1
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Steadman JA, Sultan A, Day CN, Parish MA, Warner SG, Kendrick ML, Truty MJ, Jin Z, Thiels CA. Impact of proton pump inhibitors on pathologic response rates following fluoropyrimidine-based neoadjuvant chemotherapy in pancreatic cancer patients. J Surg Oncol 2024. [PMID: 39257300 DOI: 10.1002/jso.27837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) negatively impact fluoropyrimidine-based chemotherapy efficacy in colorectal cancer. This study assessed PPI impact on major pathologic response (mPR) rates of pancreatic adenocarcinoma (PDAC) patients receiving fluoropyrimidine-based chemotherapy. METHODS An institutional retrospective review of resected PDAC patients receiving neoadjuvant fluoropyrimidine-based chemotherapy (98% FOLFIRINOX) from 2011 to 2021 was conducted. Outcomes were stratified by use or nonuse of PPIs within 6 months of neoadjuvant chemotherapy initiation. Primary outcome was mPR defined as complete or near complete response. RESULTS Among 540 patients included, the median age was 64 (IQR: 60-70) years, 297 (55%) were male, and 202 (37%) were PPI users. 170 (31%) patients had mPR with similar rates among PPI users and nonusers (29% vs. 33%, p = 0.38). No difference in mPR was seen between PPI users and nonusers receiving chemoradiation (35% vs. 36%, p = 0.89) or ≥8 cycles of NAC (33% vs. 36%, p = 0.55). Median OS for PPI users was 30.9 versus 31.7 months for nonusers (p = 0.62). On multivariable analysis, PPI therapy was not associated with decreased survival. CONCLUSION PPI usage did not significantly influence mPR or OS following neoadjuvant fluoropyrimidine-based chemotherapy in resected PDAC patients. Further analysis of all patients, not just those who underwent resection, is required.
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Affiliation(s)
- Jessica A Steadman
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmer Sultan
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Courtney N Day
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Marie A Parish
- Division of Pharmacy Cancer Care, Mayo Clinic, Rochester, Minnesota, USA
| | - Susanne G Warner
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zhaohui Jin
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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2
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Yao Q, Xiong J, Zhou L, Zhao Z. Clinical characteristics and prognosis of patients with primary squamous cell carcinoma of the retromolar trigone: A SEER-based analysis. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101675. [PMID: 37923133 DOI: 10.1016/j.jormas.2023.101675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Primary squamous cell carcinoma of the retromolar trigone (primary SCC RMT) is an uncommon malignant tumor. There is still much to learn about its clinicopathological characteristics and prognosis. In order to better understand the clinicopathological features and predictive survival aspects of primary SCC RMT, this study examined data from the SEER database from 2000 to 2020. Furthermore, in order to forecast the overall survival (OS) and cancer-specific survival (CSS) of patients with primary SCC RMT, we created nomograms. METHOD The Surveillance, Epidemiology and End Results (SEER) database was used to retrieve the information on individuals with primary SCC RMT who received a diagnosis between 2000 and 2020. Both univariate and multivariate analyses were conducted using the Cox proportional risk regression model. Using R software, prognostic nomograms were created to forecast the OS and CSS likelihood. The nomograms' prediction abilities were evaluated using the consistency index (C-index), calibration curve, and receiver operating characteristic (ROC) curve. RESULT A total of 1717 patients with primary SCC RMT were included, they were randomly assigned to the primary and validation cohorts in a 7:3 ratio using R software. Multivariate Cox regression revealed that age, marital status, regional nodes positive, Summary stage, TNM stage, T stage, N stage, surgery were independent prognostic factors of OS, and age, marital status, regional nodes positive, tumor sizes, Summary stage, N stage, surgery were independent prognostic factors of CSS in the primary cohort. The C-index of the nomogram OS was 0.705 (95 % CI: 0.685-0.725) and the C-index of CSS was 0.734 (95 % CI:0.714-0.754) in the primary cohort. In validation cohort, the C-index of the nomogram OS and CSS were 0.730 (95 % CI: 0.710-0.750) and 0.723 (95 % CI: 0.684-0.762), respectively. The 1-, 3-, and 5-year OS and CSS rates in the primary cohort and validation cohort were approximately in line with the nomogram estimations, in accordance to the calibration curves. CONCLUSION We conducted an analysis using the SEER database to investigate the features, survival outcomes, and prognostic parameters of patients with primary SCC RMT. And we developed two prognostic nomograms that can be used by clinicians to forecast the 1-, 3-, and 5-year overall survival and cancer-specific survival of patients with primary SCC RMT.
