Postoperative adjuvant chemotherapy improves survival after surgical resection for pancreatic carcinoma

Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions

Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.

Analysis of prognostic factors for pancreatic head cancer according to para-aortic lymph node

This study was designed to investigate the relationship between prognosis of pancreatic head cancer and status of para-aortic lymph node (PALN). A total of 233 patients with pancreatic head cancer who underwent surgical resection between February 2008 and October 2015 were enrolled in this study. Univariate and multivariate analyses were used to reveal the prognostic factors. Prognostic factors for patients with and without metastasis of PALN were analyzed, respectively. The 5-year overall survival (OS) rate was 19.0% for all patients, and the positive rate of PALN metastasis was 18.9% (44/233). The 1-, 2-, 3-, and 5-year OS rates in patients without metastasis of PALN were 79.4%, 54.8%, 36.4%, and 22.9%, respectively, whereas the 1-, 2-, and 3-year survival rates were 54.0%, 14.8%, and 0%, respectively, in patients with metastasis of PALN. Preoperative CA19-9 level, tumor size, T status, N status, and adjuvant therapy were independent prognostic factors for all patients confirmed by multivariate analysis. For patients without PALN metastasis, back pain, tumor size, T status, N status, portal or superior mesenteric vein invasion, and adjuvant therapy were independent prognostic factors, while the only one influence factor for 2-year OS was adjuvant therapy for patients with metastasis of PALN. Metastasis of PALN was associated with poor prognosis for patients with pancreatic head cancer. Patients with and without metastasis of PALN had different prognostic factors, and adjuvant therapy was the only prognostic factor for patients with metastasis of PALN.

A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Resectable pancreatic ductal adenocarcinoma continues to carry a poor prognosis. Of the controllable clinical variables known to affect outcome, margin status is paramount. Though the importance of a R0 resection is generally accepted, not all margins are easily managed. The superior mesenteric artery [SMA] in particular is the most challenging to clear. The aim of this study was to systematically review the literature with specific focus on the role of a SMA periadventitial dissection during PD and it's effect on margin status in pancreatic adenocarcinoma.

STUDY DESIGN

The MEDLINE, EMBASE and Cochrane databases were searched for abstracts that addressed the effect of margin status on survival and recurrence following pancreaticoduodenectomy [PD]. Quantitative analysis was performed.

RESULTS

The overall incidence of a R1 resection ranged from 16% to 79%. The margin that was most often positive following PD was the SMA margin, which was positive in 15-45% of resected specimens. Most studies suggested that a positive margin was associated with decreased survival. No consistent definition of R0 resection was observed.

CONCLUSIONS

Margin positivity in resectable pancreatic adenocarcinoma is associated with poor survival. Inability to clear the SMA margin is the most common cause of incomplete resection. More complete and consistently reported data are needed to evaluate the potential effect of periadventitial SMA dissection on margin status, local recurrence, or survival.

Influence of perineural invasion on survival and recurrence in patients with resected pancreatic cancer

BACKGROUND

Perineural invasion (PNI) has been reported as one of the sources of locoregional recurrence in resected pancreatic cancer (PC). However the impact of PNI in resected pancreatic cancer remains controversial. The purpose of this study was to determine the association between PNI status and clinical outcomes.

METHODS

Publications were identified which assessed prognostic significance of PNI status in resected pancreatic cancer up to February 2013. A meta-analysis was performed to clarify the association between PNI status and clinical outcomes.

RESULTS

A total of 21 studies met the inclusion criteria, covering 4,459 cases. Analysis of these data showed that intrapancreatic PNI was correlated with reduced overall survival only in resected pancreatic ductal adenocarcinoma (PDAC) patients (HR=1.982, 95%CI: 1.526-2.574, p=0.000). Extrapancreatic PNI was correlated with reduced overall survival in all resected pancreatic cancer patients (HR=1.748, 95%CI: 1.372- 2.228, p=0.000). Moreover, intrapancreatic PNI status may be associated with tumor recurrence in all resected pancreatic cancer patients (HR=2.714, 95%CI: 1.885-3.906, p=0.000).

