1
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Palm RF, Boyer E, Kim DW, Denbo J, Hodul PJ, Malafa M, Fleming JB, Shridhar R, Chuong MD, Mellon EA, Frakes JM, Hoffe SE. Neoadjuvant chemotherapy and stereotactic body radiation therapy for borderline resectable pancreas adenocarcinoma: influence of vascular margin status and type of chemotherapy. HPB (Oxford) 2023; 25:1110-1120. [PMID: 37286392 DOI: 10.1016/j.hpb.2023.04.019] [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: 11/04/2022] [Revised: 01/29/2023] [Accepted: 04/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The influence of chemotherapy type and vascular margin status after sequential chemotherapy and stereotactic body radiation therapy (SBRT) for borderline resectable pancreatic cancer (BRPC) is unknown. METHODS A retrospective review was performed on BRPC patients treated with chemotherapy and 5-fraction SBRT from 2009 to 2021. Surgical outcomes and SBRT-related toxicity were reported. Clinical outcomes were estimated by Kaplan-Meier with log rank comparisons. RESULTS A total of 303 patients received neoadjuvant chemotherapy and SBRT to a median dose of 40 Gy prescribed to the tumor-vessel interface and median dose of 32.4 Gyto 95% of the gross tumor volume. One hundred and sixty-nine patients (56%) were resected and benefited from improved median OS (41.1 vs 15.5 months, P < 0.001). Close/positive vascular margins were not associated with worse OS or FFLRF. Type of neoadjuvant chemotherapy did not influence OS for resected patients, but FOLFIRINOX was associated with improved median OS in unresected patients (18.2 vs 13.1 months, P = 0.001). CONCLUSION For BRPC, the effect of a positive or close vascular margin may be mitigated by neoadjuvant therapy. Shorter duration neoadjuvant chemotherapy as well as the optimal biological effective dose of radiotherapy should be prospectively explored.
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Affiliation(s)
- Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA.
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Dae W Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason Denbo
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason B Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Advent Health, Orlando, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami FL, USA
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
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2
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Chui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford) 2023; 25:1011-1021. [PMID: 37301633 DOI: 10.1016/j.hpb.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies. METHODS A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset. RESULTS A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury. CONCLUSIONS The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
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Affiliation(s)
- Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
| | - Sumit Sahni
- Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia.
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3
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Saha A, Wadsley J, Sirohi B, Goody R, Anthony A, Perumal K, Ulahanan D, Collinson F. Can Concurrent Chemoradiotherapy Add Meaningful Benefit in Addition to Induction Chemotherapy in the Management of Borderline Resectable and Locally Advanced Pancreatic Cancer?: A Systematic Review. Pancreas 2023; 52:e7-e20. [PMID: 37378896 DOI: 10.1097/mpa.0000000000002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES The role of concomitant chemoradiotherapy or radiotherapy (RT) after induction chemotherapy (IC) in borderline resectable and locally advanced pancreatic ductal adenocarcinoma is debatable. This systematic review aimed to explore this. METHODS We searched PubMed, MEDLINE, EMBASE, and Cochrane database. Studies were selected reporting outcomes on resection rate, R0 resection, pathological response, radiological response, progression-free survival, overall survival, local control, morbidity, and mortality. RESULTS The search resulted in 6635 articles. After 2 rounds of screening, 34 publications were selected. We found 3 randomized controlled studies and 1 prospective cohort study, and the rest were retrospective studies. There is consistent evidence that addition of concomitant chemoradiotherapy or RT after IC improves pathological response and local control. There are conflicting results in terms of other outcomes. CONCLUSIONS Concomitant chemoradiotherapy or RT after IC improves local control and pathological response in borderline resectable and locally advanced pancreatic ductal adenocarcinoma. The role of modern RT in improving other outcome requires further research.
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Affiliation(s)
- Animesh Saha
- From the Department of Radiation Oncology, Apollo Multispecilty Hospitals, Kolkata, India
| | - Jonathan Wadsley
- Department of Clinical Oncology, Weston Park Cancer Centre, Sheffield, United Kingdom
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, India
| | | | - Alan Anthony
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | | | - Danny Ulahanan
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | - Fiona Collinson
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
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4
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Fossaert V, Mimmo A, Rhaiem R, Rached LJ, Brasseur M, Brugel M, Pegoraro F, Sanchez S, Bouché O, Kianmanesh R, Piardi T. Neoadjuvant chemotherapy for borderline resectable and upfront resectable pancreatic cancer increasing overall survival and disease-free survival? Front Oncol 2022; 12:980659. [PMID: 36387257 PMCID: PMC9640996 DOI: 10.3389/fonc.2022.980659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2022] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic neoplasm. Surgery is the factual curative option, but most patients present with advanced disease. In order to increase resectability, results of neoadjuvant chemotherapy (NAC) on metastatic disease were extrapolated to the neoadjuvant setting by many centers. The aim of our study was to retrospectively evaluate the outcome of patients who underwent upfront surgery (US)-PDAC and borderline (BR)-PDAC, and those resected after NAC to determine prognostic factors that might affect the outcome in these resected patients. METHODS One hundred fifty-one patients between January 2012 and March 2021 in our department were reviewed. Epidemiological characteristics and pre-operative induction treatment were assessed. Pathological reports were analyzed to evaluate the quality of oncological resection (R0/R1). Post-operative mortality and morbidity and survival data were reviewed. RESULTS One hundred thirteen patients were addressed for US, and 38 were considered BR and referred for surgery after induction chemotherapy. The pancreatic resection R0 was 71.5% and R1 28.5%. pT3 rate was significantly higher in the US than BR (58,4% vs 34,2%, p= 0.005). The mean OS and DFS rates were 29.4 months 15.9 months respectively. There was no difference between OS and DFS of US vs BR patients. N0 patients had significantly longer OS and DFS (p=<0.001). R0 patients had significantly longer OS (p=0.03) and longer DFS (P=0.08). In the multivariate analysis, the presence of postoperative pancreatic fistula, R1 resection, N+ and not access to adjuvant chemotherapy were bad prognostic factors of OS. CONCLUSIONS Our study suggests the benefits of NAC for BR patients in downstaging tumors and rendering them amenable to resection, with same oncological result compared to US.
