significant delay in tumor growth and improved survival in pancreatic cancer-bearing mice. Increased MDSC were measured in the peripheral blood of patients with pancreatic cancer. Treatment with Gem also led to a decrease of this population in pancreatic cancer patients, suggesting that combination therapy with DC-based cancer vaccination and Gem may lead to improved treatments for patients with pancreatic cancer.
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Affiliation(s)
- Tomar Ghansah
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:230-41. [PMID: 22038501 DOI: 10.1007/s00534-011-0466-6] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The value of pancreatoduodenectomy (PD) with extended lymphadenectomy for pancreatic cancer has been evaluated by many retrospective studies and 3 randomized controlled trials (RCT). However, the protocols used and the results found in the 3 RCTs were diverse. Therefore, a multicenter RCT was proposed in 1998 to evaluate the primary end point of long-term survival and the secondary end points of morbidity, mortality and quality of life of patients undergoing standard versus extended lymphadenectomy in radical PD for pancreatic cancer. METHODS From March 2000 to May 2003, 112 patients with potentially curable pancreatic head cancer were enrolled and intraoperatively randomized to a standard or extended lymphadenectomy group. No resected patients received any adjuvant treatments. RESULTS A hundred and one eligible patients were analyzed. Demographic and histopathological characteristics of the two groups were similar. The mean operating time, intraoperative blood loss and number of retrieved lymph nodes were greater in the extended group, but the other operative results were comparable. CONCLUSIONS Although this multicenter RCT was conducted in a strict setting, extended lymphadenectomy in radical PD did not benefit long-term survival in patients with resectable pancreatic head cancer and led to levels of morbidity, mortality and quality of life comparable to those found after standard lymphadenectomy.
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Affiliation(s)
- Yuji Nimura
- The First Department of Surgery, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Toomey P, Hernandez J, Golkar F, Ross S, Luberice K, Rosemurgy A. Pancreatic adenocarcinoma: complete tumor extirpation improves survival benefit despite larger tumors for patients who undergo distal pancreatectomy and splenectomy. J Gastrointest Surg 2012; 16:376-81. [PMID: 22135126 DOI: 10.1007/s11605-011-1765-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 10/16/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Patients with pancreatic adenocarcinoma have poor survival. Presumably, tumors in the body or tail of the pancreas, due to paucity of symptoms, present later than patients with tumors in the head of the pancreas. This study was undertaken to determine if tumors amenable to complete extirpation by distal pancreatectomy/splenectomy have worse survival when compared to their proximal counterparts. METHODS Since 1992, patients undergoing pancreaticoduodenectomy or distal pancreatectomy/splenectomy for pancreatic adenocarcinoma have been prospectively followed. The impact of resection was evaluated using a survival curve analysis (Mantel-Cox). Data are presented as median, mean ± SD. RESULTS Two hundred twenty patients underwent pancreaticoduodenectomy and 33 patients underwent distal pancreatectomy/splenectomy for pancreatic adenocarcinoma. Comparing overall survival, there was not a significant difference between patients undergoing pancreaticoduodenectomy (16.8 months, 25.6 ± 26) and distal pancreatectomy/splenectomy (15.2 months, 19.7 ± 18.6), p = 0.34. Patients undergoing distal pancreatectomy/splenectomy had significantly larger tumors (4 cm, 5 ± 2.3) compared to patients undergoing pancreaticoduodenectomy (3 cm, 3 ± 1.4), p = 0.005. CONCLUSION Long-term survival after resection of pancreatic adenocarcinoma is poor despite the location within the pancreas. Complete tumor extirpation continues to be an independent predictor of survival, regardless of operation undertaken, despite larger tumors for patients who undergo distal pancreatectomy/splenectomy.
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Affiliation(s)
- Paul Toomey
- Tampa General Hospital Medical Group, 409 Bayshore Blvd, Tampa, FL 33606, USA
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16
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Yoon KW, Heo JS, Choi DW, Choi SH. Factors affecting long-term survival after surgical resection of pancreatic ductal adenocarcinoma. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:394-401. [PMID: 22200040 PMCID: PMC3243856 DOI: 10.4174/jkss.2011.81.6.394] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/26/2011] [Accepted: 09/14/2011] [Indexed: 01/09/2023]
Abstract
PURPOSE Some patients who undergo surgical resection of pancreatic cancer survive longer than other patients. The purpose of this study was to identify the factors that affect long-term survival after resection of histopathologically confirmed pancreatic ductal adenocarcinoma. METHODS A single-center, retrospective study was conducted among 164 patients who underwent surgical resection of pancreatic cancer, between May 1995 and December 2004. The patient follow-up process was conducted via telephone survey and review of electronic medical records for at least 5 years or until death. RESULTS We compared patients with long-term (≥60 months, n = 19) and short-term survival (<60 months, n = 145). Resection margin status, differentiation of the tumor, tumor stage, pre-operative serum level of albumin, total bilirubin and carbohydrate antigen (CA) 19-9 level are related with survival difference (all factors, P < 0.05). Multivariate analysis revealed that a pre-operative serum total bilirubin level <7 mg/dL and a pre-operative serum CA19-9 level <37 U/mL is a statistically significant prognostic factor for long-term survival. CONCLUSION The preoperative serum total bilirubin and serum CA19-9 levels are associated with long-term survival after surgical resection of pancreatic cancer.
