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Lucocq J, Hawkyard J, Haugk B, Mownah O, Menon K, Furukawa T, Inoue Y, Hirose Y, Sasahira N, Feretis M, Balakrishnan A, Ceresa C, Davidson B, Pande R, Dasari B, Tanno L, Karavias D, Helliwell J, Young A, Nunes Q, Urbonas T, Silva M, Gordon-Weeks A, Barrie J, Gomez D, Van Laarhoven S, Robertson F, Nawara H, Doyle J, Bhogal R, Harrison E, Roalso M, Ciprani D, Aroori S, Ratnayake B, Koea J, Capurso G, Bellotti R, Stättner S, Alsaoudi T, Bhardwaj N, Rajesh S, Jeffery F, Connor S, Cameron A, Jamieson N, Sheen A, Mittal A, Samra J, Gill A, Roberts K, Søreide K, Pandanaboyana S. Adjuvant chemotherapy for adenocarcinoma arising from intraductal papillary mucinous neoplasia: multicentre ADENO-IPMN study. Br J Surg 2024; 111:znae100. [PMID: 38659247 DOI: 10.1093/bjs/znae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The clinical impact of adjuvant chemotherapy after resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia is unclear. The aim of this study was to identify factors related to receipt of adjuvant chemotherapy and its impact on recurrence and survival. METHODS This was a multicentre retrospective study of patients undergoing pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia between January 2010 and December 2020 at 18 centres. Recurrence and survival outcomes for patients who did and did not receive adjuvant chemotherapy were compared using propensity score matching. RESULTS Of 459 patients who underwent pancreatic resection, 275 (59.9%) received adjuvant chemotherapy (gemcitabine 51.3%, gemcitabine-capecitabine 21.8%, FOLFIRINOX 8.0%, other 18.9%). Median follow-up was 78 months. The overall recurrence rate was 45.5% and the median time to recurrence was 33 months. In univariable analysis in the matched cohort, adjuvant chemotherapy was not associated with reduced overall (P = 0.713), locoregional (P = 0.283) or systemic (P = 0.592) recurrence, disease-free survival (P = 0.284) or overall survival (P = 0.455). Adjuvant chemotherapy was not associated with reduced site-specific recurrence. In multivariable analysis, there was no association between adjuvant chemotherapy and overall recurrence (HR 0.89, 95% c.i. 0.57 to 1.40), disease-free survival (HR 0.86, 0.59 to 1.30) or overall survival (HR 0.77, 0.50 to 1.20). Adjuvant chemotherapy was not associated with reduced recurrence in any high-risk subgroup (for example, lymph node-positive, higher AJCC stage, poor differentiation). No particular chemotherapy regimen resulted in superior outcomes. CONCLUSION Chemotherapy following resection of adenocarcinoma arising from intraductal papillary mucinous neoplasia does not appear to influence recurrence rates, recurrence patterns or survival.
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MESH Headings
- Humans
- Female
- Male
- Retrospective Studies
- Aged
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/drug therapy
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/therapy
- Pancreatic Neoplasms/surgery
- Chemotherapy, Adjuvant
- Middle Aged
- Neoplasm Recurrence, Local/epidemiology
- Pancreatectomy
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/drug therapy
- Adenocarcinoma, Mucinous/therapy
- Adenocarcinoma, Mucinous/mortality
- Gemcitabine
- Deoxycytidine/analogs & derivatives
- Deoxycytidine/therapeutic use
- Deoxycytidine/administration & dosage
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/drug therapy
- Carcinoma, Pancreatic Ductal/therapy
- Carcinoma, Pancreatic Ductal/surgery
- Capecitabine/administration & dosage
- Capecitabine/therapeutic use
- Pancreatic Intraductal Neoplasms/pathology
- Pancreatic Intraductal Neoplasms/therapy
- Pancreatic Intraductal Neoplasms/mortality
- Pancreatic Intraductal Neoplasms/surgery
- Adenocarcinoma/pathology
- Adenocarcinoma/drug therapy
- Adenocarcinoma/mortality
- Adenocarcinoma/therapy
- Propensity Score
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Jake Hawkyard
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Beate Haugk
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Omar Mownah
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Krishna Menon
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Takaki Furukawa
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuki Hirose
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Michael Feretis
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anita Balakrishnan
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Carlo Ceresa
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Brian Davidson
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Lulu Tanno
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Dimitrios Karavias
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Jack Helliwell
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Quentin Nunes
- Department of Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, UK
| | - Tomas Urbonas
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael Silva
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Gordon-Weeks
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jenifer Barrie
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Dhanny Gomez
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Stijn Van Laarhoven
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Francis Robertson
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Hossain Nawara
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Joseph Doyle
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ricky Bhogal
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ewen Harrison
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Marcus Roalso
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Debora Ciprani
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Bathiya Ratnayake
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Tareq Alsaoudi
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neil Bhardwaj
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Srujan Rajesh
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fraser Jeffery
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Saxon Connor
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew Cameron
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Jamieson
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Amy Sheen
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jas Samra
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony Gill
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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2
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Choi M, Wang SE, Park JS, Kim HS, Choi SH, Lee JH, Chong JU, Nagakawa Y, Wada K, Nakamura Y, Sunagawa H, Dasari BVM, Peng CM, Seng LL, Wolters H, Gurbadam U, Park BUK, Winslow E, Fishbein T, Hawksworth J, Radkani P, Kang CM. Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: an international multicenter cohort study. Int J Surg 2023; 109:2906-2913. [PMID: 37300881 PMCID: PMC10583921 DOI: 10.1097/js9.0000000000000537] [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] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Adjuvant therapy prolongs survival in patients with pancreatic ductal adenocarcinoma. However, no clear guidelines are available regarding the oncologic effects of adjuvant therapy (AT) in resected invasive intraductal papillary mucinous neoplasms (IPMN). The aim was to investigate the potential role of AT in patients with resected invasive IPMN. MATERIALS AND METHODS From 2001 to 2020, 332 patients with invasive pancreatic IPMN were retrospectively reviewed in 15 centres in eight countries. Propensity score-matched and stage-matched survival analyses were conducted. RESULTS A total of 289 patients were enroled in the study after exclusion (neoadjuvant therapy, unresectable disease, uncertain AT status, and stage IV). A total of 170 patients were enroled in a 1:1 propensity score-matched analysis according to the covariates. In the overall cohort, disease-free survival was significantly better in the surgery alone group than in the AT group ( P =0.003), but overall survival (OS) was not ( P =0.579). There were no significant differences in OS in the stage-matched analysis between the surgery alone and AT groups (stage I, P =0.402; stage II, P =0.179). AT did not show a survival benefit in the subgroup analysis according to nodal metastasis (N0, P =0.481; N+, P =0.705). In multivariate analysis, node metastasis (hazard ratio, 4.083; 95% CI, 2.408-6.772, P <0.001), and cancer antigen 19-9 greater than or equal to 100 (hazard ratio, 2.058; 95% CI, 1.247-3.395, P =0.005) were identified as adverse prognostic factors in resected invasive IPMN. CONCLUSION The current AT strategy may not be recommended to be performed with resected invasive IPMN in stage I and II groups, unlike pancreatic ductal adenocarcinoma. Further investigations of the potential role of AT in invasive IPMN are recommended.
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Affiliation(s)
- Munseok Choi
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Korea
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | | | | | - Sung Hoon Choi
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongam-si, Korea
| | - Jin Ho Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroki Sunagawa
- Department of Gastrointestinal Surgery, Nakagami Hospital, Okinawa, Japan
| | - Bobby VM Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Cheng-Ming Peng
- Department of General Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Lee Lip Seng
- Hepatopancreatobiliary Unit, Department of General Surgery, Changi General Hospital, Singapore
| | - Heiner Wolters
- Department of Visceral and General Surgery, St. Josefs-Hospital, Dortmund, Germany
| | - Unenbat Gurbadam
- Department of Surgery, National Cancer Center Hospital, Ulan Bator, Mongolia
| | - Byoung UK Park
- Department of Pathology, The University of California, San Francisco, CA
| | - Emily Winslow
- Department of Pathology, The University of California, San Francisco, CA
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Thomas Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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3
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Kim JR, Jang KT, Jang JY. Intraductal papillary neoplasm of the bile duct: review of updated clinicopathological and imaging characteristics. Br J Surg 2023; 110:1229-1240. [PMID: 37463281 DOI: 10.1093/bjs/znad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/04/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile duct (IPNB) is a relatively rare disease and is known as one of the premalignant lesions in the biliary tract. The concept of IPNB has changed through numerous studies and is still evolving. As a lesser studied clinical entity compared with its pancreatic counterpart, intraductal papillary mucinous neoplasm, IPNB has been described in many similar terms, including biliary papillomatosis, biliary intraductal papillary-mucinous neoplasm, and papillary cholangiocarcinoma. This is based on the diversity of histopathological spectrum of IPNB. METHODS This review investigated previous studies including original articles, case studies, and expert opinions. Recently, two types of IPNB (types 1 and 2) have been proposed and validated based on the content first established in the WHO 2010 criteria. RESULTS This review provides a comprehensive analysis of existing literature, summarizing the clinical, radiological, morphological, and pathological characteristics of IPNB. CONCLUSION Given the ongoing ambiguity and controversies surrounding IPNB, future research, including large population-based studies and molecular investigations, is essential to enhance understanding of this disease.
