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Ahmed TM, Zhu Z, Yasrab M, Blanco A, Kawamoto S, He J, Fishman EK, Chu L, Javed AA. Preoperative Prediction of Lymph Node Metastases in Nonfunctional Pancreatic Neuroendocrine Tumors Using a Combined CT Radiomics-Clinical Model. Ann Surg Oncol 2024:10.1245/s10434-024-16064-4. [PMID: 39179862 DOI: 10.1245/s10434-024-16064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/04/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND PanNETs are a rare group of pancreatic tumors that display heterogeneous histopathological and clinical behavior. Nodal disease has been established as one of the strongest predictors of patient outcomes in PanNETs. Lack of accurate preoperative assessment of nodal disease is a major limitation in the management of these patients, in particular those with small (< 2 cm) low-grade tumors. The aim of the study was to evaluate the ability of radiomic features (RF) to preoperatively predict the presence of nodal disease in pancreatic neuroendocrine tumors (PanNETs). PATIENTS AND METHODS An institutional database was used to identify patients with nonfunctional PanNETs undergoing resection. Pancreas protocol computed tomography was obtained, manually segmented, and RF were extracted. These were analyzed using the minimum redundancy maximum relevance analysis for hierarchical feature selection. Youden index was used to identify the optimal cutoff for predicting nodal disease. A random forest prediction model was trained using RF and clinicopathological characteristics and validated internally. RESULTS Of the 320 patients included in the study, 92 (28.8%) had nodal disease based on histopathological assessment of the surgical specimen. A radiomic signature based on ten selected RF was developed. Clinicopathological characteristics predictive of nodal disease included tumor grade and size. Upon internal validation the combined radiomics and clinical feature model demonstrated adequate performance (AUC 0.80) in identifying nodal disease. The model accurately identified nodal disease in 85% of patients with small tumors (< 2 cm). CONCLUSIONS Non-invasive preoperative assessment of nodal disease using RF and clinicopathological characteristics is feasible.
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Affiliation(s)
- Taha M Ahmed
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Zhuotun Zhu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mohammad Yasrab
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alejandra Blanco
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Satomi Kawamoto
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Linda Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, NYU Langone Grossman School of Medicine, New York, NY, USA.
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Litjens G, Nakamoto A, Brosens LAA, Maas MC, Scheenen TWJ, Zámecnik P, van Geenen EJM, Prokop M, van Laarhoven KJHM, Hermans JJ. Ferumoxtran-10-enhanced MRI for pre-operative metastatic lymph node detection in pancreatic, duodenal, or periampullary adenocarcinoma. Eur Radiol 2024:10.1007/s00330-024-10838-w. [PMID: 38907886 DOI: 10.1007/s00330-024-10838-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/18/2024] [Accepted: 04/26/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES To assess 3-Tesla (3-T) ultra-small superparamagnetic iron oxide (USPIO)-enhanced MRI in detecting lymph node (LN) metastases for resectable adenocarcinomas of the pancreas, duodenum, or periampullary region in a node-to-node validation against histopathology. METHODS Twenty-seven consecutive patients with a resectable pancreatic, duodenal, or periampullary adenocarcinoma were enrolled in this prospective single expert centre study. Ferumoxtran-10-enhanced 3-T MRI was performed pre-surgery. LNs found on MRI were scored for suspicion of metastasis by two expert radiologists using a dedicated scoring system. Node-to-node matching from in vivo MRI to histopathology was performed using a post-operative ex vivo 7-T MRI of the resection specimen. Sensitivity and specificity were calculated using crosstabs. RESULTS Eighteen out of 27 patients (median age 65 years, 11 men) were included in the final analysis (pre-surgery withdrawal n = 4, not resected because of unexpected metastases peroperatively n = 2, and excluded because of inadequate contrast-agent uptake n = 3). On MRI 453 LNs with a median size of 4.0 mm were detected, of which 58 (13%) were classified as suspicious. At histopathology 385 LNs with a median size of 5.0 mm were found, of which 45 (12%) were metastatic. For 55 LNs node-to-node matching was possible. Analysis of these 55 matched LNs, resulted in a sensitivity and specificity of 83% (95% CI: 36-100%) and 92% (95% CI: 80-98%), respectively. CONCLUSION USPIO-enhanced MRI is a promising technique to preoperatively detect and localise LN metastases in patients with pancreatic, duodenal, or periampullary adenocarcinoma. CLINICAL RELEVANCE STATEMENT Detection of (distant) LN metastases with USPIO-enhanced MRI could be used to determine a personalised treatment strategy that could involve neoadjuvant or palliative chemotherapy, guided resection of distant LNs, or targeted radiotherapy. REGISTRATION The study was registered on clinicaltrials.gov NCT04311047. https://clinicaltrials.gov/ct2/show/NCT04311047?term=lymph+node&cond=Pancreatic+Cancer&cntry=NL&draw=2&rank=1 . KEY POINTS LN metastases of pancreatic, duodenal, or periampullary adenocarcinoma cannot be reliably detected with current imaging. This technique detected LN metastases with a sensitivity and specificity of 83% and 92%, respectively. MRI with ferumoxtran-10 is a promising technique to improve preoperative staging in these cancers.
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Affiliation(s)
- Geke Litjens
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Atsushi Nakamoto
- Department of Radiology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marnix C Maas
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom W J Scheenen
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrik Zámecnik
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mathias Prokop
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kees J H M van Laarhoven
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John J Hermans
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Kazami Y, Oba A, Ono Y, Sato T, Inoue Y, Saiura A, Takahashi Y, Ito H. Intraoperative paraaortic lymph node sampling during resection for pancreatic cancer: evolving role in the modern chemotherapy era. HPB (Oxford) 2023; 25:1169-1178. [PMID: 37357111 DOI: 10.1016/j.hpb.2023.05.366] [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: 03/01/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The role of paraaortic lymph node (PALN) sampling for pancreatic cancer (PC) remains controversial. This study aimed to assess the yield of PALN sampling and its impact on long-term outcomes. METHODS Patients treated from 2005 to 2018 were included. Since 2015, patients with borderline resectable or unresectable (BR/UR) tumours received standardized neoadjuvant therapy (NAT), whereas patients with resectable tumours underwent upfront resection. RESULTS Among 771 patients with PALN excision, metastasis was confirmed in 76 patients (10%) and 59 proceeded to planned resection. PALN metastasis was associated with early recurrence and shorter survival after upfront resection (1-year recurrence-free rate: 23% vs 57% for resectable tumours, P < 0.001, 9% vs 52% for BR/UR tumours, P = 0.006; median overall survival (OS): 19 vs 31 months for resectable tumours, P < 0.001, 17 vs 23 months for BR/UR tumours, P = 0.057). In contrast, they were both similar between patients with/without PALN metastasis following NAT for BR tumours (1-year recurrence-free rate, 50% vs 58%, P = 0.88; median OS, 28 vs 35 months, P = 0.45, respectively). CONCLUSIONS Occult metastasis to PALNs is not uncommon in patients with potentially resectable PC. Its prognostic impact depends on the treatment strategy, and the intraoperative decision for resection should be individualized.
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Affiliation(s)
- Yusuke Kazami
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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Zhu M, Zhuo Q, Liu W, Guan C, Zuo Y. Imaging evaluation of para-aortic lymph nodes in cervical cancer. Acta Radiol 2023; 64:2611-2617. [PMID: 37321631 DOI: 10.1177/02841851231179178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND In recent years, much literature has reported the diagnostic value of computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT in para-aortic lymph node metastasis of cervical cancer. PURPOSE To compare and analyze the para-aortic lymph node presentations found in cervical cancer on different images in order to determine the best precise imaging method for identifying metastatic lymph nodes. MATERIAL AND METHODS PubMed, Web of Science, MEDLINE, and other databases were searched for the non-invasive detection of metastatic lymph nodes for a comprehensive comparison. RESULTS Positive lymph nodes on CT are significantly related to the following factors: short axis ≥10 mm; and round or central necrosis. Positive lymph nodes on MRI are significantly related to the following factors: short axis ≥8 mm; inhomogeneous signal intensity; morphology: round, irregular edge, extracapsular invasion, central necrosis, loss of lymph node structure, burrs, or lobes; and ADC value decreases, combined with local actuality. On PET-CT examination, when the short axis of the lymph node is >5 mm, the SUV is >2.5, or the FDG uptake is greater than that of the surrounding tissue, it is a metastatic lymph node. CONCLUSION In conclusion, different imaging techniques show metastatic lymph nodes in different ways. Combining the patient's medical history with the symptoms of the aforementioned lymph nodes, together with one or more imaging techniques, is important to diagnose para-aortic lymph nodes in cervical cancer.
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Affiliation(s)
- Minying Zhu
- Department of Gynecological Oncology, Cancer Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, PR China
| | - Qingchan Zhuo
- Department of Gynecological Oncology, Cancer Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, PR China
| | - Wenci Liu
- Department of Radiology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, PR China
| | - Chengnong Guan
- Department Cancer Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, PR China
| | - Yufang Zuo
- Department of Gynecological Oncology, Cancer Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, PR China
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Gu Q, He M, He Y, Dai A, Liu J, Chen X, Liu P. CT-measured body composition radiomics predict lymph node metastasis in localized pancreatic ductal adenocarcinoma. Discov Oncol 2023; 14:16. [PMID: 36735166 PMCID: PMC9898483 DOI: 10.1007/s12672-023-00624-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To explored the value of CT-measured body composition radiomics in preoperative evaluation of lymph node metastasis (LNM) in localized pancreatic ductal adenocarcinoma (LPDAC). METHODS We retrospectively collected patients with LPDAC who underwent surgical resection from January 2016 to June 2022. According to whether there was LNM after operation, the patients were divided into LNM group and non-LNM group in both male and female patients. The patient's body composition was measured by CT images at the level of the L3 vertebral body before surgery, and the radiomics features of adipose tissue and muscle were extracted. Multivariate logistic regression (forward LR) analyses were used to determine the predictors of LNM from male and female patient, respectively. Sexual dimorphism prediction signature using adipose tissue radiomics features, muscle tissue radiomics features and combined signature of both were developed and compared. The model performance is evaluated on discrimination and validated through a leave-one-out cross-validation method. RESULTS A total of 196 patients (mean age, 60 years ± 9 [SD]; 117 men) were enrolled, including 59 LNM in male and 36 LNM in female. Both male and female CT-measured body composition radiomics signatures have a certain predictive power on LNM of LPDAC. Among them, the female adipose tissue signature showed the highest performance (area under the ROC curve (AUC), 0.895), and leave one out cross validation (LOOCV) indicated that the signature could accurately classify 83.5% of cases; The prediction efficiency of the signature can be further improved after adding the muscle radiomics features (AUC, 0.924, and the accuracy of the LOOCV was 87.3%); The abilities of male adipose tissue and muscle tissue radiomics signatures in predicting LNM of LPDAC was similar, AUC was 0.735 and 0.773, respectively, and the accuracy of LOOCV was 62.4% and 68.4%, respectively. CONCLUSIONS CT-measured body composition Radiomics strategy showed good performance for predicting LNM in LPDAC, and has sexual dimorphism. It may provide a reference for individual treatment of LPDAC and related research about body composition in the future.
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Affiliation(s)
- Qianbiao Gu
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Mengqing He
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Yaqiong He
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Anqi Dai
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Jianbin Liu
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Xiang Chen
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
| | - Peng Liu
- Department of Radiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, 410005 China
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Li Q, Song Z, Zhang D, Li X, Liu Q, Yu J, Li Z, Zhang J, Ren X, Wen Y, Tang Z. Feasibility of a CT-based lymph node radiomics nomogram in detecting lymph node metastasis in PDAC patients. Front Oncol 2022; 12:992906. [PMID: 36276058 PMCID: PMC9579427 DOI: 10.3389/fonc.2022.992906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/20/2022] [Indexed: 12/02/2022] Open
Abstract
Objectives To investigate the potential value of a contrast enhanced computed tomography (CECT)-based radiological-radiomics nomogram combining a lymph node (LN) radiomics signature and LNs’ radiological features for preoperative detection of LN metastasis in patients with pancreatic ductal adenocarcinoma (PDAC). Materials and methods In this retrospective study, 196 LNs in 61 PDAC patients were enrolled and divided into the training (137 LNs) and validation (59 LNs) cohorts. Radiomic features were extracted from portal venous phase images of LNs. The least absolute shrinkage and selection operator (LASSO) regression algorithm with 10-fold cross-validation was used to select optimal features to determine the radiomics score (Rad-score). The radiological-radiomics nomogram was developed by using significant predictors of LN metastasis by multivariate logistic regression (LR) analysis in the training cohort and validated in the validation cohort independently. Its diagnostic performance was assessed by receiver operating characteristic curve (ROC), decision curve (DCA) and calibration curve analyses. Results The radiological model, including LN size, and margin and enhancement pattern (three significant predictors), exhibited areas under the curves (AUCs) of 0.831 and 0.756 in the training and validation cohorts, respectively. Nine radiomic features were used to construct a radiomics model, which showed AUCs of 0.879 and 0.804 in the training and validation cohorts, respectively. The radiological-radiomics nomogram, which incorporated the LN Rad-score and the three LNs’ radiological features, performed better than the Rad-score and radiological models individually, with AUCs of 0.937 and 0.851 in the training and validation cohorts, respectively. Calibration curve analysis and DCA revealed that the radiological-radiomics nomogram showed satisfactory consistency and the highest net benefit for preoperative diagnosis of LN metastasis. Conclusions The CT-based LN radiological-radiomics nomogram may serve as a valid and convenient computer-aided tool for personalized risk assessment of LN metastasis and help clinicians make appropriate clinical decisions for PADC patients.