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Affiliation(s)
- Kyoung Won Yoon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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17
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Role of extended surgery for pancreatic cancer: critical review of the four major RCTs comparing standard and extended surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:785-91. [PMID: 21837405 DOI: 10.1007/s00534-011-0432-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Pancreatic ductal carcinoma is one of the most dismal malignancies in the gastrointestinal system. Despite the development of several adjuvant therapeutic options, surgical treatment is still the only procedure that can completely cure this disease. Since pancreatic cancer easily extends to the adjacent tissues or develops distant metastasis, there has been argument as to whether we should perform extended surgery in order to widely eradicate peripancreatic tissue. After the report from Japanese surgeons that showed a survival benefit of the extended surgery for the invasive ductal carcinoma of the pancreas in the late 1980s, many Japanese surgeons applied the extended surgery for pancreatic cancer. However, the major problems of these studies were the retrospective and non-randomized nature of the study design. Thereafter, randomized controlled trials (RCT) comparing a standard and extended resection for the pancreatic cancer have been conducted first in Europe, second and third in the USA, and, subsequently, fourth in Japan. Unexpectedly, the survival benefit of the aggressive surgery has been refuted in all of the four major RCTs. This fact implied to us that surgery alone is not enough and that another adjuvant therapeutic option is necessary in order to improve the patients' survival of pancreatic cancer.
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18
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Shrikhande SV, Barreto SG. Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence. World J Gastrointest Surg 2010; 2:39-46. [PMID: 21160848 PMCID: PMC2999214 DOI: 10.4240/wjgs.v2.i2.39] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 12/11/2009] [Accepted: 12/18/2009] [Indexed: 02/06/2023] Open
Abstract
Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.
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Affiliation(s)
- Shailesh V Shrikhande
- Shailesh V Shrikhande, Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai 400 012, India
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19
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Yokoyama Y, Nimura Y, Nagino M. Advances in the treatment of pancreatic cancer: limitations of surgery and evaluation of new therapeutic strategies. Surg Today 2009; 39:466-75. [PMID: 19468801 DOI: 10.1007/s00595-008-3904-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2008] [Accepted: 04/02/2008] [Indexed: 01/21/2023]
Abstract
Pancreatic ductal carcinoma is one of the most dismal malignancies of the gastrointestinal system. Even after curative resection, the actual 5-year survival is only 10%-20%. Of all the treatments used against pancreatic cancer, surgery is still the only one that can achieve complete cure. Pancreatic cancer spreads easily to the adjacent tissues and distant metastasis is common. Typically, this cancer invades the retropancreatic neural tissue, duodenum, portal vein (PV), and superior mesenteric vein (SMV), or regional lymph nodes. For this reason, aggressive surgery that removes the cancerous lesion completely is recommended. Several retrospective and prospective studies have been conducted to validate the usefulness of aggressive surgery for pancreatic cancer in the past few decades. Surprisingly, the survival benefits of aggressive surgery have been denied by most randomized controlled trials (RCTs). This implies that surgery alone is not enough. Thus, adjuvant therapy, such as radiotherapy and chemotherapy, has been given in combination with surgery to improve survival. Although the benefits of radiotherapy alone are limited, the results of chemotherapy are promising. Other newly evolving molecular targeting drugs may also improve the treatment outcomes of pancreatic cancer.
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Affiliation(s)
- Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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20
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Iqbal N, Lovegrove R, Tilney H, Abraham A, Bhattacharya S, Tekkis P, Kocher H. A comparison of pancreaticoduodenectomy with extended pancreaticoduodenectomy: A meta-analysis of 1909 patients. Eur J Surg Oncol 2009; 35:79-86. [DOI: 10.1016/j.ejso.2008.01.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 01/08/2008] [Indexed: 12/21/2022] Open
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21
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Adequate lymphadenectomy results in accurate nodal staging without an increase in morbidity in patients with gastric adenocarcinoma. Am J Surg 2008; 196:413-7. [DOI: 10.1016/j.amjsurg.2007.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 10/26/2007] [Accepted: 10/26/2007] [Indexed: 12/18/2022]
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22
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Samra JS, Gananadha S, Hugh TJ. Surgical management of carcinoma of the head of pancreas: extended lymphadenectomy or modified en bloc resection? ANZ J Surg 2008; 78:228-36. [PMID: 18366391 DOI: 10.1111/j.1445-2197.2008.04426.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatoduodenectomy for the treatment of periampullary cancer was described over 70 years ago. The technique has evolved in an attempt to improve the dismal prognosis for patients with pancreatic cancers. Radical regional resection has been proposed to decrease the incidence of local recurrence as well as to improve survival. These extended resections have failed to show a significant survival benefit in prospective randomized controlled studies. Furthermore, extended pancreatic resections may be associated with increased morbidity. The concept of modified en bloc resection has been advocated and is soundly based on anatomical and pathological principals. This procedure is a modification of the radical regional resection previously described. It involves resection of the peripancreatic retroperitoneal tissue and lymph nodes en bloc with the head of pancreas, in order to achieve an R0 resection but without the morbidity associated with an extended lymphadenectomy. Conceptually, this procedure may be the most appropriate technique for the management of pancreatic head cancers although the ultimate effect on long-term survival can only be judged after further clinical studies.