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Affiliation(s)
- Violette Fossaert
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Antonio Mimmo
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Rami Rhaiem
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Linda J. Rached
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Mathilde Brasseur
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Mathias Brugel
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Francesca Pegoraro
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Stephane Sanchez
- Pôle Territorial Santé Publique et Performance des Hôpitaux Champagne Sud, University Reims Champagne-Ardenne, Troyes, France
| | - Olivier Bouché
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Reza Kianmanesh
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Department of Surgery, Hepato-Bilio-Pancreatic and Metabolic Unit, University Reims Champagne-Ardenne, Troyes, France
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5
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Hyman DW, Almerey T, Mujkanovic A, Hammons I, Tice M, Stauffer JA. Comparing Post-Operative Outcomes of Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Neoadjuvant Therapy Versus Surgery First Approach. Am Surg 2022; 88:1868-1874. [PMID: 35465681 DOI: 10.1177/00031348221087900] [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: 11/17/2022]
Abstract
OBJECTIVES Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality. METHODS All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher's exact test and continuous variables by Student's t-test. RESULTS Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively. CONCLUSION Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.
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Affiliation(s)
- David W Hyman
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Tariq Almerey
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Amer Mujkanovic
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Isaac Hammons
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Mary Tice
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - John A Stauffer
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
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6
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van Dongen JC, Suker M, Versteijne E, Bonsing BA, Mieog JSD, de Vos-Geelen J, van der Harst E, Patijn GA, de Hingh IH, Festen S, Ten Tije AJ, Busch OR, Besselink MG, van Tienhoven G, Koerkamp BG, van Eijck CHJ. Surgical Complications in a Multicenter Randomized Trial Comparing Preoperative Chemoradiotherapy and Immediate Surgery in Patients With Resectable and Borderline Resectable Pancreatic Cancer (PREOPANC Trial). Ann Surg 2022; 275:979-984. [PMID: 33201120 DOI: 10.1097/sla.0000000000004313] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the effect of preoperative chemoradiotherapy on surgical complications in patients after pancreatic resection for (borderline-)resectable pancreatic cancer. SUMMARY OF BACKGROUND DATA Preoperative chemoradiotherapy is increasingly used in patients with (borderline-)resectable pancreatic cancer. concerns have been raised about the potential harmful effect of any preoperative therapy on the surgical complication rate after pancreatic resection. METHODS An observational analysis was performed within the multicenter randomized controlled PREOPANC trial (April 2013-July 2017). The trial randomly assigned (1:1) patients to preoperative chemoradiotherapy followed by surgery and the remaining adjuvant chemotherapy or to immediate surgery, followed by adjuvant chemotherapy. The main analysis consisted of a per-protocol approach. The endpoints of the present analyses were the rate of postoperative complications. RESULTS This study included 246 patients from 16 centers, of whom 66 patients underwent resection after preoperative therapy and 98 patients after immediate surgery. No differences were found regarding major complications (37.9% vs 30.6%, P=0.400), postpancreatectomy hemorrhage (9.1% vs 5.1%, P=0.352), delayed gastric emptying (21.2% vs 22.4%, P=0.930), bile leakage (4.5% vs 3.1%, P=0.686), intra-abdominal infections (12.1% vs 10.2%, P=0.800), and mortality (3.0% vs 4.1%, P=1.000). There was a significant lower incidence of postoperative pancreatic fistula in patients who received preoperative chemoradiotherapy (0% vs 9.2%, P=0.011). CONCLUSIONS Preoperative chemoradiotherapy did not increase the incidence of surgical complications or mortality and reduced the rate of postoperative pancreatic fistula after resection in patients with (borderline-)resectable pancreatic cancer.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Breda, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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7
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Suto H, Okano K, Oshima M, Ando Y, Matsukawa H, Takahashi S, Shibata T, Kamada H, Kobara H, Tsuji A, Masaki T, Suzuki Y. Efficacy and Safety of Neoadjuvant Chemoradiation Therapy Administered for 5 Versus 2 Weeks for Resectable and Borderline Resectable Pancreatic Cancer. Pancreas 2022; 51:269-277. [PMID: 35584385 DOI: 10.1097/mpa.0000000000002011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Indications of preoperative treatment for resectable (R-) or borderline resectable (BR-) pancreatic ductal adenocarcinoma (PDAC) are unclear, and the protocol remains to be standardized. METHODS Included 65 patients with R- and BR-PDAC with venous involvement (V-) received neoadjuvant chemoradiotherapy with S-1 and 50 Gy of radiation as the 5-week regimen. The outcomes of this group were compared with those of 52 patients who underwent S-1 and 30 Gy of radiation as the 2-week regimen, previously collected as our prospective phase II study. RESULTS Compared with the 2-week regimen, there were no significant differences in the rate of protocol completion, adverse events, mortality and morbidity, or R0 resection in the 5-week regimen. In subgroup analyses of R-PDAC, there were no significant differences in overall survival and recurrence-free survival between the groups. In contrast, the 5-week regimen had significantly better overall survival and recurrence-free survival than the 2-week regimen for BRV-PDAC. Similar results were observed after propensity score matching analysis. CONCLUSIONS The 5-week regimen of neoadjuvant chemoradiotherapy has good clinical efficacy and safety for R- and BRV-PDAC. The 5-week regimen could achieve better outcomes than the 2-week regimen for BRV-PDAC. In contrast, both regimens achieved similar outcomes for R-PDAC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Akihito Tsuji
- Clinical Oncology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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8
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Mohamed A, Nicolais L, Fitzgerald TL. Revisiting the Pancreatic Fistula Risk Score: Clinical Nomogram Accurately Assesses Risk. Am Surg 2021:31348211047471. [PMID: 34633224 DOI: 10.1177/00031348211047471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Surgeons have created numerous iterations of the pancreatic fistula risk score (FRS) to predict risk for clinically relevant postoperative pancreatic fistula (CR-POPF). The multitude of often conflicting models makes it difficult for surgeons to apply data in clinical practice. METHODS We conducted a retrospective cohort study utilizing National Surgical Quality Improvement Program data from 2015 to 2018. The study included patients undergoing pancreaticoduodenectomy. Missing data were resolved with multiple imputations. RESULTS The study included 5975 patients; 1018 (17%) had a CR-POPF. On multivariate analysis, male sex (odds ratio (OR) 1.60 CI: 1.29-1.98 P < .001), obesity (OR 1.65 CI: 1.31-2.08 P < .001), and soft gland texture (OR 3.21 CI: 2.45-4.23 P < .001) were all associated with increased odds of a CR-POPF. Variables not associated with CR-POPF included diabetes, preoperative bilirubin, preoperative albumin, and American Society of Anesthesiologists (ASA) classification. On multivariate analysis, duct diameter >6 mm (OR .52 CI: .34-.77 P = .001), pancreatic adenocarcinoma pathology (OR .67 CI: .53-.84 P < .001), and neoadjuvant treatment (OR .71 CI: .51-.98 P = .042) were all associated with decreased odds of a CR-POPF. We constructed a clinically relevant nomogram from this model known as the Portland FRS. Model characteristics were superior to previously published FRS models. The area under the curve (AUC) for the Portland FRS was .72 (CI: .704-.737). In comparison, AUCs for the Alternative and Seoul FRS were .70 and .64, respectively. CONCLUSION Utilizing readily available clinical data, the Portland FRS can accurately predict the risk for pancreatic fistula. The nomogram may assist surgeons in patient counseling and perioperative management.