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Affiliation(s)
- Jae Ri Kim
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul, Korea
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4
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Habib JR, Kinny-Köster B, Amini N, Shoucair S, Cameron JL, Thompson ED, Fishman EK, Hruban RH, Javed AA, He J, Wolfgang CL. Predictors, Patterns, and Timing of Recurrence Provide Insight into the Disease Biology of Invasive Carcinomas Arising in Association with Intraductal Papillary Mucinous Neoplasms. J Gastrointest Surg 2022; 26:2311-2320. [PMID: 35915375 DOI: 10.1007/s11605-022-05428-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/10/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify predictors, patterns, and timing of recurrence after resection of invasive carcinomas arising in association with an IPMN. BACKGROUND Postoperative management of an invasive carcinoma arising in association with an intraductal papillary mucinous neoplasm (IPMN), a biologically distinct entity from PanIN-derived pancreatic ductal adenocarcinoma (PDAC), remains largely based on guidelines for PanIN-derived PDAC. To minimize treatment failure and inform disease-specific management, cancer recurrence must be better characterized. METHODS Patients were identified from a prospectively maintained registry between 1996 and 2018. Predictors of recurrence were evaluated by employing Cox regression models to determine risk-adjusted hazard ratios (HR) with 95% confidence intervals (95%CI). The patterns and timing of recurrence were recognized and compared utilizing a log-rank test, respectively. RESULTS Of the 213 patients included, 92 (43.2%) recurred with a median RFS of 23.7 months (16.7-30.7). The predominant pattern of recurrence included any systemic (65.2%). The median time to local recurrence was longer than systemic (21.6 versus 11.4 months, p = 0.05). Poor differentiation [HR: 3.01, 95%CI (1.06-8.61)] and nodal disease [N1, HR: 2.23, 95%CI (1.12-4.60); and N2, HR: 5.67 95%CI (2.93-10.99)] emerged as independent predictors of systemic recurrence. For local-specific recurrences, poor differentiation [HR: 3.73, 95%CI (1.04-13.45)] and an R1 margin [high-grade dysplasia or invasive carcinoma; HR: 2.66, 95%CI (1.14-6.21)] emerged as independent predictors. CONCLUSIONS The predominant pattern of recurrence after resection of invasive carcinomas arising in association with IPMNs is systemic, and occurs earlier than local recurrence. Poor differentiation and nodal disease are associated with systemic recurrence while poor differentiation and an R1 margin are associated with local recurrence. Future studies should investigate the role of systemic (chemotherapy) versus local (radiation) therapies and surveillance strategies in a personalized manner.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benedict Kinny-Köster
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth D Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.
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5
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Hughes DL, Hughes I, Silva MA. Determining the role of adjuvant therapy in Invasive Intraductal Papillary Mucinous Neoplasms; a systematic review and meta-analysis. Eur J Surg Oncol 2022; 48:1567-1575. [DOI: 10.1016/j.ejso.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/14/2022] [Accepted: 01/30/2022] [Indexed: 11/28/2022] Open
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6
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Zang C, Li S, Chi B, Chen S, Ye Z. An intraductal papillary mucinous neoplasm associated tubular adenocarcinoma with sarcomatoid component: A case report. Radiol Case Rep 2021; 16:3494-3498. [PMID: 34539943 PMCID: PMC8437772 DOI: 10.1016/j.radcr.2021.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a risk factor for the development of adenocarcinoma. However, the presence of a component of sarcomatoid carcinoma in the malignant tumor has rarely been described in the literature. A 30-year-old Chinese woman was admitted to our hospital with vague abdominal pain and a poor appetite for 2 months. Computed tomography revealed a huge, unilocular, solid-cystic mass in the pancreatic body, and tail. The patient underwent an en bloc resection of the distal pancreatic tumor with splenectomy and regional lymphadenectomy. Pathologic examination revealed an IPMN associated tubular adenocarcinoma containing a component of sarcomatoid (spindle-shaped cell) carcinoma. Immunohistochemical results revealed that the mononuclear spindle-shaped cells were positive for both pan-cytokeratin and vimentin. There was no evidence of perineural or vascular infiltration, lymph nodal metastasis, or positive surgical margins. The patient developed local recurrence 3 months after surgery for which she received chemoradiotherapy at another hospital. Distant metastases were detected 6 months after the surgery and the patient expired 9 months after surgical resection. We concluded that the presence of sarcomatoid change in IPMN-associated pancreatic adenocarcinoma may indicate poor prognosis.
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Affiliation(s)
- Chuanhang Zang
- Department of Cardiothoracic Surgery, The 964th Hospital of the Chinese People's Liberation Army, Changchun, China
| | - Shuai Li
- Department of Neurosurgery, The 964th Hospital of the Chinese People's Liberation Army, Changchun, China
| | - Bo Chi
- Department of Neurosurgery, The 964th Hospital of the Chinese People's Liberation Army, Changchun, China
| | - Shuai Chen
- Department of Emergency Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhexuan Ye
- Department of Ophthalmology, The 964th Hospital of the Chinese People's Liberation Army, Changchun, China
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7
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Chong E, Ratnayake B, Dasari BVM, Loveday BPT, Siriwardena AK, Pandanaboyana S. Adjuvant Chemotherapy in the Treatment of Intraductal Papillary Mucinous Neoplasms of the Pancreas: Systematic Review and Meta-Analysis. World J Surg 2021; 46:223-234. [PMID: 34545418 PMCID: PMC8677688 DOI: 10.1007/s00268-021-06309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 12/28/2022]
Abstract
Background The present systematic review aimed to compare survival outcomes of invasive intraductal papillary mucinous neoplasms (IIPMNs) treated with adjuvant chemotherapy versus surgery alone and to identify pathologic features that may predict survival benefit from adjuvant chemotherapy. Method A systematic search of MEDLINE, PubMed, Scopus, and EMBASE was performed using the PRISMA framework. Studies comparing adjuvant chemotherapy and surgery alone for patients with IIPMNs were included. Primary endpoint was overall survival (OS). A narrative synthesis was performed to identify pathologic features that predicted survival benefits from adjuvant chemotherapy. Results Eleven studies and 3393 patients with IIPMNs were included in the meta-analysis. Adjuvant chemotherapy significantly reduced the risk of death in the overall cohort (HR 0.57, 95% CI 0.38–0.87, p = 0.009) and node-positive patients (HR 0.29, 95% CI 0.13–0.64, p = 0.002). Weighted median survival difference between adjuvant chemotherapy and surgery alone in node-positive patients was 11.6 months (95% CI 3.83–19.38, p = 0.003) favouring chemotherapy. Adjuvant chemotherapy had no impact on OS in node-negative patients (HR 0.53, 95% CI 0.20–1.43, p = 0.209). High heterogeneity (I2 > 75%) was observed in pooled estimates of hazard ratios. Improved OS following adjuvant chemotherapy was reported for patients with stage III/IV disease, tumour size > 2 cm, node-positive status, grade 3 tumour differentiation, positive margin status, tubular carcinoma subtype, and presence of perineural or lymphovascular invasion. Conclusion Adjuvant chemotherapy was associated with improved OS in node-positive IIPMNs. However, the findings were limited by marked heterogeneity. Future large multicentre prospective studies are needed to confirm these findings and explore additional predictors of improved OS to guide patient selection for adjuvant chemotherapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06309-8.
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Affiliation(s)
- Eric Chong
- Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, University of Auckland, Auckland, New Zealand
| | - Bathiya Ratnayake
- Faculty of Medical and Health Sciences, Surgical and Translational Research Centre, University of Auckland, Auckland, New Zealand
| | - Bobby V M Dasari
- Hepatobiliary and Transplant Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Benjamin P T Loveday
- Hepatobiliary and Upper Gastrointestinal Unit, Royal Melbourne Hospital, Victoria, Australia
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - Ajith K Siriwardena
- Hepatobiliary and Pancreatic Unit, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- Pancreatic and Transplant Surgery, HPB and Transplant Unit, Department of Hepatobiliary, Freeman Hospital, Newcastle upon Tyne, UK.
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK.
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8
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Intraductal Papillary Mucinous Carcinoma Versus Conventional Pancreatic Ductal Adenocarcinoma: A Comprehensive Review of Clinical-Pathological Features, Outcomes, and Molecular Insights. Int J Mol Sci 2021; 22:ijms22136756. [PMID: 34201897 PMCID: PMC8268881 DOI: 10.3390/ijms22136756] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 12/18/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMN) are common and one of the main precursor lesions of pancreatic ductal adenocarcinoma (PDAC). PDAC derived from an IPMN is called intraductal papillary mucinous carcinoma (IPMC) and defines a subgroup of patients with ill-defined specificities. As compared to conventional PDAC, IPMCs have been associated to clinical particularities and favorable pathological features, as well as debated outcomes. However, IPMNs and IPMCs include distinct subtypes of precursor (gastric, pancreato-biliary, intestinal) and invasive (tubular, colloid) lesions, also associated to specific characteristics. Notably, consistent data have shown intestinal IPMNs and associated colloid carcinomas, defining the “intestinal pathway”, to be associated with less aggressive features. Genomic specificities have also been uncovered, such as mutations of the GNAS gene, and recent data provide more insights into the mechanisms involved in IPMCs carcinogenesis. This review synthetizes available data on clinical-pathological features and outcomes associated with IPMCs and their subtypes. We also describe known genomic hallmarks of these lesions and summarize the latest data about molecular processes involved in IPMNs initiation and progression to IPMCs. Finally, potential implications for clinical practice and future research strategies are discussed.