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Affiliation(s)
- Jaswinder S Samra
- Royal North Shore Hospital, Upper Gastrointestinal Surgical Unit, Sydney, New South Wales, Australia.
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23
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Büchler P, Friess H, Müller M, AlKhatib J, Büchler MW. Survival benefit of extended resection in pancreatic cancer. Am J Surg 2007. [DOI: 10.1016/j.amjsurg.2007.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kocher HM, Sohail M, Benjamin IS, Patel AG. Technical limitations of lymph node mapping in pancreatic cancer. Eur J Surg Oncol 2007; 33:887-91. [PMID: 17433604 DOI: 10.1016/j.ejso.2007.02.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 02/28/2007] [Indexed: 12/11/2022] Open
Abstract
AIM The high incidence of lymphatic and peri-neural invasion in pancreatic cancer results in poor loco-regional control. Radical pancreatico-duodenectomy may achieve better loco-regional control, but is accompanied by increasing morbidity. Our hypothesis was that if intra-operative mapping of pathological lymph nodes (LN) is technically feasible in pancreatic cancer, it would allow for selective radical resection. METHODS In an ethically approved and statistically powered feasibility study of 72 (stopped after 20% enrollment) patients with suspected pancreatic cancer undergoing resection, we injected methylene blue dye peri- and intra-tumorally and studied its progress to identify putative 'sentinel lymph node(s)'. The Kausch-Whipple procedure (or total pancreatectomy, if required) was carried out in addition to radical LN dissection, which was evaluated histopathologically according to the Japanese criteria. RESULTS Over 18 months, 14/16 patients prospectively recruited underwent lymph node mapping and a mean of 20 (range 11-37) LNs per patient were harvested. Methylene blue dye injection identified blue LN(s) in 4/14 patients, none of which were positive for malignant deposits, whilst 10/14 patients had LN metastases. The commonest stations for LN metastasis were 17A or B (9/10), 8A (2/10) and 6 (3/10). The median survival for the 13 patients with cancer was 22.3 months (IQR: 10.4-30 months). CONCLUSION Sentinel lymph node mapping is not technically feasible in pancreatic cancer.
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Affiliation(s)
- H M Kocher
- Department of Surgery, King's College Hospital, London, UK.
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Tang ZY, Wu YL, Gao SL, Shen HW. Effects of the proteasome inhibitor bortezomib on gene expression profiles of pancreatic cancer cells. J Surg Res 2007; 145:111-23. [PMID: 17714734 DOI: 10.1016/j.jss.2007.03.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Revised: 03/13/2007] [Accepted: 03/15/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly chemoresistant malignancy. Gemcitabine is a widely used clinical chemotherapeutic agent against locally advanced and metastatic pancreatic cancer. Proteasome inhibitor bortezomib has been shown to result in enhanced cytotoxicity and apoptosis when used alone or in combination with gemcitabine in pancreatic cancer cell lines. MATERIALS AND METHODS To determine the effect of bortezomib on gene expression profile of pancreatic adenocarcinoma cells with different sensitivity to gemcitabine, we used Affymetrix HG U133A 2.0 GeneChip (Santa Clara, CA) and measured changes induced by bortezomib in pancreatic cancer cell lines with high (BxPC-3) and low (PANC-1) sensitivity to gemcitabine, at time points 24 h. Selected genes were subsequently validated by quantitative real-time polymerase chain reaction. RESULTS Forty-four common genes in both PANC-1 and BxPC-3 cells were identified as up-regulated (>3-fold) induced by bortezomib analyzed by microarray, which are associated with multiple cytotoxic and cytoprotective effects. Bcl-2 was repressed by bortezomib in both PANC-1 and BxPC-3 cells, while no changes induced in either cell by bortezomib were disclosed in all five members of nuclear factor-kappa B family. Other interesting genes related to apoptosis or drug metabolism, such as TP53 and ABCB1 (mdr1), were not found differentially expressed in common. CONCLUSIONS Bortezomib exhibits antitumor effects toward pancreatic cancer in vitro and in vivo. Genes with divergent apoptotic effects are induced by bortezomib, which may become promising targets for pancreatic cancer treatment.
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Affiliation(s)
- Zhi-Yu Tang
- Department of Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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27
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Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger T. Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space. World J Surg Oncol 2007; 5:44. [PMID: 17459163 PMCID: PMC1865381 DOI: 10.1186/1477-7819-5-44] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Accepted: 04/25/2007] [Indexed: 11/22/2022] Open
Abstract
Background Prognosis after surgical therapy for pancreatic cancer is poor and has been attributed to early lymph node involvement as well as to a strong tendency of cancer cells to infiltrate into the retropancreatic tissue and to spread along the peripancreatic neural plexuses. The objective of our study was to classify the anatomical-surgical layer of the mesopancreas and to describe the surgical principles relevant for resection of the mesopancreas (RMP). Immunohistochemical investigation of the mesopancreatic-perineural lymphogenic structures was carried out with the purpose of identifying possible routes of metastatic spread. Methods Resection of the mesopancreas (RMP) was performed in fresh corpses. Pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated. Results The mesopancreas strains itself dorsally of the mesenteric vessels as a whitish-firm, fatty tissue-like layer. Macroscopically, in the dissected en-bloc specimens of pancreas and mesopancreas nerve plexuses were found running from the dorsal site of the pancreatic head to the mesopancreas to establish a perineural plane. Immunohistochemical examinations revealed the lymphatic vessels localized in direct vicinity of the neuronal plexuses between pancreas and mesopancreas. Conclusion The mesopancreas as a perineural lymphatic layer located dorsally to the pancreas and reaching beyond the mesenteric vessels has not been classified in the anatomical or surgical literature before. The aim to ensure the greatest possible distance from the retropancreatic lymphatic tissue which drains the carcinomatous focus can be achieved in patients with pancreatic cancer only by complete resection of the mesopancreas (RMP).