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Affiliation(s)
- Abdimajid Mohamed
- Division of Surgical Oncology, 12261Tufts University School of Medicine, Boston, MA, USA
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9
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van Dongen JC, Wismans LV, Suurmeijer JA, Besselink MG, de Wilde RF, Groot Koerkamp B, van Eijck CHJ. The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies. HPB (Oxford) 2021; 23:1321-1331. [PMID: 34099372 DOI: 10.1016/j.hpb.2021.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer. METHODS This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models. RESULTS Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity. CONCLUSION Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Leonoor V Wismans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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10
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Tabchouri N, Bouquot M, Hermand H, Benoit O, Loiseau JC, Dokmak S, Aussilhou B, Gaujoux S, Turrini O, Delpero JR, Sauvanet A. A Novel Pancreatic Fistula Risk Score Including Preoperative Radiation Therapy in Pancreatic Cancer Patients. J Gastrointest Surg 2021; 25:991-1000. [PMID: 32314240 DOI: 10.1007/s11605-020-04600-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most serious complication following pancreaticoduodenectomy (PD). Identifying patients at high or low risk of developing POPF is important in perioperative management. This study aimed to determine a predictive risk score for POPF following PD, and compare it to preexisting scores. METHODS All patients who underwent open PD from 2012 to 2017 in two high-volume centers were included. The training dataset was used for the development of the POPF predictive risk score (using the 2016 ISGPS definition), while the testing dataset was used for external validation. The proposed score was compared to the fistula risk score (FRS), the NSQIP-modified FRS (mFRS), and the alternative FRS (aFRS). RESULTS Overall, 448 and 213 patients were included in the training and testing datasets, respectively. A probabilistic predictive risk score was developed using four independent POPF risk factors (increasing age, no preoperative radiation therapy, soft pancreatic stump, and decreasing main pancreatic duct diameter). The discriminative capacities of the new score, FRS, mFRS, and aFRS were similar (AUC ranging from 0.73 to 0.79 in the training cohort and from 0.73 to 0.76 in the testing cohort). However, the new score identified more specifically patients at low risk of POPF compared with other scores, in both cohorts, with a 6% false-negative rate. CONCLUSIONS Preoperative radiation therapy is an independent protective factor of POPF following PD. It should be included in the risk score of POPF to identify more precisely patients at low risk for this complication.
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Affiliation(s)
- Nicolas Tabchouri
- Department of HPB Surgery, Hôpital Beaujon, Paris, France.,Department of Digestive Surgery, Hôpital Trousseau, Tours, France
| | - Morgane Bouquot
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Hélène Hermand
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | - Olivier Benoit
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | | | - Safi Dokmak
- Department of HPB Surgery, Hôpital Beaujon, Paris, France
| | | | | | - Olivier Turrini
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Jean Robert Delpero
- Department of Digestive Surgery, Institut Paoli Calmettes, Marseille, France
| | - Alain Sauvanet
- Department of HPB Surgery, Hôpital Beaujon, Paris, France. .,University Paris, Paris, France. .,AP-HP, Department of HBP Surgery, DIGEST Medico-Universitary Department, Hôpital Beaujon APHP, 100 boulevard du Général Leclerc, 92110, Clichy, France.
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11
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Eskander MF, Cloyd JM. Predicting post-operative pancreatic fistula: one size may not fit all. Hepatobiliary Surg Nutr 2021; 10:113-115. [PMID: 33575298 DOI: 10.21037/hbsn-20-497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Mariam F Eskander
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center; Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center; Columbus, OH, USA
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12
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Rykina-Tameeva N, Nahm CB, Mehta S, Gill AJ, Samra JS, Mittal A. Neoadjuvant therapy for pancreatic cancer changes the composition of the pancreatic parenchyma. HPB (Oxford) 2020; 22:1631-1636. [PMID: 32247587 DOI: 10.1016/j.hpb.2020.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/16/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a prominent complication following pancreatic cancer resections. The primary aim of this study was to evaluate the histological changes that occur in the pancreas due to neoadjuvant therapy (NAT) by comparing the acinar, collagen and fat scores in resected PDAC specimens of patients who did and did not receive NAT. Secondary aims included (1) the difference in rates of POPF in PDAC patients who received NAT versus upfront resection; and (2) the association between acinar/collagen/fat scores and the development of POPF. METHODS Consecutive patients who underwent pancreaticoduodenectomy for PDAC, with and without NAT were included for analysis. Acinar, collagen and fat scores were determined from histology slides of the pancreatic resection margin. RESULTS One hundred and thirty-four patients were included. There was a significant decrease in the median acinar score (48 vs 23, p = 0.003) and increase in the collagen score (28 vs 50, p = 0.011) for patients who received NAT and a significant correlation with the number of cycles of NAT. This study found no statistical difference between NAT and the development of POPF. CONCLUSION The use of NAT in the treatment of PDAC changes the composition of the pancreas.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia
| | - Shreya Mehta
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia.