CONCLUSION

PNI was an independent and poor prognostic factor in resected PDAC patients. Moreover, intrapancreatic PNI status may be associated with tumor recurrence.

The outcome of cryoablation in treating advanced pancreatic cancer: a comparison with palliative bypass surgery alone

OBJECTIVE

This study aimed to investigate the efficacy and safety of palliative bypass surgery combined with cryoablation in treating patients with advanced pancreatic cancer and compare this combination therapy with palliative bypass surgery alone.

METHODS

Medical records of 118 patients with advanced pancreatic cancer who received palliative bypass surgery combined with cryoablation (the combination treatment group) or bypass surgery alone (the bypass surgery alone group) at the Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital (Tianjin, China) were retrospectively reviewed. Their baseline and peri-operative parameters were collected and compared.

RESULTS

In both groups abdominal distension and pain was significantly ameliorated after treatment. Preoperative jaundice was more common in the bypass surgery group while backache was more frequent in the combination treatment group, which were both relieved by treatment. The pre-operative serum bilirubin level was higher in the bypass surgery group and was decreased significantly after treatment. However, a significant reduction in tumor size and serum carbohydrate antigen 19-9 level was found only in the combination treatment group. There was no significant difference in the incidence of postoperative complications and prognosis between the two groups.

CONCLUSIONS

Cryoablation can reduce tumor size and relieve the patients' symptoms and signs such as abdominal discomfort and backache, although it could not improve the patients' prognosis significantly. It is a safe and efficient modality when combined with bypass surgery for patients with advanced pancreatic cancer.

Precursor lesions for sporadic pancreatic cancer: PanIN, IPMN, and MCN

Pancreatic cancer is still a dismal disease. The high mortality rate is mainly caused by the lack of highly sensitive and specific diagnostic tools, and most of the patients are diagnosed in an advanced and incurable stage. Knowledge about precursor lesions for pancreatic cancer has grown significantly over the last decade, and nowadays we know that mainly three lesions (PanIN, and IPMN, MCN) are responsible for the development of pancreatic cancer. The early detection of these lesions is still challenging but provides the chance to cure patients before they might get an invasive pancreatic carcinoma. This paper focuses on PanIN, IPMN, and MCN lesions and reviews the current level of knowledge and clinical measures.

Combined analysis of intratumoral human equilibrative nucleoside transporter 1 (hENT1) and ribonucleotide reductase regulatory subunit M1 (RRM1) expression is a powerful predictor of survival in patients with pancreatic carcinoma treated with adjuvant gemcitabine-based chemotherapy after operative resection

BACKGROUND

Although postoperative adjuvant chemotherapy for pancreatic carcinoma improves survival in some patients, its efficacy varies among individuals. The aim of this study was to determine the usefulness of intratumoral expression of human equilibrative nucleoside transporter 1 (hENT1) and ribonucleotide reductase regulatory subunit M1 (RRM1) as predictive markers of the efficacy of adjuvant gemcitabine-based chemotherapy for pancreatic carcinoma after operative resection.

METHODS

The expression of intratumoral hENT1 and RRM1 was examined immunohistochemically in 109 patients with pancreatic carcinoma who received adjuvant gemcitabine-based chemotherapy after operative resection. Relationships between clinicopathologic factors, including hENT1 and RRM1 expression, and disease-free and overall survival (DFS and OS) were evaluated by univariate and multivariate analyses.

RESULTS

The 5-year DFS and OS rates for the 109 patients were 26% and 31%, respectively. In univariate analysis, both hENT1 and RRM1 expression were significantly associated with DFS (hENT1, P = .004; RRM1, P = .011) and OS (hENT1, P = .001; RRM1, P = .040). In multivariate analysis, both were independent factors for DFS (hENT1, P = .001; RRM1, P = .009) and OS (hENT1, P = .001, RRM1, P = .019). Evaluation of the combination analysis of both was also identified as a powerful independent predictor of DFS (P < .001) and OS (P < .001).

CONCLUSION

Expression of hENT1 and RRM1 is predictive of the efficacy of adjuvant gemcitabine-based chemotherapy for pancreatic carcinoma after operative resection. In addition, their combined analysis has greater predictive value than either factor alone.