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Affiliation(s)
- Qian Li
- Department of Radiology, Chongqing Medical University, Chongqing, China
- Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Sciences, Chongqing, China
- Chongqing School, University of Chinese Academy of Sciences, Chongqing, China
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Zuhua Song
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Dan Zhang
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Xiaojiao Li
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Qian Liu
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Jiayi Yu
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Zongwen Li
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Jiayan Zhang
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Xiaofang Ren
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Youjia Wen
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Zhuoyue Tang
- Department of Radiology, Chongqing Medical University, Chongqing, China
- Chongqing Institute of Green and Intelligent Technology, Chinese Academy of Sciences, Chongqing, China
- Chongqing School, University of Chinese Academy of Sciences, Chongqing, China
- Department of Radiology, Chongqing General Hospital, Chongqing, China
- *Correspondence: Zhuoyue Tang,
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Shi L, Wang L, Wu C, Wei Y, Zhang Y, Chen J. Preoperative Prediction of Lymph Node Metastasis of Pancreatic Ductal Adenocarcinoma Based on a Radiomics Nomogram of Dual-Parametric MRI Imaging. Front Oncol 2022; 12:927077. [PMID: 35875061 PMCID: PMC9298539 DOI: 10.3389/fonc.2022.927077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/06/2022] [Indexed: 12/12/2022] Open
Abstract
PurposeThis study aims to uncover and validate an MRI-based radiomics nomogram for detecting lymph node metastasis (LNM) in pancreatic ductal adenocarcinoma (PDAC) patients prior to surgery.Materials and MethodsWe retrospectively collected 141 patients with pathologically confirmed PDAC who underwent preoperative T2-weighted imaging (T2WI) and portal venous phase (PVP) contrast-enhanced T1-weighted imaging (T1WI) scans between January 2017 and December 2021. The patients were randomly divided into training (n = 98) and validation (n = 43) cohorts at a ratio of 7:3. For each sequence, 1037 radiomics features were extracted and analyzed. After applying the gradient-boosting decision tree (GBDT), the key MRI radiomics features were selected. Three radiomics scores (rad-score 1 for PVP, rad-score 2 for T2WI, and rad-score 3 for T2WI combined with PVP) were calculated. Rad-score 3 and clinical independent risk factors were combined to construct a nomogram for the prediction of LNM of PDAC by multivariable logistic regression analysis. The predictive performances of the rad-scores and the nomogram were assessed by the area under the operating characteristic curve (AUC), and the clinical utility of the radiomics nomogram was assessed by decision curve analysis (DCA).ResultsSix radiomics features of T2WI, eight radiomics features of PVP and ten radiomics features of T2WI combined with PVP were found to be associated with LNM. Multivariate logistic regression analysis showed that rad-score 3 and MRI-reported LN status were independent predictors. In the training and validation cohorts, the AUCs of rad-score 1, rad-score 2 and rad-score 3 were 0.769 and 0.751, 0.807 and 0.784, and 0.834 and 0.807, respectively. The predictive value of rad-score 3 was similar to that of rad-score 1 and rad-score 2 in both the training and validation cohorts (P > 0.05). The radiomics nomogram constructed by rad-score 3 and MRI-reported LN status showed encouraging clinical benefit, with an AUC of 0.845 for the training cohort and 0.816 for the validation cohort.ConclusionsThe radiomics nomogram derived from the rad-score based on MRI features and MRI-reported lymph status showed outstanding performance for the preoperative prediction of LNM of PDAC.
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Affiliation(s)
- Lin Shi
- Cancer Center, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Ling Wang
- Cancer Center, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Cuiyun Wu
- Cancer Center, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Yuguo Wei
- Precision Health Institution, General Electric Healthcare, Hangzhou, China
| | - Yang Zhang
- Cancer Center, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Junfa Chen
- Cancer Center, Department of Radiology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
- *Correspondence: Junfa Chen,
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Pande R, Chughtai S, Ahuja M, Brown R, Bartlett DC, Dasari BV, Marudanayagam R, Mirza D, Roberts K, Isaac J, Sutcliffe RP, Chatzizacharias NA. Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma. World J Gastrointest Surg 2022; 14:429-441. [PMID: 35734625 PMCID: PMC9160687 DOI: 10.4240/wjgs.v14.i5.429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/19/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Para-aortic lymph nodes (PALN) are found in the aortocaval groove and they are staged as metastatic disease if involved by pancreatic ductal adenocarcinoma (PDAC). The data in the literature is conflicting with some studies having associated PALN involvement with poor prognosis, while others not sharing the same results. PALN resection is not included in the standard lymphadenectomy during pancreatic resections as per the International Study Group for Pancreatic Surgery and there is no consensus on the management of these cases. AIM To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC. METHODS This is a retrospective cohort study of data retrieved from a prospectively maintained database on consecutive patients undergoing pancreatectomies for PDAC where PALN was sampled between 2011 and 2020. Statistical comparison of the data between PALN+ and PALN- subgroups, survival analysis with the Kaplan-Meier method and risk analysis with univariable and multivariable time to event Cox regression analysis were performed, specifically assessing oncological outcomes such as median overall survival (OS) and disease-free survival (DFS). RESULTS 81 cases had PALN sampling and 17 (21%) were positive. Pathological N stage was significantly different between PALN+ and PALN- patients (P = 0.005), while no difference was observed in any of the other characteristics. Preoperative imaging diagnosed PALN positivity in one case. OS and DFS were comparable between PALN+ and PALN- patients with lymph node positive disease (OS: 13.2 mo vs 18.8 mo, P = 0.161; DFS: 13 mo vs 16.4 mo, P = 0.179). No difference in OS or DFS was identified between PALN positive and negative patients when they received chemotherapy either in the neoadjuvant or in the adjuvant setting (OS: 23.4 mo vs 20.6 mo, P = 0.192; DFS: 23.9 mo vs 20.5 mo, P = 0.718). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 mo vs 14.2 mo; P = 0.015) and DFS (4.4 mo vs 9.8 mo; P < 0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence. CONCLUSION PALN involvement does not affect OS when patients complete the indicated treatment pathway for PDAC, surgery and chemotherapy, and should not be considered as a contraindication to resection.
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Affiliation(s)
- Rupaly Pande
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Shafiq Chughtai
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Manish Ahuja
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Rachel Brown
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - David C Bartlett
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Bobby V Dasari
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Ravi Marudanayagam
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Darius Mirza
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Keith Roberts
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - John Isaac
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
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Elsherif SB, Javadi S, Le O, Lamba N, Katz MHG, Tamm EP, Bhosale PR. Baseline CT-based Radiomic Features Aid Prediction of Nodal Positivity after Neoadjuvant Therapy in Pancreatic Cancer. Radiol Imaging Cancer 2022; 4:e210068. [PMID: 35333131 PMCID: PMC8965532 DOI: 10.1148/rycan.210068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Purpose To study the association between CT-derived textural features of pancreatic cancer and patient outcome. Materials and Methods This retrospective study evaluated 54 patients (median age, 62 years [range, 40-88 years]; 32 men) with pancreatic cancer who underwent chemoradiation followed by surgical resection and lymph node dissection from May 2012 to June 2016. Three-dimensional segmentation of the pancreatic tumor was performed on baseline dual-energy CT images: 70-keV pancreatic parenchymal phase (PPP) images and iodine material density images. Then, 15 and 19 radiomic features were extracted from each phase, respectively. Logistic regression with elastic net regularization was used to select textural features associated with outcome, and receiver operating characteristic analysis evaluated feature performance. Survival curves were generated using the Kaplan-Meier method. Results The feature of integral total (∫ T), representing the mean intensity in Hounsfield units times the contour volume in milliliters of PPP imaging (hereafter, "∫ T (HU·mL) (PPP)"), is inversely associated with posttherapy pathologic lymph node (ypN) category. A threshold ∫ T (HU·mL) (PPP) less than 507.85 predicted ypN1-2 classification with 96% sensitivity, 34% specificity, and area under the curve of 0.61. Patients with an ∫ T (HU·mL) (PPP) of less than 507.85 had decreased overall survival (median, 2.8 years) compared with patients with an ∫ T (HU·mL) (PPP) of 507.85 or greater (one event at 3.4 years) (P = .006). Patients with an ∫ T (HU·mL) (PPP) of less than 507.85 had decreased progression-free survival (median, 1.5 years) compared with patients with an ∫ T (HU·mL) (PPP) of 507.85 or greater (median, 2.7 years) (P = .001). Conclusion A CT-based radiomic signature may help predict ypN category in patients with pancreatic cancer. Keywords: CT-Dual Energy, Abdomen/GI, Pancreas, Tumor Response, Outcomes Analysis © RSNA, 2022 Supplemental material is available for this article.
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10
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Bian Y, Guo S, Jiang H, Gao S, Shao C, Cao K, Fang X, Li J, Wang L, Ma C, Zheng J, Jin G, Lu J. Radiomics nomogram for the preoperative prediction of lymph node metastasis in pancreatic ductal adenocarcinoma. Cancer Imaging 2022; 22:4. [PMID: 34991733 PMCID: PMC8734356 DOI: 10.1186/s40644-021-00443-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 12/12/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To develop and validate a radiomics nomogram for the preoperative prediction of lymph node (LN) metastasis in pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS In this retrospective study, 225 patients with surgically resected, pathologically confirmed PDAC underwent multislice computed tomography (MSCT) between January 2014 and January 2017. Radiomics features were extracted from arterial CT scans. The least absolute shrinkage and selection operator method was used to select the features. Multivariable logistic regression analysis was used to develop the predictive model, and a radiomics nomogram was built and internally validated in 45 consecutive patients with PDAC between February 2017 and December 2017. The performance of the nomogram was assessed in the training and validation cohort. Finally, the clinical usefulness of the nomogram was estimated using decision curve analysis (DCA). RESULTS The radiomics signature, which consisted of 13 selected features of the arterial phase, was significantly associated with LN status (p < 0.05) in both the training and validation cohorts. The multivariable logistic regression model included the radiomics signature and CT-reported LN status. The individualized prediction nomogram showed good discrimination in the training cohort [area under the curve (AUC), 0.75; 95% confidence interval (CI), 0.68-0.82] and in the validation cohort (AUC, 0.81; 95% CI, 0.69-0.94) and good calibration. DCA demonstrated that the radiomics nomogram was clinically useful. CONCLUSIONS The presented radiomics nomogram that incorporates the radiomics signature and CT-reported LN status is a noninvasive, preoperative prediction tool with favorable predictive accuracy for LN metastasis in patients with PDAC.
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Affiliation(s)
- Yun Bian
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Shiwei Guo
- Department of Pancreatic Surgery, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Hui Jiang
- Department of Pathology, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Suizhi Gao
- Department of Pancreatic Surgery, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Kai Cao
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xu Fang
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Li Wang
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Chao Ma
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Jianming Zheng
- Department of Pathology, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Gang Jin
- Department of Pancreatic Surgery, Changhai Hospital, The Naval Medical University, Shanghai, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, The Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Feng P, Cheng B, Wang ZD, Liu JG, Fan W, Liu H, Qi CY, Pan JJ. Application and progress of medical imaging in total mesopancreas excision for pancreatic head carcinoma. World J Gastrointest Surg 2021; 13:1315-1326. [PMID: 34950422 PMCID: PMC8649561 DOI: 10.4240/wjgs.v13.i11.1315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/11/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head carcinoma (PHC) is one of the common gastrointestinal malignancies with a high morbidity and poor prognosis. At present, radical surgery is still the curative treatment for PHC. However, in clinical practice, the actual R0 resection rate, the local recurrence rate, and the prognosis of PHC are unsatisfactory. Therefore, the concept of total mesopancreas excision (TMpE) is proposed to achieve R0 resection. Although there have various controversies and discussions on the definition, the range of excision, and clinical prognosis of TMpE, the concept of TMpE can effectively increase the R0 resection rate, reduce the local recurrence rate, and improve the prognosis of PHC. Imaging is of importance in preoperative examination for PHC; however, traditional imaging assessment of PHC does not focus on mesopancreas. This review discusses the application of medical imaging in TMpE for PHC, to provide more accurate preoperative evaluation, range of excision, and more valuable postoperative follow-up evaluation for TMpE through imaging. It is believed that with further extensive research and exploratory application of TMpE for PHC, large-sample and multicenter studies will be realized, thus providing reliable evidence for imaging evaluation.