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Choi M, Chong JU, Hwang HK, Seo HI, Yang K, Ryu JH, Roh Y, Kim DH, Lee JH, Lee WJ, Choi SH, Kang CM. Role of postoperative adjuvant therapy in resected invasive intraductal papillary mucinous neoplasm of the pancreas: A multicenter external validation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:671-679. [PMID: 34028187 DOI: 10.1002/jhbp.996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Adjuvant therapy is beneficial in prolonging survival in patients with pancreatic ductal adenocarcinoma (PDAC). However, no clear guidelines are available on the oncologic effect of adjuvant therapy in resected invasive intraductal papillary mucinous neoplasms (inv-IPMN). METHODS In total, 551 patients with PDAC and 67 patients with inv-IPMN of the pancreas were reviewed. For external validation, 46 patients with inv-IPMN from six other Korean institutions were enrolled. Propensity score-matched analysis and stage-matched survival analysis were conducted. RESULTS The mean follow-up durations in the inv-IPMN and PDAC groups were 43.36 months (SD, 42.34 months) and 43.35 months (SD, 35.62 months), respectively. The 5-year overall survival (OS) was significantly better in the resected inv-IPMN group than in the PDAC group in the overall stage-matched analysis (P < .001). In the inv-IPMN cohort, OS was better in the surgery alone group (P = .042). In subgroup analysis, no significant survival difference was found between the adjuvant therapy and surgery alone groups according to the stage (stage I; P = .285, stage II or III; P = .077). Multicenter external validation did not show a better OS in the adjuvant therapy group (P = .531). On multivariable analysis, only perineural invasion (PNI) was identified as an adverse prognostic factor in resected inv-IPMN (HR 4.844; 95% CI 1.696-13.838, P = .003). CONCLUSIONS inv-IPMN has a more indolent course than PDAC. Current strategy of adjuvant therapy may not improve the OS in patients with resected inv-IPMN. Further investigations on the potential role of adjuvant therapy in inv-IPMN are mandatory.
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Affiliation(s)
- Munseok Choi
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung-Il Seo
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kwangho Yang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Younghoon Roh
- Department of Surgery, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Dong Hyun Kim
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jin Ho Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Choi
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongam-si, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Picado O, Dosch AR, Garcia-Buitrago MT, Yakoub D, Dudeja V, Rodgers SE. The Role of Perioperative Chemotherapy in the Management of Colloid Carcinoma of the Pancreas. Pancreas 2021; 50:306-312. [PMID: 33835960 DOI: 10.1097/mpa.0000000000001787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Colloid carcinoma (CC) of the pancreas is associated with an improved prognosis compared with pancreatic ductal adenocarcinoma (PDAC), yet studies on the optimal management of these rare lesions are lacking. METHODS Patients with CC or PDAC treated from 2004 to 2014 were identified in the National Cancer Database. Clinicopathologic characteristics were compared between groups and stratified by disease stage. Survival analysis evaluating the role of perioperative chemotherapy was performed. RESULTS A total of 1295 CC patients (11%) and 10,855 PDAC patients (89%) were identified. Pancreatic ductal adenocarcinoma was associated with a higher likelihood of mortality compared with CC (hazard ratio, 1.35; 95% confidence interval, 1.25-1.45; P < 0.001). When stratifying by stage, perioperative chemoradiation improved overall survival in early stage (I/IIA) PDAC but had no effect in CC patients. However, for node-positive disease (stage IIB), median overall survival was improved with adjuvant chemoradiation for both CC patients (22 vs 13 months; P < 0.001) and PDAC patients (20 vs 11 months; P < 0.001) compared with surgery alone. CONCLUSIONS Surgery alone may be sufficient for the management of node-negative (I/IIA) CC lesions in contrast to conventional PDAC, whereas CC patients with stage IIB disease have a survival benefit from perioperative chemoradiation.
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Affiliation(s)
- Omar Picado
- From the Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery
| | - Austin R Dosch
- From the Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery
| | - Monica T Garcia-Buitrago
- Division of Gastrointestinal Pathology, Department of Pathology, University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Danny Yakoub
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center. Memphis, TN
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, University of Alabama, Birmingham, AL
| | - Steven E Rodgers
- From the Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery
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11
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Krawczyk M, Ziarkiewicz-Wróblewska B, Podgórska J, Grzybowski J, Gierej B, Krawczyk P, Grąt M, Kornasiewicz O, Skalski M, Wróblewski T. Intraductal papillary neoplasm of the bile duct - A comprehensive review. Adv Med Sci 2021; 66:138-147. [PMID: 33556909 DOI: 10.1016/j.advms.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/14/2020] [Accepted: 01/21/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile ducts is a rare tumor type. Management decisions are currently based upon a small case series. The authors have large own experience with IPNB. OBJECTIVE The review aims at reporting on clinicopathological features of IPNB in order to provide guidance for management. METHODS We searched PubMed, Medline, Microsoft Academic and Embase databases to identify studies of relevance. The analysis of own experience was also included. RESULTS We analyzed 59 retrospective series and 25 cases from authors' clinical experience. The main sign was jaundice and cholangitis, 33% and 48%, respectively. CT's were performed in 63-76% and MR in 40-56%. Intraductal mass was found in 31-32% and duct dilatation in 27-30%. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was performed in 48-62%. IPNB with invasive carcinoma was found in 35.7-60% and IPNB with intraepithelial neoplasia in 36-60%. Histopathological confirmation before surgery was rare. The main treatment of IPNB is resection, in our material, both, hepatectomy and hepatectomy plus bile duct resections were performed in 40% of patients. The percentage of postoperative complications was 20%. The 5-year survival rate of all IPNB's patients was 53.6%; in patients with associated invasive carcinoma - 22.2% and without invasive carcinoma - 100% (p = 0.001). CONCLUSIONS Early surgery is advisable for radiologically suspected IPNB. The results of treatment depend on histopathology. They are worse at intraductal invasive carcinoma than at neoplasm with neoplasia.
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12
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Mungo B, Croce C, Oba A, Ahrendt S, Gleisner A, Friedman C, Schulick RD, Del Chiaro M. Controversial Role of Adjuvant Therapy in Node-Negative Invasive Intraductal Papillary Mucinous Neoplasm. Ann Surg Oncol 2020; 28:1533-1542. [PMID: 32743713 DOI: 10.1245/s10434-020-08916-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Adjuvant chemotherapy and/or chemoradiation [chemo(radiation)] is considered the standard of care for resected patients with pancreatic adenocarcinoma. However, invasive carcinoma arising from an intraductal papillary mucinous neoplasm (IPMN) seems to have different biologic behavior and prognosis. Retrospective data suggest a survival benefit of adjuvant chemo(radiation) for resected invasive IPMNs with metastatic nodal disease; however, it is unclear whether this remains valid for node-negative patients. PATIENTS AND METHODS To compare the outcome of patients with invasive IPMNs who received adjuvant chemo(radiation) with that of those treated with surgery alone, we queried the National Cancer Database regarding data of patients who underwent pancreatic resection for invasive IPMN between 2006 and 2015. A propensity score analysis was conducted to balance covariates between treatment groups. RESULTS For the study, 492 patients were eligible, of whom 267 (54.3%) received adjuvant chemo(radiation). Estimated 1- and 3-year overall survival rates were 88.9% and 73.5% versus 93.2% and 72.8% for patients who did or did not receive adjuvant chemo(radiation), respectively. Among patients with negative nodal stage, there was no difference in overall survival between patients who received versus patients who did not receive adjuvant chemo(radiation) (P = 0.973). In contrast, among patients with positive nodal disease, those who received adjuvant chemo(radiation) had significantly better OS compared with those who did not (P = 0.001). CONCLUSIONS In patients with resected invasive IPMNs, adjuvant chemo(radiation) was associated with significantly improved overall survival only in presence of nodal metastases. This finding can help clinicians to select adjuvant treatment in a patient-tailored fashion.
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Affiliation(s)
- Benedetto Mungo
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Chiara Croce
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
| | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
| | - Chloe Friedman
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA. .,University of Colorado Cancer Center, Denver, CO, USA.
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13
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Rodrigues C, Hank T, Qadan M, Ciprani D, Mino-Kenudson M, Weekes CD, Ryan DP, Clark JW, Allen JN, Hong TS, Wo JY, Ferrone CR, Warshaw AL, Lillemoe KD, Fernandez-Del Castillo C. Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2020; 20:722-728. [PMID: 32222340 DOI: 10.1016/j.pan.2020.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is limited data on the efficacy of adjuvant therapy (AT) in patients with invasive intraductal papillary mucinous neoplasms of the pancreas (IPMN). This single center retrospective cohort study aims to assess the impact of AT on survival in these patients. METHODS Patients undergoing surgery for invasive IPMN between 1993 and 2018 were included in the study. We compared the clinicopathologic features and evaluated overall survival (OS) using multivariate Cox regression adjusting for adjuvant therapy, age, T and N stage, perineural and lymphovascular invasion. We also assessed survival differences between surgery alone and AT in node negative (N0) and node positive (N+) subgroups. RESULTS 103 patients were included in the study; 69 underwent surgery alone while 34 also received AT. Patients in the AT group were significantly younger, presented at higher T and N stages and had more perineural and lymphovascular invasion. Median OS in the surgery alone group was 134 months and 65 months in the AT group, p = 0.052. On multivariate analysis, AT was not associated with improved OS; hazard ratio (HR) = 1.03 (0.52-2.05). In N0 patients, compared to surgery alone, AT was associated with a worse median OS (65 vs 167 months, p = 0.03), whereas in N+ patients there was a non-significant improvement (50.5 vs 20.4 months, p = 0.315). CONCLUSION AT did not improve survival in the overall cohort even after multivariate analysis. N0 patients have excellent survival, and AT should probably be avoided in them, whereas it may be considered in patients with N+ disease.