Hospital Volume, Margin Status, and Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers ( P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively ( P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.

Factors affecting long-term survival after surgical resection of pancreatic ductal adenocarcinoma

PURPOSE

Some patients who undergo surgical resection of pancreatic cancer survive longer than other patients. The purpose of this study was to identify the factors that affect long-term survival after resection of histopathologically confirmed pancreatic ductal adenocarcinoma.

METHODS

A single-center, retrospective study was conducted among 164 patients who underwent surgical resection of pancreatic cancer, between May 1995 and December 2004. The patient follow-up process was conducted via telephone survey and review of electronic medical records for at least 5 years or until death.

RESULTS

We compared patients with long-term (≥60 months, n = 19) and short-term survival (<60 months, n = 145). Resection margin status, differentiation of the tumor, tumor stage, pre-operative serum level of albumin, total bilirubin and carbohydrate antigen (CA) 19-9 level are related with survival difference (all factors, P < 0.05). Multivariate analysis revealed that a pre-operative serum total bilirubin level <7 mg/dL and a pre-operative serum CA19-9 level <37 U/mL is a statistically significant prognostic factor for long-term survival.

CONCLUSION

The preoperative serum total bilirubin and serum CA19-9 levels are associated with long-term survival after surgical resection of pancreatic cancer.

Prognostic impact of dihydropyrimidine dehydrogenase expression on pancreatic adenocarcinoma patients treated with S-1-based adjuvant chemotherapy after surgical resection

BACKGROUND AND OBJECTIVES

The aim of this study is to investigate the prognostic value of intratumoral expression of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), and orotate phosphoribosyltransferase (OPRT) in patients treated with S-1-based chemotherapy after surgical resection for pancreatic adenocarcinoma.

METHODS

Intratumoral TS, DPD, and OPRT expression was investigated in 106 patients with resected pancreatic adenocarcinoma by immunohistochemistry. Associations between clinicopathological factors, including intratumoral TS, DPD, and OPRT expression, and survival were evaluated by univariate and multivariate analyses.

RESULTS

Of 106 patients, 72 had received S-1-based adjuvant chemotherapy (S-1(+) group), and 34 had not (S-1(-) group). High TS, DPD, and OPRT expression was observed in 64%, 37%, and 66% of patients, respectively. Among S-1(+) group patients, survival was significantly better for patients with low DPD expression than for patients with high DPD expression (P = 0.022). Intratumoral DPD expression was the only independent prognostic factor for patients treated with S-1-based adjuvant chemotherapy by multivariate analysis (P = 0.037). Intratumoral TS and OPRT expression did not appear to influence survival.

CONCLUSIONS

Intratumoral DPD expression may be a relevant predictive marker of survival benefit associated with S-1-based adjuvant chemotherapy for pancreatic adenocarcinoma.

Prognostic impact of para-aortic lymph node metastasis in pancreatic ductal adenocarcinoma

BACKGROUND

The aim of the present study was to clarify the prognostic impact of para-aortic lymph node metastasis in pancreatic ductal adenocarcinoma.

METHODS

Medical records of 103 consecutive patients with pancreatic ductal adenocarcinoma, who underwent pancreatic resection with regional and para-aortic lymph node dissection were reviewed retrospectively. Clinicopathological factors and survival were compared between patients with and without para-aortic lymph node metastasis.

RESULTS

Tumor size (p = 0.045), extrapancreatic nerve plexus invasion (p = 0.043), UICC pT factor (p = 0.026), and surgical margin status (p = 0.002) were associated significantly with para-aortic lymph node metastasis. Postoperative adjuvant chemotherapy (p < 0.001) and absence of extrapancreatic nerve plexus invasion (p = 0.041) were associated independently with longer survival, but para-aortic lymph node metastasis (p = 0.078) was not associated significantly with survival by multivariate analysis. The 2- and 5-year survival rates and median survival time of patients with and without para-aortic lymph node metastasis were 12, 0%, 12.4 months and 49, 23%, 14.5 months, respectively, and there was a significant difference in survival between the two groups by a log-rank test (p < 0.001). Postoperative adjuvant chemotherapy significantly improved the survival of patients with para-aortic lymph node metastasis (p = 0.025).