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Affiliation(s)
- Pei Feng
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Bo Cheng
- Department of Pathology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Zhen-Dong Wang
- Department of Ultrasound, Beijing Sihui Hospital of Traditional Chinese Medicine, Beijing 100022, China
| | - Jun-Gui Liu
- Department of Hepatobiliary Surgery, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Wei Fan
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Heng Liu
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Chao-Ying Qi
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
| | - Jing-Jing Pan
- Department of Radiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China
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12
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Fang X, Liu F, Li J, Cao K, Wang T, Zhang H, Li Q, Meng Y, Yu J, Feng X, Jiang H, Wang L, Lu J, Shao C, Bian Y. Computed tomography nomogram to predict a high-risk intraductal papillary mucinous neoplasm of the pancreas. Abdom Radiol (NY) 2021; 46:5218-5228. [PMID: 34409514 DOI: 10.1007/s00261-021-03247-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/26/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The intraductal papillary mucinous neoplasm (IPMN) of the pancreas is regarded as a precursor to pancreatic cancer; this study aimed to develop and validate a model based on CT characteristics for the non-invasive prediction of the high-risk IPMN of the pancreas. MATERIALS AND METHODS In this retrospective study, all patients underwent multidetector CT and surgical resection. A prediction model was developed based on a training set consisting of 136 patients with low-risk IPMN and 85 patients with high-risk IPMN between October 2012 and April 2019, and a multivariable logistic regression model was adopted to establish a nomogram. The nomogram performance was determined by its discrimination, calibration, and clinical usefulness. The model was validated in 80 consecutive patients between May 2019 and April 2020, of which 47 and 33 patients had low-risk and high-risk IPMNs, respectively. RESULTS The multivariable logistic regression model of CT characteristics included the enhancing mural nodule size, the main pancreatic duct (MPD) diameter, the abrupt change in caliber of the MPD with distal pancreatic atrophy, cyst size, thickened enhancing cyst wall, and the presence of lymphadenopathy. The individualized prediction nomogram using these predictors of the high-risk IPMN achieved an area under the curve (AUC) of 0.92 (95% CI 0.88-0.95) in the training set and 0.87 (95% CI 0.79-0.95) in the validation set. The decision curve analysis demonstrated that the nomogram was clinically useful. CONCLUSION The CT nomogram, which is a non-invasive predictive tool, can preoperatively predict the risk of malignant IPMN and help identify patients who require a surgical procedure.
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Differential detection of metastatic and inflammatory lymph nodes using inflow-based vascular-space-occupancy (iVASO) MR imaging. Magn Reson Imaging 2021; 85:128-132. [PMID: 34687849 DOI: 10.1016/j.mri.2021.10.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/31/2021] [Accepted: 10/17/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate the potential value of inflow-based vascular-space-occupancy (iVASO) MR imaging in differentiating metastatic from inflammatory lymph nodes (LNs). METHODS Ten female New Zealand rabbits with 2.5-3.0 kg body weight were studied. VX2 cells and egg yolk emulsion were inoculated into left and right thighs, respectively, to induce ten metastatic and ten inflammatory popliteal LNs. Conventional MRI and iVASO were performed 2 h prior to, and 10, 20 days after inoculation (D0, D10, D20). The short-axis diameter (S), short- to long-axis diameter ratio (SLR), and arteriolar blood volume (BVa) at each time point and their longitudinal changes of each model were recorded and compared. At D20, all rabbits were sacrificed to perform histological evaluation after the MR scan. RESULTS The mean values of S, SLR and BVa showed no significant difference between the two groups at D0 (P = 0.987, P = 0.778, P = 0.975). The BVa of the metastatic group was greater than that of the inflammatory at both D10 and D20 (P < 0.05; P < 0.001), whereas the S and SLR of the metastatic group were greater only at D20 (P < 0.001; P = 0.001). Longitudinal analyses showed that the BVa of the metastatic group increased at both D10 and D20 (P = 0.004; P = 0.001), while that of the inflammatory group only increased at D10 (P = 0.024). CONCLUSION The BVa measured with iVASO has the potential to detect early metastatic LNs.
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Lee HK, Yoon YS, Han HS, Lee JS, Na HY, Ahn S, Park J, Jung K, Jung JH, Kim J, Hwang JH, Lee JC. Clinical Impact of Unexpected Para-Aortic Lymph Node Metastasis in Surgery for Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13174454. [PMID: 34503264 PMCID: PMC8431119 DOI: 10.3390/cancers13174454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Radiologically identified para-aortic lymph node (PALN) metastasis is contraindicated for pancreatic cancer (PC) surgery. There is no clinical consensus for unexpected intraoperative PALN enlargement. To analyze the prognostic role of unexpected PALN enlargement in resectable PC, we retrospectively reviewed data of 1953 PC patients in a single tertiary center. Patients with unexpected intraoperative PALN enlargement (group A1, negative pathology, n = 59; group A2, positive pathology, n = 13) showed median overall survival (OS) of 24.6 (95% CI: 15.2-33.2) and 13.0 (95% CI: 4.9-19.7) months, respectively. Patients with radiological PALN metastasis without other metastases (group B, n = 91) showed median OS of 8.6 months (95% CI: 7.4-11.6). Compared with group A1, groups A2 and B had hazard ratios (HRs) of 2.79 (95% CI, 1.4-5.7) and 2.67 (95% CI: 1.8-4.0), respectively. Compared with group A2, group B had HR of 0.96 (95% CI: 0.5-1.9). Multivariable analysis also showed positive PALN as a negative prognostic factor (HR 2.57, 95% CI: 1.2-5.3), whereas positive regional lymph node did not (HR 1.32 95% CI: 0.8-2.3). Thus, unexpected malignant PALN has a negative prognostic impact comparable to radiological PALN metastasis. This results suggests prompt pathologic evaluation for unexpected PALN enlargements is needed and on-site modification of surgical strategy would be considered.
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Affiliation(s)
- Ho-Kyoung Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Jun Suh Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (Y.-S.Y.); (H.-S.H.); (J.S.L.)
| | - Hee Young Na
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Soomin Ahn
- Samsung Medical Center, Department of Pathology and Translational Genomics, Seoul 06351, Korea;
| | - Jaewoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jae Hyup Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.P.); (K.J.); (J.H.J.); (J.K.); (J.-H.H.)
- Correspondence:
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15
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Preoperative risk factors for para-aortic lymph node positivity in pancreatic cancer. Pancreatology 2021; 21:606-612. [PMID: 33648880 DOI: 10.1016/j.pan.2021.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to identify the preoperative risk factors for para-aortic lymph node (PALN) positivity, including micrometastasis, in pancreatic cancer. METHODS Medical records of patients with pancreatic cancer who underwent curative resection were retrospectively reviewed, and the relationships between preoperative risk factors and PALN positivity were identified. Clinicopathological and prognostic factors for overall survival were analyzed. Micrometastasis was investigated by immunohistochemistry. RESULTS 400 patients were enrolled. PALN positivity by hematoxylin and eosin staining, micrometastasis, and negative were found in 46 (11%), 32 (8%), and 322 (81%) patients, respectively. The median overall survival times of patients with PALN positivity, including micrometastasis, was 22.5 months. Multivariate logistic regression identified borderline or locally advanced status (p=0.037), elevated preoperative carbohydrate antigen (CA) 19-9 level (p<0.001), larger tumor size ≥30 mm (p=0.001) and larger PALN size ≥10 mm (p=0.019) as independent preoperative risk factors of PALN positivity. Multivariate overall survival analysis demonstrated borderline or locally advanced status (p=0.013), elevated preoperative CA19-9 level (p<0.001) and PALN positivity (p=0.048) were independent poor prognostic factors. CONCLUSIONS Borderline or locally advanced status, elevated preoperative CA19-9 level, and larger tumor and PALN size were risk factors for PALN positivity, and thus, they may contribute to the optimization of preoperative treatments for patients with potential PALN positivity.
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Tseng DSJ, Pranger BK, van Leeuwen MS, Pennings JP, Brosens LA, Mohammad NH, de Meijer VE, van Santvoort HC, Erdmann JI, Molenaar IQ. The Role of CT in Assessment of Extraregional Lymph Node Involvement in Pancreatic and Periampullary Cancer: A Diagnostic Accuracy Study. Radiol Imaging Cancer 2021; 3:e200014. [PMID: 33817647 DOI: 10.1148/rycan.2021200014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 10/15/2020] [Accepted: 11/18/2020] [Indexed: 01/06/2023]
Abstract
Purpose To investigate the diagnostic accuracy of CT in assessing extraregional lymph node metastases in pancreatic head and periampullary cancer. Materials and Methods This prospective observational cohort study was performed at two tertiary hepatopancreatobiliary (HPB) referral centers between March 2013 and December 2014. Patients undergoing pancreatoduodenectomy or bypass surgery with or without palliative radiofrequency ablation were included. Extraregional lymph node involvement was defined as positive lymph nodes in the aortocaval window. Two expert HPB radiologists assessed aortocaval lymph nodes at preoperative CT according to a standardized protocol. All tissue from the aortocaval window was collected intraoperatively. Positive histopathologic finding was the reference standard. Analysis of predictive values and diagnostic accuracy was performed. Results A total of 198 consecutive patients (mean age, 66 years; range, 39-86 years; 105 men) with pancreatic head or periampullary carcinoma were included. In 70% of patients, a pancreatoduodenectomy was performed, 4% underwent total pancreatectomy, 4% underwent radiofrequency ablation, and 22% underwent bypass surgery. Forty-four patients (22%) had histologically positive aortocaval lymph nodes. Negative predictive value of CT in assessing aortocaval lymph nodes was 80% for both observers, and positive predictive value was 31%-33%. Overall diagnostic accuracy was 69%-70%. Conclusion CT has a low diagnostic accuracy in assessing extraregional lymph node metastases in patients suspected of having pancreatic or periampullary cancer.Keywords: CT, Abdomen/GI, Pancreas, Oncology© RSNA, 2021.
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Affiliation(s)
- Dorine S J Tseng
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Bobby K Pranger
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Maarten S van Leeuwen
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Jan Pieter Pennings
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Lodewijk A Brosens
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Nadja Haj Mohammad
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - Joris I Erdmann
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Heidelberglaan 100, HG G04.228, PO Box 85500, 3508 GA, Utrecht, the Netherlands (D.S.J.T., H.C.v.S., I.Q.M.); University of Groningen and University Medical Center Groningen, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Groningen, the Netherlands (B.K.P., V.E.d.M., J.I.E.); Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands (M.S.v.L.); University of Groningen and University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands (J.P.P.); Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands (L.A.B.); Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (N.H.M.)
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17
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Yamada M, Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Aramaki T, Endo M, Uesaka K. Clinical Implication of Node-negative Resectable Pancreatic Cancer. Ann Surg Oncol 2021; 28:2257-2264. [PMID: 33452602 DOI: 10.1245/s10434-020-09543-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 11/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Lymph node metastasis is one of the strongest prognostic factors of pancreatic cancer. However, the clinical implication of pathologically node-negative pancreatic cancer (pN0-PC) has not been fully investigated. METHODS Patients who underwent surgical resection for radiologically resectable pancreatic cancer between 2002 and 2018 were included in this study. A clinicopathological examination focusing on pN0-PC was performed. RESULTS Of all 533 patients, 155 (29.1%) were diagnosed with pN0-PC and 378 (70.9%) were diagnosed with node-positive pancreatic cancer (pN1/2-PC). The 5-year survival rates of patients with pN0-PC and pN1/2-PC were 57.1% and 25.0%, respectively (p < 0.001). A multivariate analysis revealed six prognostic factors in pN0-PC: age ≥ 70 years, nonadministration of adjuvant chemotherapy, anterior serosal invasion, nerve plexus invasion, and microscopic lymphatic and venous invasions. The 5-year survival rates of patients who had pN0-PC with 0-1 risk factor, with 2-3 risk factors, and with 4-6 risk factors were 87.6%, 47.9%, and 16.4%, respectively. Survival of patients who had pN0-PC with 4-6 risk factors was comparable to that of pN1/2 patients. The diagnostic capability of metastasis-negative lymph node was unsatisfactory, with a predictive value of < 43%. CONCLUSIONS Although the prognosis of patients with pN0-PC was better than that of patients with pN1/2-PC, it is not satisfactory. Survival of patients who had pN0-PC with 0-1 risk factors was extremely favorable; however, survival of patients who had pN0-PC with 4-6 risk factors was similar to those with pN1/2-PC.