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Affiliation(s)
- Qing Yao
- Department of Stomatology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Heping District, Shenyang 110004, China; Department of Stomatology, General Hospital of Fushun Mining Bureau, 24 Central Street, Xinfu District, Fushun 113000, China.
| | - Jinhua Xiong
- Department of Radiology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New Area, Shanghai 200120, China
| | - Liguo Zhou
- Department of Stomatology, General Hospital of Fushun Mining Bureau, 24 Central Street, Xinfu District, Fushun 113000, China
| | - Zhiguo Zhao
- Department of Stomatology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Heping District, Shenyang 110004, China.
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3
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Stoop TF, Seelen LWF, van 't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, den Dulk M, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Te Riele W, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2640-2653. [PMID: 38105377 DOI: 10.1245/s10434-023-14650-6] [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: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy. PATIENTS AND METHODS A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion. RESULTS Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS. CONCLUSIONS Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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4
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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5
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Leonhardt CS, Pils D, Qadan M, Jomrich G, Assawasirisin C, Klaiber U, Sahora K, Warshaw AL, Ferrone CR, Schindl M, Lillemoe KD, Strobel O, Fernández-del Castillo C, Hank T. The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment. Ann Surg 2024; 279:314-322. [PMID: 37042245 PMCID: PMC10782940 DOI: 10.1097/sla.0000000000005874] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
OBJECTIVE To investigate the oncological outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) who had an R 0 or R 1 resection based on the revised R status (1 mm) after neoadjuvant therapy (NAT). BACKGROUND The revised R status is an independent prognostic factor in upfront-resected PDAC; however, the significance of 1 mm margin clearance after NAT remains controversial. METHODS Patients undergoing pancreatectomy after NAT for PDAC were identified from 2 prospectively maintained databases. Clinicopathological and survival data were analyzed. The primary outcomes were overall survival (OS), recurrence-free survival (RFS), and pattern of recurrence in association with R 0 >1 mm and R 1 ≤1 mm resections. RESULTS Three hundred fifty-seven patients with PDAC were included after NAT and subsequent pancreatic resection. Two hundred eight patients (58.3%) received FOLFIRINOX, 41 patients (11.5%) received gemcitabine-based regimens, and 299 individuals (83.8%) received additional radiotherapy. R 0 resections were achieved in 272 patients (76.2%) and 85 patients (23.8%) had R 1 resections. Median OS after R 0 was 41.0 months, compared with 20.6 months after R 1 resection ( P = 0.002), and even longer after additional adjuvant chemotherapy ( R 0 44.8 vs R1 20.1 months; P = 0.0032). Median RFS in the R 0 subgroup was 17.5 months versus 9.4 months in the R 1 subgroup ( P < 0.0001). R status was confirmed as an independent predictor for OS ( R 1 hazard ratio: 1.56, 95% CI: 1.07-2.26) and RFS ( R 1 hazard ratio: 1.52; 95% CI: 1.14-2.0). In addition, R 1 resections were significantly associated with local but not distant recurrence ( P < 0.0005). CONCLUSIONS The revised R status is an independent predictor of postresection survival and local recurrence in PDAC after NAT. Achieving R 0 resection with a margin of at least 1 mm should be a primary goal in the surgical treatment of PDAC after NAT.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Pils
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gerd Jomrich
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Charnwit Assawasirisin
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ulla Klaiber
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Martin Schindl
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oliver Strobel
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Hank
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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6
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Leonhardt CS, Hank T, Pils D, Gustorff C, Sahora K, Schindl M, Verbeke CS, Strobel O, Klaiber U. Prognostic impact of resection margin status on survival after neoadjuvant treatment for pancreatic cancer: systematic review and meta-analysis. Int J Surg 2024; 110:453-463. [PMID: 38315795 PMCID: PMC10793837 DOI: 10.1097/js9.0000000000000792] [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: 07/04/2023] [Accepted: 09/10/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND A greater than 1 mm tumour-free resection margin (R0 >1 mm) is a prognostic factor in upfront-resected pancreatic ductal adenocarcinoma. After neoadjuvant treatment (NAT); however, the prognostic impact of resection margin (R) status remains controversial. METHODS Randomised and non-randomised studies assessing the association of R status and survival in resected pancreatic ductal adenocarcinoma after NAT were sought by