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Affiliation(s)
- Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Debora Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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14
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Successful treatment with conversion surgery following chemoradiotherapy for unresectable invasive intraductal papillary mucinous neoplasm. Clin J Gastroenterol 2020; 13:579-584. [PMID: 31919675 DOI: 10.1007/s12328-019-01086-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/17/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Recent advances in chemotherapy and chemoradiotherapy (CRT) have enabled the use of conversion surgery in selected patients with initially unresectable pancreatic duct adenocarcinoma after a favorable response to preoperative treatment. However, conversion surgery for invasive intraductal papillary mucinous neoplasm (IPMN) has not been reported. CASE REPORT A 63-year-old man was referred to our hospital for invasive IPMN treatment. Computed tomography revealed a multilocular tumor of 7.2 × 5.8 cm in diameter, which surrounded approximately 180° of the superior mesenteric artery and totally occluded the superior mesenteric vein (SMV). He was diagnosed with unresectable invasive IPMN. CRT was performed using four cycles of S-1 (100 mg/day) based on body surface area for 14 days every 3 weeks plus gemcitabine 1,000 mg/m2 on days 8 and 15 with concurrent radiotherapy (50.4 Gy in 28 fractions). Response to chemotherapy revealed partial response according to the Response Evaluation Criteria in Solid Tumors; subsequently, subtotal stomach-preserving pancreaticoduodenectomy with SMV resection was performed. The postoperative course was uneventful. Four courses of adjuvant chemotherapy with TS-1 100 mg / day were administered postoperatively. At 5 years and 9 months after initiating treatment, the patient was alive without recurrence.
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15
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Aronsson L, Marinko S, Ansari D, Andersson R. Adjuvant therapy in invasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:689. [PMID: 31930090 DOI: 10.21037/atm.2019.10.37] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a cystic tumor with a disease spectrum ranging from low-grade dysplasia to invasive carcinoma. The evidence for adjuvant treatment in invasive IPMN is limited and mostly derived from studies in conventional pancreatic ductal adenocarcinoma (PDAC). We performed a systematic review focusing on all clinical studies concerning the efficacy of adjuvant therapy in patients with invasive IPMN. We identified 8 retrospective cohort studies, using either adjuvant chemotherapy alone (n=1), adjuvant radiotherapy alone (n=1) or adjuvant chemotherapy in combination with radiation (n=6). Adjuvant therapy was associated with a survival benefit in 7 out of the 8 studies. Specific survival benefit was noted for patients with node-positive disease, higher TNM stage, positive resection margins, poor differentiation and tubular subtype. We conclude that adjuvant therapy may be beneficial in invasive IPMN, but current data suggest that it should be given selectively based on individual tumor characteristics. Further prospective, randomized studies are warranted.
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Affiliation(s)
- Linus Aronsson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Sofia Marinko
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Ansari
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
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16
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Tag-Adeen M, Ozawa E, Ogihara K, Iwatsu S, Akazawa Y, Ohnita K, Adachi T, Sumida Y, Nakao K. The role of pancreatic juice cytology in the diagnosis of pancreatic intraductal papillary mucinous neoplasm. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:775-781. [PMID: 30168338 DOI: 10.17235/reed.2018.5564/2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM pancreatic juice cytology (PJC) is an important predictor of malignant intraductal papillary mucinous neoplasm (IPMN). This study aimed to determine the role of PJC for the prediction of malignant IPMN (intraductal papillary mucinous cancer [IPMC]). METHODS medical records of IPMN patients who underwent surgery between 2012 and 2016 at the Nagasaki University Hospital were reviewed. Patients who underwent preoperative PJC were classified as high risk stigmata (HRS), worrisome features (WF) and no-criteria, based on imaging criteria. PJC class III or higher was considered as positive and only invasive IPMN was defined as IPMC. PJC was validated in each group with regard to sensitivity, specificity, accuracy with the corresponding 95% confidence intervals (95% CI) and area under receiver operating curve (AUROC) analysis. A p-value of < 0.05 was considered as statistically significant. RESULTS preoperative pancreatic juice was obtained in 33/52 IPMN patients; only patients with adequate aspirate for cytology (n = 29) were included. In the HRS group (n = 9), 4/6 non-IPMC had a negative PJC and 3/3 IPMC had a positive PJC. In the WF group (n = 17), 9/11 non-IPMC had a negative PJC and 3/6 IPMC had a positive PJC. Adding PJC to imaging results improved the AUROCs of HRS and WF from 0.63 and 0.62 to 0.83 and 0.66, respectively. PJC was negative in all no-criteria cases (n = 3; one IPMC and two non-IPMC). In all 29 patients, PJC sensitivity was 60% (95% CI: 26%-88%), specificity was 79% (95% CI: 54%-94%), accuracy was 72% (95% CI: 63%-89%) and the AUROC was 0.69 (p = 0.03). CONCLUSION PJC is a statistically significant IPMC predictor that can improve the validity of imaging for IPMC prediction.
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Affiliation(s)
- Mohammed Tag-Adeen
- Department off Internal Medicine, Faculty of Medicine, South Valley University, Egypt
| | - Eisuke Ozawa
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan., Nagasaki
| | - Kumi Ogihara
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinichi Iwatsu
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuko Akazawa
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Ken Ohnita
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Yorihisa Sumida
- Department of Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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17
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Fan Z, Cheng H, Jin K, Gong Y, Huang Q, Xu J, Ni Q, Yu X, Liu C, Luo G. AJCC 7th edition staging classification is more applicable than AJCC 8th edition staging classification for invasive IPMN. World J Surg Oncol 2019; 17:137. [PMID: 31387646 PMCID: PMC6685146 DOI: 10.1186/s12957-019-1682-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Both the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging systems have been introduced for pancreatic adenocarcinoma. However, the applicability of these classifications for invasive intraductal papillary mucinous neoplasms (IPMN) has not been systematically examined. Methods Patients with invasive IPMN were retrieved from a cohort of 18 geographical sites (1973–2014 varying) in the Surveillance, Epidemiology, and End Results (SEER) cancer registry. The 7th and 8th editions of the AJCC staging were compared. Survival rates and multivariate analyses were computed. Results In total, 1216 patients with resected invasive IPMN were included. A major difference between the 7th and 8th systems is the definition of stage IIA (7th, beyond the pancreas without involvement of major arteries; 8th, maximum tumor diameter > 4 cm). The hazard ratio (HR) of stage IIA disease (versus stage IA, HR = 2.33, P < 0.001) was higher than that of stage IB disease (HR = 1.48, P = 0.087) by the 7th edition classification, whereas the HR of stage IIA disease (HR = 1.26, P = 0.232) was even lower than that of stage IB disease (HR = 1.48, P = 0.040) by the 8th edition classification. In addition, for the 8th edition staging system, tumor size was not a predictor of survival in patients with resectable tumor > 2 cm (size > 4 cm versus > 2 ≤ 4 cm, HR = 0.91, P = 0.420). Conclusions The AJCC 7th edition staging classification is more applicable than the 8th edition classification for invasive IPMN.
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Affiliation(s)
- Zhiyao Fan
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - He Cheng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Yitao Gong
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Qiuyi Huang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China.,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China
| | - Chen Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China. .,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China. .,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China.
| | - Guopei Luo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China. .,Shanghai Pancreatic Cancer Institute, Shanghai, 200032, China. .,Pancreatic Cancer Institute, Fudan University, Shanghai, 200032, China.
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Marchegiani G, Andrianello S, Dal Borgo C, Secchettin E, Melisi D, Malleo G, Bassi C, Salvia R. Adjuvant chemotherapy is associated with improved postoperative survival in specific subtypes of invasive intraductal papillary mucinous neoplasms (IPMN) of the pancreas: it is time for randomized controlled data. HPB (Oxford) 2019; 21:596-603. [PMID: 30366881 DOI: 10.1016/j.hpb.2018.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/04/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Very little is known about adjuvant chemotherapy for invasive Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas. The aim was to assess whether adjuvant chemotherapy affects survival. METHODS Retrospective evaluation of invasive IPMNs. Patients treated with surgery alone or followed by adjuvant chemotherapy were compared in terms of survival. RESULTS A total of 102 invasive IPMNs were analyzed. Median follow-up was 72 (5-318) months and 18.6% received adjuvant chemotherapy. Overall, recurrence rate was 40.2%, while 5-year overall survival and disease specific survival (DSS) were 65.3% and 69.4%, respectively. N1 disease (HR5.58, CI95% 2.49-12.51, p < 0.01), tubular type (HR2.35, CI95% 1.71-4.82, p = 0.05) and G3 tumors (HR4.54, CI95% 2.12-15.49, <0.01) were predictors of reduced DSS. Overall, there was no difference in the 5-year DSS comparing patients treated with adjuvant chemotherapy to surgery alone (61.8 vs. 69.4%, p = 0.8). Adjuvant chemotherapy significantly improved DSS only in N1 (5-years-DSS 76 vs. 35.8%, p = 0.01) and tubular carcinomas (5-years-DSS 88.9 vs. 53%, p = 0.03). CONCLUSIONS Adjuvant therapy improves survival only in invasive IPMNs with nodal disease or tubular differentiation. Future trials are needed to improve the level of evidence about adjuvant chemotherapy.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Chiara Dal Borgo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Erica Secchettin
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Davide Melisi
- Department of Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy.