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Affiliation(s)
- Mihoko Yamada
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takeshi Aramaki
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masahiro Endo
- Division of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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18
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CT-Radiomic Approach to Predict G1/2 Nonfunctional Pancreatic Neuroendocrine Tumor. Acad Radiol 2020; 27:e272-e281. [PMID: 32037260 DOI: 10.1016/j.acra.2020.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/31/2019] [Accepted: 01/01/2020] [Indexed: 12/14/2022]
Abstract
RATIONALE AND OBJECTIVES Tumor grading of nonfunctional pancreatic neuroendocrine tumors (NF-pNETs) determines the choice of clinical treatment and management. The pathological grade of pancreatic neuroendocrine tumors is usually assessed on postoperative specimens. The goal of our study is to establish a tumor grade (G) prediction model for preoperative G1/2 NF-pNETs using radiomics for multislice spiral CT image analysis. MATERIALS AND METHODS This retrospective study included a primary cohort of 59 patients and an independent validation cohort of 40 consecutive patients; their multislice spiral CT images were collected from October 2012 to October 2016 and October 2016 to June 2018, respectively. All 99 patients were diagnosed with clinicopathologically confirmed NF-pNETs. Most significant radiomic features were selected using the minimum redundancy and maximum relevance algorithm. Support vector machine classifier with a radial basis function-based predictive model was subsequently developed for clinical use. RESULTS A total of 585 radiomics features were extracted from every phase for each patient. Six of these radiomics features were identified as most discriminant features for G1 and G2 tumors and used to construct the tumor grade prediction model. The prediction model resulted in the area under the curve values of 0.968 (95% CI: 0.900-0.991) and 0.876 (95% CI: 0.700-0.963) for the training cohort and validation cohort, respectively. Sensitivity and specificity were 96.4% and 83.9%, and 90.9% and 88.9% for the training and validation cohorts, respectively. The decision curves indicated that if the threshold probability is above 0.1, using the rad-score in the current study on G1/2 NF-pNETs is more beneficial than the treat-all-patients scheme or the treat-none scheme. CONCLUSION Radiomics developed with a combination of nonenhanced and portal venous phases can achieve favorable predictive accuracy for histological grade for G1/G2 NF-pNETs.
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19
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Therapeutic response assessment in pancreatic ductal adenocarcinoma: society of abdominal radiology review paper on the role of morphological and functional imaging techniques. Abdom Radiol (NY) 2020; 45:4273-4289. [PMID: 32936417 DOI: 10.1007/s00261-020-02723-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/17/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is the third leading cause of cancer-related death in the United States and is projected to be the second by 2030. Systemic combination chemotherapy is considered an essential first-line treatment for the majority of patients with PDA, in both the neoadjuvant and palliative settings. In addition, a number of novel therapies are being tested in clinical trials for patients with advanced PDA. In all cases, accurate and timely assessment of treatment response is critical to guide therapy, reduce drug toxicities and cost from a failing therapy, and aid adaptive clinical trials. Conventional morphological imaging has significant limitations, especially in the context of determining primary tumor response and resectability following neoadjuvant therapies. In this article, we provide an overview of current therapy options for PDA, highlight several morphological imaging findings that may be helpful to reduce over-staging following neoadjuvant therapy, and discuss a number of emerging imaging, and non-imaging, tools that have shown promise in providing a more precise quantification of disease burden and treatment response in PDA.
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20
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Kim JS, Hwang HK, Lee WJ, Kang CM. Unexpected Para-aortic Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma: a Contraindication to Resection? J Gastrointest Surg 2020; 24:2789-2799. [PMID: 31792906 DOI: 10.1007/s11605-019-04483-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Margin-negative resection is the only cure for pancreatic cancer. However, para-aortic lymph node metastasis is considered a contraindication to curative resection in pancreatic cancer. To determine if there are long-term survival differences according to the presence or absence of para-aortic lymph node metastasis in patients undergoing pancreatectomy, we evaluated oncologic outcomes in resected pancreatic cancer with unexpected para-aortic lymph node metastasis confirmed on intraoperative frozen section biopsy. METHODS We retrospectively investigated 362 patients with pathologically confirmed pancreatic ductal adenocarcinoma who underwent pancreatectomy between 1996 and 2016. RESULTS Patients with a metastatic para-aortic lymph node had the poorest median disease-specific survival [hazard ratio 14, 95% confidence interval 10-19]. However, after chemotherapy, patients with a metastatic para-aortic lymph node had a much higher disease-specific survival rate (para-aortic lymph node+/postoperative chemotherapy- versus para-aortic lymph node+/postoperative chemotherapy+, P = 0.0003, adjusted P = 0.0015). Patients with a metastatic para-aortic lymph node who underwent postoperative chemotherapy had a similar survival benefit to patients with metastatic regional lymph node without para-aortic lymph node metastasis, regardless of postoperative chemotherapy (para-aortic lymph node+/postoperative chemotherapy+ versus regional lymph node+/postoperative chemotherapy-, P = 0.3047, adjusted P > 0.9999; para-aortic lymph node+/postoperative chemotherapy+ versus regional lymph node+/postoperative chemotherapy+, P = 0.0905, adjusted P = 0.4525). CONCLUSIONS Unexpected para-aortic lymph node metastasis on frozen section biopsy may no longer be a contraindication to curative resection in "resectable" pancreatic ductal adenocarcinoma, as long as postoperative adjuvant chemotherapy can be administered.
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Affiliation(s)
- Ji Su Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, #50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, #50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, #50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, #50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.
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21
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Gao J, Han F, Jin Y, Wang X, Zhang J. A Radiomics Nomogram for the Preoperative Prediction of Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma. Front Oncol 2020; 10:1654. [PMID: 32974205 PMCID: PMC7482654 DOI: 10.3389/fonc.2020.01654] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/28/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To construct and verify a CT-based multidimensional nomogram for the evaluation of lymph node (LN) status in pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS We retrospectively assessed data from 172 patients with clinicopathologically confirmed PDAC surgically resected between February 2014 and November 2016. Patients were assigned to either a training cohort (n = 121) or a validation cohort (n = 51). We acquired radiomics features from the preoperative venous phase (VP) CT images. The maximum relevance-minimum redundancy (mRMR) algorithm and the least absolute shrinkage and selection operator (LASSO) methods were used to select the optimal features. We used multivariable logistic regression to construct a combined radiomics model for visualization in the form of a nomogram. Performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve approach, calibration testing, and analysis of clinical usefulness. RESULTS A Rad score consisting of 10 LN status-related radiomics features was found to be significantly associated with the actual LN status (P < 0.01). A nomogram that consisted of Rad scores, CT-reported parenchymal atrophy, and CT-reported LN status performed well in terms of predictive power in the training cohort (area under the curve, 0.92), and this was confirmed in the validation cohort (area under the curve, 0.95). The nomogram also performed well in the calibration test and decision curve analysis, demonstrating its potential clinical value. CONCLUSION A multidimensional radiomics nomogram consisting of Rad scores, CT-reported parenchymal atrophy, and CT-reported LN status may contribute to the non-invasive evaluation of LN status in PDAC patients.
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Affiliation(s)
| | | | | | | | - Jiawen Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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22
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Qian L, Xie J, Xu Z, Deng X, Chen H, Peng C, Li H, Chai W, Xie J, Wang W, Shen B. The Necessity of Dissection of No. 14 Lymph Nodes to Patients With Pancreatic Ductal Adenocarcinoma Based on the Embryonic Development of the Head of the Pancreas. Front Oncol 2020; 10:1343. [PMID: 32850429 PMCID: PMC7433687 DOI: 10.3389/fonc.2020.01343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022] Open
Abstract
Objectives: Pancreaticoduodenectomy (PD) followed by lymphadenectomy is performed for patients with pancreatic ductal adenocarcinoma (PDAC) located in the head of the pancreas. Because the head of the pancreas could be divided into dorsal or ventral primordium in relation to embryonic development, the metastasis of lymph node (LN) may differ. In this retrospective study, we evaluated the impact of extended or standard LN dissection for PDAC located in ventral or dorsal primordia of the pancreatic head. Methods: From February 2016 to November 2018, 178 patients who underwent PD for PDAC were enrolled at the Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University. According to the tumor location and the range of LN dissection, all patients were divided into three groups: ventral primordium with extended lymphadenectomy (VE group), ventral primordium with standard lymphadenectomy (VS group), and dorsal primordium with extended lymphadenectomy (DE group). Clinical and pathological features were retrospectively analyzed as were the long-term survival outcomes. Results: More patients in the VE group were detected with metastasis in the lymph nodes around the superior mesenteric artery (LN14) than those in the DE group (LN along the right side of the superior mesenteric artery, LN14ab): 22.9 vs. 5.9%, p = 0.005; (LN along the left side of the superior mesenteric artery, LN14cd): 10.0 vs. 0.0%, p = 0.022. LN14 was involved in more patients in the VE group than in the VS group (22.9 vs. 5.0%, p = 0.015). For IIb-stage patients in the VE group, the overall survival time (18.3 vs. 9.3 months, p < 0.001) and disease-free survival time (12.2 vs. 5.1 months, p = 0.045) were longer in those with LN14cd (–) than those with LN14cd (+). Conclusion: This study suggested that patients with PDAC located in the ventral head of the pancreas had higher risk of LN14 involvement compared with those at dorsal. Thus, a thorough dissection of LN14 in PDAC located in the ventral head of the pancreas is recommended to optimize the regional extended lymphadenectomy.
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Affiliation(s)
- Lihan Qian
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Junjie Xie
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiwei Xu
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaxing Deng
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Chen
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Chenghong Peng
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Hongwei Li
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Weimin Chai
- Department of Radiology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Xie
- Department of Pathology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weishen Wang
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
| | - Baiyong Shen
- Departement of General Surgery, Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Research Institute of Pancreatic Disease, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
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23
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Deng Y, Ming B, Wu JL, Zhou T, Zhang SY, Chen Y, Lan C, Zhang XM. Magnetic resonance imaging for preoperative staging of pancreatic cancer based on the 8 th edition of AJCC guidelines. J Gastrointest Oncol 2020; 11:329-336. [PMID: 32399274 DOI: 10.21037/jgo.2020.03.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Preoperative staging of pancreatic cancer determines the choice of treatment. Magnetic resonance imaging (MRI) plays an important role in preoperative staging of pancreatic cancer. The American Joint Committee on Cancer (AJCC) TNM staging system was revised to its 8th version in 2016, there has been no report correlating the 8th edition of the AJCC TNM staging with preoperative MRI examinations and pathological findings. The purpose of our study is to determine the staging accuracy and evaluate the resectability by using MRI about pancreatic cancer compared with intraoperative or pathological findings according to the 8th edition of the AJCC TNM staging system. Methods One hundred thirty-two patients with a pathological diagnosis of pancreatic cancer who underwent preoperative MRI were identified. The clinical data, MRI findings and pathological findings were analyzed. Preoperative MRI staging and resectability evaluation were compared with pathological findings. The accuracy of MRI for preoperative T and N staging was evaluated, and the sensitivity, specificity and accuracy of MRI in evaluating the resectability were assessed. All the staging and resectability assessments were according to the 8th edition of the AJCC TNM staging system. Results Analysis showed that the accuracy of MRI for evaluation of the T and N stages was 82.6% (109/132) and 74.2% (98/132), respectively. The sensitivity and specificity of MRI in assessing the resectability were 94.2% and 71.4%, respectively. Integrating the 8th edition of the AJCC TNM stage, no significant differences were identified between the preoperative MRI and pathological results for the staging of pancreatic cancer (P=0.805). Conclusions MRI is highly accurate for T staging and moderately accurate for N staging. MRI provides important preoperative evaluation of the stage and resectability of pancreatic cancer based on the 8th edition of the AJCC TNM staging system.