systematic searches of MEDLINE, Web of Science and CENTRAL. Hazard ratios (HR) and their corresponding 95% CI were collected to generate log HR using the inverse-variance method. Random-effects meta-analyses were performed and the results presented as weighted HR. Sensitivity and meta-regression analyses were conducted to account for different surgical procedures and varying length of follow-up, respectively. RESULTS Twenty-two studies with a total of 4929 patients were included. Based on univariable data, R0 greater than 1 mm was significantly associated with prolonged overall survival (OS) (HR 1.76, 95% CI 1.57-1.97; P<0.00001) and disease-free survival (DFS) (HR 1.66, 95% CI 1.39-1.97; P<0.00001). Using adjusted data, R0 greater than 1 mm was significantly associated with prolonged OS (HR 1.65, 95% CI 1.39-1.97; P<0.00001) and DFS (HR 1.76, 95% CI 1.30-2.39; P=0.0003). Results for R1 direct were comparable in the entire cohort; however, no prognostic impact was detected in sensitivity analysis including only partial pancreatoduodenectomies. CONCLUSION After NAT, a tumour-free margin greater than 1 mm is independently associated with improved OS as well as DFS in patients undergoing surgical resection for pancreatic cancer.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Hank
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Pils
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Charlotte Gustorff
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Caroline S. Verbeke
- Department of Pathology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Oliver Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulla Klaiber
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
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7
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Vitello D, Talamonti MS. Modern Treatment Strategies for Borderline Resectable Pancreatic Cancer. Cancer Treat Res 2024; 192:67-88. [PMID: 39212916 DOI: 10.1007/978-3-031-61238-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) continues to be a daunting clinical challenge. In 2023, it is estimated that 64,000 people will be newly diagnosed with PDAC and 51,000 people will die from PDAC. By 2030, PDAC is predicted to be the second leading cause of cancer-related death, second only to lung cancer (Siegel et al in, CA Cancer J Clin 73(1):17-48, 2023). It is a disease characterized by its late presentation, rapid demise thereafter, and, until recently, relatively ineffective systemic therapies. Despite this grim prognosis, appreciable progress has been made in the identification of patients with localized disease, who may be candidates for potentially curative resections, and in the understanding of the technical nuances and efficacy of aggressive surgical procedures. Currently, the overall 5-year survival rate is 15-25% for patients who undergo resection and receive adjuvant chemotherapy with or without chemoradiation therapy.
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Affiliation(s)
- Dominic Vitello
- Feinberg School of Medicine, Department of Surgery, Northwestern University, Evanston, IL, USA
| | - Mark S Talamonti
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA.
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8
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van Oosten AF, Daamen LA, Groot VP, Biesma NC, Habib JR, van Goor IWJM, Kinny-Köster B, Burkhart RA, Wolfgang CL, van Santvoort HC, He J, Molenaar IQ. Predicting post-recurrence survival for patients with pancreatic cancer recurrence after primary resection: A Bi-institutional validated risk classification. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106910. [PMID: 37173152 DOI: 10.1016/j.ejso.2023.04.009] [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: 09/12/2022] [Revised: 03/07/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Over 80% of patients will develop disease recurrence after radical resection of pancreatic ductal adenocarcinoma (PDAC). This study aims to develop and validate a clinical risk score predicting post-recurrence survival (PRS) at time of recurrence. METHODS All patients who had recurrence after undergoing pancreatectomy for PDAC at the Johns Hopkins Hospital or at the Regional Academic Cancer Center Utrecht during the study period were included. Cox proportional hazard model was used to develop the risk model. Performance of the final model was assessed in a test set after internal validation. RESULTS Of 718 resected PDAC patients, 72% had recurrence after a median follow-up of 32 months. The median overall survival was 21 months and the median PRS was 9 months. Prognostic factors associated with shorter PRS were age (hazard ratio [HR] 1.02; 95% confidence interval [95%CI] 1.00-1.04), multiple-site recurrence (HR 1.57; 95%CI 1.08-2.28), and symptoms at time of recurrence (HR 2.33; 95%CI 1.59-3.41). Recurrence-free survival longer than 12 months (HR 0.55; 95%CI 0.36-0.83), FOLFIRINOX and gemcitabine-based adjuvant chemotherapy (HR 0.45; 95%CI 0.25-0.81; HR 0.58; 95%CI 0.26-0.93, respectively) were associated with a longer PRS. The resulting risk score had a good predictive accuracy (C-index: 0.73). CONCLUSION This study developed a clinical risk score based on an international cohort that predicts PRS in patients who underwent surgical resection for PDAC. This risk score will become available on www.evidencio.com and can help clinicians with patient counseling on prognosis.