| | - Anthony J Gill
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
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13
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Mangieri CW, Strode MA, Moaven O, Clark CJ, Shen P. Utilization of chemoradiation therapy provides strongest protective effect for avoidance of postoperative pancreatic fistula following pancreaticoduodenectomy: A NSQIP analysis. J Surg Oncol 2020; 122:1604-1611. [PMID: 32935353 DOI: 10.1002/jso.26202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/05/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The utilization of neoadjuvant therapy (NAT) before performing pancreaticoduodenectomy for malignancy has been well established as a protective factor for the prevention of postoperative pancreatic fistula (POPF). However, there is a paucity of published data evaluating the specific NAT regimen that is the most protective against POPF development. We evaluated the differences between neoadjuvant chemotherapy (CT) and chemoradiation therapy (CRT) with regard to the effect on POPF rates. METHODS The main and targeted pancreatectomy American College of Surgeons National Surgical Quality Improvement Program registries for 2014-2016 were retrospectively reviewed. A total of 10,665 pancreaticoduodenectomy cases were present. The primary outcome was POPF development. The factors that have previously been shown to be associated with or suspected to be associated with POPF were evaluated. The factors included NAT, sex, age, body mass index (BMI), diabetes, smoking, steroid therapy, preoperative weight loss, preoperative albumin level, perioperative blood transfusions, wound classification, American Society of Anesthesiologists classification, duct size (<3 mm, 3-6 mm, and >6 mm), gland texture (soft, intermediate, and hard), and anastomotic technique. The factors identified to be statistically significant were then used for propensity score matching to compare POPF development between the cases utilizing CT versus CRT. RESULTS A total of 10,117 cases met the inclusion criteria. The development of POPF was significantly associated, on multivariate analysis, with a lack of NAT, male sex, higher BMI, nondiabetic status, nonsmoker status, decreased weight loss, preoperative albumin level, decreased duct size, and soft gland texture. NAT, duct size, and gland texture had the strongest associations with the development of POPF (p < .0001). The overall 1765 cases (17.45%) received NAT and the POPF rate for cases with NAT was 10.20% versus 20.10% for cases without NAT (p < .0001). A total of 1031 cases underwent CT and 734 cases underwent CRT, respectively. A total of 708 paired cases were selected for analysis based on propensity score matching. The POPF rates were 11.20% versus 3.50% for CT and CRT, respectively (p < .0001). There was no difference in the frequencies of specific POPF grades. The decreased POPF rate with CRT correlated with firmer gland texture rates. CONCLUSIONS To our knowledge, this is the largest analysis of specific NAT regimens with regard to the development of POPF following pancreaticoduodenectomy. CRT provided the strongest protective effect. That protective effect is most likely due to increased fibrosis in the pancreatic parenchyma from radiation therapy. These findings provide additional support to consider CRT over CT alone in the treatment of pancreatic cancer when NAT will be utilized.
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Affiliation(s)
- Christopher W Mangieri
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, USA
| | - Matthew A Strode
- Department of Surgery, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Omeed Moaven
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Clancy J Clark
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Perry Shen
- Department of Surgical Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
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14
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Navez J, Hubert C, Dokmak S, Frick De La Maza I, Tabchouri N, Benoit O, Hermand H, Zech F, Gigot JF, Sauvanet A. Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers. J Gastrointest Surg 2020; 24:1597-1604. [PMID: 31325133 DOI: 10.1007/s11605-019-04316-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers. METHODS Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed. RESULTS Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01). CONCLUSION In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.
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Affiliation(s)
- Julie Navez
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Catherine Hubert
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Safi Dokmak
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Isadora Frick De La Maza
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Nicolas Tabchouri
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Olivier Benoit
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Hélène Hermand
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France
| | - Francis Zech
- Institute of Experimental and Clinical Research, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Jean-François Gigot
- Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Alain Sauvanet
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l'Appareil Digestif, et Université Paris VII, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, Clichy, 92110, Paris, France.
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15
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Aziz H, Zeeshan M, Jie T, Maegawa FB. Neoadjuvant Chemoradiation Therapy is Associated with Adverse Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Cancer. Am Surg 2020. [DOI: 10.1177/000313481908501136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of neoadjuvant chemoradiation therapy in patients with pancreatic adenocarcinoma is emerg-ing as an acceptable therapy option. The effects of neoadjuvant therapy on 30 days’ outcomes in patients with pancreatic cancer are not well defined in the literature. NSQIP (2009–2012) was used. Only patients with a diagnosis of pancreatic cancer and those who underwent a Whipple were included in the analysis. Patient who underwent neoadjuvant chemoradiation therapy were compared with those who did not receive therapy. Main outcome measures were as follows: complications, ≥2 units of blood transfusions, length of stay, readmission rates, return to the operating room, and 30-day mortality. A total of 1445 patients (395: neoadjuvant chemoradiation and 1050: no neoadjuvant therapy) were identified. The mean age was 67 ± 12 years, and 51 per cent of the patients were male. Neoadjuvant chemoradiation therapy was associated with increase in readmission rates (18% vs 12.2%, P 0.02), unanticipated return to the operating room (2.3% vs 1.1%, P 0.03) with no difference in mortality rates. Neoadjuvant chemoradiation therapy is associated with increase in inhospital complications. These differences in outcomes may be explained by the more advance stage of pancreatic cancer in these subsets of patients. Resource utilization and preoperative rehabilitation are of utmost significance to overcome this rise in complications associated with neoadjuvant chemoradiation therapy.
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Affiliation(s)
- Hassan Aziz
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplantation at Keck Hospital of USC, Los Angeles, California
| | - Muhammad Zeeshan
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Tun Jie
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona; and
| | - Felipe B. Maegawa
- Department of Surgery, Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona
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16
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Kusafuka T, Kato H, Iizawa Y, Noguchi D, Gyoten K, Hayasaki A, Fujii T, Murata Y, Tanemura A, Kuriyama N, Azumi Y, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy. BMC Surg 2020; 20:129. [PMID: 32527310 PMCID: PMC7291550 DOI: 10.1186/s12893-020-00785-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/31/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon's hand. METHODS Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT. RESULTS In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (1.5%). According to multivariate analysis, a high pancreas-visceral fat CT value ratio (p = 0.002), serrated-type contour (p = 0.02) and no history of chemoradiotherapy (p = 0.019) were identified as independent risk factors for POPF grade B/C. Even in patients with soft pancreas, the incidence of POPF grade B/C was 0% (0/57) in patients with a pancreas-visceral fat CT value ratio of less than - 0.4 and smooth-type contour, whereas the incidence was markedly high (45.0%, 9/20) in patients with a pancreas-visceral fat CT value ratio of - 0.4 or greater and serrated-type contour, indicating that patients with soft pancreas should be categorized into POPF high-risk and low-risk groups according to preoperative CT scan results. CONCLUSIONS The pancreas-visceral fat CT value ratio and serrated-type pancreas are useful markers to preoperatively identify true POPF high-risk groups in patients undergoing PD, regardless of the pancreatic texture judged intraoperatively.
