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Kinoshita S, Terai T, Nagai M, Nakamura K, Kohara Y, Yasuda S, Matsuo Y, Doi S, Sakata T, Migita K, Ouji-Sageshima N, Ito T, Sho M. Clinical significance and therapeutic implication of CD200 in pancreatic cancer. Pancreatology 2024; 24:1280-1287. [PMID: 39419752 DOI: 10.1016/j.pan.2024.10.007] [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] [Received: 03/16/2024] [Revised: 09/29/2024] [Accepted: 10/12/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND CD200, a negative regulator of T cells as well as a marker for cancer stem cells, represents a significant prognostic factor and potential therapeutic target in certain cancers. However, its clinical significance remains unknown in pancreatic ductal adenocarcinoma (PDAC). METHODS CD200 was assessed in 220 resected PDAC patients who underwent surgery with or without neoadjuvant chemoradiotherapy (NACRT). We examined the clinicopathological outcomes associated with CD200 and further assessed its clinical implications regarding immunological and cancer stem cell properties. RESULTS NACRT was associated with higher CD200 expression (66.4 % vs. 32.2 %, P < 0.001) compared to upfront surgery. CD200 was identified as an independent poor prognostic factor in NACRT (hazard ratio 1.90, 95 % confidence interval 1.12-3.23, P = 0.016), but not in upfront surgery patients. Post-recurrence survival was significantly worse in CD200+ patients compared to CD200- patients in the NACRT group, but there was no significant difference observed in the upfront surgery group. CD200 expression was correlated with significantly lower levels of CD4+, CD8+, and CD45RO+ tumor-infiltrating lymphocytes. Furthermore, the correlation of CD200 with pancreatic cancer stem cell markers CD44/CD24/ESA was stronger in irradiated human pancreatic cancer cells. CONCLUSIONS Our data underscore novel roles for CD200 in immune evasion as well as therapy resistance in pancreatic cancer. CD200 may represent a novel poor prognostic predictive factor and potential therapeutic target for PDAC with NACRT.
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Affiliation(s)
- Shoichi Kinoshita
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yuichiro Kohara
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Shunsuke Doi
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takeshi Sakata
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kazuhiro Migita
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Noriko Ouji-Sageshima
- Department of Immunology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Toshihiro Ito
- Department of Immunology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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Terai T, Nishiwada S, Nagai M, Nakamura K, Kohara Y, Yasuda S, Matsuo Y, Doi S, Sakata T, Kumada H, Watanabe M, Sho M. Clinical impact of carbonic anhydrase 9 expression on neoadjuvant chemoradiotherapy in pancreatic ductal adenocarcinoma. Pancreatology 2024; 24:938-946. [PMID: 39152081 DOI: 10.1016/j.pan.2024.08.003] [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] [Received: 06/15/2024] [Revised: 08/04/2024] [Accepted: 08/09/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND PDAC cells upregulate carbonic anhydrase 9 (CA9) expression in order to survive in hypoxic tumor environments, which plays a key role in tumor progression. However, the relationship between CA9 expression and preoperative treatment has not been clarified. We evaluated the clinical impact of CA9 expression on the efficacy of neoadjuvant chemoradiotherapy (NACRT) in pancreatic ductal adenocarcinoma (PDAC). METHODS We investigated CA9 expression in 273 surgical specimens and 20 serum samples obtained from patients with PDAC and evaluated their clinical outcomes. We analyzed the function of CA9 using human pancreatic cancer cell lines. RESULTS CA9 was positively expressed in 36.2 % of patients who underwent NACRT, which was significantly lower than those who underwent upfront surgery (US) (58.9 %, p < 0.001). Interestingly, patients who were CA9-positive in the US group had a significantly poorer prognosis than that of those in the NACRT group (median survival time [MST], 21.5 months vs. 49.2 months, p < 0.001), while there was no significant difference between patients who were CA9-negative in the US and NACRT groups (MST, 45.8 months vs. 46.3 months, p = 0.357). Moreover, serum CA9 levels tended to correlate positively with CA9 expression in cancer tissues. In-vitro experiments demonstrated that CA9 expression was reduced after treatments with radiation and chemoradiation therapy (RT/CRT), and that CA9 knockdown suppressed the impact of RT/CRT on cancer cell proliferation. CONCLUSIONS CA9 may act as a target molecule for RT/CRT, highlighting its clinical importance as a valuable biomarker for more stringent indications for NACRT.
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Affiliation(s)
- Taichi Terai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Yuichiro Kohara
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Shunsuke Doi
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Takeshi Sakata
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Hirokimi Kumada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Mizuki Watanabe
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, Japan.