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Affiliation(s)
- A Floortje van Oosten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Division of Imaging and Oncology, University Medical Center Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent P Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Nanske C Biesma
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Joseph R Habib
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iris W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Benedict Kinny-Köster
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, New York University Langone Medical Center, New York City, NY, USA
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Langone Medical Center, New York City, NY, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands.
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9
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Palm RF, Boyer E, Kim DW, Denbo J, Hodul PJ, Malafa M, Fleming JB, Shridhar R, Chuong MD, Mellon EA, Frakes JM, Hoffe SE. Neoadjuvant chemotherapy and stereotactic body radiation therapy for borderline resectable pancreas adenocarcinoma: influence of vascular margin status and type of chemotherapy. HPB (Oxford) 2023; 25:1110-1120. [PMID: 37286392 DOI: 10.1016/j.hpb.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/29/2023] [Accepted: 04/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND The influence of chemotherapy type and vascular margin status after sequential chemotherapy and stereotactic body radiation therapy (SBRT) for borderline resectable pancreatic cancer (BRPC) is unknown. METHODS A retrospective review was performed on BRPC patients treated with chemotherapy and 5-fraction SBRT from 2009 to 2021. Surgical outcomes and SBRT-related toxicity were reported. Clinical outcomes were estimated by Kaplan-Meier with log rank comparisons. RESULTS A total of 303 patients received neoadjuvant chemotherapy and SBRT to a median dose of 40 Gy prescribed to the tumor-vessel interface and median dose of 32.4 Gyto 95% of the gross tumor volume. One hundred and sixty-nine patients (56%) were resected and benefited from improved median OS (41.1 vs 15.5 months, P < 0.001). Close/positive vascular margins were not associated with worse OS or FFLRF. Type of neoadjuvant chemotherapy did not influence OS for resected patients, but FOLFIRINOX was associated with improved median OS in unresected patients (18.2 vs 13.1 months, P = 0.001). CONCLUSION For BRPC, the effect of a positive or close vascular margin may be mitigated by neoadjuvant therapy. Shorter duration neoadjuvant chemotherapy as well as the optimal biological effective dose of radiotherapy should be prospectively explored.
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Affiliation(s)
- Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA.
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Dae W Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason Denbo
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Jason B Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Advent Health, Orlando, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami FL, USA
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa FL, USA
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10
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Qin Z, Hu Z, Lai M, Wang F, Liu X, Yin L. A nomogram for predicting survival in Patients with oral tongue keratinized squamous cell carcinoma: A SEER-based study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101422. [PMID: 36781109 DOI: 10.1016/j.jormas.2023.101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVE Oral tongue keratinized squamous cell carcinoma (OTKSCC), a relatively rare form of tongue cancer (TC) in clinical practice, accompanied by features of cell keratosis, is an uncommon histological subtype. However, its specific clinicopathological features and prognosis have not been adequately described. In this study, we aimed to create a nomogram using R language software to predict overall survival (OS) of patients with OTKSCC to assess the prognosis of OTKSCC patients. METHODS We extracted clinical and related prognostic data of OTKSCC patients from 1975 to 2019 from the Surveillance, Epidemiology, and End Results database. Independent prognostic factors were selected using univariate and multivariate Cox analyses, and a nomogram was constructed using R software. The C-index, area under the curve (AUC) of receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA) were used to assess the clinical utility of the nomogram. Finally, OS was assessed using the Kaplan-Meier method. RESULTS A total of 2450 OTKSCC patients were included in the study. Univariate and multivariate Cox regression analyses were used to identify age, T stage, N stage, surgery, and radiation therapy as independent risk factors (p<0.05). In the training cohort, the calibration index of the nomogram was 0.725, while the AUC values for nomogram, age, T stage, N stage, surgery and radiation therapy were 0.878, 0.639, 0.781, 0.661, 0.724 and 0.354, respectively. At the same time, in the verification queue, the calibration index of the nomogram was 0.726, while the AUC values for nomogram, age, T stage, N stage, surgery and radiation therapy were 0.859,0.612,0.826,0.675,0.758 and 0.303, respectively. Ideal uniformity of the models from the training and validation cohorts was demonstrated in the calibration and DCA curves. Univariate survival analysis showed that age, T stage, N stage, surgery, and radiotherapy were statistically significant for prognosis (p<0.05). CONCLUSION Age, T stage, N stage, surgery, and radiation therapy are independently associated with the OS, and the established nomogram is an effective visualization tool for predicting the OS of OTKSCC patients.
