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Wang M, Zhu P, Chen Z, Yang L. Conversion therapy, palliative chemotherapy and surgery, which of these is the best treatment for locally advanced and advanced pancreatic cancer? Anticancer Drugs 2022; 33:e686-e691. [PMID: 34459461 PMCID: PMC8670342 DOI: 10.1097/cad.0000000000001235] [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] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/04/2021] [Indexed: 11/26/2022]
Abstract
A retrospective study was conducted to analyze which translational therapy, palliative chemotherapy and surgery is the best treatment for locally advanced and advanced pancreatic cancer, and to screen out the dominant population for the best treatment. A total of 83 patients with pancreatic cancer, including locally advanced and advanced pancreatic cancer, who had lost the opportunity for radical surgery and were admitted to Zhejiang Provincial People's Hospital between January 2015 and July 2021 were collected. A total of 39 patients received palliative chemotherapy, 25 patients received conversion therapy and 19 patients tried surgery at the first visit. We conducted survival follow-up and prognostic evaluation of 83 patients. The median overall survival (mOS) and median progression-free survival (mPFS) of 25 pancreatic cancer patients who received conversion therapy were longer than those of pancreatic cancer patients who received palliative chemotherapy (mOS: 16 months vs. 9 months, P = 0.001; mPFS: 11 months vs. 7.5 months, P = 0.038) and surgery (mOS: 16 months vs. 9 months, P = 0.018; mPFS: 11 months vs. 5.5 months, P < 0.001). Multivariate and Kaplan-Meier analysis showed that age, distant metastasis, and the degree of CA199 declined after chemotherapy were independent factors affecting overall survival (OS) of pancreatic cancer patients who received conversion therapy. Conversion therapy can improve OS and progression-free survival in patients with locally advanced or advanced pancreatic cancer to a certain extent. Some patients with advanced pancreatic cancer have surprising results after receiving conversion therapy.
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Affiliation(s)
- Mingxing Wang
- Graduate School of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui Province
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Pengfei Zhu
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Zheling Chen
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Liu Yang
- Graduate School of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui Province
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
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Lee PY, Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Surgical and survival outcomes after robotic and open pancreaticoduodenectomy with positive margins. J Chin Med Assoc 2021; 84:698-703. [PMID: 34050108 DOI: 10.1097/jcma.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Though nowadays a palliative pancreaticoduodenectomy (PD) can be performed safely with relatively low mortality and acceptable morbidity rates in experienced centers, there have been no studies on the routine use of a palliative PD or on the advantages of performing surgical resection as a debulking procedure. Furthermore, the impact of resection margins on survival outcomes has been a matter of controversy. Therefore, this study aimed to clarify the role of robotic PD (RPD) in pancreatic and periampullary adenocarcinomas with positive resection margins. METHODS Patients undergoing RPDs and open PDs (OPDs) were included in this study. Based on the resection margins, the patients were divided into the R0, R1, and R2 PD groups. Surgical risks and survival outcomes were analyzed. RESULTS There were 348 PDs, including 29 (8.3%) palliative and 319 (91.7%) curative. Primary tumor origin, tumor sizes, perineural invasions, and abnormal serum carcinoembryonic antigen (CEA) levels were factors leading to palliative resection. The multivariate analysis showed that only pancreatic head adenocarcinomas and abnormal serum CEA levels (>5 ng/mL) were independent predictors. The surgical risks between curative and palliative PD were similar. There were no significant differences in the surgical risks and other surgical parameters between palliative RPDs and OPDs. For curative resection, RPDs resulted in less blood loss, greater harvested lymph nodes yield, less postoperative complications, less delayed gastric emptying, and shorter hospital stays than OPDs. The survival outcome was significantly better following R0 resection in overall periampullary adenocarcinomas, whereas a significant survival difference was shown only between the R0 and R2 resections for pancreatic head adenocarcinomas. CONCLUSION Compared with R0 PDs, palliative R1 PDs could benefit patients with pancreatic head adenocarcinomas when considering survival outcomes without increasing surgical risks. RPD can be considered for curative purposes and as an alternative for palliative management.