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Akahori T, Terai T, Nagai M, Nakamura K, Kohara Y, Yasuda S, Matsuo Y, Doi S, Sakata T, Sho M. Total neoadjuvant therapy improves survival of patients with borderline resectable pancreatic cancer with arterial involvement. Ann Gastroenterol Surg 2024; 8:151-162. [PMID: 38250684 PMCID: PMC10797818 DOI: 10.1002/ags3.12726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/20/2023] [Accepted: 07/27/2023] [Indexed: 01/23/2024] Open
Abstract
Aim This study aimed to evaluate the prognostic impact of total neoadjuvant therapy (TNT) for borderline resectable pancreatic cancer with arterial involvement (BR-A) pancreatic cancer. Methods We analyzed 81 patients initially diagnosed as BR-A who received initial treatments between 2007 and 2021. Among them, 18 patients who received upfront surgery were classified as the UFS group, while 30 patients who were treated with neoadjuvant chemoradiotherapy were classified as the NACRT group. Furthermore, 33 patients who planned to receive a combination treatment of over 6 months of systemic chemotherapies followed by chemoradiotherapy before surgery were classified as the TNT group. Results There were no significant differences in the patients' backgrounds between the three groups at the time of initial treatment. The resection rates of the UFS, NACRT, and TNT groups were 89%, 77%, and 67%, respectively. NACRT had no impact on the prognosis compared to upfront surgery. In sharp contrast, the TNT group had a significantly better prognosis compared to the other groups, especially after pancreatic resection. Multivariate analysis demonstrated that TNT and resection were independent prognostic factors for the patients of BR-A. Conclusion TNT can be a promising therapeutic strategy for patients with BR-A.
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Affiliation(s)
| | - Taichi Terai
- Department of SurgeryNara Medical UniversityNaraJapan
| | - Minako Nagai
- Department of SurgeryNara Medical UniversityNaraJapan
| | - Kota Nakamura
- Department of SurgeryNara Medical UniversityNaraJapan
| | | | | | - Yasuko Matsuo
- Department of SurgeryNara Medical UniversityNaraJapan
| | - Shunsuke Doi
- Department of SurgeryNara Medical UniversityNaraJapan
| | | | - Masayuki Sho
- Department of SurgeryNara Medical UniversityNaraJapan
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Nagai M, Nakamura K, Terai T, Kohara Y, Yasuda S, Matsuo Y, Doi S, Sakata T, Sho M. Significance of multiple tumor markers measurements in conversion surgery for unresectable locally advanced pancreatic cancer. Pancreatology 2023; 23:721-728. [PMID: 37328387 DOI: 10.1016/j.pan.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND This study aimed to evaluate the significance of multiple tumor markers (TMs) measurements in determining the indications for conversion surgery (CS) in the management of unresectable locally advanced pancreatic cancer (UR-LAPC). METHODS A total of 103 patients with UR-LAPC, treated between 2008 and June 2021, were enrolled in this study. Three TMs, including carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and Duke pancreatic monoclonal antigen type 2 (DUPAN-2), were measured. RESULTS Twenty-five patients (24%) underwent CS. The median preoperative treatment period was 9.5 months. The median survival time (MST) from the initial treatment for patients with CS was significantly longer than that for patients without surgery (34.6 vs. 18.9 months, P < 0.001). The number of elevated TMs before CS was one in five patients and two in five patients, while 15 patients had normal levels of all three TMs. Notably, the MST from the initial treatment for patients with all three preoperative normal TMs levels was favorable for 70.5 months. In contrast, patients with one or two preoperatively elevated TMs levels had a significantly worse prognosis (25.4 and 21.0 months, respectively, P < 0.001). Furthermore, the relapse-free survival of patients with three preoperative normal TMs levels was significantly longer than those with one or two elevated TMs levels (21.9 vs. 11.3 or 3.0 months, respectively, P < 0.001). Non-normal values of all TMs before CS were identified as independent poor prognostic factors. CONCLUSIONS Simultaneous measurement and assessment of the three TMs levels may help determine the surgical indications for UR-LAPC after systemic anticancer treatment.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, Nara, Japan
| | | | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Shunsuke Doi
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takeshi Sakata
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan.
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Oncologic Benefits of Neoadjuvant Treatment versus Upfront Surgery in Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14184360. [PMID: 36139520 PMCID: PMC9497278 DOI: 10.3390/cancers14184360] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/31/2022] [Accepted: 09/03/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Borderline resectable pancreatic cancer (BRPC) has been primarily indicated for neoadjuvant treatment (NAT) in the last decade. This study is the updated meta-analysis for only patients with BRPC including recent NAT regimens such as FOLFIRINOX. The OS, R0 resection rate, and node-negativity rate was improved in NAT group compared with upfront surgery. Providing high-quality evidence is important to standardize the treatment protocol and help physicians decide the appropriate pancreatic cancer treatment. Abstract Neoadjuvant treatment (NAT) followed by surgery is the primary treatment for borderline resectable pancreatic cancer (BRPC). However, there is limited high-level evidence supporting the efficacy of NAT in BRPC. PubMed was searched to identify studies that compared the survival between BRPC patients who underwent NAT and those who underwent upfront surgery (UFS). The overall survival (OS) was compared using intention-to-treat (ITT) analysis. A total of 1204 publications were identified, and 19 publications with 21 data sets (2906 patients; NAT, 1516; UFS, 1390) were analyzed. Two randomized controlled trials and two prospective studies were included. Thirteen studies performed an ITT analysis, while six presented the data of resected patients. The NAT group had significantly better OS than the UFS group in the ITT analyses (HR: 0.63, 95% CI = 0.53–0.76) and resected patients (HR: 0.68, 95% CI = 0.60–0.78). Neoadjuvant chemotherapy with gemcitabine or S-1 and FOLFIRINOX improved the survival outcomes. Among the resected patients, the R0 resection and node-negativity rates were significantly higher in the NAT group. NAT improved the OS, R0 resection rate, and node-negativity rate compared with UFS. Standardizing treatment regimens based on high-quality evidence is fundamental for developing an optimal protocol.