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Germany
| | - Mario Domeyer
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Germany
| | - Tanja Wolloscheck
- Institute of Anatomy and Cell Biology, Johannes Gutenberg-University of Mainz, Germany
| | - Moritz A Konerding
- Institute of Anatomy and Cell Biology, Johannes Gutenberg-University of Mainz, Germany
| | - Theodor Junginger
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Germany
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28
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Michalski CW, Kleeff J, Wente MN, Diener MK, Büchler MW, Friess H. Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer. Br J Surg 2007; 94:265-73. [PMID: 17318801 DOI: 10.1002/bjs.5716] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although some retrospective studies of extended radical lymphadenectomy for pancreatic cancer have suggested a survival advantage, this is controversial. METHODS A literature search identified randomized controlled trials comparing extended with standard lymphadenectomy in pancreatic cancer surgery. Overall survival was analysed using hazard ratios and standard errors. Pooled estimates of overall treatment effects were calculated using a random effects model (odds ratio and 95 per cent confidence interval). RESULTS Of four randomized trials identified for systematic review, three were included in a meta-analysis of survival. The log hazard ratios (standard errors) for survival for the three trials were 0.36 (0.22), - 0.15 (0.17) and - 0.21 (0.15); the weighted mean log hazard ratio for survival overall was 0.93 (95 per cent confidence interval 0.77 to 1.13), revealing no significant differences between the standard and extended procedure (P = 0.480). Morbidity and mortality rates were also comparable, with a trend towards higher rates of delayed gastric emptying for extended lymphadenectomy. The number of resected lymph nodes was significantly higher in the extended lymphadenectomy groups (P < 0.001). CONCLUSION The extended procedure does not benefit overall survival, and there may even be a trend towards increased morbidity. Therefore extended lymphadenectomy should be performed only within adequately powered controlled trials, if at all.
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Affiliation(s)
- C W Michalski
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
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29
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Garcea G, Dennison AR, Ong SL, Pattenden CJ, Neal CP, Sutton CD, Mann CD, Berry DP. Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas. Eur J Surg Oncol 2007; 33:892-7. [PMID: 17398060 DOI: 10.1016/j.ejso.2007.02.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 02/20/2007] [Indexed: 12/15/2022] Open
Abstract
AIMS We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival. METHODS Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves). RESULTS Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291). CONCLUSION Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.
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Affiliation(s)
- G Garcea
- Department of Hepatobiliary & Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester, UK.
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Nakao A, Fujii T, Sugimoto H, Kanazumi N, Nomoto S, Kodera Y, Inoue S, Takeda S. Oncological problems in pancreatic cancer surgery. World J Gastroenterol 2006; 12:4466-72. [PMID: 16874856 PMCID: PMC4125631 DOI: 10.3748/wjg.v12.i28.4466] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Despite the development of more sophisticated diagnostic techniques, pancreatic carcinoma has not yet been detected in the early stage. Surgical resection provides the only chance for cure or long-term survival. The resection rate has increased due to recent advances in surgical techniques and the application of extensive surgery. However, the postoperative prognosis has been poor due to commonly occurring liver metastasis, local recurrence and peritoneal dissemination. Recent molecular-biological studies have clarified occult metastasis, micrometastasis and systemic disease in pancreatic cancer. Several oncological problems in pancreatic cancer surgery are discussed in the present review.
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Affiliation(s)
- Akimasa Nakao
- Department of Surgery II, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Moon HJ, An JY, Heo JS, Choi SH, Joh JW, Kim YI. Predicting survival after surgical resection for pancreatic ductal adenocarcinoma. Pancreas 2006; 32:37-43. [PMID: 16340742 DOI: 10.1097/01.mpa.0000194609.24606.4b] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES We reviewed the pancreatectomies that were done for pancreatic ductal adenocarcinoma to evaluate patient survival and prognostic predictors. METHODS A review was performed on 94 patients who underwent surgical resection for pancreatic ductal adenocarcinomas from 1995 to 2002. The perioperative factors were compared between the proximal and distal lesions by the chi2 test and t test. Possible predictors for survival were examined for by univariate and multivariate analysis. RESULTS The 5-year survival was 16%. The proximal lesions had a smaller tumor size (3.0 +/- 0.11 vs. 3.9 +/- 0.33 cm, respectively; P = 0.03), a higher incidence of nodal involvement (60.6% vs. 34.8%, respectively; P = 0.031), and poorer histologic differentiation (25.4% vs. 13.0%, respectively; P = 0.01) compared with the distal lesions, and both types of lesions had similar rates of intraoperative transfusion, complete resection, and survival. The factors shown to have favorable independent prognostic significance were negative resection margins (hazard ratio [HR] = 0.23; 95% confidence interval [CI] = 0.12-0.42; P < 0.001), a tumor diameter less than 3 cm (HR = 0.46; 95% CI = 0.27-0.78; P = 0.004), well/moderate tumor differentiation (HR = 0.37; 95% CI = 0.19-0.72; P = 0.004), and adjuvant therapy (HR = 0.61; 95% CI = 0.37-0.99; P = 0.49). CONCLUSIONS For the long-term survival of patients with pancreatic ductal adenocarcinoma, complete excision is the most important therapeutic option, and adjuvant therapy is a significant contributing factor.