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Affiliation(s)
- Yan Deng
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Bing Ming
- Department of Radiology, Deyang People's Hospital, Deyang 618000, China
| | - Jia-Long Wu
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Ting Zhou
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Shi-Yong Zhang
- Department of Radiology, Deyang People's Hospital, Deyang 618000, China
| | - Yong Chen
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Chuan Lan
- Department of Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Xiao-Ming Zhang
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
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24
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Liu P, Gu Q, Hu X, Tan X, Liu J, Xie A, Huang F. Applying a radiomics-based strategy to preoperatively predict lymph node metastasis in the resectable pancreatic ductal adenocarcinoma. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2020; 28:1113-1121. [PMID: 33074215 DOI: 10.3233/xst-200730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE This retrospective study is designed to develop a Radiomics-based strategy for preoperatively predicting lymph node (LN) status in the resectable pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Eighty-five patients with histopathological confirmed PDAC are included, of which 35 are LN metastasis positive and 50 are LN metastasis negative. Initially, 1,124 radiomics features are computed from CT images of each patient. After a series of feature selection, a Radiomics logistic regression (LOG) model is developed. Subsequently, the predictive efficiency of the model is validated using a leave-one-out cross-validation method. The model performance is evaluated on discrimination and compared with the conventional CT evaluation method based on subjective CT image features. RESULTS Radiomics LOG model is developed based on eight most related radiomics features. Remarkable differences are demonstrated between patients with LN metastasis positive and LN metastasis negative in Radiomics LOG scores namely, 0.535±1.307 (mean±standard deviation) vs. -1.514±1.800 (mean±standard deviation) with p < 0.001. Radiomics LOG model shows significantly higher predictive efficiency compared to the conventional evaluation method of LN status in which areas under ROC curves are AUC = 0.841 with 95% confidence interval (CI: 0.758∼0.925) vs. AUC = 0.682 with (95% CI: 0.566∼0.798). Leave-one-out cross validation indicates that the Radiomics LOG model correctly classifies 70.3% cases, while the conventional CT evaluation method only correctly classifies 57.0% cases. CONCLUSION A radiomics-based strategy provides an individualized LN status evaluation in PDAC patients, which may help clinicians implement an optimal personalized patient treatment.
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Affiliation(s)
- Peng Liu
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Qianbiao Gu
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Xiaoli Hu
- Department of Radiology, First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Xianzheng Tan
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Jianbin Liu
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - An Xie
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Feng Huang
- Department of Radiology, Hunan Provincial People's Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, China
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25
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Abstract
OBJECTIVE The objective of this study was to explore the exact relationship between the arterial radiomics score (rad-score) and lymph node (LN) metastasis in pancreatic ductal adenocarcinoma (PDAC). METHODS A total of 225 patients with pathologically confirmed PDAC who underwent multislice computed tomography within 1 month of resection from December 2016 to August 2017 were retrospectively studied. For each patient, 1029 radiomics features of arterial phase were extracted, which were reduced using the least absolute shrinkage and selection operator logistic regression algorithm. Multivariate logistic regression models were used to analyze the association between the arterial rad-score and LN metastasis. RESULTS Lymph node-negative and LN-positive patients accounted for 107 (47.56%) and 118 (52.44%) of the cohort, respectively. The rad-score, which consisted of 12 selected features of the arterial phase, was significantly associated with LN status (P < 0.05). Univariate analysis revealed that the arterial rad-score and T stage were independently and positively associated with risk of LN metastasis (P < 0.05). Multivariate analyses revealed a significant association between the arterial rad-score and the LN metastasis (P < 0.0001). Higher arterial rad-score was associated with LN metastasis (P for trend <0.0001). CONCLUSIONS The arterial rad-score is independently and positively associated with the risk of LN metastasis in PDAC.
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26
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Schwarz L, Tortajada P, Pittau G, Di Fiore F, Sefrioui D, Bridoux V, Laurenzi A, Tuech JJ, Sa Cunha A. “Laparoscopic Para-Aortic Lymph Node Sampling” First Approach for Pancreatic Adenocarcinoma as an Oncological Practice. J Laparoendosc Adv Surg Tech A 2019; 29:900-904. [DOI: 10.1089/lap.2018.0775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Normandie University, Rouen, France
| | - Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
- Department of HPB Surgery and Transplantation, Hôpital Paul Brousse, Aphp, Villejuif, France
| | - Gabriella Pittau
- Department of HPB Surgery and Transplantation, Hôpital Paul Brousse, Aphp, Villejuif, France
| | - Frederic Di Fiore
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Normandie University, Rouen, France
- Department of Digestive Oncology, Rouen University Hospital, Rouen, France
| | - David Sefrioui
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Normandie University, Rouen, France
- Department of Digestive Oncology, Rouen University Hospital, Rouen, France
| | - Valérie Bridoux
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Andrea Laurenzi
- Department of HPB Surgery and Transplantation, Hôpital Paul Brousse, Aphp, Villejuif, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Normandie University, Rouen, France
| | - Antonio Sa Cunha
- Department of HPB Surgery and Transplantation, Hôpital Paul Brousse, Aphp, Villejuif, France
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Doussot A, Bouvier A, Santucci N, Lequeu JB, Cheynel N, Ortega-Deballon P, Rat P, Facy O. Pancreatic ductal adenocarcinoma and paraaortic lymph nodes metastases: The accuracy of intraoperative frozen section. Pancreatology 2019; 19:710-715. [PMID: 31174978 DOI: 10.1016/j.pan.2019.05.465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/11/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) with paraaortic lymph nodes metastases (PALN +) is associated with poor survival. Still, there are no current guidelines advocating systematic detection of PALN+. METHODS All consecutive patients who underwent surgical exploration/resection with concurrent paraaortic (group 16) lymphadenectomy for PDAC between 2009 and 2016 were considered for inclusion. Resection was systematically aborted in case of intraoperative PALN + detection. Diagnostic performance of preoperative imaging upon blind review and intraoperative PALN dissection with frozen section (FS) for PALN detection were evaluated. Additionally, the prognostic significance of PALN + on overall survival (OS) was analyzed. RESULTS Over the study period, among 129 patients undergoing surgery for PDAC, 113 had intraoperative PALN dissection with FS analysis. Median number of resected PALN was 3 (range, 1-15). Overall, PALN+ was found in 19 patients (16.8%). Upon blind review, preoperative imaging performed poorly for PALN + detection with a low agreement between imaging and final pathology (Kappa-Cohen index<0.2). In contrast, PALN FS showed high detection performances and strong agreement with final pathology (Kappa-Cohen index = 0.783, 95%CI 0.779-0.867, p < 0.001). Regarding survival outcomes, there was no difference between patients with PALN+ and patients not resected in the setting of liver metastases or locally unresectable disease found at exploration (p = 0.708). CONCLUSIONS Before PD for PDAC, intraoperative PALN dissection and FS analysis yields accurate PALN assessment and allows appropriate patient selection. This should be routinely performed and aborting resection should be strongly considered in case of PALN+.
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Affiliation(s)
- Alexandre Doussot
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France; Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France.
| | - Aurélie Bouvier
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France
| | - Nicolas Santucci
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France
| | | | - Nicolas Cheynel
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France
| | | | - Patrick Rat
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France
| | - Olivier Facy
- Department of Digestive Surgical Oncology, University Hospital of Dijon, France
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Zhang X, Zhang J, Fan H, Liu Y, He Q. Risk factors related to metastasis of para-aortic lymph nodes in pancreatic ductal adenocarcinoma: A retrospective observational study. Medicine (Baltimore) 2018; 97:e12370. [PMID: 30290595 PMCID: PMC6200498 DOI: 10.1097/md.0000000000012370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
This study was designed to explore the risk factors related to metastasis of para-aortic lymph node (PALN).Clinicopathologic data of 241 patients with resectable or borderline resectable pancreatic cancer who underwent pancreaticoduodenectomy with extended lymphadenectomy between January 2008 and December 2015 were collected, potential factors related to metastasis of PALN were analyzed.Positive rate of PALN was 19.5% (47/241). Univariate analysis showed that back pain (P = .028), preoperative CA19-9 level (P < .001), tumor size (P < .001), portal vein (PV)/superior mesenteric vein (SMV) invasion (P < .001), superior mesenteric artery (SMA) invasion (P < .001), and diameter > 1.0 cm were in correlation with PALN involvement, multivariate analysis revealed that preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were independent risk factors to metastasis of PALN. Patients with LN8+ had a higher positive rate of PALN than with LN8- (38.1% vs 15.6%, P = .001), similar results could be found when LN12+ (35.8% vs 13.2%, P < .001) and LN14+ (41.2% vs 11.0%, P < .001), multivariate analysis showed that LN8+ and LN14+ were closely in correlation with PALN metastasis.Several factors were related to the status of PALN, preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were 4 independent risk factors to PALN metastasis. LN8+ and LN14+ were 2 strong predictors of PALN metastasis. A comprehensive analysis covering all possible risk factors related to metastasis of PALN should be given before design of treatment plan whenever involvement of PALN was suspected.
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Affiliation(s)
- Xingmao Zhang
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital
| | - Jie Zhang
- The First Hospital of Combination of the Western Medicine and Traditional Chinese Medicine, Xiaozhuang Hospital, Capital Medical University, Beijing, China
| | - Hua Fan
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital
| | - Yu Liu
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital
| | - Qiang He
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital
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Rong D, Mao Y, Hu W, Xu S, Wang J, He H, Li S, Zhang R. Intravoxel incoherent motion magnetic resonance imaging for differentiating metastatic and non-metastatic lymph nodes in pancreatic ductal adenocarcinoma. Eur Radiol 2018; 28:2781-2789. [PMID: 29404768 DOI: 10.1007/s00330-017-5259-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/14/2017] [Accepted: 12/20/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To evaluate the diagnostic potential of intravoxel incoherent motion (IVIM) DWI for differentiating metastatic and non-metastatic lymph node stations (LNS) in pancreatic ductal adenocarcinoma (PDAC). METHODS 59 LNS histologically diagnosed following surgical resection from 15 patients were included. IVIM DWI with 12 b values was added to the standard MRI protocol. Evaluation of parameters was performed pre-operatively and included the apparent diffusion coefficient (ADC), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*) and perfusion fraction (f). Diagnostic performance of ADC, D, D* and f for differentiating between metastatic and non-metastatic LNS was evaluated using ROC analysis. RESULTS Metastatic LNS had significantly lower D, D*, f and ADC values than the non-metastatic LNS (p< 0.01). The best diagnostic performance was found in D, with an area under the ROC curve of 0.979, while the area under the ROC curve values of D*, f and ADC were 0.867, 0.855 and 0.940, respectively. The optimal cut-off values for distinguishing metastatic and non-metastatic lymph nodes were D = 1.180 × 10-3 mm2/s; D* = 14.750 × 10-3 mm2/s, f = 20.65 %, and ADC = 1.390 × 10-3 mm2/s. CONCLUSION IVIM DWI is useful for differentiating between metastatic and non-metastatic LNS in PDAC. KEY POINTS • IVIM DWI is feasible for diagnosing LN metastasis in PDAC. • Metastatic LNS has lower D, D*, f, ADC values than non-metastatic LNS. • D-value from IVIM model has best diagnostic performance, followed by ADC value. • D* has the lowest AUC value.
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Affiliation(s)
- Dailin Rong
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China
- Department of Radiology, Sun Yat-sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
| | - Yize Mao
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China
- Department of Hepato-Biliary-Pancreatic Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
| | - Wanming Hu
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China
- Department of Pathology, Sun Yat-sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
| | - Shuhang Xu
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, Guangdong Province, People's Republic of China
| | - Jun Wang
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China
- Department of Hepato-Biliary-Pancreatic Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
- Department of Ultrasound, Sun Yat-sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
| | - Haoqiang He
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China
- Department of Radiology, Sun Yat-sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China
| | - Shengping Li
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China.
- Department of Hepato-Biliary-Pancreatic Oncology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China.
| | - Rong Zhang
- State Key Laboratory of Oncology in Southern China, Guangzhou, 510060, China.
- Department of Radiology, Sun Yat-sen University Cancer Center, No. 651 Dongfeng Road East, Guangzhou, 510060, China.