CONCLUSIONS

The prognosis of patients with para-aortic lymph node metastasis is poor in pancreatic ductal adenocarcinoma. However, postoperative adjuvant chemotherapy may improve survival.

Number of metastatic lymph nodes, but not lymph node ratio, is an independent prognostic factor after resection of pancreatic carcinoma

BACKGROUND

This study evaluated the prognostic significance of the number of metastatic lymph nodes and the ratio of metastatic nodes to total number of examined lymph nodes (lymph node ratio, LNR) after resection of pancreatic carcinoma.

STUDY DESIGN

Records of 119 consecutive patients with pancreatic ductal carcinoma, who underwent R0 or R1 pancreatectomy with regional node dissection, were reviewed retrospectively. Clinical factors, pathologic factors including number of metastatic nodes and LNR, and survival were analyzed by univariate and multivariate analyses.

RESULTS

Overall survival rates were 78%, 28%, and 20% at 1, 3, and 5 years, respectively. The median numbers of evaluated lymph nodes and involved nodes were 28 and 3, respectively. Univariate analysis revealed that tumor location, postoperative adjuvant chemotherapy, tumor differentiation, choledochal invasion, portal or splenic vein invasion, extrapancreatic nerve plexus invasion, resection margin status, node status, number of involved nodes, LNR, International Union against Cancer (UICC) pT factor, and UICC stage correlated significantly (p < 0.05) with increased survival. By multivariate analysis, negative node metastasis (p = 0.008) and 0 or 1 involved node (p = 0.004), but not LNR, correlated independently with longer survival. The 1-, 3-, and 5-year survival rates of patients with 0 or 1 metastatic node and patients with 2 or more metastatic nodes were 91%, 48%, and 40% and 66%, 10%, and 0%, respectively.

CONCLUSIONS

The number of metastatic nodes, but not LNR, is one of the most powerful prognostic factors after resection of pancreatic carcinoma.

Prognostic impact of perioperative serum CA 19-9 levels in patients with resectable pancreatic cancer

BACKGROUND

Pancreatic cancer is one of the most deadly cancers, and serum carbohydrate antigen 19-9 (CA19-9) level has been reported to be a useful prognostic marker in pancreatic cancer. The purpose of this study was to determine which prognostic factor (preoperative or postoperative serum CA19-9 level) is more useful.

METHODS

Pre- and postoperative serum CA19-9 levels were measured in 109 patients who underwent surgical resection for pancreatic cancer between 1998 and 2009, and their relationships to clinicopathological factors and overall survival were analyzed with univariate and multivariate methods.

RESULTS

In univariate analysis, tumor location (P = 0.019), postoperative adjuvant chemotherapy (P < 0.001), residual tumor factor status (P < 0.001), UICC pT stage (P = 0.004), lymph node metastasis (P = 0.015), and UICC final stage (P = 0.015) were significantly associated with overall survival. Differences in overall survival were significant between groups divided on the basis of four postoperative CA19-9 cutoff values (37, 100, 200, and 500 U/ml) but not significant between groups divided on the basis of the same four preoperative CA19-9 cutoff values. Pre- to postoperative increase in CA19-9 level also was significantly associated with poor prognosis. In multivariate analysis, postoperative adjuvant chemotherapy (hazard ratio, 1.59; P = 0.004) and postoperative CA19-9 cutoff value of 37 U/ml (HR, 1.64; P = 0.004) remained independent predictors of prognosis.

CONCLUSIONS

Postoperative CA19-9 level is a better prognostic factor than preoperative CA19-9 level, and curative surgery for resectable pancreatic cancer should be tried regardless of the preoperative CA19-9 level.

Impact of selection bias on the utilization of adjuvant therapy for pancreas adenocarcinoma

BACKGROUND

Improved outcomes have been associated with the use of adjuvant therapy after resection of pancreas adenocarcinoma. However, the frequency with which patients receive adjuvant therapy and the factors impacting its use remain largely undefined. We hypothesized that nonutilization of adjuvant therapy was primarily associated with patient comorbidity and onset of postoperative complications.