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Affiliation(s)
- Hyoun Jong Moon
- Department of Surgery, Myoungji Hospital, Kwandong University College of Medicine, Goyang, Korea
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32
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Yamamoto S, Tomita Y, Hoshida Y, Morooka T, Nagano H, Dono K, Umeshita K, Sakon M, Ishikawa O, Ohigashi H, Nakamori S, Monden M, Aozasa K. Prognostic significance of activated Akt expression in pancreatic ductal adenocarcinoma. Clin Cancer Res 2004; 10:2846-50. [PMID: 15102693 DOI: 10.1158/1078-0432.ccr-02-1441] [Citation(s) in RCA: 195] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Akt is a serine/threonine kinase that plays a central role in tumorigenesis. Among the members of Akt family, Akt2 is associated with the development of human cancers. The present study was designed to clarify the prognostic significance of Akt2 and activated Akt expression in pancreatic ductal adenocarcinoma (PDAC). In addition, activated extracellular signal-regulated kinase 1 and 2 (ERK1/2) and the proliferation activity of tumor cells detected by Ki-67 immunohistochemistry were examined. EXPERIMENTAL DESIGN Immunohistochemical analysis was performed on paraffin-embedded specimens from 65 patients with PDAC; 36 males and 29 females with ages ranging from 48 to 79 years (median, 66 years) of age. Expression levels of Akt2, phosphorylated Akt (p-Akt), and phosphorylated ERK 1/2 (p-ERK 1/2) were categorized as either weaker (low intensity) or equal to stronger (high intensity) compared with those in the endothelial cells of the same specimens. For Ki-67 immunohistochemistry, cases were divided into two groups: level 1, Ki-67 labeling index (LI), <20%; level 2, Ki-67 LI, > or = 20%. RESULTS Twenty-six (42.6%), 28 (45.9%), 39 (63.9%), and 46 (75.4%) of the tumors showed high intensity of Akt2, p-Akt, and p-ERK 1/2 expression, and Ki-67 LI level 2, respectively. A significant positive correlation was observed between Akt2 and p-Akt expression (P < 0.01). Multivariate analysis revealed that p-Akt expression, Ki-67 LI, and histological differentiation are independent prognosticators for PDAC. CONCLUSIONS p-Akt expression is a significant prognostic indicator for PDAC. Inhibition of Akt is a possible molecular approach for treatment of PDAC.
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Affiliation(s)
- Shinji Yamamoto
- Department of Surgery and Clinical Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Alexakis N, Halloran C, Raraty M, Ghaneh P, Sutton R, Neoptolemos JP. Current standards of surgery for pancreatic cancer. Br J Surg 2004; 91:1410-27. [PMID: 15499648 DOI: 10.1002/bjs.4794] [Citation(s) in RCA: 201] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.
Methods
An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.
Results
Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.
Conclusion
The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.
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Affiliation(s)
- N Alexakis
- Department of Surgery, University of Liverpool, Royal Liverpool University Hospital, 5th floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
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Neoptolemos JP, Cunningham D, Friess H, Bassi C, Stocken DD, Tait DM, Dunn JA, Dervenis C, Lacaine F, Hickey H, Raraty MGT, Ghaneh P, Büchler MW. Adjuvant therapy in pancreatic cancer: historical and current perspectives. Ann Oncol 2003; 14:675-92. [PMID: 12702520 DOI: 10.1093/annonc/mdg207] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The results from pancreatic ductal adenocarcinoma appear to be improving with increased resection rates and reduced postoperative mortality reported by specialist pancreatic cancer teams. Developments with medical oncological treatments have been difficult, however, due to the fundamentally aggressive biological nature of pancreatic cancer and its resistance to chemotherapy coupled with a relative dearth of randomised controlled trials. The European Study Group for Pancreatic Cancer (ESPAC)-1 trial recruited nearly 600 patients and is the largest trial in pancreatic cancer. The results demonstrated that the current best adjuvant treatment is chemotherapy using bolus 5-fluorouracil with folinic acid. The median survival of patients randomly assigned to chemoradiotherapy was 15.5 months and is comparable with many other studies, but the median survival in the chemotherapy arm was 19.7 months and is as good or superior to multimodality treatments including intra-operative radiotherapy, adjuvant chemoradiotherapy and neo-adjuvant therapies. The use of adjuvant 5-fluorouracil with folinic acid may be supplanted by gemcitabine but requires confirmation by ongoing clinical trials, notably ESPAC-3, which plans to recruit 990 patients from Europe, Canada and Australasia. Major trials such as ESPAC-1 and ESPAC-3 have set new standards for the development of adjuvant treatment and it is now clear that such treatment in this field has the potential to significantly improve both patient survival and quality of life after curative resection.