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19
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Bernard ME, Sutera PA, Iarrobino NA, Quan K, Burton SA, Bahary N, Hogg M, Zureikat A, Heron DE. Initial Results of a Prospective Study of Adjuvant Pancreatic Stereotactic Body Radiation Therapy for Close or Positive Margins. Adv Radiat Oncol 2018; 4:294-301. [PMID: 31011674 PMCID: PMC6460098 DOI: 10.1016/j.adro.2018.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/16/2018] [Indexed: 12/31/2022] Open
Abstract
Purpose Patients with close or positive margins after surgery for pancreatic carcinoma are at a high risk for recurrence. Stereotactic body radiation therapy (SBRT) allows for safe dose escalation with great conformity and short duration of treatment. Herein, we report the initial results of a prospective observational study that evaluated the efficacy and safety of this treatment option. Methods and Materials Patients eligible for the study had pathologically proven T1-4N0-1M0 pancreatic adenocarcinoma with a positive margin (≤1 mm) or a close margin defined as <2.5 mm. Patients were treated with either neoadjuvant or adjuvant chemotherapy, if eligible for systemic therapy. All patients received 36 Gy in 3 fractions to the close or positive margin site. Results From February 2013 to January 2018, 50 patients were enrolled with 49 patients treated on protocol and included in the analysis. The median age was 71 years. The median clinical target volume was 11.3 cc and median planning target volume 22.0 cc. The median overall survival was 23.7 months (95% confidence interval, 13.6-33.8). Local progression-free survival at 1 and 2 years was 85% and 77%, respectively. Regional progression-free survival at 1 and 2 years was 73% and 73%, respectively. Distant metastases-free survival was 57% and 49% at 1 and 2 years, respectively. Grade 3+ radiation toxicity was only 4.1% and occurred in 2 patients. Conclusions Adjuvant pancreatic SBRT was shown to be a safe and feasible treatment option for patients with high-risk pancreatic adenocarcinoma and close or positive margins. This is the first prospective study of SBRT in high-risk postoperative pancreatic cancer. Our results yielded significant local and regional control with low rates of acute toxicity. This technique does not interrupt the administration of systemically dosed multiagent chemotherapy and can be safely interdigitated between cycles because SBRT is only 1 week of treatment.
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Affiliation(s)
- Mark E. Bernard
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Philip A. Sutera
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nicholas A. Iarrobino
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kimmen Quan
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven A. Burton
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Department of Medical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Melissa Hogg
- Department of Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amer Zureikat
- Department of Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dwight E. Heron
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Corresponding author. Department of Radiation Oncology, UPMC Hillman Cancer Center, 5230 Centre Ave, Suite 544, Pittsburgh, PA 15232.
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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21
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Aronsson L, Andersson R, Ansari D. Intraductal papillary mucinous neoplasm of the pancreas - epidemiology, risk factors, diagnosis, and management. Scand J Gastroenterol 2017; 52:803-815. [PMID: 28446039 DOI: 10.1080/00365521.2017.1318948] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is one of the most common cystic neoplasms of the pancreas. It is a heterogeneous disease and can be divided into ductal types and morphological subtypes. The incidence of IPMN is increasing, likely due to the widespread use of cross-sectional imaging and a growing elderly population. IPMN poses an increasing demand on the health care system. Current guidelines provide indications for surgery and recommendations for surveillance, but management of IPMN is still challenging in routine clinical practice. In this article, we review current knowledge about IPMN and provide future directions for improving diagnosis and management.
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Affiliation(s)
- Linus Aronsson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Roland Andersson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Daniel Ansari
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
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22
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Fong ZV, Fernández-del Castillo C. Intraductal Papillary Mucinous Neoplasm of the Pancreas. Surg Clin North Am 2016; 96:1431-1445. [DOI: 10.1016/j.suc.2016.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Abstract
In this article, we aimed to review the literature on the clinics and management of intraductal papillary mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm of the pancreas is a mucin-producing cystic mass originating from the pancreatic ductal system. Approximately 25% of the pancreatic neoplasms resected surgically and 50% of pancreatic cysts detected incidentally are IPMNs. They can be benign or malignant in character, while malignant transformation of benign forms can be encountered. It is important to determine IPMNs in the early stages, implementation of appropriate treatment approaches, and follow-up to provide better prognosis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the IPMN. Due to the recent advances and widespread implementation of radiological imaging techniques, the incidental detection rate of IPMNs has increased significantly. The effective treatment of the disease is possible via the detailed diagnosis of the disease, determination of the prognostic factors, and a multidisciplinary approach. Recent literature also emphasized the molecular profile determination approaches for assessment of prognosis of patients with IPMN. Current knowledge on IPMN, a clinically important epidemiologic problem, shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.
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Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current State of the Art and Ongoing Controversies. Ann Surg 2016; 263:908-17. [PMID: 26727096 DOI: 10.1097/sla.0000000000001567] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the widespread use and advances in radiographic imaging, Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas are identified with increasing frequency. Although many studies have addressed its biology and treatment, true understanding of its natural history continues to elude us. Its malignant potential places careproviders in a clinical dilemma of balancing the morbidity of pancreatectomy against the risk of malignant transformation while under continuous surveillance. Recently, there have been conflicting data published in the literature, generating more uncertainty in the field. In this article, we critically analyze the contrasting consensus guidelines from the International Association of Pancreatology and the American Gastroenterology Association, and address lingering questions and controversies. We also synthesize newly published data in the context of current standard of care, and provide a comprehensive review and recommendations for the clinical diagnosis, treatment, and follow-up strategy in the management of patients with Intraductal Papillary Mucinous Neoplasms.
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25
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Systematic Review and Meta-analysis of Current Experience in Treating IPNB: Clinical and Pathological Correlates. Ann Surg 2016; 263:656-63. [PMID: 26501712 DOI: 10.1097/sla.0000000000001426] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To systematically review studies reporting clinicopathological features of intraductal papillary neoplasm of the bile duct (IPNB) to provide evidence-based guidance for management. BACKGROUND IPNB is a rare tumor type. Management decisions are currently based upon anecdotal evidence and small case series. To data, there has been no systematic review of IPNB literature. METHODS MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched and data were extracted from relevant studies. Meta-analysis was used to pool study estimates. Evidence of association was determined by comparing pooled crude odds ratios (OR) derived from abstracted data. RESULTS Fifty-seven retrospective case series were included. At least 43% of 476 specimens contained invasive disease. Invasive tumors were found at significantly higher frequency in pancreaticobiliary than intestinal, gastric or oncocytic-type IPNB [pooled OR 2.5, 95% confidence interval (CI) 1.5-4.2, P < 0.001]. A significantly higher proportion of pancreaticobiliary tumors compared with intestinal tumors expressed MUC-1 [86.4% (95% CI 75.1%-94.7%) vs 13.2% (95% CI 4.6%-25.2%), respectively P < 0.001]. IPNB identified in centers from Asia were more likely to be intrahepatic and were less frequently invasive compared with those from Western centers. Pooled estimates of absolute survival after IPNB resection were 96% (95% CI 93%-99%) at 1 year, 79% (95% CI 69%-88%) at 3 years, and 65% (95% CI 46%-76%) at 5 years. CONCLUSIONS Early surgery is advisable for radiologically suspected IPNB as it is frequently invasive. The pathobiology of IPNB demonstrates geographic variation. Pancreaticobiliary IPNB expresses MUC1 and is more frequently associated with invasive disease than other IPNB subtypes.
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Han DH, Lee H, Park JY, Kwon W, Heo JS, Choi SH, Choi DW. Validation of international consensus guideline 2012 for intraductal papillary mucinous neoplasm of pancreas. Ann Surg Treat Res 2016; 90:124-30. [PMID: 26942155 PMCID: PMC4773456 DOI: 10.4174/astr.2016.90.3.124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/26/2015] [Accepted: 11/04/2015] [Indexed: 12/14/2022] Open
Abstract
Purpose Intraductal papillary mucinous neoplasm (IPMN) has variable malignant potential ranging from premalignant intraductal lesions to malignant neoplasms with invasive carcinoma. To help physicians managing patients with IPMN, International consensus guidelines was made in 2006 and revised in 2012. This study was designed to evaluate the clinical usefulness of guidelines and to validate. Methods From October 1996 to December 2011, we retrospectively reviewed the data of 230 patients who underwent pancreatic resection for IPMN. Univariate and multivariable analyses were used to identify significant predictors of malignancy in IPMN. Results Of the 230 patients, 62 patients (27%) were diagnosed with invasive carcinoma. Jaundice (P < 0.001; 95% confidence interval [CI], 3.086–40.010) main pancreatic duct diameter equal to or greater than 10 mm (P < 0.001; 95% CI, 1.723–6.673) and also abdominal pain (P < 0.001; 95% CI, 4.363–22.600) show statistical significance in univariate and multivariate analysis. "High-risk stigmata" was statistical powerful predictors of malignancy than "worrisome features". International consensus guidelines 2012 had improvement on specificity but deterioration of sensitivity. Conclusion Revised guidelines seemed to bring about an improvement of weak side of Sendai criteria. Abdominal pain, jaundice, main pancreas duct greater than 10 mm can be clinical variables to predict malignancy.