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Affiliation(s)
- Tomoki Kusafuka
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshinori Azumi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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17
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Perri G, Prakash L, Malleo G, Caravati A, Varadhachary GR, Fogelman D, Pant S, Koay EJ, Herman J, Maggino L, Milella M, Kim M, Ikoma N, Tzeng CW, Salvia R, Lee JE, Bassi C, Katz MHG. The Sequential Radiographic Effects of Preoperative Chemotherapy and (Chemo)Radiation on Tumor Anatomy in Patients with Localized Pancreatic Cancer. Ann Surg Oncol 2020; 27:3939-3947. [PMID: 32266574 PMCID: PMC7471157 DOI: 10.1245/s10434-020-08427-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence and magnitude of indicators of radiographic response of pancreatic cancer to systemic chemotherapy and (chemo)radiation administered prior to anticipated pancreatectomy are unclear. METHODS Sequential computed tomography scans of 226 patients with localized pancreatic cancer who received chemotherapy consisting of 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) or gemcitabine and nanoparticle albumin-bound paclitaxel (GA) with or without (chemo)radiation and who subsequently underwent surgery with curative intent from January 2010 to December 2018 at The University of Texas MD Anderson Cancer Center and Verona University Hospital were re-reviewed and compared. RESULTS Overall, 141 patients (62%) received FOLFIRINOX, 70 (31%) received GA, and 15 (7%) received both; 164 patients (73%) received preoperative (chemo)radiation following chemotherapy and prior to surgery; and 151 (67%), 70 (31%), and 5 (2%) patients had Response Evaluation Criteria in Solid Tumors (RECIST) stable disease, partial response, and progressive disease, respectively. The tumors of 29% of patients with borderline resectable or locally advanced cancer were downstaged after preoperative therapy. Radiographic downstaging was more common with chemotherapy than with (chemo)radiation (24% vs. 6%; p = 0.04), and the median tumor volume loss after chemotherapy was significantly greater than that after (chemo)radiation (28% vs. 17%; p < 0.01). CONCLUSIONS Less than one-third of patients treated with FOLFIRINOX or GA with or without (chemo)radiation experienced either RECIST partial response or radiographic downstaging prior to surgery. The incidence of tumor downstaging was higher and the magnitude of tumor volume loss was greater following chemotherapy than after (chemo)radiation.
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Affiliation(s)
- Giampaolo Perri
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Prakash
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Maggino
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Michele Milella
- Department of Gastrointestinal Medical Oncology, Verona University Hospital, Verona, Italy
| | - Michael Kim
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jeffrey E Lee
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Matthew H G Katz
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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19
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Lof S, Korrel M, van Hilst J, Alseidi A, Balzano G, Boggi U, Butturini G, Casadei R, Dokmak S, Edwin B, Falconi M, Keck T, Malleo G, de Pastena M, Tomazic A, Wilmink H, Zerbi A, Besselink MG, Abu Hilal M. Impact of Neoadjuvant Therapy in Resected Pancreatic Ductal Adenocarcinoma of the Pancreatic Body or Tail on Surgical and Oncological Outcome: A Propensity-Score Matched Multicenter Study. Ann Surg Oncol 2019; 27:1986-1996. [PMID: 31848815 PMCID: PMC7210228 DOI: 10.1245/s10434-019-08137-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several studies have suggested a survival benefit of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head. Data concerning NAT for PDAC located in pancreatic body or tail are lacking. METHODS Post hoc analysis of an international multicenter retrospective cohort of distal pancreatectomy for PDAC in 34 centers from 11 countries (2007-2015). Patients who underwent resection after NAT were matched (1:1 ratio), using propensity scores based on baseline characteristics, to patients who underwent upfront resection. Median overall survival was compared using the stratified log-rank test. RESULTS Among 1236 patients, 136 (11.0%) received NAT, most frequently FOLFIRINOX (25.7%). In total, 94 patients receiving NAT were matched to 94 patients undergoing upfront resection. NAT was associated with less postoperative major morbidity (Clavien-Dindo ≥ 3a, 10.6% vs. 23.4%, P = 0.020) and pancreatic fistula grade B/C (9.6% vs. 21.3%, P = 0.026). NAT did not improve overall survival [27 (95% CI 14-39) versus 31 months (95% CI 19-42), P = 0.277], as compared with upfront resection. In a sensitivity analysis of 251 patients with radiographic tumor involvement of splenic vessels, NAT (n = 37, 14.7%) was associated with prolonged overall survival [36 (95% CI 18-53) versus 20 months (95% CI 15-24), P = 0.049], as compared with upfront resection. CONCLUSION In this international multicenter cohort study, NAT for resected PDAC in pancreatic body or tail was associated with less morbidity and pancreatic fistula but similar overall survival in comparison with upfront resection. Prospective studies should confirm a survival benefit of NAT in patients with PDAC and splenic vessel involvement.