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Affiliation(s)
- J P Neoptolemos
- Department of Surgery, University of Liverpool, Liverpool, UK.
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Iacono C, Accordini S, Bortolasi L, Facci E, Zamboni G, Montresor E, Marinello PD, Serio G. Results of pancreaticoduodenectomy for pancreatic cancer: extended versus standard procedure. World J Surg 2002; 26:1309-14. [PMID: 12297922 DOI: 10.1007/s00268-002-5976-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In Western experience, the long-term survival benefit after extended pancreaticoduodenectomy (EPD) in patients with pancreatic ductal adenocarcinoma is still controversial. The aim of this work was to evaluate weather EPD for pancreatic ductal adenocarcinoma prolongs long-term survival compared to standard pancreaticoduodenectomy (SPD). From November 1992 to September 1996, we performed pancreatic resections in 30 patients affected by stage I-III pancreatic ductal adenocarcinoma: 13 patients underwent SPD and 17 patients underwent EPD, consecutively. The two groups of patients were similar for all the demographic, clinical, and pathological characteristics, and all the intraoperative factors considered except the number of resected lymph nodes (mean number per case = 34.2 +/- 15.5 in the EPD group versus 12.8 +/- 3.6 in the SPD group, p <0.001) and the operative time (median time per case = 375 minutes in the EPD group versus 270 minutes in the SPD group, p = 0.009). Patients in the two groups experienced a similar postoperative course. The estimated survival probability at 1 and 3 years after operation was 0.76 (95% confidence interval [CI]: 0.49 to 0.90) and 0.24 (95% CI: 0.07 to 0.45) in the EPD group; 0.31 (95% CI: 0.09 to 0.55) and 0.08 (95% CI: 0.00 to 0.29) in the SPD group (p = 0.014). According to a Cox model, the treatment was associated with R0 patients' long-term survival (SPD versus EPD: hazard ratio (HR) = 4.82, 95% CI: 1.66 to 14.00, p = 0.004). Grading of tumor differentiation was confirmed to be a relevant prognostic factor (poor versus moderate: HR = 4.33, 95% CI: 1.49 to 12.61, p = 0.007), whereas type of resection had no significant effect (pylorus-preserving versus hemigastrectomy: HR = 1.49, 95% CI: 0.56 to 3.95, p = 0.42). The proportion of R0 patients with local recurrence was lower in the EPD group (20.0% versus 70.0%, p = 0.034).
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Affiliation(s)
- Calogero Iacono
- Department of Surgery, Division of General Surgery C, University of Verona, University Hospital, 37134 Verona, Italy.
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Schäfer M, Müllhaupt B, Clavien PA. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 2002; 236:137-48. [PMID: 12170018 PMCID: PMC1422559 DOI: 10.1097/00000658-200208000-00001] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.
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Affiliation(s)
- Markus Schäfer
- Department of Surgery and Division of Gastroenterology, University of Zürich, Zürich, Switzerland
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Ozawa F, Friess H, Künzli B, Shrikhande SV, Otani T, Makuuchi M, Büchler MW. Treatment of pancreatic cancer: the role of surgery. Dig Dis 2001; 19:47-56. [PMID: 11385251 DOI: 10.1159/000050653] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pancreatic cancer shows an aggressive growth behavior which results in an extremely poor prognosis. It is presently the 4th to 5th leading cause of cancer-related deaths in Western countries with an incidence of 8-10 new cases per 100,000 inhabitants. Since current conservative oncological therapies fail to influence the long-term outcome, curative resection remains the only possibility with a potential for cure. During the past decades, a considerable decrease in postoperative mortality after pancreatic resection and a significant increase in the resection rate have been achieved. Although several types of pancreatic resection have evolved, standard procedures are the classical Whipple resection for cancers of the pancreatic head and left resection for cancers of pancreatic body and tail. Since the pylorus-preserving Whipple resection and extended Whipple resection are still debated as better alternatives to the classical Whipple procedure, large, controlled clinical trials in patients need to be conducted to reach reliable conclusions. However, there is mounting evidence that the pylorus-preserving Whipple procedure offers a better postoperative outcome than the classical Whipple operation without compromising radicality and thereby the long-term prognosis. Despite the progress in surgical treatment of pancreatic cancer, the overall prognosis following resection remains unsatisfactory to date. It is hoped that progress in multimodality treatment and modern therapies, resulting from both clinical and advanced basic research, can improve the prognosis of this malignancy in the near future.