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Affiliation(s)
- Dong Hyeon Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Huisong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Young Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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McMillan MT, Lewis RS, Drebin JA, Teitelbaum UR, Lee MK, Roses RE, Fraker DL, Vollmer CM. The efficacy of adjuvant therapy for pancreatic invasive intraductal papillary mucinous neoplasm (IPMN). Cancer 2015; 122:521-33. [PMID: 26587698 DOI: 10.1002/cncr.29803] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND The literature investigating pancreatic invasive intraductal papillary mucinous neoplasm (IPMN) has largely come from small institutional studies, preventing adequately powered comparisons of adjuvant therapy versus surgery alone (SA) within specific patient subgroups. METHODS Patients with resected, stage I through IV, invasive IPMN and conventional pancreatic ductal adenocarcinoma (PDAC) were identified in the National Cancer Data Base (1998-2010). Cox modeling of patients with invasive IPMN was used to compare overall survival (OS) between patients who received adjuvant therapy and those who underwent SA. A second model was used to compare OS between patients with invasive IPMN and those with PDAC. RESULTS For the 1220 patients with invasive IPMN, the median OS was 28.9 months; the 1-year and 5-year actuarial survival rates were 76% and 17%, respectively; and 47% received adjuvant therapy. Cox modeling associated SA with worse OS (hazard ratio, 1.36; 95% confidence interval, 1.17-1.58; P = .00005) as well as American Joint Committee on Cancer (AJCC) TNM stage III/IV disease, positive lymph node status, positive margins, and poor tumor differentiation (all P ≤ .05). In addition, Cox modeling stratified by the following characteristics demonstrated improved OS with adjuvant therapy: AJCC TNM stage II or III/IV, positive lymph node status, positive margins, and poorly differentiated tumors. There was no survival advantage from adjuvant therapy for patients who had AJCC TNM stage I or lymph node-negative disease. Patients who had invasive IPMN had improved risk-adjusted OS compared with those who had PDAC (hazard ratio, 0.73; 95% confidence interval, 0.68-0.78; P < .00001). CONCLUSIONS Invasive IPMN appears to be more indolent than conventional PDAC. Adjuvant therapy is associated with improved OS compared with SA in patients with invasive IPMN, especially for those with higher stage disease, positive lymph nodes, positive margins, or poorly differentiated tumors. Conversely, this benefit does not extend to patients with stage I or lymph node-negative disease.
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Affiliation(s)
- Matthew T McMillan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Russell S Lewis
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey A Drebin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ursina R Teitelbaum
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Fong ZV, Castillo CFD. Intraductal Papillary Mucinous Adenocarcinoma of the Pancreas: Clinical Outcomes, Prognostic Factors, and the Role of Adjuvant Therapy. VISZERALMEDIZIN 2015; 31:43-6. [PMID: 26288615 PMCID: PMC4433131 DOI: 10.1159/000373912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Intraductal papillary mucinous adenocarcinoma (IPMCs) occur more frequently in main-duct intraductal papillary mucinous neoplasms. METHODS Review of the literature. RESULTS The prognosis of IPMCs depends on its histopathological subtype: colloid IPMCs have superior survival rates mainly secondary to more favorable pathological features, whereas tubular IPMCs have survival outcomes similar to that of conventional pancreatic adenocarcinomas. The epithelial background plays an equally important role in defining the biology of IPMCs: gastric IPMC subtypes demonstrate an overall worse survival outcome when compared to intestinal, pancreatobiliary, and oncocytic subtypes. Lymph node involvement is one of the strongest predictors of survival in IPMC, with a decreasing overall survival as the lymph node ratio increases. There is little evidence to support adjuvant chemoradiation in patients with IPMC. CONCLUSION Our current understanding of IPMC biology based on histopathological and epithelial background subtypes as well as clinicopathological predictors should influence patient counseling and selection for adjuvant therapy.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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29
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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30
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Favorable response after gemcitabine-radiotherapy for invasive pancreatic intraductal papillary mucinous neoplasm: a case report. Int Surg 2015; 98:340-5. [PMID: 24229021 DOI: 10.9738/intsurg-d-13-00031.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The efficacy of chemoradiotherapy for invasive pancreatic ductal carcinoma derived from an intraductal papillary mucinous neoplasm (IPMN) has not been established. The subject of the present report was a 53-year-old man admitted for the treatment of IPMN. The tumor, located in the pancreatic body, was of the mixed type of IPMN, and it involved the branch duct, where it was 38 mm in diameter, and the main duct, where it was 6 mm in diameter. Distal pancreatectomy was performed and the postoperative course was uneventful; however, histopathologic diagnosis revealed invasive ductal carcinoma with a positive surgical margin in the pancreatic duct. Although total pancreatectomy was recommended, chemoradiotherapy (50.4-Gy irradiation and gemcitabine) was preferred by the patient. At 9-month follow up, computed tomography and magnetic resonance imaging showed a cystic mass at the surgical margin of the pancreas. Endoscopic ultrasonography showed a 44-mm cystic lesion with nodules in the remnant pancreas, on the basis of which he underwent total pancreatectomy. Pathologic examination of the resected specimen revealed absence of the epithelium at the surgical margin of the main pancreatic duct, and malignant cells were not detected.
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31
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Tian X, Gao H, Ma Y, Zhuang Y, Yang Y. Surgical treatment and prognosis of 96 cases of intraductal papillary mucinous neoplasms of the pancreas: a retrospective cohort study. Int J Surg 2014; 13:49-53. [PMID: 25461854 DOI: 10.1016/j.ijsu.2014.11.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/05/2014] [Accepted: 11/22/2014] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The indications, the extent and type of surgery for intraductal papillary mucinous neoplasm (IPMN) are still controversial. This study aimed to investigate clinical manifestation, individualized surgical treatment, and prognosis of IPMN of pancreas. METHODS The clinical data of 96 IPMN cases treated in our hospital between January 2006 and December 2013 were retrospectively analyzed. Among the 96 patients (58 male and 38 female), 46 were main-duct type, 29 were branch-duct type, 21 were mixed type. Pancreatectomy was performed on 78 cases, including pancreaticoduodenectomy on 43 patients, distal pancreatectomy on 25, segmental pancreatectomy on 6, and total pancreatectomy on 4. A regular follow-up without surgical treatment was performed on 18 cases with asymptomatic side branch IPMN less than 3 cm in diameter. RESULTS The overall postoperative morbidity rate was 33.3%, and there was no perioperative mortality. 46 cases were non-invasive IPMN, 32 cases were invasive IPMN including 14 cases with lymph node metastasis. The five-year survival rate for patients with non-invasive and invasive carcinomas was 96.2% and 35.2%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis. No progression was found during the follow-up in 18 asymptomatic small branch duct type IPMN patients. CONCLUSION IPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive surgical treatment. Patients of branch duct type IPMN with lesion <3 cm in diameter and without clinical manifestations can be managed with close follow-up.
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Affiliation(s)
- Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, 8th Xishiku Street, Xicheng, Beijing 100034, People's Republic of China
| | - Hongqiao Gao
- Department of General Surgery, Peking University First Hospital, 8th Xishiku Street, Xicheng, Beijing 100034, People's Republic of China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, 8th Xishiku Street, Xicheng, Beijing 100034, People's Republic of China
| | - Yan Zhuang
- Department of General Surgery, Peking University First Hospital, 8th Xishiku Street, Xicheng, Beijing 100034, People's Republic of China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, 8th Xishiku Street, Xicheng, Beijing 100034, People's Republic of China.
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Chin JY, Pitman MB, Hong TS. Intraductal papillary mucinous neoplasm: clinical surveillance and management decisions. Semin Radiat Oncol 2014; 24:77-84. [PMID: 24635864 DOI: 10.1016/j.semradonc.2013.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a relatively rare cystic neoplasm. Although most IPMNs appear to be benign and may be managed by surveillance, all IPMNs are considered premalignant lesions with malignant potential. As such, current efforts are focused on identifying those neoplasms that are at high risk for malignancy to optimize treatment strategy and outcome. IPMNs with invasive carcinoma have clinical outcomes that approach those of conventional pancreatic ductal adenocarcinoma. Management guidelines recommend surgical resection for IPMNs with high-risk imaging or cytologic features. The role of adjuvant therapy is unclear, and we review the evidence for chemoradiation here. Some studies suggest adjuvant chemoradiation may have the greatest impact in malignant IPMNs with adverse histologic features, that is, lymph node metastasis at the time of diagnosis or positive surgical margins. As more IPMNs are recognized and treated, more evidence will accumulate to guide clinicians regarding appropriate use of radiotherapy in the management of IPMN.
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Affiliation(s)
- Joanna Y Chin
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Paini M, Crippa S, Partelli S, Scopelliti F, Tamburrino D, Baldoni A, Falconi M. Molecular pathology of intraductal papillary mucinous neoplasms of the pancreas. World J Gastroenterol 2014; 20:10008-10023. [PMID: 25110429 PMCID: PMC4123331 DOI: 10.3748/wjg.v20.i29.10008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Since the first description of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas in the eighties, their identification has dramatically increased in the last decades, hand to hand with the improvements in diagnostic imaging and sampling techniques for the study of pancreatic diseases. However, the heterogeneity of IPMNs and their malignant potential make difficult the management of these lesions. The objective of this review is to identify the molecular characteristics of IPMNs in order to recognize potential markers for the discrimination of more aggressive IPMNs requiring surgical resection from benign IPMNs that could be observed. We briefly summarize recent research findings on the genetics and epigenetics of intraductal papillary mucinous neoplasms, identifying some genes, molecular mechanisms and cellular signaling pathways correlated to the pathogenesis of IPMNs and their progression to malignancy. The knowledge of molecular biology of IPMNs has impressively developed over the last few years. A great amount of genes functioning as oncogenes or tumor suppressor genes have been identified, in pancreatic juice or in blood or in the samples from the pancreatic resections, but further researches are required to use these informations for clinical intent, in order to better define the natural history of these diseases and to improve their management.