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Affiliation(s)
- Zishun Qin
- The First Clinical Medical College, Lanzhou University, Lanzhou,730000, China; School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China.
| | - Zonghao Hu
- School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China.
| | - Minqin Lai
- School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China.
| | - Feng Wang
- School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China
| | - Xiaoyuan Liu
- School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China
| | - Lihua Yin
- The First Clinical Medical College, Lanzhou University, Lanzhou,730000, China; School/Hospital of Stomatology, Lanzhou university, Lanzhou,730000, China.
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11
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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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12
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Cha DE, Yu AT, Khajoueinejad N, Gleeson E, Shaltiel T, Berger Y, Macfie R, Golas BJ, Sarpel U, Labow DM, Hiotis S, Cohen NA. Perineural Invasion of Pancreatic Ductal Adenocarcinoma is Associated with Early Recurrence after Neoadjuvant Therapy Followed by Resection. World J Surg 2023; 47:1801-1808. [PMID: 37014430 DOI: 10.1007/s00268-023-06983-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is increasingly utilized in the treatment of pancreatic ductal adenocarcinoma (PDAC). However, there are limited data on risk factors and patterns of recurrence after surgical resection. This study aimed to analyze timing and recurrence patterns of PDAC after NAT followed by curative resection. METHODS The medical charts of patients with PDAC treated with NAT followed by curative-intent surgical resection at a single health system from January 1, 2012 to January 1, 2020 were retrospectively reviewed. Early recurrence was defined as recurrence within 12 months of surgical resection. RESULTS 91 patients were included and median follow up was 20.1 months. Recurrence occurred in 50 (55%) patients, with median recurrence free survival (RFS) of 11.9 months. Overall, 18 (36%) patients had local and 32 (64%) had distant recurrences. Median RFS and overall survival (OS) between local and distant recurrence were similar. Perineural invasion (PNI) and the presence of a T2 + tumor was significantly higher in recurrence group than in no recurrence group. PNI was a significant risk factor for early recurrence. CONCLUSION After NAT and surgical resection of PDAC, disease recurrence was common, with distant metastasis being the most common. PNI was significantly higher in the recurrence group.
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Affiliation(s)
- Da Eun Cha
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Allen T Yu
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Nazanin Khajoueinejad
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Tali Shaltiel
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Yael Berger
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Rebekah Macfie
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Benjamin J Golas
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Umut Sarpel
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Daniel M Labow
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Spiros Hiotis
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA
| | - Noah A Cohen
- Division of Surgical Oncology Mount Sinai Hospital, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, New York, NY, 10029, USA.
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13
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Chalfant H, Bonds M, Scott K, Condacse A, Dennahy IS, Martin WT, Little C, Edil BH, McNally LR, Jain A. Innovative Imaging Techniques Used to Evaluate Borderline-Resectable Pancreatic Adenocarcinoma. J Surg Res 2023; 284:42-53. [PMID: 36535118 PMCID: PMC10131671 DOI: 10.1016/j.jss.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/23/2022]
Abstract
A diagnosis of pancreatic cancer carries a 5-y survival rate of less than 10%. Furthermore, the detection of pancreatic cancer occurs most often in later stages of the disease due to its location in the retroperitoneum and lack of symptoms (in most cases) until tumors become more advanced. Once diagnosed, cross-sectional imaging techniques are heavily utilized to determine the tumor stage and the potential for surgical resection. However, a major determinant of resectability is the extent of local vascular involvement of the mesenteric vessels and critical tributaries; current imaging techniques have limited capacity to accurately determine vascular involvement. Surrounding inflammation and fibrosis can be difficult to discriminate from viable tumor, making determination of the degree of vascular involvement unreliable. New innovations in fluorescence and optoacoustic imaging techniques may overcome these limitations and make determination of resectability more accurate. These imaging modalities are able to more clearly discern between viable tumor tissue and non-neoplastic inflammation or desmoplasia, allowing clinicians to more reliably characterize vascular involvement and develop individualized treatment plans for patients. This review will discuss the current imaging techniques used to diagnose pancreatic cancer, the barriers that current techniques raise to accurate staging, and novel fluorescence and optoacoustic imaging techniques that may provide more accurate clinical staging of pancreatic cancer.