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Affiliation(s)
- Po-Ying Lee
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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Factors Predicting Response, Perioperative Outcomes, and Survival Following Total Neoadjuvant Therapy for Borderline/Locally Advanced Pancreatic Cancer. Ann Surg 2021; 273:341-349. [PMID: 30946090 DOI: 10.1097/sla.0000000000003284] [Citation(s) in RCA: 235] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify predictive factors associated with operative morbidity, mortality, and survival outcomes in patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) undergoing total neoadjuvant therapy (TNT). BACKGROUND The optimal preoperative treatment sequencing for BR/LA PDA is unknown. TNT, or systemic chemotherapy followed by chemoradiation (CRT), addresses both occult metastases and positive margin risks and thus is a potentially optimal strategy; however, factors predictive of perioperative and survival outcomes are currently undefined. METHODS We reviewed our experience in BR/LA patients undergoing resection from 2010 to 2017 following TNT assessing operative morbidity, mortality, and survival in order to define outcome predictors and response endpoints. RESULTS One hundred ninety-four patients underwent resection after TNT, including 123 (63%) BR and 71 (37%) LA PDAC. FOLFIRINOX or gemcitabine along with nab-paclitaxel were used in 165 (85%) and 65 (34%) patients, with 36 (19%) requiring chemotherapeutic switch before long-course CRT and subsequent resection. Radiologic anatomical downstaging was uncommon (28%). En bloc venous and/or arterial resection was required in 125 (65%) patients with 94% of patients achieving R0 margins. The 90-day major morbidity and mortality was 36% and 6.7%, respectively. Excluding operative mortalities, the median, 1-year, 2-year, and 3-year recurrence-free survival (RFS) [overall survival (OS)] rates were 23.5 (58.8) months, 65 (96)%, 48 (78)%, and 32 (62)%, respectively. Radiologic downstaging, vascular resection, and chemotherapy regimen/switch were not associated with survival. Only 3 factors independently associated with prolonged survival, including extended duration (≥6 cycles) chemotherapy, optimal post-chemotherapy CA19-9 response, and major pathologic response. Patients achieving all 3 factors had superior survival outcomes with a survival detriment for each failing factor. In a subset of patients with interval metabolic (PET) imaging after initial chemotherapy, complete metabolic response highly correlated with major pathologic response. CONCLUSION Our TNT experience in resected BR/LA PDAC revealed high negative margin rates despite low radiologic downstaging. Extended duration chemotherapy with associated biochemical and pathologic responses highly predicted postoperative survival. Potential modifications of initial chemotherapy treatment include extending cycle duration to normalize CA19-9 or achieve complete metabolic response, or consideration of chemotherapeutic switch in order to achieve these factors may improve survival before moving forward with CRT and subsequent resection.
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Complete Response of Synchronous Liver Metastasis in a Pancreatic Ductal Adenocarcinoma, When Surgery Could Represent a Therapeutic Option. Can J Gastroenterol Hepatol 2020; 2020:8679751. [PMID: 33102398 PMCID: PMC7569435 DOI: 10.1155/2020/8679751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022] Open
Abstract
Metastatic pancreatic ductal adenocarcinoma (PDAC) is characterized by poor prognosis and short survival. Today, the use of new polytherapeutic regimens increases clinical outcome of these patients opening new clinical scenario. A crucial issue related to the actual improvement achieved with these new regimens is represented by the occasional possibility to observe a radiological complete response of metastatic lesions in patients with synchronous primary tumor. What could be the best therapeutic management of these patients? Could surgery represent an indication? Herein, we reported a case of a patient with PDAC of the head with multiple liver metastases, who underwent first-line chemotherapy with mFOLFIRINOX. After 10 cycles, he achieved a complete radiological response of liver metastases and a partial response of pancreatic lesion. A duodenocephalopancreasectomy was performed. Due to liver a lung metastases after 8 months from surgery, a second-line therapy was started with a disease-free survival and overall survival of 8 months and 45 months, respectively. Improvement in the molecular characterization of PDAC could help in the selection of patients suitable for multimodal treatments. This trial is registered with NCT02892305 and NCT00855634.