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MESH Headings
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Carcinoma, Pancreatic Ductal/classification
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/metabolism
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Papillary/classification
- Carcinoma, Papillary/genetics
- Carcinoma, Papillary/metabolism
- Carcinoma, Papillary/pathology
- DNA Methylation
- Epigenesis, Genetic
- Gene Expression Regulation, Neoplastic
- Genetic Predisposition to Disease
- Genetic Testing
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/classification
- Neoplasms, Cystic, Mucinous, and Serous/genetics
- Neoplasms, Cystic, Mucinous, and Serous/metabolism
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreatic Neoplasms/classification
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/metabolism
- Pancreatic Neoplasms/pathology
- Phenotype
- Predictive Value of Tests
- Signal Transduction
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IPMN: surgical treatment. Langenbecks Arch Surg 2013; 398:1029-37. [PMID: 23999775 DOI: 10.1007/s00423-013-1106-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 08/19/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE Cystic pancreatic tumors are being detected more frequently, and particularly, intraductal papillary mucinous neoplasia (IPMN) has recently attracted increased attention. The detection rate of IPMN has increased over the last decade; however, management of this neoplasm remains controversial. METHODS Based on a review of the relevant literature and the international guidelines, we discuss the diagnostic evaluation of IPMN, its treatment, and prognosis. RESULTS While IPMN represents only a distinct minority of all pancreatic cancers, they appear to be a relatively frequent neoplastic form of pancreatic cystic neoplasm. It may not be possible to differentiate main duct disease from branch duct disease (MD-IPMN vs. BD-IPMN) prior to surgery. This distinction has not only an impact on treatment but also on prognosis, as MD-IPMN is more often malignant. IPMN has updated consensus guideline indications for conservative and surgical resection. CONCLUSIONS Since patients with IPMN of the pancreas are at risk of developing recurrent IPMN and pancreatic ductal adenocarcinoma in the remnant pancreas and extrapancreatic malignancies, early recognition, treatment, and systemic surveillance are of great importance. No conclusions can be drawn from the available evidence with respect to the efficacy of surveillance and follow-up treatment programs. A better understanding of the natural course of IPMN and the biology of pancreatic cancer is mandatory to enable further diagnostic and treatment improvements.
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Balsarkar D, Takahata S, Tanaka M. Intraductal papillary mucinous neoplasms of the pancreas: is the puzzle solved? Indian J Gastroenterol 2013; 32:213-21. [PMID: 23512214 DOI: 10.1007/s12664-013-0327-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 02/10/2013] [Indexed: 02/04/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMN) are drawing more attention and being detected more frequently. This review focuses on current understanding of the management of IPMN, regarding morphological classification, subclassification by cell lineage features, molecular abnormalities, radiological and imaging evaluation, progression to cancer, incidence and risk factors for malignancy, risk of distinct pancreatic adenocarcinoma and extrapancreatic malignancies, treatment strategy, and types of surgical resection. In particular, missing links in solving the IPMN puzzles are described with regard to differential diagnosis, role of cyst fluid analysis, multifocal IPMN, histological evaluation of the surgical specimen, observation without resection, follow up of patients after resection, role of adjuvant therapy for invasive carcinoma, screening for other neoplasms in patients with IPMN on follow up, prognostic factors influencing long-term outcomes, and role of endoscopic therapy.
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Affiliation(s)
- Dharmesh Balsarkar
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Caponi S, Vasile E, Funel N, De Lio N, Campani D, Ginocchi L, Lucchesi M, Caparello C, Lencioni M, Cappelli C, Costa F, Pollina L, Ricci S, Mosca F, Falcone A, Boggi U. Adjuvant chemotherapy seems beneficial for invasive intraductal papillary mucinous neoplasms. Eur J Surg Oncol 2013; 39:396-403. [PMID: 23290583 DOI: 10.1016/j.ejso.2012.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/28/2012] [Accepted: 12/07/2012] [Indexed: 12/20/2022] Open
Abstract
AIMS The incidence of intraductal papillary mucinous neoplasm (IPMN) is rising and these neoplasms now represent up to 25% of resected pancreatic neoplasms. The optimal postoperative management of resected invasive IPMN is still debated in the absence of large prospective clinical trials and of validated prognostic factors in this setting. The objective of our study was to identify potential prognostic factors and to investigate the role of adjuvant therapies for patients radically resected for invasive IPMN. METHODS We retrospectively reviewed clinical and pathological data regarding a large series of patients with invasive IPMN who underwent surgical resection in the last six years at University Hospital of Pisa. RESULTS Sixty-four patients were considered for the analysis, thirty-three of whom received adjuvant chemotherapy with gemcitabine. In our series node involvement and high tumoral grade emerged as the major pathologic prognostic factors. Patients treated with adjuvant chemotherapy with gemcitabine experienced a longer disease-free survival than those who received surgery alone. CONCLUSIONS Gemcitabine-based chemotherapy seems beneficial as adjuvant treatment for patients with resected invasive IPMN.
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Affiliation(s)
- S Caponi
- Department of Oncology, Transplants, and New Technologies, U.O. Oncologia 2 Universitaria, Azienda Ospedaliero-Universitaria Pisana, Polo Oncologico Area Vasta Nord-Ovest, Istituto Toscano Tumori, Via Roma 67, 56126 Pisa, Italy
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Caponi S, Funel N, Frampton AE, Mosca F, Santarpia L, Van der Velde AG, Jiao LR, De Lio N, Falcone A, Kazemier G, Meijer GA, Verheul HM, Vasile E, Peters GJ, Boggi U, Giovannetti E. The good, the bad and the ugly: a tale of miR-101, miR-21 and miR-155 in pancreatic intraductal papillary mucinous neoplasms. Ann Oncol 2012; 24:734-41. [PMID: 23139258 DOI: 10.1093/annonc/mds513] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This multicenter study evaluated three candidate microRNAs (miRNAs) (miR-21, miR-155 and miR-101) as potential biomarkers in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. PATIENTS AND METHODS miRNA expression was quantified by quantitative RT-PCR in 86 laser-microdissected specimens, including 65 invasive IPMNs, 16 non-invasive IPMNs and 5 normal pancreatic ductal tissues. Univariate and multivariate analyses compared miRNAs and clinical parameters with overall (OS) and disease-free survival (DFS). RESULTS miR-21 and miR-155 were up-regulated in invasive IPMNs compared with non-invasive IPMNs, as well as in non-invasive IPMNs compared with normal tissues. Conversely, miR-101 levels were significantly higher in non-invasive IPMNs and normal tissues compared with invasive IPMNs. High levels of miR-21 were associated with worse OS [hazard ratio (HR) = 2.47, 95% confidence interval (CI) = 1.37-5.65, P = 0.0047]. Patients with high-miR-21 expression also had a shorter median DFS (10.9 versus 29.9 months, P = 0.01). Multivariate analysis confirmed miR-21 as independently prognostic for mortality and disease progression (death risk: HR = 3.3, 95% CI = 1.5-7.0, P = 0.02; progression risk: HR = 2.3, 95% CI = 1.2-4.8, P = 0.02), as well as positive lymph-node status (death risk: HR = 2.6, 95% CI = 1.1-6.3, P = 0.03; progression risk: HR = 2.2, 95% CI = 1.0-4.8, P = 0.04). CONCLUSIONS miR-21, miR-155 and miR-101 showed significant differences in invasive versus non-invasive IPMNs. miR-21 emerged as an independent prognostic biomarker in invasive IPMNs and should be validated in prospective studies.
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Affiliation(s)
- S Caponi
- Unit Medical Oncology-2, Azienda Ospedaliero-Universitaria Pisana, Pisa
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Adjuvant stereotactic body radiotherapy for resected pancreatic adenocarcinoma with close or positive margins. J Gastrointest Cancer 2012; 43:70-6. [PMID: 20809393 DOI: 10.1007/s12029-010-9203-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate the role of stereotactic body radiotherapy (SBRT) as adjuvant therapy for resected pancreatic adenocarcinoma with close or positive margins. METHODS Between September 2006 and January 2010, 24 patients were treated with adjuvant SBRT following surgical resection. Eight (33.3%) patients had close margins of 1-2.5 mm to the retroperitoneal, vascular structures, and periduodenal adipose tissue. Sixteen (66.7%) patients had positive margins at retroperitoneal margin and vascular structures. Twenty-three patients received 24 Gy (20-24 Gy) in one fraction, and one had 30 Gy in three fractions. The median target volume was 11 cc (4.5-30 cc). Eighteen patients were treated with the Cyberknife® Robotic Radiosurgery System and six patients were treated with Trilogy™ intensity-modulated radiosurgery. Kaplan-Meier survival analyses were used to estimate freedom-from-local-progression (FFLP), and overall survival (OS) rates. PET/CT or CT was used to monitor disease recurrence following SBRT. RESULTS The median follow-up for all patients was 12.5 months (1.4-39.5 months), and among surviving patients it was 16.3 months (2-39.5 months). The FFLP rates at 6 months, 1 and 2 years were 94.7%, 66%, and 44%, respectively. Overall, FFLP was achieved in seven (87.5%) patients with close margins, and 10 (62.5%) with positive margins. After SBRT, 19 patients resumed or started a 6-month course of gemcitabine-based chemotherapy at a median interval of 18 days (range, 9-31 days) post-SBRT. The median OS was 26.7 months and the 1- and 2-year OS rates were 80.4% and 57.2%, respectively. Of the 24 patients, 12 (50%) developed distant metastases of whom two (25%) had close margins and 10 (62.5%) had positive margins. Ten patients (41.7%) were free of progression at last follow-up (range, 3-39.5 months). Three patients (12.5%) had grade 1-2 acute GI toxicities, and two patients (8.3%) had grade 1 and 2 late toxicities. No patients experienced grade 3 or 4 toxicity, including bowel perforation, secondary to SBRT. CONCLUSIONS Our data suggest that adjuvant SBRT for resected pancreatic cancer can be achieved with minimal toxicity. This shorter treatment course allowed initiation of systemic chemotherapy shortly after the completion of SBRT.