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Soer EC, Verbeke CS. Pathology reporting of margin status in locally advanced pancreatic cancer: challenges and uncertainties. J Gastrointest Oncol 2021; 12:2512-2520. [PMID: 34790412 PMCID: PMC8576237 DOI: 10.21037/jgo-20-391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/04/2020] [Indexed: 12/24/2022] Open
Abstract
Chemo(radio)therapy is becoming the new standard for patients with locally advanced pancreatic cancer. In case of tumor regression on imaging, surgical resection can be undertaken, albeit often with the need for extended procedures. Reevaluation of the current routine pathology procedures is required to establish the appropriate histopathological approach of the resulting specimens. This review focusses on margin status, which is universally considered a core data item of the pathology report, of relevance to both the management of the individual patient and the evaluation of the result of surgery in this particular patient group. As explained in this review, due to the cytoreductive effect of neoadjuvant therapy, the conventional definition of a tumor-free margin ("R0") based on 1 mm clearance is not adequate. Furthermore, the complexity of many of the specimens following extended or multivisceral en bloc surgical resection make margin assessment challenging. These large specimens require extensive sampling, which is not always easily implemented in daily practice. At present, there is marked divergence in pathology practice, and consequently, neither the true R0-rate nor the exact prognostic effect of the margin status have been definitively established for resected locally advanced pancreatic cancer. A concerted effort towards uniform and optimal margin assessment is unfortunately still lacking.
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Affiliation(s)
- Eline C. Soer
- Department of Pathology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Caroline S. Verbeke
- Department of Pathology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pathology, Oslo University Hospital, Oslo, Norway
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van Dongen JC, Wismans LV, Suurmeijer JA, Besselink MG, de Wilde RF, Groot Koerkamp B, van Eijck CHJ. The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies. HPB (Oxford) 2021; 23:1321-1331. [PMID: 34099372 DOI: 10.1016/j.hpb.2021.04.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer. METHODS This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models. RESULTS Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity. CONCLUSION Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Leonoor V Wismans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Nakamura K, Sho M, Akahori T, Nishiwada S, Kunishige T, Nakagawa K, Nagai M, Takagi T, Terai T, Ikeda N. Clinical relevance of CD70 expression in resected pancreatic cancer: Prognostic value and therapeutic potential. Pancreatology 2021; 21:573-580. [PMID: 33541781 DOI: 10.1016/j.pan.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/30/2020] [Accepted: 01/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aberrant expression of CD70 in several malignancies is potentially associated with poor patient prognosis and could serve as a therapeutic target. However, the clinical relevance of CD70 expression in pancreatic cancer has not been thoroughly explored. METHODS We evaluated CD70 expression in 166 surgical specimens obtained from human patients with pancreatic cancer. We analyzed the function of CD70 in proliferation and migration using pancreatic cancer cell lines with silenced CD70 expression. RESULTS CD70 expression was positively stained in 42 patients (25%). In the whole cohort, high CD70 expression was not associated with overall survival (OS: 33.1 vs. 40.8 months, P = 0.256), although it was significantly associated with inferior OS in a population of patients that completed adjuvant chemotherapy (OS: 45.4 vs. 63.8 months, P = 0.027). Moreover, the incidence of hematogenous metastasis was significantly higher in patients with high CD70 expression than in those with low CD70 expression (P = 0.020). This finding was also statistically significant in multivariate analyses (P = 0.001). In vitro experiments demonstrated that CD70 expression contributed to cancer cell proliferation independently of gemcitabine treatment as well as cell migration. Furthermore, real-time polymerase chain reaction analysis of frozen surgical tissues showed a correlation between the expression of CD70 and mesenchymal markers. CONCLUSIONS CD70 expression in pancreatic cancer might be involved in hematogenous metastasis. Furthermore, our results imply that CD70 overexpression can serve as a novel prognostic factor and a potential therapeutic target in patients who have completed adjuvant chemotherapy.