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In Reply: All Positives May Not Be the Same in Pancreatic Cancer: Lessons Learned From the Past. Am J Clin Oncol 2020; 43:676. [PMID: 32889841 DOI: 10.1097/coc.0000000000000723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Kim Y, Kim SC, Song KB, Kim J, Kang DR, Lee JH, Park KM, Lee YJ. Improved survival after palliative resection of unsuspected stage IV pancreatic ductal adenocarcinoma. HPB (Oxford) 2016; 18:325-31. [PMID: 27037201 PMCID: PMC4814604 DOI: 10.1016/j.hpb.2015.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/25/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Palliative resection of stage IV pancreatic ductal adenocarcinoma (PDAC) has not shown its benefit until now. In our retrospective review, we compared the results of palliative resection to non-resection. METHODS Between 2000 and 2009, metastasis of PDAC was confirmed in the operating room in 150 patients. 35 underwent palliative resection (resection group; R) and 115 did bypass or biopsy. 35 patients (biopsy or bypass group: NR) in the 115 patients were matched with the patients undergoing resection for tumor size and the metastasis of peritoneal seeding. Demographic, clinical, operative data and survival were analyzed. RESULTS There was no significant difference of major complication (Clavien-Dindo classification 3-5) between two groups. There was no 30-day mortality in either group. More patients in R received postoperative chemotherapy (82.9% vs. 57.1%; P = 0.019). Multivariate analysis showed resection and postoperative chemotherapy as independent factor related to survival (hazard ratio, 0.44; 95% CI, 0.25-0.76; P = 0.003). Patients in R showed better survival rates compared to those in NR (P < 0.001). CONCLUSION Our study suggests resection for stage IV PDAC can be associated with increased survival. In patients of stage IV PDAC, palliative resection with chemotherapy could have some benefit in selected patients.
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Affiliation(s)
- Younghwan Kim
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Song Cheol Kim
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea,Correspondence Song Cheol Kim, Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 388-1 Pungnap 2-dong, Songpa-gu, Seoul 136-178, South Korea. Tel: +82 2 3010 6730. Fax: +82 2 3010 6701.
| | - Ki Byoung Song
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Jayoun Kim
- Department of Medical Humanities and Social Medicine, Office of Biostatistics, Ajou University School of Medicine, Suwon, South Korea
| | - Dae Ryong Kang
- Department of Medical Humanities and Social Medicine, Office of Biostatistics, Ajou University School of Medicine, Suwon, South Korea
| | - Jae Hoon Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Kwang-Min Park
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Young-Joo Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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Gluth A, Werner J, Hartwig W. Surgical resection strategies for locally advanced pancreatic cancer. Langenbecks Arch Surg 2015; 400:757-65. [DOI: 10.1007/s00423-015-1318-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 02/07/2023]
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Cannistrà M, Ruggiero M, Zullo A, Serafini S, Grande R, Nardo B. Metastases of pancreatic adenocarcinoma: A systematic review of literature and a new functional concept. Int J Surg 2015; 21 Suppl 1:S15-21. [PMID: 26123383 DOI: 10.1016/j.ijsu.2015.04.093] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Pancreatic cancer, especially Pancreatic Adenocarcinoma, is still associated with a high mortality and morbidity for affected patients notwithstanding considerable progresses in diagnosis and both surgical pharmacological therapy. Despite metastases from colorectal, gastric and neuroendocrine primary tumor and their treatment are widely reported, the literature has been rarely investigated the impact of localization and numbers of pancreatic metastases. This study performed a systematic analysis of the most recent scientific literature on the natural history of Pancreatic Adenocarcinoma focusing attention on the role that the "M" parameter has on a possible prognostic stratification of these patients. MATERIAL AND METHODS PubMed and Science Direct databases were searched for relevant articles on these issue. RESULTS Initial database searches yielded 7231 studies from PubMed and 29101 from Science Direct. We evaluated 1031 eligible full text articles. CONCLUSIONS An updated insight into the world of Pancreatic Tumors might help physicians in better evaluating mechanisms of metastases, patients selection and survival and in programming appropriate interventions to modify the worst outcomes of advanced disease.
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Affiliation(s)
- Marco Cannistrà
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Michele Ruggiero
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Alessandra Zullo
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
| | - Simone Serafini
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy.
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University of Catanzaro, Italy.
| | - Bruno Nardo
- Department of Surgery, Annunziata Hospital of Cosenza, Cosenza, Italy; Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Italy.