METHODS

A prospectively maintained database was reviewed to identify patients who underwent potentially curative resection of histologically confirmed pancreas adenocarcinoma at our institution from January 1996 to May 2007. Clinicopathological data and postoperative treatment history were collected to identify variables associated with receipt of adjuvant therapy.

RESULTS

Of 119 patients, 33% did not receive adjuvant therapy. The frequency with which patients underwent adjuvant therapy did not change over time. On multivariate analysis, patient age 70 years or greater, major postoperative complications, distal pancreatectomy, absence of nodal metastases, and absence of perineural invasion were associated with decreased utilization of adjuvant therapy.

DISCUSSION

One-third of patients in this contemporary dataset of patients did not go on to receive adjuvant therapy. The likelihood of receiving adjuvant treatment is negatively impacted by the course of postoperative recovery. Moreover, the fact that adjuvant therapy was undertaken less often for older patients and patients with favorable pathological features highlights the selection bias impacting the decision to pursue postoperative therapy for this disease. This selective utilization of postoperative therapy for patients with adverse oncological characteristics is likely to bias any retrospective analysis attempting to measure the efficacy of adjuvant treatment for pancreas adenocarcinoma.

Invasive intraductal papillary-mucinous neoplasm of the pancreas: comparison with pancreatic ductal adenocarcinoma

BACKGROUND AND OBJECTIVES

The aim of this study was to clarify the clinicopathological differences between patients with invasive intraductal papillary-mucinous neoplasm (IPMN) of the pancreas and pancreatic ductal adenocarcinoma.

METHODS

The medical records of 16 patients with invasive IPMN and 106 patients with pancreatic ductal adenocarcinoma, who underwent surgical resection, were retrospectively reviewed, and the clinicopathological factors and survival were compared between the two groups.

RESULTS

The presence of retroperitoneal tissue invasion, portal or splenic vein invasion, nodal involvement, and positive surgical margins were significantly lower in patients with invasive IPMN than in those with ductal adenocarcinoma (P < 0.05). The actuarial 5-year overall survival rates in patients with invasive IPMN and ductal carcinoma were 40% and 18%, respectively (P = 0.008). However, the actuarial 5-year survival rate of patients with invasive IPMN was only 27% for UICC stage II disease, although this was significantly higher than that of patients with UICC stage II ductal adenocarcinoma (P = 0.049).

CONCLUSIONS

Invasive IPMN has a favorable prognosis compared with pancreatic ductal adenocarcinoma that is likely due to the less aggressive nature of the disease. However, the prognosis for cases of advanced invasive IPMN is not always favorable despite complete tumor resection.

Impact of adjuvant gemcitabine plus S-1 chemotherapy after surgical resection for adenocarcinoma of the body or tail of the pancreas

BACKGROUND

Few patients with pancreatic body or tail carcinoma are candidates for surgical resection, and the efficacy of postoperative adjuvant chemotherapy for patients with pancreatic body or tail carcinoma has not been elucidated. The aim of this study was to determine the effect of adjuvant gemcitabine and S-1 therapy for patients with adenocarcinoma of the body or tail of the pancreas who had undergone surgical resection by distal pancreatectomy.

MATERIALS AND METHODS

Medical records of 34 patients with pancreatic body or tail carcinoma who underwent surgical resection were reviewed retrospectively. Eighteen patients received postoperative adjuvant gemcitabine and S-1 chemotherapy. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival.

RESULTS

There were no deaths due to surgery. Overall, 1-, 2-, and 5-year survival rates were 69%, 40%, and 25%, respectively (median survival time, 14.4 months). Univariate analysis revealed that adjuvant gemcitabine plus S-1 chemotherapy, blood transfusion, splenic artery invasion, lymph node metastasis, surgical margin status, and International Union Against Cancer stage were associated significantly with long-term survival (P < 0.05). Furthermore, use of a Cox proportional hazards regression model indicated that adjuvant gemcitabine plus S-1 chemotherapy and absence of lymph node metastasis were significant independent predictors of a favorable prognosis (P < 0.05).

CONCLUSION

Postoperative adjuvant gemcitabine plus S-1 chemotherapy may improve survival after surgical resection for pancreatic body or tail carcinoma.