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Affiliation(s)
- Sanne Lof
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Gianpaolo Balzano
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | | | - Riccardo Casadei
- Department of Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Safi Dokmak
- Department of Surgery, Hospital of Beaujon, Clichy, France
| | - Bjørn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Tobias Keck
- Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Hanneke Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University Hospital, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK. .,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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20
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Pecorelli N, Pagnanelli M, Cinelli L, Di Salvo F, Partelli S, Crippa S, Tamburrino D, Castoldi R, Belfiori G, Reni M, Falconi M, Balzano G. Postoperative Outcomes and Functional Recovery After Preoperative Combination Chemotherapy for Pancreatic Cancer: A Propensity Score-Matched Study. Front Oncol 2019; 9:1299. [PMID: 31850203 PMCID: PMC6901953 DOI: 10.3389/fonc.2019.01299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction: Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). However, recent literature reported an increased clinical burden in patients undergoing pancreaticoduodenectomy (PD) following NACT. Therefore, the aim of our study was to assess the impact of NACT on postoperative outcomes and recovery after PD. Methods: A retrospective propensity score-matched study was performed including all patients who underwent PD for PDAC in a single center between 2015 and 2018. Patients treated with NACT for resectable, borderline resectable or locally advanced PDAC were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients who underwent upfront resection. Propensity scores were calculated using 7 perioperative variables, including gender, age, BMI, ASA score, Charlson-Deyo comorbidity score, fistula risk score (FRS), vascular resection. Primary outcome was the number and severity of complications at 90-days after surgery measured by the comprehensive complication index (CCI). Data are reported as median (IQR) or number of patients (%). Results: Of 283 resected patients, 95 (34%) were treated with NACT. Before matching, NACT patients were younger, had less comorbidities (Charlson-Deyo score 0 vs. 1, p = 0.04), similar FRS [2 (0–3) for both groups], and more vascular resections performed [n = 28 (30%) vs. n = 26 (14%), p < 0.01]. After propensity-score matching, preoperative and intraoperative characteristics were comparable. Postoperatively, CCI was similar between groups [8.7 (0–29.6) for both groups, p = 0.59]. NACT patients had a non-statistically significant increase in superficial incisional surgical site infections [n = 12 (13%) vs. 6 (6%), p = 0.14], while no difference was found for overall infectious complications and organ-space SSI. The occurrence of clinically-relevant pancreatic fistula was similar between groups [10 (11%) vs. 13 (14%), p = 0.51]. No difference was found between groups for length of hospital stay [8 (7–15) vs. 8 (7–14) days, p = 0.62], and functional recovery outcomes. Conclusion: After propensity score adjustment for perioperative risk factors, NACT did not worsen postoperative outcomes and functional recovery following PD for PDAC compared to upfront resection.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Francesca Di Salvo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Castoldi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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21
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Vicente D, Lee AJ, Hall CS, Lucci A, Lee JE, Kim MP, Katz MH, Hurd MW, Maitra A, Rhim, MD AD, Tzeng CWD. Circulating Tumor Cells and Transforming Growth Factor Beta in Resected Pancreatic Adenocarcinoma. J Surg Res 2019; 243:90-99. [DOI: 10.1016/j.jss.2019.04.090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/05/2019] [Accepted: 04/30/2019] [Indexed: 12/22/2022]
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22
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Cloyd JM, Prakash L, Vauthey JN, Aloia TA, Chun YS, Tzeng CW, Kim MP, Lee JE, Katz MHG. The role of preoperative therapy prior to pancreatoduodenectomy for distal cholangiocarcinoma. Am J Surg 2019; 218:145-150. [PMID: 30224070 DOI: 10.1016/j.amjsurg.2018.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/31/2018] [Accepted: 08/31/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although increasingly administered to patients with pancreatic ductal adenocarcinoma, the role of preoperative therapy for patients with distal cholangiocarcinoma is undefined. METHODS All patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy between 1999 and 2014 were retrospectively reviewed. Differences in clinicopathologic characteristics and overall survival (OS) were compared between patients who underwent surgery de novo and those who received preoperative therapy. RESULTS Twenty-one patients (46.7%) received preoperative therapy and 24 (53.3%) did not. Five-year OS rates were not statistically significantly different between patients who received preoperative therapy and those who did not (46.6% vs 49.1%, p > 0.05). On multivariate cox proportional hazards analysis, lymph node positivity was the strongest predictor of OS (HR 4.68 (95%CI 1.52-14.42)). Whereas preoperative therapy was not associated with improved OS (HR 1.06 (95%CI 0.42-2.66)), the receipt of either pre- or post-operative therapy was (HR 0.40 (95%CI 0.16-1.00)). CONCLUSION While these results do not support the routine administration of preoperative therapy to patients with distal cholangiocarcinoma, it may be an alternative treatment strategy appropriate for a subset of patients with high risk clinical or pathologic features.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA.
| | - Laura Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Michel P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, USA
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23
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Sonohara F, Yamada S, Takami H, Hayashi M, Kanda M, Tanaka C, Kobayashi D, Nakayama G, Koike M, Fujiwara M, Fujii T, Kodera Y. Novel implications of combined arterial resection for locally advanced pancreatic cancer in the era of newer chemo-regimens. Eur J Surg Oncol 2019; 45:1895-1900. [PMID: 31147087 DOI: 10.1016/j.ejso.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/08/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In this study, we assessed the prognostic efficacy and feasibility of combined arterial resection (AR) for locally advanced pancreatic cancer (LAPC), and aimed to identify significant prognostic factors for patients who underwent combined AR. METHODS Between 1981 and 2018, 733 consecutive patients who underwent pancreatic surgery for PC were identified. The 730 cases with detailed information were enrolled in the analysis. RESULTS Among 730 resected PC patients, 44 (6%) underwent AR including 21 hepatic (48%), 12 celiac (27%), five splenic (12%), four superior mesenteric (9%), and two other arteries (4%). The combined AR surgery showed significantly longer operative time (median, 608 vs 451 min, P < 0.0001), and the incidence of intraoperative blood transfusion was significantly higher in AR than surgery without AR (P = 0.0002), whereas there was no significant difference in the intraoperative blood loss (970 vs 1200 mL, P = 0.2) and occurrence of major complications (P = 0.5). In prognostic analysis of AR cases, multivariate Cox proportional hazard models revealed preoperative and postoperative therapy were the independent factors for both recurrence-free survival (RFS) and overall survival (OS) (preoperative therapy: RFS, HR = 0.21, P = 0.007; OS, HR = 0.18, P = 0.01; postoperative therapy: RFS, HR = 0.31, P = 0.003; OS, HR = 0.19, P = 0.002). CONCLUSION This study showed the feasibility of combined AR for LAPC and robust association of pre- and postoperative therapy and survival after AR surgery. Preoperative therapy following combined AR surgery is potentially powerful strategy for LAPC.