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Tol JAMG, Eshuis WJ, Besselink MGH, van Gulik TM, Busch ORC, Gouma DJ. Non-radical resection versus bypass procedure for pancreatic cancer - a consecutive series and systematic review. Eur J Surg Oncol 2014; 41:220-7. [PMID: 25511567 DOI: 10.1016/j.ejso.2014.11.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/06/2014] [Accepted: 11/16/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Most survival studies comparing non-radical resections to bypass surgery in patients with pancreatic cancer often do not differentiate between an R1 and R2 resection. The aim of this study was to evaluate whether non-radical R1 and R2 resections have better postoperative outcomes and survival compared to a palliative bypass. METHODS A single center cohort study was performed analyzing mortality, morbidity and 1-year survival after R1 (tumor cells within 1 mm from the circumferential margin), R2 and bypass surgery in patients with pancreatic cancer. For the systematic review, studies were identified comparing R1 or R2 resections with bypass, in patients with pancreatic cancer. Postoperative outcomes were compared including the cohort study. RESULTS The cohort study (n=405) showed higher morbidity rates after R1 (n=191) and R2 (n=11) resections compared to bypass (52% and 73% vs. 34%, p < 0.01). In-hospital mortality did not differ (overall 1.7%). 1-year survival rates were 71%, 46% and 32% after R1, R2 resection and bypass (p=0.6 between R2 and bypass). The systematic review identified 8 studies, after including the cohort study 1535 patients were analyzed. Increased morbidity after R1-R2 resection (48%) compared to bypass (30-34%) was found. Median survival was 14-18 months after R1 resection vs. 9-13 months after bypass and 8.5-11.5 months after R2 resection vs. 7.5-10.7 months after bypass. CONCLUSION An R2 resection should be avoided in patients with pancreatic cancer due to its poor prognosis. Survival benefit after an R1 resection, as compared to bypass surgery, justifies a resection despite the increased morbidity rate.
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Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - W J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Buc E, Orry D, Antomarchi O, Gagnière J, Da Ines D, Pezet D. Resection of pancreatic ductal adenocarcinoma with synchronous distant metastasis: is it worthwhile? World J Surg Oncol 2014; 12:347. [PMID: 25407113 PMCID: PMC4289271 DOI: 10.1186/1477-7819-12-347] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 07/04/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study is to report prolonged survival in patients with metastatic pancreatic ductal adenocarcinoma (PDAC) managed by chemotherapy and surgery. METHODS Between January 2009 and August 2013, 284 patients with metastatic PDAC were managed in our oncologic department. Among them, three (1%) with a single metastasis (liver in two cases and interaorticaval in one case) underwent one- or two-stage surgical resection of the metastasis and the main tumor. Perioperative data were recorded retrospectively, including disease-free and overall survival. RESULTS The three patients had chemotherapy (FOLFOX or FOLFIRINOX regimen) with objective response or stable disease prior to surgery. Median time between chemotherapy and surgery was 9 (8 to 15) months. Resection consisted in pancreaticoduodenectomy in the three cases. None of the patients had grade III/IV postoperative complications, and median hospital stay was 12 (12 to 22) days. All the patients had postoperative chemotherapy. Only one patient experienced recurrence 11 months after surgery and died after 32.5 months. The two other patients were alive with no recurrence 26.3 and 24.7 months after initial treatment. CONCLUSION Radical resection of PDAC with single distant metastases can offer prolonged survival with low morbidity after accurate selection by neoadjuvant chemotherapy.
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Affiliation(s)
- Emmanuel Buc
- />Department of Digestive and HPB Surgery, CHU Estaing - 1, Place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - David Orry
- />Department of Oncologic Surgery, Centre Georges François Leclerc, Dijon, France
| | - Olivier Antomarchi
- />Department of Digestive and HPB Surgery, CHU Estaing - 1, Place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Johan Gagnière
- />Department of Digestive and HPB Surgery, CHU Estaing - 1, Place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - David Da Ines
- />Department of Radiology, CHU Estaing, Clermont-Ferrand, France
| | - Denis Pezet
- />Department of Digestive and HPB Surgery, CHU Estaing - 1, Place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
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Influence of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy: single centre experience. Langenbecks Arch Surg 2014; 399:649-57. [PMID: 24682374 DOI: 10.1007/s00423-014-1184-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/16/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE Controversy prevails on the impact of preoperative biliary drainage (PBD) on postoperative complications and clinical outcome of pancreatic cancer. We determined whether PBD is associated with increased morbidity and mortality rates after pancreaticoduodenectomy. METHODS A total of 131 consecutive patients who underwent pancreaticoduodenectomy (93 jaundiced, 38 with no jaundice) were included in this study. Overall, 57 % of jaundiced patients underwent PBD, while 43 % were not drained. The impact of PBD on postoperative morbidity and mortality was evaluated by means of logistic regression analysis. The Kaplan-Meier method was applied to determine the effect of PBD on survival of patients with malignant lesions. RESULTS Mortality and morbidity rate was 3 % and 54.6 %, respectively. PBD was demonstrated to be the unique predictor of complications (odds ration [OR] = 10.18; 95 % confidence interval [CI], 3.65-28.39, p < 0.001). The jaundiced patients who were drained exhibited high frequencies of wound infection (p < 0.001), post-pancreatectomy haemorrhage (p = 0.0185) and hyperglycaemia (p < 0.001). In addition, an increased frequency of pancreatic fistula emerged among drained patients compared to those who were not drained (p = 0.036). PBD did not affect survival of patient with malignant lesions. CONCLUSIONS With the exception of the classical indications, PBD should be carefully evaluated in patients with resectable pancreatic cancer.