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Masuda T, Dann AM, Elliott IA, Baba H, Kim S, Sedarat A, Muthusamy VR, Girgis MD, Joe Hines O, Reber HA, Donahue TR. A Comprehensive Assessment of Accurate Lymph Node Staging and Preoperative Detection in Resected Pancreatic Cancer. J Gastrointest Surg 2018; 22:295-302. [PMID: 29043580 DOI: 10.1007/s11605-017-3607-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/28/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The current (seventh edition) American Joint Commission on Cancer (AJCC) Staging System for pancreatic ductal adenocarcinoma (PDAC) dichotomizes pathologic lymph node (LN) involvement into absence (pN0) or presence (pN1) of disease. The recently announced eighth edition also includes stratification on the number of positive nodes. Furthermore, LNs detected on preoperative imaging (CT, MRI, or endoscopic ultrasound-EUS) are considered to be pathologically involved in other gastrointestinal cancers. However, this is less well defined for PDAC. Therefore, the three aims of this study were to determine (1) whether the new AJCC staging system led to more accurate staging, (2) the number of nodes needed to be examined to detect pathologic involvement, and (3) if pN disease could be reliably detected on preoperative imaging in PDAC. METHODS A retrospective review of all patients undergoing pancreatectomy at a single US academic center from January 1990 to September 2015. Pathology reports of resected specimens were reviewed to determine the total number of LNs examined and those positive for metastasis. CT, MRI, and/or EUS reports were used to determine the presence or absence of preoperatively detectable LN enlargement. RESULTS Of the 490 surgical resections for PDAC, pN1 disease was detected in 59.4% (n = 291) and was positively correlated with the number of LNs pathologically examined (P < 0.001). Patients with pN1 disease had a shorter overall survival (OS) than those without nodal involvement (25.1 vs. 44.0 months; P < 0.001); however, OS was not different when stratifying by the number of nodes as on the eighth AJCC system. Pathologic examination of > 20 LNs in treatment naïve patients was optimal to detect pN1 disease and predict longer OS for those without nodal involvement (median survival > 41.1 months, P = 0.03 when compared to < 15 or 15-19 LNs examined). LNs were detected by CT, MRI, or EUS in 30.7% (103/335) of patients. The positive predictive value (PPV) of preoperative LN detection for pathologic involvement was 77.3% for treatment naïve patients and 84.2% for those without biliary obstruction. CONCLUSIONS Although the LN scoring in the seventh PDAC AJCC Staging System was sufficient to predict OS of our patients, more LNs than previously considered (20 vs. 15) were optimal to detect pathologic involvement. Preoperative LN detection was an accurate predictor of pN1 disease for treatment naïve patients without biliary obstruction.
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Affiliation(s)
- Toshiro Masuda
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA.,Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto, 860-0811, Japan
| | - Amanda M Dann
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA
| | - Irmina A Elliott
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjyo, Chuo-ku, Kumamoto, 860-0811, Japan
| | - Stephen Kim
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Alireza Sedarat
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
| | - V Raman Muthusamy
- Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Mark D Girgis
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA
| | - O Joe Hines
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA
| | - Howard A Reber
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA
| | - Timothy R Donahue
- Department of Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, CHS Room 72-215, PO Box 956904, Los Angeles, CA, 90095, USA. .,Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, Los Angeles, CA, USA.
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Hempel S, Plodeck V, Mierke F, Distler M, Aust DE, Saeger HD, Weitz J, Welsch T. Para-aortic lymph node metastases in pancreatic cancer should not be considered a watershed for curative resection. Sci Rep 2017; 7:7688. [PMID: 28794500 PMCID: PMC5550512 DOI: 10.1038/s41598-017-08165-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/07/2017] [Indexed: 12/12/2022] Open
Abstract
No international consensus regarding the resection of the para-aortic lymph node (PALN) station Ln16b1 during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) has been reached. The present retrospectively investigated 264 patients with PDAC who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005–2015. In 95 cases, the PALN were separately labelled and histopathologically analysed. Metastatic PALN (PALN+) were found in 14.7% (14/95). PALN+ stage was associated with increased regional lymph node metastasis. The median overall survival (OS) of patients with metastatic PALN and with non-metastatic PALN (PALN−) was 14.1 and 20.2 months, respectively. Five of the PALN+ patients (36%) survived >19 months. The OS of PALN+ and those staged pN1 PALN− was not significantly different (P = 0.743). Patients who underwent surgical exploration or palliative surgery (n = 194) had a lower median survival of 8.8 (95% confidence interval: 7.3–10.1) months. PALN status could not be reliably predicted by preoperative computed tomography. We concluded that the survival data of PALN+ cases is comparable with advanced pN+ stages; one-third of the patients may expect longer survival after radical resection. Therefore, routine refusal of curative resection in the case of PALN metastasis is not indicated.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Verena Plodeck
- Department of Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Franz Mierke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Daniela E Aust
- Institute for Pathology, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Hans-Detlev Saeger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany.
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Abstract
PURPOSE The purpose of this study is to investigate the value of multidetector computed tomography (MDCT) assessment of resectability in hilar cholangiocarcinoma, and to identify the factors associated with unresectability and accurate evaluation of resectability. METHODS From January 2007 to June 2015, a total of 77 consecutive patients were included. All patients had preoperative MDCT (with MPR and MinIP) and surgical treatment, and were pathologically proven with hilar cholangiocarcinoma. The MDCT images were reviewed retrospectively by two senior radiologists and one hepatobiliary surgeon. The surgical findings and pathologic results were considered to be the gold standard. The Chi square test was used to identify factors associated with unresectability and accurate evaluation of resectability. RESULTS The sensitivity, specificity, and overall accuracy of MDCT assessment were 83.3 %, 75.9 %, and 80.5 %, respectively. The main causes of inaccuracy were incorrect evaluation of N2 lymph node metastasis (4/15) and distant metastasis (4/15). Bismuth type IV tumor, main or bilateral hepatic artery involvement, and main or bilateral portal vein involvement were highly associated with unresectability (P < 0.001). Patients without biliary drainage had higher accuracy of MDCT evaluation of resectability compared to those with biliary drainage (P < 0.001). CONCLUSION MDCT is reliable for preoperative assessment of resectability in hilar cholangiocarcinoma. Bismuth type IV tumor and main or bilateral vascular involvement highly suggest the unresectability of hilar cholangiocarcinoma. Patients without biliary drainage have a more accurate MDCT evaluation of resectability. We suggest MDCT should be performed before biliary drainage to achieve an accurate evaluation of resectability in hilar cholangiocarcinoma.
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Kurita A, Kodama Y, Nakamoto Y, Isoda H, Minamiguchi S, Yoshimura K, Kuriyama K, Sawai Y, Uza N, Hatano E, Uemoto S, Togashi K, Haga H, Chiba T. Impact of EUS-FNA for preoperative para-aortic lymph node staging in patients with pancreatobiliary cancer. Gastrointest Endosc 2016; 84:467-475.e1. [PMID: 26970011 DOI: 10.1016/j.gie.2016.02.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 02/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS In patients with pancreatobiliary cancer, para-aortic lymph node (PALN) metastasis is considered to be the involvement beyond the regional lymph nodes, namely, distant metastasis. Effective methods for preoperative PALN staging, however, are not established. This study aimed to compare the diagnostic capability for PALN metastasis between EUS-FNA and (18)F-fluorodeoxyglucose positron emission tomography with CT (PET/CT). METHODS We performed a prospective, nonrandomized, single-center trial. Between December 2010 and March 2014, 208 patients with pancreatobiliary cancer without apparent distant metastasis except for PALNs were assessed for study eligibility before surgery. Among them, 52 consecutive patients with PALN enlargement were enrolled in the study. (18)F-Fluorodeoxyglucose PET/CT and EUS-FNA were performed sequentially as a single combined procedure to evaluate PALN metastases. The primary outcome was to compare the diagnostic capability of EUS-FNA and PET/CT for PALN metastasis. RESULTS Of 71 enlarged PALNs in the 52 patients, 30 (42.3%) were finally diagnosed as metastases in 21 patients (40.4%). Of the 21 patients with PALN metastases, preoperative EUS-FNA or PET/CT made a correct diagnosis in 20 (95.2%) or 12 (57.1%), respectively. EUS-FNA had higher sensitivity and specificity for the diagnosis of PALN metastasis (sensitivity, 96.7% [29/30]; 95% confidence interval, 82.2%-99.9%; specificity, 100% [39/39]; 95% confidence interval, 91.0%-100%) than PET/CT. CONCLUSIONS EUS-FNA is superior to PET/CT for preoperative PALN staging in patients with pancreatobiliary cancer. Because of the clinical benefit of EUS-FNA to reduce unnecessary surgery, it should be part of the standard preoperative examination for patients with pancreatobiliary cancer. (UMIN clinical trials registry number: 000006408.).
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Affiliation(s)
- Akira Kurita
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan; Division of Gastroenterology and Hepatology, Digestive Disease Center, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Yuzo Kodama
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroyoshi Isoda
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Kenichi Yoshimura
- Innovative Clinical Research Center, Kanazawa University Hospital, Kanazawa, Japan
| | - Katsutoshi Kuriyama
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yugo Sawai
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Etsuro Hatano
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Tsutomu Chiba
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Agalianos C, Gouvas N, Papaparaskeva K, Dervenis C. Positive para-aortic lymph nodes following pancreatectomy for pancreatic cancer. Systematic review and meta-analysis of impact on short term survival and association with clinicopathologic features. HPB (Oxford) 2016; 18:633-41. [PMID: 27485057 PMCID: PMC4972380 DOI: 10.1016/j.hpb.2016.04.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relation between para-aortic lymph nodes (PALN) involvement and pancreatic ductal adenocarcinoma (PDAC) survival, along with the optimal handling of this particular lymph node station remain unclear. A systematic review and meta-analysis was performed to assess this. METHODS A search of Medline, Embase, Ovid and Cochrane databases was performed until July 2015 to identify studies reporting on the relation of PALN involvement and PDAC outcomes and a meta-analysis was performed following data extraction. RESULTS Ten retrospective studies and two prospective non randomized studies (2467 patients) were included. Patients with positive PALN had worse one (p < 0.00001) and two year (p < 0.00001) survival when compared with patients with negative PALN. Even when comparing only patients with positive lymph nodes (N1), patients with PALN involvement presented with a significant lower one (p = 0.03) and two (p = 0.002) year survival. PALN involvement was associated with an increased possibility of positive margin (R1) resection (p < 0.00001), stations' 12, 14 and 17 malignant infiltration (p < 0.00001), but not with tumour stage (p = 0.78). DISCUSSION Involvement of PALN is associated with decreased survival in pancreatic cancer patients. However, existence of long term survivors among this subgroup of patients should be further evaluated, in order to identify factors associated with their favourable prognosis.
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Affiliation(s)
- Christos Agalianos
- Athens Naval and Veterans Hospital, Department of Surgery, Athens, Greece,Correspondence Christos Agalianos, Department of General Surgery, Athens Naval & Veterans Hospital, 70 Dinokratous Str., GR-11521 Athens, Greece. Tel: +30 6932399731.Department of General SurgeryAthens Naval & Veterans Hospital70 Dinokratous Str.AthensGR-11521Greece
| | - Nikolaos Gouvas
- “Konstantopouleio” Hospital of Athens, Department of Surgery, Athens, Greece
| | - Kleo Papaparaskeva
- “Konstantopouleio” Hospital of Athens, Department of Pathology, Athens, Greece
| | - Christos Dervenis
- “Konstantopouleio” Hospital of Athens, Department of Surgery, Athens, Greece
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Yang SJ, Hwang HK, Kang CM, Lee WJ. Preoperative defining system for pancreatic head cancer considering surgical resection. World J Gastroenterol 2016; 22:6076-6082. [PMID: 27468199 PMCID: PMC4948265 DOI: 10.3748/wjg.v22.i26.6076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/27/2016] [Accepted: 02/22/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To provide appropriate treatment, it is crucial to share the clinical status of pancreas head cancer among multidisciplinary treatment members.
METHODS: A retrospective analysis of the medical records of 113 patients who underwent surgery for pancreas head cancer from January 2008 to December 2012 was performed. We developed preoperative defining system of pancreatic head cancer by describing “resectability - tumor location - vascular relationship - adjacent organ involvement - preoperative CA19-9 (initial bilirubin level) - vascular anomaly”. The oncologic correlations with this reporting system were evaluated.
RESULTS: Among 113 patients, there were 75 patients (66.4%) with resectable, 34 patients (30.1%) with borderline resectable, and 4 patients (3.5%) with locally advanced pancreatic cancer. Mean disease-free survival was 24.8 mo (95%CI: 19.6-30.1) with a 5-year disease-free survival rate of 13.5%. Pretreatment tumor size ≥ 2.4 cm [Exp(B) = 3.608, 95%CI: 1.512-8.609, P = 0.044] and radiologic vascular invasion [Exp(B) = 5.553, 95%CI: 2.269-14.589, P = 0.002] were independent predictive factors for neoadjuvant treatment. Borderline resectability [Exp(B) = 0.222, P = 0.008], pancreatic head cancer involving the pancreatic neck [Exp(B) = 9.461, P = 0.001] and arterial invasion [Exp(B) = 6.208, P = 0.010], and adjusted CA19-9 ≥ 50 [Exp(B) = 1.972 P = 0.019] were identified as prognostic clinical factors to predict tumor recurrence.
CONCLUSION: The suggested preoperative defining system can help with designing treatment plans and also predict oncologic outcomes.