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Affiliation(s)
- Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Tomohiro Kunishige
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Tadataka Takagi
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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10
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Nishiwada S, Sho M, Cui Y, Yamamura K, Akahori T, Nakagawa K, Nagai M, Nakamura K, Takagi T, Ikeda N, Li W, Baba H, Goel A. A gene expression signature for predicting response to neoadjuvant chemoradiotherapy in pancreatic ductal adenocarcinoma. Int J Cancer 2020; 148:769-779. [PMID: 32895958 DOI: 10.1002/ijc.33284] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/25/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022]
Abstract
In patients with pancreatic ductal adenocarcinoma (PDAC), optimal treatment selection, including multimodality regimens such as neoadjuvant chemoradiotherapy (NACRT), can be clinically transformative. Unfortunately, currently no predictive biomarkers are available that can guide the use of NACRT in PDAC patients. Accordingly, herein we developed a novel gene signature that can preoperatively predict NACRT-sensitivity in PDAC patients. Herein, we evaluated the performance of a 10-gene panel in 749 PDAC cases, which included two public datasets (The Cancer Genome Atlas and International Cancer Genome Consortium; n = 276), and three clinical specimen cohorts (n = 417), and a pre-NACRT endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy cohort (n = 56). The potential predictive performance of this signature was evaluated and compared to CA-19-9 levels and key clinicopathological factors. We first evaluated the prognostic potential of a 10-gene panel which significantly predicted overall survival in both public datasets (P < .01, P < .01), and two in-house patient cohorts (P < .01, P = .04). In the pre-NACRT EUS-FNA cohort, we established a radio-sensitivity gene panel (RSGP) which yielded highly robust (area under the curve [AUC] = 0.91; 95% CI: 0.81-0.97) for predicting response to gemcitabine-based NACRT. Multivariate logistic regression analysis revealed that RSGP was an independent predictor for response to NACRT (OR = 2.70; 95% CI: 1.25-5.85), and this response-prediction was even more robust when CA-19-9 levels were included into the model. In conclusion, we have validated and developed a novel gene signature that is highly robust in predicting response to NACRT, even in preoperative settings, highlighting its clinical significance for optimizing and personalizing treatment strategies in PDAC patients.
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Affiliation(s)
- Satoshi Nishiwada
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas, USA.,Department of Surgery, Nara Medical University, Nara, Japan.,Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Ya Cui
- Department of Biological Chemistry, School of Medicine, University of California, Irvine, California, USA
| | - Kensuke Yamamura
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas, USA.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, Nara, Japan
| | | | - Naoya Ikeda
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Wei Li
- Department of Biological Chemistry, School of Medicine, University of California, Irvine, California, USA
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ajay Goel
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas, USA.,Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Duarte, California, USA
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11
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Nagai M, Sho M, Akahori T, Nakagawa K, Nakamura K. Application of liquid biopsy for surgical management of pancreatic cancer. Ann Gastroenterol Surg 2020; 4:216-223. [PMID: 32490335 PMCID: PMC7240145 DOI: 10.1002/ags3.12317] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/19/2019] [Accepted: 01/17/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest forms of cancer. Although drug development over the past decade has gradually improved the prognosis of PDAC, the prognosis remains extremely poor. The predominant determinant of a poor prognosis is that patients are already at the advanced stage when they are diagnosed. Therefore, it is essential to detect early-stage PDAC to ensure a good prognosis. However, in general, being asymptomatic at the early stage makes the detection of early-stage PDAC very difficult. Recently, much attention has been focused on the utility of a liquid biopsy as a biomarker. Theoretically, early-stage tumors can be detected even under asymptomatic conditions. A number of studies on liquid biopsies have been reported so far. Several biomarkers, including circulating tumor DNA (ctDNA), circulating tumor cells (CTCS), and exosomes, are used in liquid biopsies, with the potential to be applied to the clinical setting. Each biomarker is reported to have different utilities, such as the detection of early-stage disease, the differential diagnosis of PDAC from other types of pancreatic tumors, the prediction of the prognosis or risk of recurrence, and monitoring the treatment response. In this review, we focus on ctDNA, CTCS, and exosomes as representative liquid biopsy biomarkers and describe the specific functions of each biomarker in the treatment of PDAC. Furthermore, we discuss the application of liquid biopsies, especially for the surgical management of PDAC.
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Affiliation(s)
- Minako Nagai
- Department of Surgery Nara Medical University Kashihara Japan
| | - Masayuki Sho
- Department of Surgery Nara Medical University Kashihara Japan
| | | | - Kenji Nakagawa
- Department of Surgery Nara Medical University Kashihara Japan
| | - Kota Nakamura
- Department of Surgery Nara Medical University Kashihara Japan
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12
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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13
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Pan L, Fang J, Tong C, Chen M, Zhang B, Juengpanich S, Wang Y, Cai X. Survival benefits of neoadjuvant chemo(radio)therapy versus surgery first in patients with resectable or borderline resectable pancreatic cancer: a systematic review and meta-analysis. World J Surg Oncol 2019; 18:1. [PMID: 31892339 PMCID: PMC6937851 DOI: 10.1186/s12957-019-1767-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/02/2019] [Indexed: 12/28/2022] Open
Abstract
Background Pancreatic adenocarcinoma is a highly lethal malignancy. Neoadjuvant chemo(radio)therapy [NAC(R)T] is recommended to use for borderline resectable pancreatic cancer (BRPC) and high-risk resectable pancreatic cancer (RPC), but no high-level evidence exists. Methods We searched PubMed, EMBASE, Web of Science, and Cochrane library to identify trials comparing survival data of NAC(R)T with SF for RPC or BRPC. Overall survival (OS) was synthesized in analysis of all the patients (intention-to-treat [ITT] analysis) and resected patients respectively. Results The meta-analysis included 17 trials with 2286 participants. For BRPC, NAC(R)T improved OS both in ITT analysis (HR, 0.49; 95% CI, 0.37–0.65; P < 0.001) and in analysis of resected patients (HR, 0.66; 95% CI, 0.51–0.85; P = 0.001) in comparison to SF, accompanied with comparable overall resection rate [odds ratio (OR), 0.69; 95% Cl, 0.41–1.16; P = 0.159]. Disease-free survival, R0 rate, and recurrence were also in favor of NAC(R)T. For RPC, OS in analysis of resected patients was higher with NAC(R)T (HR, 0.75; 95% CI, 0.63–0.89; P = 0.001), but OS in ITT analysis was similar (HR, 1.02; 95% CI, 0.85–1.22; P = 0.818). The overall resection rate (OR, 0.50; 95% Cl, 0.25–0.99; P = 0.048) was lower, but R0 rate was higher with NAC(R)T. No differences in disease-free survival and recurrence between NAC(R)T and SF. Survival benefits of NAC(R)T basically persisted across sensitivity and subgroup analyses. Conclusions This meta-analysis demonstrates that NAC(R)T can provide survival benefits in BRPC patients and a subgroup of RPC patients compared with SF. Future research should focus on investigating the potential biomarkers to screen the subgroup of RPC patients who can benefit from neoadjuvant therapy. Trial registration CRD42018103086.