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Werner J, Combs SE, Springfeld C, Hartwig W, Hackert T, Büchler MW. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 2013; 10:323-33. [PMID: 23629472 DOI: 10.1038/nrclinonc.2013.66] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most aggressive cancers, and surgical resection is a requirement for a potential cure. However, the majority of patients are diagnosed with advanced-stage disease, either metastatic (50%) or locally advanced cancer (30%). Although palliative chemotherapy is the standard of care for patients with metastatic disease, management of locally advanced adenocarcinoma is controversial. Several treatment options, including extended surgical resections, neoadjuvant therapy with subsequent resections, as well as palliative radiotherapy and/or chemotherapy, should be considered. However, there is little evidence available to support treatment options for locally advanced disease. As valid predictive biomarkers for stratification of therapy are not available today, future trials need to define the role of the different treatment options. This Review summarizes the current evidence and discusses available treatment options for both locally advanced and metastatic pancreatic adenocarcinoma.
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Affiliation(s)
- Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Gillen S, Schuster T, Friess H, Kleeff J. Palliative resections versus palliative bypass procedures in pancreatic cancer—a systematic review. Am J Surg 2012; 203:496-502. [DOI: 10.1016/j.amjsurg.2011.05.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 05/04/2011] [Accepted: 05/04/2011] [Indexed: 12/14/2022]
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Bypass surgery versus intentionally incomplete resection in palliation of pancreatic cancer: is resection the lesser evil? J Gastrointest Surg 2011; 15:829-35. [PMID: 21359594 DOI: 10.1007/s11605-011-1469-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 02/08/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVE As technical expertise increases, the indication for pancreatic resection for advanced pancreatic cancer has been expanded over the last years. Recently, several groups reported their series of unintentionally incomplete tumor resections and reported a potential survival benefit for patients after incomplete resection when compared with palliative bypass surgery. We investigated in a retrospective analysis whether even tumor resection that was intended to be incomplete might provide a better outcome than conventional palliative procedures. METHODS Twenty-two patients with a locally non-resectable or disseminated adenocarcinoma of the pancreas underwent a palliative intentionally incomplete resection. Outcome after resection was compared with that of 46 patients matched for age, sex, and histopathological tumor type who underwent a palliative bypass operation. RESULTS Overall surgical morbidity was significantly higher in the resection group (59%) compared with the bypass group (33%, p < 0.05), resulting in a higher relaparotomy rate and a significantly longer postoperative hospital stay (p < 0.001). Surgery-related mortality was significantly higher in the resection group (p < 0.05). Overall survival showed no statistically significant difference between the two groups. CONCLUSIONS Because of the higher surgery-related morbidity and mortality and lack of survival benefit in cases of advanced adenocarcinoma of the pancreas, intentionally incomplete palliative resection is not advisable.
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Papanikolaou IS, Karatzas PS, Triantafyllou K, Adler A. Role of pancreatic endoscopic ultrasonography in 2010. World J Gastrointest Endosc 2010; 2:335-43. [PMID: 21160583 PMCID: PMC2999104 DOI: 10.4253/wjge.v2.i10.335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 09/04/2010] [Accepted: 09/11/2010] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.