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Abstract
Imaging tests are central to the diagnosis and staging of pancreatic adenocarcinoma. We performed a systematic review and meta-analysis of the pertinent evidence on 5 imaging tests (computed tomography (CT), magnetic resonance imaging, CT angiography, endoscopic ultrasound with fine-needle aspiration, and combined positron emission tomography with CT). Searches of several databases up to March 1, 2014, yielded 9776 articles, and 24 provided comparative effectiveness of 2 or more imaging tests. Multiple reviewers applied study inclusion criteria, extracted data from each study, rated the risk of bias, and graded the strength of evidence. Data included accuracy of diagnosis and resectability in primary untreated pancreatic adenocarcinoma, including tumor stage, nodal stage, metastases, and vascular involvement. Where possible, study results were combined using bivariate meta-analysis. Studies were at low or moderate risk of bias. Most comparisons between imaging tests were insufficient to permit conclusions, due to imprecision or inconsistency among study results. However, moderate-grade evidence revealed that CT and magnetic resonance imaging had similar sensitivities and specificities for both diagnosis and vascular involvement. Other conclusions were based on low-grade evidence. In general, more direct evidence is needed to inform decisions about imaging tests for pancreatic adenocarcinoma.
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Paiella S, Sandini M, Gianotti L, Butturini G, Salvia R, Bassi C. The prognostic impact of para-aortic lymph node metastasis in pancreatic cancer: A systematic review and meta-analysis. Eur J Surg Oncol 2016; 42:616-24. [PMID: 26916137 DOI: 10.1016/j.ejso.2016.02.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate by a meta-analytic approach the long-term prognostic impact of para-aortic lymph node (PALN) involvement in resected ductal adenocarcinoma of the pancreas. METHODS MEDLINE, Embase, PubMed and the Cochrane Library were searched from January 1990 to June 2015. Trials reporting Kaplan-Meier curves and comparing overall long-term survival of negative and metastatic PALN in patients who underwent resection for pancreatic cancer were included. Lymph nodes were classified according to the Japan Pancreatic Society rules and identified using hematoxylin and eosin staining. Hazard ratios (HRs) and 95%CI were estimated for each trial and pooled in a meta-analysis. RESULTS Thirteen eligible studies including 2141 patients (364 positive PALN; 1777 negative PALN) were identified. Most of the studies were retrospective. Heterogeneity among trials was high (I(2) = 98.7%; p < .001). PALN metastasis was associated with increased mortality when compared with patients with negative PALN regardless regional nodal status [HR 1.85, 95%CI 1.48-2.31; p < .001]. Median survival was significantly decreased in patients with positive PALN (WMD = -4.92 months 95%CI -6.40; -3.43; p < .001). Moreover, metastatic PALN affected mortality also when regional lymph nodes were positive [HR 1.67, 95%CI 1.34-2.08; p < .001]. No publication bias was detected. CONCLUSIONS PALN metastasis appears to correlate with poor prognosis in patients with pancreatic adenocarcinoma. The assessment of PALN status may be considered for a more accurate staging of the disease and appropriated subgroup survival reporting. However, the definitive avoidance of the resection in case of intraoperative metastatic PALN needs further investigation.
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Affiliation(s)
- S Paiella
- Unit of General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - M Sandini
- Department of Surgery and Translational Medicine, Milano Bicocca University, Monza, Italy
| | - L Gianotti
- Department of Surgery and Translational Medicine, Milano Bicocca University, Monza, Italy
| | - G Butturini
- Unit of General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Unit of General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Unit of General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Takaori K, Bassi C, Biankin A, Brunner TB, Cataldo I, Campbell F, Cunningham D, Falconi M, Frampton AE, Furuse J, Giovannini M, Jackson R, Nakamura A, Nealon W, Neoptolemos JP, Real FX, Scarpa A, Sclafani F, Windsor JA, Yamaguchi K, Wolfgang C, Johnson CD. International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer. Pancreatology 2016; 16:14-27. [PMID: 26699808 DOI: 10.1016/j.pan.2015.10.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cancer is one of the most devastating diseases with an extremely high mortality. Medical organizations and scientific societies have published a number of guidelines to address active treatment of pancreatic cancer. The aim of this consensus review was to identify where there is agreement or disagreement among the existing guidelines and to help define the gaps for future studies. METHODS A panel of expert pancreatologists gathered at the 46th European Pancreatic Club Meeting combined with the 18th International Association of Pancreatology Meeting and collaborated on critical reviews of eight English language guidelines for the clinical management of pancreatic cancer. Clinical questions (CQs) of interest were proposed by specialists in each of nine areas. The recommendations for the CQs in existing guidelines, as well as the evidence on which these were based, were reviewed and compared. The evidence was graded as sufficient, mediocre or poor/absent. RESULTS Only 4 of the 36 CQs, had sufficient evidence for agreement. There was also agreement in five additional CQs despite the lack of sufficient evidence. In 22 CQs, there was disagreement regardless of the presence or absence of evidence. There were five CQs that were not addressed adequately by existing guidelines. CONCLUSION The existing guidelines provide both evidence- and consensus-based recommendations. There is also considerable disagreement about the recommendations in part due to the lack of high level evidence. Improving the clinical management of patients with pancreatic cancer, will require continuing efforts to undertake research that will provide sufficient evidence to allow agreement.
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Affiliation(s)
- Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy
| | - Andrew Biankin
- Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospitals Freiburg, Germany
| | - Ivana Cataldo
- Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Fiona Campbell
- Department of Pathology, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Massimo Falconi
- Pancreatic Surgery Unit, Università Vita e Salute, Milano, Italy
| | - Adam E Frampton
- HPB Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital, London, United Kingdom
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University School of Medicine, Tokyo, Japan
| | - Marc Giovannini
- Endoscopic Unit, Paoli-Calmettes Institute, Marseille, France
| | - Richard Jackson
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Akira Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - William Nealon
- Division of General Surgery, Yale University, New Haven, CT, United States of America
| | - John P Neoptolemos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Francisco X Real
- Epithelial Carcinogenesis Group, CNIO-Spanish National Cancer Research Centre, Madrid, Spain
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - John A Windsor
- Department of Surgery, University of Auckland, HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand
| | - Koji Yamaguchi
- Department of Advanced Treatment of Pancreatic Disease, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Christopher Wolfgang
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, United States of America
| | - Colin D Johnson
- University Surgical Unit, Southampton General Hospital, Southampton, United Kingdom
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Fink DM, Steele MM, Hollingsworth MA. The lymphatic system and pancreatic cancer. Cancer Lett 2015; 381:217-36. [PMID: 26742462 DOI: 10.1016/j.canlet.2015.11.048] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/16/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.
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Affiliation(s)
- Darci M Fink
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
| | - Maria M Steele
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
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De Robertis R, Tinazzi Martini P, Demozzi E, Dal Corso F, Bassi C, Pederzoli P, D’Onofrio M. Diffusion-weighted imaging of pancreatic cancer. World J Radiol 2015; 7:319-328. [PMID: 26516428 PMCID: PMC4620112 DOI: 10.4329/wjr.v7.i10.319] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/27/2015] [Accepted: 08/28/2015] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) is a reliable and accurate imaging method for the evaluation of patients with pancreatic ductal adenocarcinoma (PDAC). Diffusion-weighted imaging (DWI) is a relatively recent technological improvement that expanded MRI capabilities, having brought functional aspects into conventional morphologic MRI evaluation. DWI can depict the random diffusion of water molecules within tissues (the so-called Brownian motions). Modifications of water diffusion induced by different factors acting on the extracellular and intracellular spaces, as increased cell density, edema, fibrosis, or altered functionality of cell membranes, can be detected using this MR sequence. The intravoxel incoherent motion (IVIM) model is an advanced DWI technique that consent a separate quantitative evaluation of all the microscopic random motions that contribute to DWI, which are essentially represented by molecular diffusion and blood microcirculation (perfusion). Technological improvements have made possible the routine use of DWI during abdominal MRI study. Several authors have reported that the addition of DWI sequence can be of value for the evaluation of patients with PDAC, especially improving the staging; nevertheless, it is still unclear whether and how DWI could be helpful for identification, characterization, prognostic stratification and follow-up during treatment. The aim of this paper is to review up-to-date literature data regarding the applications of DWI and IVIM to PDACs.
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41
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Liu C, Chen R, Chen Y, Fu D, Hong D, Hao J, Liu D, Li J, Li S, Li Y, Mai G, Mou Y, Ni Q, Peng L, Qian H, Qin R, Sun B, Shao C, Sun Y, Tian B, Wang J, Wang W, Wang W, Zhao G, Yu X. Should a standard lymphadenectomy during pancreatoduodenectomy exclude para-aortic lymph nodes for all cases of resectable pancreatic head cancer? A consensus statement by the Chinese Study Group for Pancreatic Cancer (CSPAC). Int J Oncol 2015; 47:1512-6. [PMID: 26314752 DOI: 10.3892/ijo.2015.3128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/10/2015] [Indexed: 02/05/2023] Open
Abstract
Understanding and formulating an appropriate strategy for the para-aortic lymph nodes (LN16) during curative surgery for pancreatic head cancer have been controversial for some time. This study intended to provide a recommendation for surgeons to perform an optimal curative surgery on pancreatic cancer patients with or without LN16 involvement. Based on an updated literature search and review, the members of the Chinese Study Group for Pancreatic Cancer (CSPAC) from high-volume centers reached a consensus on the issue of LN16 in pancreatic head cancer. Metastasis to LN16 is quite common in pancreatic head cancer cases. Depending on the location of the tumor, including the ventral and dorsal pancreas, there could be various lymph node drainage pathways whereby LN16 does not necessarily belong to the Group 3 lymph node stations for all cases of pancreatic head cancer. Although LN16 involvement generally indicates a poor prognosis, some cohorts of LN16-involved cases have benefited from a curative surgery, and there is still a lack of level I evidence to convince surgeons to abandon all resectable cases with LN16 positivity. Resection of LN16 combined with a standard lymphadenectomy during pancreatoduodenectomy is recommended by CSPAC, except in patients with both positive LN16 and criteria based on: i) the resectability status of primary tumor; ii) the extent of involved para-aortic lymph nodes; and iii) the serum tumor burden assessed preoperatively.
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Affiliation(s)
- Chen Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Rufu Chen
- Department of Pancreaticobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yingtai Chen
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Defei Hong
- Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, P.R. China
| | - Jihui Hao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, P.R. China
| | - Dawei Liu
- Department of General Surgery of Heilongjiang Provincial Hospital, Harbin, Heilongjiang, P.R. China
| | - Jiangtao Li
- Department of Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Shengping Li
- Department of Hepatobiliary Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, P.R. China
| | - Yixiong Li
- Department of Pancreatic-Bililary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Gang Mai
- Department of Hepatobiliopancreatic Surgery, The People's Hospital of Deyang, Deyang, P.R. China
| | - Yiping Mou
- Department of Gastroenterological and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, P.R. China
| | - Quanxing Ni
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
| | - Li Peng
- Department of Hepato-Pancreato-Biliary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Honggang Qian
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, P.R. China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P.R. China
| | - Chenghao Shao
- Department of Pancreatic-Biliary Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Bole Tian
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Wei Wang
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, P.R. China
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Gang Zhao
- The Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Xianjun Yu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University; Pancreatic Cancer Institute, Fudan University, Shanghai, P.R. China
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Nakayama T, Tsuchikawa T, Shichinohe T, Nakamura T, Ebihara Y, Hirano S. Pathological confirmation of para-aortic lymph node status as a potential criterion for the selection of intrahepatic cholangiocarcinoma patients for radical resection with regional lymph node dissection. World J Surg 2015; 38:1763-8. [PMID: 24378552 DOI: 10.1007/s00268-013-2433-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Para-aortic lymph node (PAN) metastasis traditionally has been defined as distant metastasis. Many studies suggest that lymph node metastasis in intrahepatic cholangiocarcinoma (ICC) is one of the strongest prognostic factors for patient survival; however, the status of the PAN was not examined separately from regional lymph node metastasis in these reports. Here, we investigated whether regional lymph node metastasis without PAN metastasis in ICC can be classified as resectable disease and whether curative resection can have a prognostic impact. METHODS Between 1998 and 2010, a total of 47 ICC patients underwent hepatic resection and systematic lymphadenectomy with curative intent. We routinely dissected the PANs and had frozen-section pathological examinations performed intraoperatively. If PAN metastases were identified, curative resection was abandoned. We retrospectively investigated the prognostic factors for patient survival after curative resection for ICC without PAN metastases, with particular attention paid to the prognostic impact of lymphadenectomy. RESULTS Univariate analysis identified concomitant portal vein resection, concomitant hepatic artery resection, intraoperative blood loss, intraoperative transfusion, and residual tumor as significant negative prognostic factors. However, lymph node status was not identified as a significant prognostic factor. The 14 patients with node-positive cancer had a survival rate of 20 % at 5 years. Based on multivariate analysis, intraoperative transfusion was an independent prognostic factor associated with a poor prognosis (risk ratio = 4.161; P = 0.0056). CONCLUSIONS Regional lymph node metastasis in ICC should be classified as resectable disease, because the survival rate after surgical intervention was acceptable when PAN metastasis was pathologically negative.