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Affiliation(s)
- Long Pan
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Jing Fang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China
| | - Chenhao Tong
- Department of General Surgery, Shaoxing People's Hospital, Zhejiang University School of Medicine, Shaoxing, 312000, China
| | - Mingyu Chen
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Bin Zhang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Sarun Juengpanich
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Yifan Wang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China. .,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China. .,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China.
| | - Xiujun Cai
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China. .,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China. .,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China.
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14
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Rangarajan K, Pucher PH, Armstrong T, Bateman A, Hamady ZZR. Systemic neoadjuvant chemotherapy in modern pancreatic cancer treatment: a systematic review and meta-analysis. Ann R Coll Surg Engl 2019; 101:453-462. [PMID: 31304767 PMCID: PMC6667953 DOI: 10.1308/rcsann.2019.0060] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma remains a disease with a poor prognosis despite advances in surgery and systemic therapies. Neoadjuvant therapy strategies are a promising alternative to adjuvant chemotherapy. However, their role remains controversial. This meta-analysis aims to clarify the benefits of neoadjuvant therapy in resectable pancreatic ductal adenocarcinoma. METHODS Eligible studies were identified from MEDLINE, Embase, Web of Science and the Cochrane Library. Studies comparing neoadjuvant therapy with a surgery first approach (with or without adjuvant therapy) in resectable pancreatic ductal adenocarcinoma were included. The primary outcome assessed was overall survival. A random-effects meta-analysis was performed, together with pooling of unadjusted Kaplan-Meier curve data. RESULTS A total of 533 studies were identified that analysed the effect of neoadjuvant therapy in pancreatic ductal adenocarcinoma. Twenty-seven studies were included in the final data synthesis. Meta-analysis suggested beneficial effects of neoadjuvant therapy with prolonged survival compared with a surgery-first approach, (hazard ratio 0.72, 95% confidence interval 0.69-0.76). In addition, R0 resection rates were significantly higher in patients receiving neoadjuvant therapy (relative risk 0.51, 95% confidence interval 0.47-0.55). Individual patient data analysis suggested that overall survival was better for patients receiving neoadjuvant therapy (P = 0.008). CONCLUSIONS Current evidence suggests that neoadjuvant chemotherapy has a beneficial effect on overall survival in resectable pancreatic ductal adenocarcinoma in comparison with upfront surgery and adjuvant therapy. Further trials are needed to address the need for practice change.
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Affiliation(s)
- K Rangarajan
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - PH Pucher
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, St Mary’s Hospital, Imperial College London, Southampton, UK
| | - T Armstrong
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A Bateman
- Department of Clinical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - ZZR Hamady
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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15
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Pouypoudat C, Buscail E, Cossin S, Cassinotto C, Terrebonne E, Blanc JF, Smith D, Marty M, Dupin C, Laurent C, Dabernat S, Chiche L, Vendrely V. FOLFIRINOX-based neoadjuvant chemoradiotherapy for borderline and locally advanced pancreatic cancer: A pilot study from a tertiary centre. Dig Liver Dis 2019; 51:1043-1049. [PMID: 31000479 DOI: 10.1016/j.dld.2019.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy, potentially relevant to increase resection rate in pancreatic cancer, is still debated. AIMS To assess tolerance, resection rate and outcomes of patients with non-metastatic pancreatic ductal adenocarcinoma treated by concomitant chemoradiotherapy. METHODS This monocentric study included all consecutive patients treated from 2010 to 2014 for non-metastatic pancreatic adenocarcinoma. Chemotherapy was followed by chemoradiotherapy in operable patients, surgical resectability being assessed by CT-scan. RESULTS Seventy-nine patients were included: 41 patients had borderline and 38 locally advanced tumours. All patients were treated by chemotherapy (FOLFIRINOX), followed by chemoradiotherapy (median dose: 59 Gy, range 45-66 Gy) for 94% of patients. Thirty-seven patients (47%) could subsequently benefit from surgery with a complete R0 resection in 94% of cases, with a postoperative mortality of 5%. Median overall survival was 21.5 months (median follow-up: 48.8 months). Local control, overall and disease-free survival were significantly higher for patients who underwent resection compared to others, with 89.2% vs 59.5% (p = 0.01), 49.7 vs 17.4 months (p < 0.01) and 25.5 vs 9.2 months (p < 0.01), respectively. CONCLUSION Neoadjuvant treatment consisting of FOLFIRINOX chemotherapy followed by chemoradiotherapy is an efficient strategy for patients with borderline and locally advanced pancreatic cancer, resulting in a 43% rate of secondary complete surgical resection associated with high local control, overall and disease-free survival.