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Affiliation(s)
- Ioannis S Papanikolaou
- Ioannis S Papanikolaou, Pantelis S Karatzas, Konstantinos Triantafyllou, Hepatogastroenterology Unit, 2nd Department of Internal Medicine-Propaedeutic, Attikon University General Hospital, Medical School, University of Athens, Athens 12462, Greece
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Uncinate process first--a novel approach for pancreatic head resection. Langenbecks Arch Surg 2010; 395:1161-4. [PMID: 20582600 DOI: 10.1007/s00423-010-0663-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Accepted: 06/10/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE Partial pancreatico-duodenectomy is the standard treatment for malignancies of the pancreatic head. We describe a technical modification with a retrograde dissection of the pancreatic head as a novel surgical approach. METHODS Retrograde resection of the pancreatic head is performed starting with the uncinate process after division of the first jejunal loop and transection of the pancreas as the last operative step of the resection. Technical aspects and possible advantages for this procedure are discussed. RESULTS The retrograde resection can be safely performed and offers a comfortable and innovative approach for pancreatico-duodenectomy. CONCLUSIONS The "uncinate process first" approach can serve as an additional approach in modern pancreatic surgery. Further studies are required to evaluate this procedure regarding operative parameters and postoperative outcome compared to the standard resection.
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di Sebastiano P, Festa L, Büchler MW, di Mola FF. Surgical aspects in management of hepato-pancreatico-biliary tumours in the elderly. Best Pract Res Clin Gastroenterol 2009; 23:919-23. [PMID: 19942168 DOI: 10.1016/j.bpg.2009.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 09/24/2009] [Accepted: 10/01/2009] [Indexed: 01/31/2023]
Abstract
Hepato-pancreatico-biliary (HPB) surgery encompasses major hepatic resection and pancreatic surgery, both procedures of high complexity with a potentially high complication rate. The establishment of centres of excellence with a high patient volume has lowered the complication and increased the resection rate. Besides this, increased life expectancy and improved general health status have increased the number of elderly patients eligible for major surgery. Because elderly patients have more co-morbidities and decreased life expectancy, the benefit of these procedures must be critically evaluated in such patients. Analysis of the literature on this subject demonstrated that pancreatico-duodenectomy can be performed safely in selected elderly patients (80 years of age or older), with morbidity and mortality rates approaching those observed in younger patients. This aspect was also confirmed by cost analysis studies that reported similar data in both groups. Similar findings are also reported for major hepatic resection in elderly patients with either hepatocellular carcinoma (HCC), Klatskin tumour or gallbladder carcinoma. Nevertheless, those elderly patients who will benefit from surgery must be critically selected.
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Affiliation(s)
- Pierluigi di Sebastiano
- Department of Surgery, IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini, San Giovanni Rotondo, Italy.
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Bockhorn M, Cataldegirmen G, Kutup A, Marx A, Burdelski C, Vashist JK, Mann O, Liebl L, König A, Izbicki JR, Yekebas EF. Crossing the Rubicon: when pancreatic resection with curative intent ends in an R2 status. Impact of "desmoplastic pseudo-pancreatitis" and anatomical site of irresectability. Ann Surg Oncol 2009; 16:1212-21. [PMID: 19225843 DOI: 10.1245/s10434-009-0363-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 01/14/2009] [Accepted: 01/14/2009] [Indexed: 01/07/2023]
Abstract
AIM To analyze the impact of pancreatitis-mimicking, concomitant alterations on intraoperative assessment of curative resectability, the anatomical site of irresectability, and outcome after nonintentional R2 resection in pancreatic cancer. METHODS Of 1,099 patients subjected to pancreatic resection for cancer, 40 (4%) underwent R2 resection (group A). The site where tumors turned out to be irresectable and the coincident presence of potentially misleading, fibro-desmoplastic alterations were analyzed. Outcome after resection was compared with 40 bypass patients matched for age, gender, histopathology, and use of additive chemotherapy (group B). RESULTS R2 resection was due to misjudgment regarding resectability in 38 patients (95%) and to uncontrollable hemorrhage in 2 patients (5%). Group A patients had significantly longer operative times (P < 0.0001), required more blood units (P < 0.0001), and had longer hospital stay than group B patients (P = 0.049). Despite a significantly higher relaparotomy rate of 20% (n = 8) in group A versus 5% (n = 2) in group B, perioperative mortality was equal (n = 2, each). Median survival was 11.5 months in group A and 7.5 months in group B (P = 0.014). "Pancreatitis-like" lesions were assessed in 70% (n = 28/40, group A) and 25% (10/40, group B; P = 0.014). The superior mesenteric artery proximal to its jejunal branches was the most likely site of irresectability (60%), followed by its peripheral course (22.5%) and the lower aspects of the celiac trunk (17.5%). CONCLUSIONS Concomitant "pancreatitis-like" alterations hamper the assessment of local resectability in pancreatic cancer. Although palliative resection results in elevated perioperative morbidity compared with bypass procedures, mortality is equal, while survival is prolonged.
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Affiliation(s)
- Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany.
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