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Affiliation(s)
- Fuminori Sonohara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hideki Takami
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Kobayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Yamada S, Takami H, Sonohara F, Hayashi M, Fujii T, Kodera Y. Effects of duration of initial treatment on postoperative complications in pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:235-241. [PMID: 30919565 DOI: 10.1002/jhbp.622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND We analyzed the clinical impact of chemotherapy or chemoradiotherapy as initial treatment (IT), focusing on treatment duration, on morbidity and mortality in patients with resected pancreatic ductal adenocarcinoma. METHODS We enrolled 509 consecutive patients, with 417 in the upfront surgery group and 92 in the IT group. The IT group was subdivided into 72 patients treated for <8 months and 20 treated ≥8 months. We compared rates of postoperative Clavien-Dindo grade ≥III complications between the groups. Multivariate logistic regression analysis was used to find independent predictors of complications. RESULTS The upfront surgery and IT groups did not significantly differ in overall postsurgical complications. In contrast, rates of overall complications significantly differed between the <8 months and ≥8 months IT groups, although their background clinical factors did not differ. In multivariate analysis, operative procedure (distal pancreatectomy and distal pancreatectomy with celiac axis resection) (odds ratio [OR] 6.950, P = 0.0416) and IT ≥8 months (OR 4.508, P = 0.0156) were independent predictive factors for postoperative complications. CONCLUSIONS Postoperative complications were significantly higher in the ≥8 months IT group, and multivariate analysis demonstrated that operative procedure and ≥8 months IT were independent predictive factors.
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Fuminori Sonohara
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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25
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Miyasaka Y, Ohtsuka T, Kimura R, Matsuda R, Mori Y, Nakata K, Kakihara D, Fujimori N, Ohno T, Oda Y, Nakamura M. Neoadjuvant Chemotherapy with Gemcitabine Plus Nab-Paclitaxel for Borderline Resectable Pancreatic Cancer Potentially Improves Survival and Facilitates Surgery. Ann Surg Oncol 2019; 26:1528-1534. [PMID: 30868514 DOI: 10.1245/s10434-019-07309-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Accumulation of evidence suggests that neoadjuvant chemotherapy improves the outcomes of borderline resectable pancreatic cancer (BRPC). Gemcitabine plus nab-paclitaxel (GnP) has been widely accepted as systemic chemotherapy for unresectable pancreatic cancer and reportedly results in remarkable tumor shrinkage. This study was performed to evaluate the safety and efficacy of neoadjuvant chemotherapy using neoadjuvant GnP for BRPC. METHODS The medical records of 57 patients who underwent treatment of BRPC from 2010 to 2017 were retrospectively reviewed. The patient characteristics and short- and intermediate-term outcomes were compared between the GnP and upfront surgery (UFS) groups. RESULTS The GnP group comprised 31 patients and the UFS group comprised 26 patients. The patient characteristics were comparable with the exception of a higher prevalence of arterial involvement in the GnP group. Twenty-seven of the 31 patients (87%) in the GnP group and all 26 patients in the UFS group underwent resection. The GnP group showed a significantly shorter operation time (429 vs. 509.5 min, p = 0.0068), less blood loss (760 vs. 1324 ml, p = 0.0115), and a higher R0 resection rate (100% vs. 77%, p = 0.0100) than the UFS group. Postoperative complications and hospital stay were comparable between the two groups, and no treatment-related mortality occurred in either group. Both the disease-free survival and overall survival times were significantly longer in the GnP group (p = 0.0018 and p = 0.0024, respectively). CONCLUSIONS Neoadjuvant GnP is a safe and effective treatment strategy for BRPC. It potentially improves patients' prognosis and facilitates surgical procedures.
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Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryuichiro Kimura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Matsuda
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Kakihara
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takamasa Ohno
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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26
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Xourafas D, Pawlik TM, Cloyd JM. Independent Predictors of Increased Operative Time and Hospital Length of Stay Are Consistent Across Different Surgical Approaches to Pancreatoduodenectomy. J Gastrointest Surg 2018; 22:1911-1919. [PMID: 29943136 DOI: 10.1007/s11605-018-3834-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/01/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND While minimally invasive approaches are increasingly being utilized for pancreatoduodenectomy (PD), factors associated with prolonged operative time (OpTime) and hospital length of stay (LOS) remain poorly defined, and it is unclear whether these factors are consistent across surgical approaches. METHODS The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was used to identify all patients who underwent open (OPD), laparoscopic (LPD), or robotic (RPD) pancreatoduodenectomy. Multivariable linear regression analyses were used to evaluate predictors of OpTime and LOS, as well as quantify the changes observed relative to each surgical approach. RESULTS Among 10,970 patients, PD procedure types varied: 9963 (92%) open, 418 (4%) laparoscopic, and 409 (4%) robotic. LOS was longer for the open and laparoscopic approaches (11 vs. 11 vs. 10 days, P = 0.0068), whereas OpTime was shortest for OPD (366 vs. 426 vs. 435 min, P < 0.0001). Independent predictors of a prolonged OpTime were ASA class ≥ 3 (P = 0.0002), preoperative XRT (P < 0.0001), pancreatic duct < 3 mm (P = 0.0001), T stage ≥ 3 (P = 0.0108), and vascular resection (P < 0.0001) for OPD; T stage ≥ 3 (P = 0.0510) and vascular resection (P = 0.0062) for LPD; and malignancy (P = 0.0460) and conversion to laparotomy (P = 0.0001) for RPD. Independent predictors of increased LOS were age ≥ 65 years (P = 0.0002), ASA class ≥ 3 (P = 0.0012), hypoalbuminemia (P < 0.0001), and preoperative blood transfusion (P < 0.0001) for OPD as well as an OpTime > 370 min (all p < 0.05) and specific postoperative complications (all p < 0.05) for all surgical approaches. CONCLUSIONS Perioperative risk factors for prolonged OpTime and hospital LOS are relatively consistent across open, laparoscopic, and robotic approaches to PD. Particular attention to these factors may help identify opportunities to improve perioperative quality, enhance patient satisfaction, and ensure an efficient allocation of hospital resources.
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Affiliation(s)
- Dimitrios Xourafas
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus, OH, USA.
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 W 10th Ave, N-907 Doan Hall, Columbus, OH, 43210, USA.