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Affiliation(s)
- Hunter Chalfant
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Morgan Bonds
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Kristina Scott
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Anna Condacse
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Isabel S Dennahy
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - W Taylor Martin
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Cooper Little
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Barish H Edil
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Lacey R McNally
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
| | - Ajay Jain
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
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14
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Martin RCG, Schoen EC, Philips P, Egger ME, McMasters KM, Scoggins CR. Impact of margin accentuation with intraoperative irreversible electroporation on local recurrence in resected pancreatic cancer. Surgery 2023; 173:581-589. [PMID: 36216618 PMCID: PMC9918678 DOI: 10.1016/j.surg.2022.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the rates of local recurrence and margin positivity in patients with borderline resectable pancreatic cancer after pancreatectomy with or without irreversible electroporation with margin accentuation. METHODS Prospective data for preoperative stages IIB (borderline resectable) and III were evaluated, with 75 patients undergoing pancreatectomy with irreversible electroporation with margin accentuation compared to 71 patients who underwent pancreatectomy alone from March 2010 to November 2020. RESULTS Both irreversible electroporation with margin accentuation and pancreatectomy-alone groups were similar for body mass index, Charleston comorbidity index, and sex. The irreversible electroporation with margin accentuation group had significantly greater preoperative stage III (irreversible electroporation 83% vs pancreatectomy alone 51%; P = .0001), with similar tumor location (head 64% vs 72%) and tumor size (median 2.9 vs 2.8). Neoadjuvant/induction chemotherapy and prior radiation therapy was similar in both groups (irreversible electroporation with margin accentuation 89% vs 72%). Surgical therapy included a greater percentage of pancreaticoduodenectomy in the pancreatectomy-alone group. Despite greater stage and greater percentage of margin positivity (irreversible electroporation with margin accentuation 27% vs 20%; P = not significant), rates of local recurrence were similar. The mean disease-free interval for local recurrence from time of diagnosis was similar (irreversible electroporation with margin accentuation 15.8 vs 16.5 pancreatectomy alone; P = not significant) and time of treatment (irreversible electroporation with margin accentuation 9.4 vs 10.5 months; P = not significant). Overall survival was improved with the irreversible electroporation with margin accentuation group, with a mean of 34.2 months versus 27.9 months in the pancreatectomy-alone group. CONCLUSION Irreversible electroporation with margin accentuation is safe and effective in stages IIB and III pancreatic adenocarcinomas that are technically resectable. Despite higher margin positivity rates, the time to local recurrence and the effects of recurrence were the same in the pancreatectomy-alone group.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY.