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Affiliation(s)
| | - Etienne Buscail
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | | | | | | | - Denis Smith
- CHU Bordeaux, Department of Oncology, Bordeaux, France
| | - Marion Marty
- CHU Bordeaux, Department of Pathology, Bordeaux, France
| | - Charles Dupin
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France
| | - Christophe Laurent
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | - Laurence Chiche
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | - Véronique Vendrely
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France; Bordeaux University, INSERM U1035, Bordeaux, France.
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16
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A Comparison Between Plastic and Metallic Biliary Stent Placement in Patients Receiving Preoperative Neoadjuvant Chemoradiotherapy for Resectable Pancreatic Cancer. World J Surg 2018; 43:642-648. [DOI: 10.1007/s00268-018-4820-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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17
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Nagai M, Sho M, Akahori T, Nishiwada S, Nakagawa K, Nakamura K, Tanaka T, Nishiofuku H, Kichikawa K, Ikeda N. Risk Factors for Late-Onset Gastrointestinal Hemorrhage After Pancreatoduodenectomy for Pancreatic Cancer. World J Surg 2018; 43:626-633. [PMID: 30225561 DOI: 10.1007/s00268-018-4791-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Late-onset gastrointestinal hemorrhage after pancreatoduodenectomy (PD) occasionally occurs repeatedly or leads to a serious condition. This retrospective study aimed to clarify its frequency and pathogenesis. METHODS A total of 147 consecutive patients who underwent PD for pancreatic cancer between 2006 and 2014 were evaluated. Patients were divided into two groups according to the occurrence of late-onset gastrointestinal hemorrhage on postoperative day 100 or later. Furthermore, recurrence and portal vein (PV) hemodynamics were thoroughly reevaluated by computed tomography. RESULTS Eleven patients experienced late-onset gastrointestinal hemorrhage. The bleeding sites were gastrojejunostomy in four patients, choledochojejunostomy in two, transverse colic marginal vein in one, and unknown in four. The median occurrence time of late-onset gastrointestinal hemorrhage was 13.3 months after PD. PV occlusion (63.6 vs. 8.9%; p < 0.001), no patency of PV-splenic vein (SPV) confluence (54.5 vs. 12.7%; p = 0.002), and SPV ligation (36.4 vs. 9.6%; p = 0.025) were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Among 11 patients who experienced late-onset gastrointestinal hemorrhage, 7 had PV occlusion and 6 had local recurrence. CONCLUSIONS Our data suggested for the first time that both oncologic and non-oncologic factors might contribute to late-onset gastrointestinal hemorrhage after PD for pancreatic cancer. Furthermore, PV occlusion, no PV-SPV patency, and SPV ligation were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Therefore, to prevent late-onset gastrointestinal hemorrhage, we must consider various approaches to maintain the patency of the PV and SPV.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hideyuki Nishiofuku
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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18
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Prognostic factors for actual long-term survival in the era of multidisciplinary treatment for pancreatic ductal adenocarcinoma. Langenbecks Arch Surg 2018; 403:693-700. [PMID: 30218193 DOI: 10.1007/s00423-018-1709-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Recent advances in multidisciplinary treatments are improving the postoperative prognosis of pancreatic ductal adenocarcinoma (PDAC). However, the prognosis even after potentially curative resection remains poor. The aim of this study was to identify the clinical and pathological features of actual 5-year survivors under current circumstances. METHODS A total of 128 patients who underwent pancreatectomy for PDAC at our institution between January 2006 and December 2011 were retrospectively analyzed. RESULTS The actual 5-year overall survival rate for all patients was 30.9%, with a median survival time of 33.1 months. Of 128 patients, 25 (19.5%) survived for 5 years after surgery without disease recurrence. A univariate analysis showed that the pretreatment serum CA19-9 value, tumor depth, lymph node metastasis, and UICC stage at resection were significant predictive factors for the actual long-term survival. A multivariate analysis showed that a pretreatment serum CA19-9 value ≥ 110 U/mL was a significant unfavorable prognostic indicator. In addition, all subjects in the 5-year survival group completed adjuvant chemotherapy. The recurrence rate in the liver was significantly lower and that in the lung significantly higher in the long-term survival group than in the short-term survival group. CONCLUSIONS The factors contributing to the long-term survival of PDAC were the pretreatment CA19-9 value and the completion of adjuvant chemotherapy. To achieve the actual long-term survival and cure after pancreatectomy for pancreatic cancer, further treatment strategies enhancing the completion rate of adjuvant chemotherapy are required.