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27
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Cools KS, Sanoff HK, Kim HJ, Yeh JJ, Stitzenberg KB. Impact of neoadjuvant therapy on postoperative outcomes after pancreaticoduodenectomy. J Surg Oncol 2018; 118:455-462. [PMID: 30114330 DOI: 10.1002/jso.25183] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical resection provides the only potentially curative treatment of pancreatic cancer. Neoadjuvant chemotherapy and/or radiation (NAT) is used to downstage patients with borderline resectable tumors. The objective of this study was to examine the postoperative morbidity and mortality of NAT after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA). METHODS Using the American College of Surgeons-National Surgical Quality Improvement Project Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA from 2014 to 2015. Patients were grouped by receipt of NAT 90 days before PD. Bivariable and multivariable analyses was used to compare postoperative outcomes. RESULTS A total of 3748 patients with PDA underwent PD; 926 (24.7%) received NAT. Those in the NAT group had more major vein resections, and longer operating times (all P < 0.001). On pathologic staging, those in the NAT group had smaller tumors (T1, 10.9% vs 5.1%; P < 0.001) and fewer nodes positive (N0, 49% vs 28%; P < 0.001). There were no differences in 30-day postoperative mortality or overall complications. On multivariable analysis, patients who received NAT had a lower likelihood of pancreatic fistula (OR, 0.67; P < 0.001). CONCLUSION NAT does not increase the overall postoperative morbidity or mortality of PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.
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Affiliation(s)
- Katherine S Cools
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hanna K Sanoff
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jen Jen Yeh
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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28
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Denbo JW, Bruno M, Dewhurst W, Kim MP, Tzeng CW, Aloia TA, Soliz J, Speer BB, Lee JE, Katz MHG. Risk-stratified clinical pathways decrease the duration of hospitalization and costs of perioperative care after pancreatectomy. Surgery 2018; 164:424-431. [PMID: 29807648 DOI: 10.1016/j.surg.2018.04.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/21/2018] [Accepted: 04/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with adverse events, increased duration of stay and hospital costs. We developed perioperative care pathways stratified by postoperative pancreatic fistula risk with the aims of minimizing variations in care, improving quality, and decreasing costs. STUDY DESIGN Three unique risk-stratified pancreatectomy clinical pathways-low-risk pancreatoduodenectomy, high-risk pancreatoduodenectomy, and distal pancreatectomy were developed and implemented. Consecutive patients treated after implementation of the risk-stratified pancreatectomy clinical pathways were compared with patients treated immediately prior. Duration of stay, rates of perioperative adverse effects, discharge disposition, and hospital readmission, as well as the associated costs of care, were evaluated. RESULTS The median hospital stay after pancreatectomy decreased from 10 to 6 days after implementation of the risk-stratified pancreatectomy clinical pathways (P < .001), and the median cost of index hospitalization decreased by 22%. Decreased changes in median hospital stay and costs of hospitalization were observed in association with low-risk pancreatoduodenectomy (P < .05) and distal pancreatectomy (P < .05), but not high-risk pancreatoduodenectomy. The rates of 90-day adverse events, grade B/C postoperative pancreatic fistula, discharge to a facility other than home, or readmission did not change after implementation. CONCLUSION Implementation of risk-stratified pancreatectomy clinical pathways decreased median stay and cost of index hospitalization after pancreatectomy without unfavorably affecting rates of perioperative adverse events or readmission, or discharge disposition. Outcomes were most favorably improved for low-risk pancreatoduodenectomy and distal pancreatectomy. Additional work is necessary to decrease the rate of postoperative pancreatic fistula, minimize variability, and improve outcomes after high-risk pancreatoduodenectomy.
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Affiliation(s)
- Jason W Denbo
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Morgan Bruno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Barbara Bryce Speer
- Department of Anesthesia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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29
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Snyder RA, Prakash LR, Nogueras-Gonzalez GM, Kim MP, Aloia TA, Vauthey JN, Lee JE, Fleming JB, Katz MH, Tzeng CWD. Vein resection during pancreaticoduodenectomy for pancreatic adenocarcinoma: Patency rates and outcomes associated with thrombosis. J Surg Oncol 2018; 117:1648-1654. [DOI: 10.1002/jso.25067] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/20/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Rebecca A. Snyder
- Department of Surgery; University of South Carolina School of Medicine-Greenville; Greenville South Carolina
| | - Laura R. Prakash
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | | | - Michael P. Kim
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Thomas A. Aloia
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jeffrey E. Lee
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology; H. Lee Moffitt Cancer Center; Tampa Florida
| | - Matthew H.G. Katz
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
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Versteijne E, Vogel JA, Besselink MG, Busch ORC, Wilmink JW, Daams JG, van Eijck CHJ, Groot Koerkamp B, Rasch CRN, van Tienhoven G. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg 2018; 105:946-958. [PMID: 29708592 PMCID: PMC6033157 DOI: 10.1002/bjs.10870] [Citation(s) in RCA: 340] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/14/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
Background Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer. Methods MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment. Results In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients. Conclusion Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374. Improved survival with neoadjuvant treatment
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Affiliation(s)
- E Versteijne
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Vogel
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J G Daams
- Medical Library, Academic Medical Centre, Amsterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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Chatzizacharias NA, Tsai S, Griffin M, Tolat P, Ritch P, George B, Barnes C, Aldakkak M, Khan AH, Hall W, Erickson B, Evans DB, Christians KK. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2018; 163:1053-1062. [PMID: 29331400 DOI: 10.1016/j.surg.2017.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer. METHODS An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed. RESULTS We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months. CONCLUSION Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Nikolaos A Chatzizacharias
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Tsai
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Griffin
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Parag Tolat
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Ritch
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ben George
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chad Barnes
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul H Khan
- Department of Gastroenterology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William Hall
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Beth Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen K Christians
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA.
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Katz MHG. Should Fear of Adverse Events Influence the Decision to Administer Preoperative Therapy to Patients with Pancreatic Cancer? Ann Surg Oncol 2017; 25:588-590. [DOI: 10.1245/s10434-017-6302-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Indexed: 12/12/2022]
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Effect of complications on oncologic outcomes after pancreaticoduodenectomy for pancreatic cancer. J Surg Res 2017. [DOI: 10.1016/j.jss.2017.02.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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