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Affiliation(s)
- Tomohide Nakayama
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan,
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Pedrazzoli S. Extent of lymphadenectomy to associate with pancreaticoduodenectomy in patients with pancreatic head cancer for better tumor staging. Cancer Treat Rev 2015; 41:577-87. [PMID: 26045226 DOI: 10.1016/j.ctrv.2015.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To define the extent of lymphadenectomy to associate with surgery for pancreatic head cancer. BACKGROUND Pancreaticoduodenectomy with extended lymphadenectomy fails to prolong patient survival. METHODS Prospective randomized and nonrandomized controlled trials (RCTs and NRCTs), meta-analyses, retrospective reviews, consensus conferences and pre- and intraoperative diagnoses of lymph node (LN) metastases were retrieved. Standard and extended lymphadenectomies were reviewed, including their effects on postoperative complications, mortality rate and long-term survival. The minimum total number of LN examined (TNLE) for adequate tumor staging, and the incidence of metastasis to each LN station were also considered. A pros and cons analysis was performed on the removal of each LN station. RESULTS Eleven retrospective studies (2514 patients), five prospective NRCTs (545 patients), and five prospective RCTs (586 patients) described different lymphadenectomies, which obtained similar long-term results. Five meta-analyses showed they did not influence long-term survival. However, N status is an important component of tumor staging. The recommended minimum TNLE is 15. The percent incidence of metastasis to each LN station was calculated considering at least 385 and up to 3725 patients. Preoperative imaging and intraoperative exploration frequently fail to identify metastatic nodes. A pros and cons analysis suggests that lymph node status is better established removing the following LN stations: 6, 8a-p, 12a-b-c, 13a-b, 14a-b-c-d, 16b1, 17a-b. Metastasis to 16b1 LNs significantly worsens prognosis. Their removal and frozen section examination, before proceeding with resection, may contraindicate resection. CONCLUSION A standard lymphadenectomy demands an adequate TNLE and removal of the LN stations metastasizing more frequently, without increasing the surgical risk.
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Sho M, Murakami Y, Motoi F, Satoi S, Matsumoto I, Kawai M, Honda G, Uemura K, Yanagimoto H, Kurata M, Fukumoto T, Akahori T, Kinoshita S, Nagai M, Nishiwada S, Unno M, Yamaue H, Nakajima Y. Postoperative prognosis of pancreatic cancer with para-aortic lymph node metastasis: a multicenter study on 822 patients. J Gastroenterol 2015; 50:694-702. [PMID: 25341657 DOI: 10.1007/s00535-014-1005-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/28/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognosis of pancreatic cancer patients with metastatic para-aortic lymph node (PALN) has been reported to be extremely poor. In general, PALN metastasis has been considered as a contraindication for pancreatic resection. The aim of this study was to reevaluate the postoperative prognostic value of PALN metastasis in pancreatic cancer and to determine the validity of pancreatic surgery. METHODS Retrospective multicenter analysis of 882 patients who have undergone curative-intent pancreatic resection with pathological evaluation of PALNs for pancreatic ductal adenocarcinoma between 2001 and 2012 was conducted. Clinicopathological data and outcomes were evaluated with univariate and multivariate analysis. RESULTS In total, 102 (12.4 %) patients had positive metastasis in PALN. Patients with metastatic PALN had significantly poorer survival than those without (17 vs. 23 months; p < 0.001). Multivariable analysis of 822 patients identified adjuvant chemotherapy, primary tumor status, regional lymph node metastasis, portal vein invasion, pre- and post-operative serum CA19-9 levels, and tumor grade as independent prognostic factors. In contrast, PALN metastasis did not have a significant prognostic value. Furthermore, the multivariate prognostic analysis in patients with PALN metastasis revealed that adjuvant chemotherapy and the number of metastatic PALN were significantly associated with long-term survival. Lung metastasis as initial recurrence was observed more often in patients with PALN metastasis in comparison with those without. CONCLUSIONS Some pancreatic cancer patients with metastatic PALN may survive for longer than expected after pancreatectomy. Adjuvant chemotherapy and the number of metastatic PALN were critical factors for long-term survival of those patients.
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Affiliation(s)
- Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan,
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Raman SP, Chen Y, Fishman EK. Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation. Semin Oncol 2015; 42:40-58. [DOI: 10.1053/j.seminoncol.2014.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Wang XY, Yang F, Jin C, Fu DL. Utility of PET/CT in diagnosis, staging, assessment of resectability and metabolic response of pancreatic cancer. World J Gastroenterol 2014; 20:15580-15589. [PMID: 25400441 PMCID: PMC4229522 DOI: 10.3748/wjg.v20.i42.15580] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/11/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the most common gastrointestinal tumors, with its incidence staying at a high level in both the United States and China. However, the overall 5-year survival rate of pancreatic cancer is still extremely low. Surgery remains the only potential chance for long-term survival. Early diagnosis and precise staging are crucial to make proper clinical decision for surgery candidates. Despite advances in diagnostic technology such as computed tomography (CT) and endoscopic ultrasound, diagnosis, staging and monitoring of the metabolic response remain a challenge for this devastating disease. Positron emission tomography/CT (PET/CT), a relatively novel modality, combines metabolic detection with anatomic information. It has been widely used in oncology and achieves good results in breast cancer, lung cancer and lymphoma. Its utilization in pancreatic cancer has also been widely accepted. However, the value of PET/CT in pancreatic disease is still controversial. Will PET/CT change the treatment strategy for potential surgery candidates? What kind of patients benefits most from this exam? In this review, we focus on the utility of PET/CT in diagnosis, staging, and assessment of resectability of pancreatic cancer. In addition, its ability to monitor metabolic response and recurrence after treatment will be emphasis of discussion. We hope to provide answers to the questions above, which clinicians care most about.
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47
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Tseng DSJ, van Santvoort HC, Fegrachi S, Besselink MG, Zuithoff NPA, Borel Rinkes IH, van Leeuwen MS, Molenaar IQ. Diagnostic accuracy of CT in assessing extra-regional lymphadenopathy in pancreatic and peri-ampullary cancer: a systematic review and meta-analysis. Surg Oncol 2014; 23:229-35. [PMID: 25466853 DOI: 10.1016/j.suronc.2014.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/17/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Computed tomography (CT) is the most widely used method to assess resectability of pancreatic and peri-ampullary cancer. One of the contra-indications for curative resection is the presence of extra-regional lymph node metastases. This meta-analysis investigates the accuracy of CT in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer. METHODS We systematically reviewed the literature according to the PRISMA guidelines. Studies reporting on CT assessment of extra-regional lymph nodes in patients undergoing pancreatoduodenectomy were included. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data. RESULTS After screening, 4 cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or peri-ampullary cancer were included. Overall, diagnostic accuracy, specificity and NPV varied from 63 to 81, 80-100% and 67-90% respectively. However, PPV and sensitivity ranged from 0 to 100% and 0-38%. Pooled sensitivity, specificity, PPV and NPV were 25%, 86%, 28% and 84% respectively. CONCLUSIONS CT has a low diagnostic accuracy in assessing extra-regional lymph node metastases in pancreatic and peri-ampullary cancer. Therefore, suspicion of extra-regional lymph node metastases on CT alone should not be considered a contra-indication for exploration.
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Affiliation(s)
- Dorine S J Tseng
- Department of Surgery, University Medical Center Utrecht, HG G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, HG G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Samira Fegrachi
- Department of Surgery, University Medical Center Utrecht, HG G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center Amsterdam, HG G4-196, P.O. Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HG STR6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Inne H Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, HG G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, HG E01.132, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, HG G04.228, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Crippa S, Salgarello M, Laiti S, Partelli S, Castelli P, Spinelli AE, Tamburrino D, Zamboni G, Falconi M. The role of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in resectable pancreatic cancer. Dig Liver Dis 2014; 46:744-9. [PMID: 24721105 DOI: 10.1016/j.dld.2014.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/03/2014] [Accepted: 03/16/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in pancreatic ductal adenocarcinoma is debated. We retrospectively assessed the value of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in addition to conventional imaging as a staging modality in pancreatic cancer. METHODS (18)Fluoro-deoxyglucose positron emission tomography/computed tomography was performed in 72 patients with resectable pancreatic carcinoma after multi-detector computed tomography positron emission tomography was considered positive for a maximum standardized uptake value >3. RESULTS Overall, 21% of patients had a maximum standardized uptake value ≤ 3, and 60% of those had undergone neoadjuvant treatment (P=0.0001). Furthermore, 11% of patients were spared unwarranted surgery since positron emission tomography/computed tomography detected metastatic disease. All liver metastases were subsequently identified with contrast-enhanced ultrasound. Sensitivity and specificity of positron emission tomography/computed tomography for distant metastases were 78% and 100%. The median CA19.9 concentration was 48.8 U/mL for the entire cohort and 292 U/mL for metastatic patients (P=0.112). CONCLUSIONS The widespread application of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in patients with resectable pancreatic carcinoma seems not justified. It should be considered in selected patients at higher risk of metastatic disease (i.e. CA19.9>200 U/mL) after undergoing other imaging tests. Neoadjuvant treatment is significantly associated with low metabolic activity, limiting the value of positron emission tomography in this setting.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Department of Surgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | | | - Silvia Laiti
- Residency Programme in Surgery, University of Verona, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Department of Surgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Paola Castelli
- Department of Pathology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Antonello E Spinelli
- Department of Medical Physics and Experimental Imaging, San Raffaele Scientific Institute, Milan, Italy
| | | | - Giuseppe Zamboni
- Department of Pathology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Department of Surgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy.
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49
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Ergul N, Gundogan C, Tozlu M, Toprak H, Kadıoglu H, Aydin M, Çermik T. Role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in diagnosis and management of pancreatic cancer; comparison with Multidetector Row Computed Tomography, Magnetic Resonance Imaging and Endoscopic Ultrasonography. Rev Esp Med Nucl Imagen Mol 2014. [DOI: 10.1016/j.remnie.2014.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schwarz L, Lupinacci RM, Svrcek M, Lesurtel M, Bubenheim M, Vuarnesson H, Balladur P, Paye F. Para-aortic lymph node sampling in pancreatic head adenocarcinoma. Br J Surg 2014; 101:530-8. [PMID: 24633831 DOI: 10.1002/bjs.9444] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The significance of positive para-aortic nodes in patients with resectable pancreatic carcinoma is unclear. This study sought to evaluate the accuracy of intraoperative detection and prognostic significance of these lymph nodes in patients with resected adenocarcinoma of the pancreatic head. METHODS From 2000 to 2010, para-aortic node sampling was performed prospectively in all patients before pancreatoduodenectomy. Frozen sections were created and nodes categorized as positive or negative for metastases. Surgeons were blinded to the frozen-section results. This was followed by standard histopathological assessment of corresponding paraffin-embedded, haematoxylin and eosin-stained material. Nodes considered uninvolved by this analysis were examined immunohistochemically for micrometastases. RESULTS A total of 111 consecutive patients were included, with a median follow-up of 20·8 (range 1·5-126) months. The 1-, 2- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 73·6, 54·0 and 24·7 per cent, and 51·8, 28·1 and 18·8 per cent respectively. Para-aortic node involvement was always associated with peripancreatic lymph node metastasis, and was detected by frozen-section analysis in 12 patients and by haematoxylin and eosin staining in 17. Sensitivity and specificity of frozen-section examination for detecting para-aortic lymph node metastases were 71 and 100 per cent respectively. Median OS for patients with and without para-aortic node involvement on frozen-section analysis was 9·7 versus 28·5 months respectively (P = 0·012), and 15·7 versus 27·2 months (P = 0·050) when assessed by haematoxylin and eosin staining. Median DFS for patients with and without para-aortic node involvement on frozen-section examination was 5·6 versus 12·9 months respectively (P = 0·041), and 8·4 versus 12·9 months (P = 0·038) for haematoxylin and eosin analysis. The presence of micrometastases in para-aortic nodes was not significantly associated with altered OS or DFS. CONCLUSION Para-aortic node sampling with frozen-section examination detects distant lymphatic involvement reliably. It should be performed systematically. When metastases are found, they should be considered a contraindication to pancreatic resection.
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Affiliation(s)
- L Schwarz
- Departments of Digestive Surgery and Marie Curie University, Paris
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