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19
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de Geus SW, Baart VM, Boonstra MC, Kuppen PJ, Prevoo HA, Mazar AP, Bonsing BA, Morreau H, van de Velde CJ, Vahrmeijer AL, Sier CF. Prognostic Impact of Urokinase Plasminogen Activator Receptor Expression in Pancreatic Cancer: Malignant Versus Stromal Cells. Biomark Insights 2017; 12:1177271917715443. [PMID: 28690396 PMCID: PMC5484551 DOI: 10.1177/1177271917715443] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/25/2017] [Indexed: 12/12/2022] Open
Abstract
The urokinase plasminogen activator receptor (uPAR) has been proposed as a potential prognostic factor for various malignancies. The aim of this study is to assess the prognostic value of uPAR expression in neoplastic and stromal cells of patients with pancreatic adenocarcinoma. Urokinase plasminogen activator receptor expression was determined by immunohistochemistry in 122 pancreatic ductal adenocarcinomas. Kaplan-Meier and Cox regression analyses were used to determine the association with survival. Respectively 66%, 82% and 62% of patients with pancreatic cancer expressed uPAR in neoplastic cells, stromal, and in both combined. Multivariate analysis showed a significant inverse association between uPAR expression in both neoplastic and stromal cells and overall survival. The prognostic impact of uPAR in stromal cells is substantial, but not as pronounced as that of uPAR expression in neoplastic cells. This study suggests a role for uPAR as a biomarker to single out higher risk subgroups of patients with pancreatic cancer.
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Affiliation(s)
- Susanna Wl de Geus
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Victor M Baart
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martin C Boonstra
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peter Jk Kuppen
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hendrica Ajm Prevoo
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hans Morreau
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Cornelis Fm Sier
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.,Antibodies for Research Applications B.V., Gouda, The Netherlands
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20
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Schorn S, Demir IE, Reyes CM, Saricaoglu C, Samm N, Schirren R, Tieftrunk E, Hartmann D, Friess H, Ceyhan GO. The impact of neoadjuvant therapy on the histopathological features of pancreatic ductal adenocarcinoma - A systematic review and meta-analysis. Cancer Treat Rev 2017; 55:96-106. [PMID: 28342938 DOI: 10.1016/j.ctrv.2017.03.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Due to increased rates of curative tumor resections exceeding 60% after FOLFIRINOX-treatment, neoadjuvant therapy/NTx is increasingly recognized as an effective therapy option for downstaging borderline or locally advanced pancreatic ductal adenocarcinoma/PDAC. Yet, the effects of NTx on the common histopathological features of PDAC have not been systematically analysed. Therefore, the aim of the current study was to assess the impact of NTx on relevant histopathological features of PDAC. PATIENTS AND METHODS Biomedical databases were systematically screened for predefined searching terms related to NTx and PDAC. The Preferred-Reporting-Items-for-Systematic-review-and-Meta-Analysis/PRISMA-guidelines were used to perform a systematic review and meta-analysis. Articles meeting the predefined criteria were analysed on relevance, and a meta-analysis was performed. RESULTS A total of 9031 studies could be identified that analysed the effect of NTx on PDAC. Only 35 studies presented comparative data on the histological features of neoadjuvantly treated vs. upfront resected PDAC patients. In meta-analyses, the beneficial effect of NTx was reflected by reduced tumor size (T1/2: RR 2.87, 95%-CI: 1.52-5.42, P=0.001, T3/4: RR 0.78, 95%-CI: 0.69-0.89, P=0.0002), lower N-Stage (N0: RR 2.14, 95%-CI: 1.85-2.46, P<0.00001, N1: RR 0.59, 95%-CI: 0.53-0.65, P<0.00001), higher R0-rates (R0: RR 1.13, 95%-CI: 1.08-1.18, P<0.00001, R1: RR 0.66, 95%-CI: 0.58-0.76, P<0.00001), less perineural invasion (Pn1: RR 0.78, 95%-CI: 0.73-0.83, P<0.00001), less lymphatic vessel invasion (RR: 0.50, 95%-CI: 0.36-0.70, P<0.0001) and fewer G3-tumors (RR 0.82, 95%-CI: 0.71-0.94, P=0.005). CONCLUSIONS NTx in PDAC seems to exert its beneficial effect in borderline or locally advanced PDAC over genuine tumor downstaging. Thus, although at least 40% of all NTx treated patients remain unresectable even with modern NTx regimes, neoadjuvantly treated PDAC showed not only increasing resectability rates especially after FOLFIRINOX, but even reach a lower tumor stage than primarily resected PDAC.
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Affiliation(s)
- Stephan Schorn
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Carmen Mota Reyes
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Cemil Saricaoglu
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Nicole Samm
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Rebekka Schirren
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Elke Tieftrunk
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Daniel Hartmann
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Güralp Onur Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.