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Alexander BM, Fernandez-del Castillo C, Ryan DP, Kachnic LA, Hezel AF, Niemierko A, Willett CG, Kozak KR, Blaszkowsky LS, Clark JW, Warshaw AL, Hong TS. Intraductal papillary mucinous adenocarcinoma of the pancreas: clinical outcomes, prognostic factors, and the role of adjuvant therapy. GASTROINTESTINAL CANCER RESEARCH : GCR 2011; 4:116-121. [PMID: 22368734 PMCID: PMC3283102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/11/2010] [Indexed: 05/31/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) arising in intraductal papillary mucinous neoplasms (IPMN) may represent a different biologic entity than classic PDAC, and there is little evidence to inform adjuvant treatment decisions. The purpose of this study was to identify prognostic factors for PDAC arising in IPMN and determine the benefit of postoperative adjuvant therapy. METHODS Forty-four patients without previous therapy who underwent surgery for invasive PDAC arising in association with IPMN at our institution were identified. Medical records were reviewed for clinical and pathologic features, adjuvant therapy, and outcomes. RESULTS On univariate analysis, positive nodes (hazard rate [HR] 14, 95% confidence interval [CI] 4.2-44), CA 19-9 > 80 (HR 6.2, 95% CI 2.2-17), lymphovascular invasion (HR 4.7, 95% CI 1.5-15), perineural invasion (HR 3.9, 95% CI 1.5-10), and positive margins (HR 3.1, 95% CI 1.2-8.0) were associated with inferior cancer-specific survival. Patients with positive nodes who received adjuvant therapy had higher median cancer-specific survival (20 months) than those who received no adjuvant therapy (3.3 months). CONCLUSIONS Patients with PDAC arising in IPMN presented at an earlier stage than is reported for classical PDAC. Adjuvant chemoradiotherapy was associated with improved overall and cancer-specific survival for patients with advanced disease. These hypothesis-generating results require validation in a larger prospective trial.
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Affiliation(s)
| | | | | | - Lisa A. Kachnic
- Department of Radiation Oncology Massachusetts General Hospital Harvard Medical School Boston, MA
| | | | - Andrzej Niemierko
- Department of Radiation Oncology Massachusetts General Hospital Harvard Medical School Boston, MA
| | | | | | | | | | | | - Theodore S. Hong
- Department of Radiation Oncology Massachusetts General Hospital Harvard Medical School Boston, MA
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part III. Intraductal papillary mucinous neoplasms. Surg Oncol 2011; 20:e109-18. [PMID: 21396811 DOI: 10.1016/j.suronc.2011.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/04/2011] [Accepted: 01/27/2011] [Indexed: 12/11/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) represent about 25% of all primary pancreatic cystic neoplasms and are increasingly recognized during the last two decades. They are characterized by intraductal proliferation of neoplastic mucinous cells forming papillary projections into the pancreatic ductal system, which is typically dilated and contains globules of mucus. IPMNs may be multifocal and have malignant potential. Modern imaging is essential in establishing preoperative diagnosis and in differentiating different subtypes of IPMNs (i.e., main-duct vs. branch-type disease). Endoscopic retrograde or magnetic resonance cholangiopancreatography accurately delineate the morphologic changes of the pancreatic ductal system. Endoscopic ultrasonography (usually used in conjunction with image-guided FNA and analysis of the aspirated material) is commonly used for differential diagnosis of IPMNs from other pancreatic cystic lesions. Surgical resection (usually anatomic pancreatectomy, depending on the location of the disease) is the treatment of choice. Total pancreatectomy may occasionally be required in selected patients, but is associated with formidable long-term morbidity. A conservative approach has recently been proposed for carefully selected patients with branch-duct IPMNs. Recurrences following surgical resection can be observed, especially in patients with multifocal disease or in the presence of underlying malignancy.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Arkadias 19-21, Athens 12462, Greece.
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Stereotactic body radiotherapy in the treatment of advanced adenocarcinoma of the pancreas. Am J Clin Oncol 2011; 34:63-9. [PMID: 20308870 DOI: 10.1097/coc.0b013e3181d270b4] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the study was to assess the feasibility and safety of stereotactic body radiotherapy (SBRT) in patients with advanced pancreatic adenocarcinoma. METHODS We reviewed outcomes of 71 patients treated with SBRT for pancreatic cancer between July 2004 and January 2009. Forty patients (56%) had locally unresectable disease, 11 patients (16%) had local recurrence following surgical resection, 8 patients (11%) had metastatic disease, and 12 patients (17%) received adjuvant SBRT for positive margins. The median dose was 24 Gy (18-25 Gy), given in a single-fraction SBRT (n = 67) or fractionated SBRT (n = 4). Kaplan-Meyer survival analyses were used to estimate freedom from local progression (FFLP) and overall survival (OS) rates. RESULTS The median follow-up among surviving patients was 12.7 months (4-26 months). The median tumor volume was 17 mL (5.1-249 mL). The overall FFLP rates at 6 months/1 year were 71.7%/48.5%, respectively. Among those with macroscopic disease, FFLP was achieved in 77.3% of patients with tumor size <15 mL (n = 22), and 59.5% for ≥15 mL (n = 37) (P = 0.02). FFLP was achieved in 73% following 24 to 25 Gy, and 45% with 18 to 22 Gy (P = 0.004). The median OS was 10.3 months, with 6 month/1 year OS rates of 65.3%/41%, respectively. Grade 1-2 acute and late GI toxicity were seen in 39.5% of patients. Three patients experienced acute grade 3 toxicities. CONCLUSIONS SBRT is feasible, with minimal grade ≥3 toxicity. The overall FFLP rate for all patients was 64.8%, comparable to rates with external beam radiotherapy. This shorter treatment course can be delivered without delay in adjuvant systemic therapy.
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Björk Werner J, Sturesson C, Dawiskiba S, Andersson R. Mucinous cystadenocarcinoma of the pancreas - outcome following different modes of treatment. Ann Gastroenterol 2011; 24:213-217. [PMID: 24713784 PMCID: PMC3959310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 05/18/2011] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Mucinous cystadenocarcinomas (MCAC) of the pancreas are rare tumors. When localized to the pancreas alone, surgical resection is mostly associated with a favorable prognosis. The potential value of palliative treatment with chemotherapy for irresectable disease is scarcely described though. The aim of this study was to describe a single-center series of patients with MCAC of the pancreas focusing on the outcome following different treatment strategies. METHODS 15 patients, 10 females and 5 males, with histologically or cytologically verified MCAC, were divided into three groups: surgical resection (n=7), chemotherapy (n=5) and no treatment (n=3). RESULTS There was no obvious difference in gender distribution between the subgroups. A tendency towards higher age was seen in the group without treatment, as was a larger tumor size as compared to the chemotherapy group. Patients were administered chemotherapy and the group without treatment seemed to present with the same prevalence of metastatic disease (3/5 and 2/3, respectively). All patients in the group without treatment died after in median 1 month following pathological diagnosis. One patient in the chemotherapy group was alive at 9-month follow up, and the others survived a median of 11 months. In the surgically treated group, 4/7 were alive at follow-up of a median of 154 months. Of the three deceased patients who had survived 44, 53 and 151 months, respectively, two had microscopically non-radical resection. CONCLUSIONS MCAC of the pancreas is, when locally confined and without metastases, associated with fairly good prognosis after surgical resection. In inoperable patients and for metastatic disease, outcome is poor.
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Affiliation(s)
- Josefin Björk Werner
- Departments of Surgery Clinical Sciences Lund, Lund University and Skåne University Hospital Lund (Josefin Björk Werner, Christian Sturesson, Roland Andersson)
| | - Christian Sturesson
- Departments of Surgery Clinical Sciences Lund, Lund University and Skåne University Hospital Lund (Josefin Björk Werner, Christian Sturesson, Roland Andersson)
| | - Sigmund Dawiskiba
- Pathology and Cytology, Clinical Sciences Lund, Lund University and Skåne University Hospital Lund (Sigmund Dawiskiba)
| | - Roland Andersson
- Departments of Surgery Clinical Sciences Lund, Lund University and Skåne University Hospital Lund (Josefin Björk Werner, Christian Sturesson, Roland Andersson)
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Jang JY, Hwang DW, Kim MA, Kang MJ, Lim CS, Lee SE, Kim SW. Analysis of Prognostic Factors and a Proposed New Classification for Invasive Papillary Mucinous Neoplasms. Ann Surg Oncol 2010; 18:644-50. [DOI: 10.1245/s10434-010-1331-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Indexed: 01/08/2023]
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Fernández-del Castillo C, Adsay NV. Intraductal papillary mucinous neoplasms of the pancreas. Gastroenterology 2010; 139:708-13, 713.e1-2. [PMID: 20650278 DOI: 10.1053/j.gastro.2010.07.025] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Carlos Fernández-del Castillo
- Pancreas and Biliary Surgery Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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