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Affiliation(s)
- F Ozawa
- Department of Visceral and Transplantation Surgery, University of Bern, Inselspital, Bern, Switzerland
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Abstract
Pancreatic cancer surgery was first performed in Japan in the 1940s, although it was not until the 1970s that pancreatic resectional surgery became widely available. In the late 1970s, influenced by the application of regional pancreatectomy by Fortner and colleagues, several institutions in Japan introduced radical pancreatic cancer surgery. Aggressive strategies in pancreatic cancer surgery were approved in Japan in the 1980s. Japanese surgeons introduced additional modifications to pancreatic cancer surgery, including radical pancreatoduodenectomy with extended lymph node and connective tissue dissection and portal vein resection. However, it became clear that such extended operations impair the quality of life of the patient, even though the resectability of cancer increased to up to about 50%. Improvements to radical pancreatoduodenectomy were therefore introduced. Pylorus-preserving pancreatoduodenectomy with extended lymphadenectomy, connective tissue dissection, and portal vein resection is a Japanese modification to radical pancreatectomy that improves the quality of life of the patient and does not reduce the survival rate. Another modification applicable to low-grade malignancies is organ-preserving pancreatectomy, such as duodenum-preserving total pancreatic head resection, ventral pancreatectomy, and medial or segmental pancreatectomy. Although aggressive Japanese surgical strategies have provided important data, most studies have been retrospective. In the near future, Japanese surgeons will need to reevaluate their strategies in term of the importance of extended lymphadenectomy with connective tissue dissection and its influence on long-term survival of patients. Such reevaluation will require randomized controlled trials performed according to a detailed and strict protocol.
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Affiliation(s)
- T Takada
- First Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
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Abstract
BACKGROUND Different results and opinions exist concerning the use of a standard or an extended lymphadenectomy, and about the indications for portal vein resection in the surgical treatment of pancreatic cancer. The site of recurrence of pancreatic cancer may help to define the usefulness of different treatments in avoiding local and/or distant recurrences. METHODS From personal experience and a literature review, 841 patients who underwent portal vein resection were collected, and 29 papers reporting the results of extended lymphadenectomy in the surgical treatment of pancreatic cancer were analyzed. A review of the site of relapse according to the surgical treatment, with or without various adjuvant treatments, was performed. Personal experience on survival rate according to the site of relapse (local, distant, local and distant) is also reported. RESULTS Portal vein resection has been performed without a significant increase in morbidity and mortality rate in a large number of patients. However, its usefulness for increasing the resectability rate and the long-term survival has yet to be established. Extended lymphadenectomy does not increase the morbidity and mortality rate, but conflicting results on long-term survival have been reported. Distant metastases, undetectable by the radiologist and the surgeon, usually kill more than 40% of the resected patients within 12 months. Only lymph node-positive patients with limited undetectable distant metastases seem to benefit from an extended lymphadenectomy. Although many data are lacking, the incidence of the different sites of relapse is the same whatever the surgical and/or adjuvant treatment performed. Overall survival and disease-free survival rate are not affected by the site of relapse. A significantly worse survival rate was observed after the radiological detection of local and distant metastasis than after an only local or only distant metastasis. CONCLUSION Portal vein resection and extended lymphadenectomy can be performed without increasing the surgical morbidity and mortality rate. We still have insufficient data to decide which patient can benefit from a more extended procedure. Standardization of operations, terminology, pathological reporting, and follow-up, together with well-designed prospective studies, will help to decide the operation of choice for pancreatic cancer.
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Affiliation(s)
- S Pedrazzoli
- Dipartimento di Scienze Mediche e Chirurgiche, Semeiotica Chirurgica, Università di Padova, Italia.
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Fernández-Cruz L, Johnson C, Dervenis C. Locoregional dissemination and extended lymphadenectomy in pancreatic cancer. Dig Surg 2000; 16:313-9. [PMID: 10449976 DOI: 10.1159/000018741] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
UNLABELLED Carcinoma of the pancreas is characterized by the high frequency of intrapancreatic (from 75 to 100%) and extrapancreatic neural invasion (from 64 to 69%). Even small-sized tumors (T(1)) show plexus invasion. Carcinoma of the pancreas is also associated with a high incidence (76%) of lymph node metastasis. The knowledge of local and regional tumor spread is mandatory in the planning of rational surgical treatment with the intention to cure. At present, it does not seem possible to predict the direction of lymph drainage leading to nodal involvement in different anatomical areas. However, the anterior and posterior pancreaticoduodenal areas are generally involved at first and nodes farther away from the primary tumor mostly show metastases only after involvement of the nearer nodes. We believe, radical pancreatoduodenectomy should be based on three aspects: wide lymph node dissection; radical retroperitoneal dissection, and pancreatectomy with an extirpation line left of the coeliac axis for tumors of the head and left pancreatectomy for tumors of the body and tail of the pancreas. CONCLUSIONS Cure or long-term palliation of pancreatic cancer is generally possible only after complete erradication of the primary tumor, including its local and regional extensions.
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Wiernik PH. Current status of and future prospects for the medical management of adenocarcinoma of the exocrine pancreas. J Clin Gastroenterol 2000; 30:357-63. [PMID: 10875462 DOI: 10.1097/00004836-200006000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Adenocarcinoma of the exocrine pancreas is one of the most refractory neoplasms to medical treatment. Although of marginal value, 5-fluorouracil (5-FU) alone or in combination with other agents or modalities has been the standard surgical adjuvant approach to localized unresectable tumor as well as the standard treatment for disseminated pancreatic cancer. Recently, a new chemotherapeutic agent, gemcitabine, has been shown to be somewhat more effective than 5-FU against metastatic pancreatic cancer. Treatment with gemcitabine usually results in a greater likelihood of objective response and better symptom control than treatment with 5-FU or drug combinations that include 5-FU. However, treatment with gemcitabine does not improve overall survival of patients with disseminated neoplasm. Newer promising agents such as 9-nitrocamptothecin have recently entered clinical trials, and novel modalities (e.g., gene therapy) are nearing full-scale clinical trial. There are reasons to believe that these and other new initiatives may soon significantly improve the medical management of adenocarcinoma of the exocrine pancreas.