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Clinical benefits of neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreatic head: an observational study using inverse probability of treatment weighting. J Gastroenterol 2017; 52:81-93. [PMID: 27169844 DOI: 10.1007/s00535-016-1217-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The efficacy of neoadjuvant chemoradiotherapy (NACRT) and subset of pancreatic ductal adenocarcinoma (PDAC) patients who are most likely to benefit from this strategy remain elusive. The aim of this study was to investigate the effects of NACRT in patients with resectable (R) or borderline resectable (BR) adenocarcinoma of the pancreatic head. BR diseases were classified into two groups: lesions involving exclusively the portal vein system (BR-PV) and those abutting the major artery (BR-A). METHODS A total of 504 patients treated with curative intent for PDAC were analyzed (R, n = 273; BR-PV, n = 129; BR-A, n = 102). Patients who underwent upfront surgery and those who underwent NACRT followed by surgery were compared using propensity score-matched and inverse probability of treatment-weighted analyses (UMIN000019719). RESULTS No significant differences were noted in the incidences of curative resection among the three categories (R, BR-PV and BR-A). Propensity score-weighted logistic regression analysis revealed that the incidence of pathologically positive resection margins was reduced by NACRT only for BR patients. Among the propensity score-matched patients, NACRT rather than upfront surgery significantly prolonged the median survival time of BR-PV patients (28.4 vs. 20.1 months; P = 0.044) but not that of R-PDAC patients (28.6 vs. 33.7 months; P = 0.960). NACRT prolonged the median survival time of BR-A patients (18.1 vs. 10.0 months; P = 0.046), but the results remained unsatisfactory. CONCLUSIONS These findings suggest that NACRT improves R0 rates and increases the survival of patients with BR-PV adenocarcinoma of the pancreatic head but not that of patients with R-PDAC.
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Zhu J, Han D, Li X, Pan F, Ma J, Kou J, Fan H, Lang R, He Q. Inferior Infracolic 'Superior Mesenteric Artery First' Approach with a No-Touch Isolation Surgical Technique in Patients with a Borderline Resectable Cancer of the Pancreatic Head. Ann Surg Oncol 2016; 23:976-980. [PMID: 27600620 DOI: 10.1245/s10434-016-5542-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early diagnosis of superior mesenteric artery (SMA) involvement is vital for patients with a borderline resectable cancer of the pancreatic head to achieve an R0 resection. We aimed to detect the effect of the inferior infracolic 'superior mesenteric artery first' approach with a no-touch isolation surgical technique in these patients. METHODS The data of 21 patients who were consecutively diagnosed with a borderline resectable cancer of the pancreatic head and treated with our technique between July 2014 and September 2015 were analyzed. RESULTS During the exploration, five patients were confirmed to have invasion to the SMA. Fourteen patients underwent a pancreaticoduodenectomy, and two patients underwent a total pancreatectomy due to a positive margin at the pancreatic neck on frozen sections. Ten men and six women, with a mean age of 64.1 years, were included in the study. Pathologic stage was T1, T2, and T3 in 1, 3, and 12 patients, respectively. Venous resection was performed in 8 patients, and an R0 resection was achieved in all patients (16/16). The mean intraoperative blood loss was 532 ml (range 200-1800 ml). At median follow-up time after surgery (12.8 months; range 4.5-18 months), two patients had a recurrence in the liver. The 1-year survival rate was 75 %, and the 1-year tumor-free survival rate was 62.5 %. CONCLUSIONS Our technique facilitates early diagnosis of arterial involvement and the achievement of an R0 resection. This technique allows the tumor to be resected in situ, and removed en bloc, and is associated with decreased blood loss.
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Affiliation(s)
- Jiqiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dongdong Han
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xianliang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Fei Pan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jun Ma
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiantao Kou
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hua Fan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement. Langenbecks Arch Surg 2016; 401:1131-1142. [PMID: 27476146 DOI: 10.1007/s00423-016-1488-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/21/2016] [Indexed: 12/22/2022]
Abstract
Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.
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Prognostic Significance of Muscle Attenuation in Pancreatic Cancer Patients Treated with Neoadjuvant Chemoradiotherapy. World J Surg 2016; 39:2975-82. [PMID: 26296840 DOI: 10.1007/s00268-015-3205-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Emerging evidences have gradually revealed the skeletal muscle attenuation (MA) was not only reflected the accumulation of lipids in skeletal muscle but also associated with physiological and pathological states. The aim of this study was to evaluate the impact of MA on the prognosis of pancreatic cancer patients treated with neoadjuvant chemoradiotherapy (NACRT). METHODS Eighty-three patients with pancreatic cancer who received NACRT were enrolled. Patients were divided according to their Hounsfield units of the skeletal muscle at the third lumbar vertebra in CT. The lower quartile was defined as MA group and the remainder as control group. RESULTS There was no significant difference in overall survival between pre-NACRT MA and control groups. In contrast, patients with post-NACRT MA had a significantly poorer prognosis than patients without. The patients in the post-NACRT MA group were significantly older than patients in the control group. There were no significant differences in most clinicopathological and perioperative factors between both groups. However, patients with post-NACRT MA had a longer hospital stay than patients without. Furthermore, the incompletion rate of the proposed adjuvant chemotherapy was significantly higher in the MA group than control. Importantly, multivariate analysis indicated that post-NACRT MA was an independent prognostic factor. CONCLUSIONS Muscle attenuation may have a significant impact in pancreatic cancer patients treated with multimodal therapy. Therefore, our data may provide new insights into perioperative patient care to improve the prognosis of resectable pancreatic cancer.
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Individualized radiotherapy (iRT) concepts for locally advanced pancreatic cancer (LAPC): indications and prognostic factors. Langenbecks Arch Surg 2015; 400:749-56. [DOI: 10.1007/s00423-015-1309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 12/25/2022]
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