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Affiliation(s)
- P H Wiernik
- Comprehensive Cancer Center at Our Lady of Mercy Medical Center, New York Medical College, Bronx, New York 10466, USA.
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Magistrelli P, Antinori A, Crucitti A, La Greca A, Masetti R, Coppola R, Nuzzo G, Picciocchi A. Prognostic factors after surgical resection for pancreatic carcinoma. J Surg Oncol 2000; 74:36-40. [PMID: 10861607 DOI: 10.1002/1096-9098(200005)74:1<36::aid-jso9>3.0.co;2-f] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical resection offers the only potential cure for pancreatic carcinoma. Several recent series have reported an encouraging increase in 5-year survival rate exceeding 20% and have emphasized the importance of patient selection based on reproducible prognostic factors. The impact on survival of demographic, intraoperative, and histopatologic factors are investigated in this study. METHODS Seventy-three patients with adenocarcinoma of the pancreas, treated at the Department of Surgery of the Catholic University of Rome during 1988-1998, were retrospectively analyzed. Survival data were reviewed, and potential prognostic factors were compared statistically by univariate and multivariate analyses. RESULTS There was no operative mortality, and the morbidity rate was 37%. Actuarial overall and disease-specific survival rates for all 73 patients were, respectively, 27% and 31% at 3 years and 13% and 21% at 5 years, with a median survival time of 16 months. T stage and nodal status significantly affected survival according to univariate analysis (P = 0.0017 and 0.04). An impact on survival, even if not of statistical significance, was shown for other pathologic or intraoperative factors. CONCLUSIONS T and nodal stage are the strongest independent predictors of survival. Limited intraoperative transfusion, reduced operative time, and clear margins also may play a role, which requires further confirmation in a larger series.
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Affiliation(s)
- P Magistrelli
- Department of General Surgery, Catholic University of Rome, Italy.
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Abstract
According to epidemiologic studies, the incidence of acute and chronic pancreatitis and carcinoma of the pancreas are increasing worldwide. This is the result not only of improved diagnostic methods introduced in the last decades (eg, contrast-enhanced computed tomography, "all-in-one" magnetic resonance imaging, single-photon emission computed tomography, and endoscopic retrograde cholangiopancreatography) but also of changes in the environment and nutritional behavior. Once a specific diagnosis has been made, the first-choice interventions in acute and chronic inflammatory pancreatic diseases are predominantly organ-and organ function-preserving surgical procedures. In pancreatic cancer, extended radical surgery and multimodal therapies seem to offer the most benefit. This article provides an overview of recently published articles focusing on surgical treatment options in acute and chronic pancreatitis and carcinoma of the pancreas.
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Affiliation(s)
- W Uhl
- Department of Visceral and Transplantation Surgery, University Hospital of Bern, Bern, Switzerland
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Bold RJ, Charnsangavej C, Cleary KR, Jennings M, Madray A, Leach SD, Abbruzzese JL, Pisters PW, Lee JE, Evans DB. Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis. J Gastrointest Surg 1999; 3:233-43. [PMID: 10481116 DOI: 10.1016/s1091-255x(99)80065-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intraoperative assessment is inaccurate in defining the relationship of a pancreatic head neoplasm to adjacent vascular structures. We evaluated the ability of preoperative contrast-enhanced CT to predict the need for vascular resection during pancreaticoduodenectomy and examined the resected vessels for histologic evidence of tumor invasion. During a 7-year period, 63 patients underwent pancreaticoduodenectomy with en bloc resection of adjacent vascular structures for a presumed pancreatic head malignancy. Clinical, radiologic, operative, and pathologic data were reviewed and analyzed. Fifty-six patients underwent resection of the superior mesenteric-portal vein confluence, three patients required inferior vena cava resection, and the hepatic artery was resected and reconstructed in eight patients. The operative mortality rate was 1.6%, and the overall complication rate was 22%. CT predicted the need for resection of the superior mesenteric or portal veins in 84% of patients. Pathologic analysis revealed tumor invasion of the vein wall in 71% of resected specimens. Tumor invasion of vascular structures adjacent to the pancreas can be predicted with preoperative CT and should alert the surgeon that vascular resection may be required. Histologic evidence of tumor cell infiltration of vessel walls was present in the majority of the resected specimens.
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Affiliation(s)
- R J Bold
- Pancreatic Tumor Study Group: Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Wagner M, Dikopoulos N, Kulli C, Friess H, Büchler M. Standard surgical treatment in pancreatic cancer. Ann Oncol 1999. [DOI: 10.1093/annonc/10.suppl_4.s247] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Slavin J, Ghaneh P, Jones L, Sutton R, Hartley M, Neoptolemos J. The future of surgery for pancreatic cancer. Ann Oncol 1999. [DOI: 10.1093/annonc/10.suppl_4.s285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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