| | - Eric C Schoen
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Prejesh Philips
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Michael E Egger
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Kelly M McMasters
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Charles R Scoggins
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, KY
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15
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Yin ZJ, Huang YJ, Chen QL. Risk factor analysis and a new prediction model of venous thromboembolism after pancreaticoduodenectomy. BMC Surg 2023; 23:25. [PMID: 36709302 PMCID: PMC9883972 DOI: 10.1186/s12893-023-01916-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/16/2023] [Indexed: 01/30/2023] Open
Abstract
AIM The present study aimed to identify risk factors for venous thromboembolism (VTE) after pancreaticoduodenectomy (PD) and to develop and internally validate a predictive model for the risk of venous thrombosis. METHODS We retrospectively collected data from 352 patients who visited our hospital to undergo PD from January 2018 to March 2022. The number of patients recruited was divided in an 8:2 ratio by using the random split method, with 80% of the patients serving as the training set and 20% as the validation set. The least absolute shrinkage and selection operator (Lasso) regression model was used to optimize feature selection for the VTE risk model. Multivariate logistic regression analysis was used to construct a prediction model by incorporating the features selected in the Lasso model. C-index, receiver operating characteristic curve, calibration plot, and decision curve were used to assess the accuracy of the model, to calibrate the model, and to determine the clinical usefulness of the model. Finally, we evaluated the prediction model for internal validation. RESULTS The predictors included in the prediction nomogram were sex, age, gastrointestinal symptoms, hypertension, diabetes, operative method, intraoperative bleeding, blood transfusion, neutrophil count, prothrombin time (PT), activated partial thromboplastin time (APTT), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio (AST/ALT), and total bilirubin (TBIL). The model showed good discrimination with a C-index of 0.827, had good consistency based on the calibration curve, and had an area under the ROC curve value of 0.822 (P < 0.001, 95%confidence interval:0.761-0.882). A high C-index value of 0.894 was reached in internal validation. Decision curve analysis showed that the VTE nomogram was clinically useful when intervention was decided at the VTE possibility threshold of 10%. CONCLUSION The novel model developed in this study is highly targeted and enables personalized assessment of VTE occurrence in patients who undergo PD. The predictors are easily accessible and facilitate the assessment of patients by clinical practitioners.
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Affiliation(s)
- Zhi-Jie Yin
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
| | - Ying-Jie Huang
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
| | - Qi-Long Chen
- grid.412631.3Digestive and Vascular Center, Department of Pancreatic Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054 People’s Republic of China
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16
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Kent TS. Scoring System to Predict Survival After Resection of Locally Advanced Pancreas Cancer: What is Achieved? Ann Surg Oncol 2023; 30:2576-2577. [PMID: 36662329 DOI: 10.1245/s10434-022-13088-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023]
Affiliation(s)
- Tara S Kent
- BIDMC Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St, LMOB 9B, Boston, MA, 02215, USA.
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17
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Evaluation of local recurrence after pancreaticoduodenectomy for borderline resectable pancreatic head cancer with neoadjuvant chemotherapy: Can the resection level change after chemotherapy? Surgery 2022; 173:1220-1228. [PMID: 36424197 DOI: 10.1016/j.surg.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/12/2022] [Accepted: 10/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Neoadjuvant treatment has significant survival benefits for patients with pancreatic cancer. However, local recurrence remains a serious issue, even after neoadjuvant treatment. This study investigated local recurrence after pancreaticoduodenectomy and determined the optimal resection level after neoadjuvant treatment. METHODS This retrospective study analyzed consecutive patients who underwent pancreaticoduodenectomy for borderline resectable pancreatic cancer after 4 cycles of neoadjuvant treatment-gemcitabine plus nab-paclitaxel between April 2015 and March 2020. Patients with borderline resectable-artery pancreatic cancer were classified according to the dissection level around the artery: level 3 group, hemi-, or whole circumferential arterial nerve plexus was dissected; and level 2 group, the nerve plexus was preserved. RESULTS Fifty-six patients with borderline resectable-artery pancreatic cancer underwent pancreaticoduodenectomy after neoadjuvant treatment (level 3 group, n = 40; level 2 group, n = 16). The resection level in the level 2 group was changed based on post-neoadjuvant treatment computed tomography images or intraoperative frozen section diagnosis. The overall and local recurrence rates were significantly higher in the level 2 group than in the level 3 group (overall recurrence, 93.8% vs 70.0%; P = .037) (local recurrence, 50.0% vs 5.0%; P < .001). Ten patients experienced local recurrence, of which 8 belonged to the level 2 group. Among them, 4 patients were confirmed as cancer-negative by surgical margin analysis or intraoperative frozen section diagnosis but experienced recurrence around the arteries. CONCLUSION For treating borderline resectable-artery pancreatic cancer, changing the resection level based on post-neoadjuvant treatment computed tomography images increased the risk of local recurrence. All patients with borderline resectable-artery should undergo level 3 dissection, regardless of the response to neoadjuvant treatment.
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18
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Li B, Guo S, Yin X, Ni C, Gao S, Li G, Ni C, Jiang H, Lau WY, Jin G. Risk factors of positive resection margin differ in pancreaticoduodenectomy and distal pancreatosplenectomy for pancreatic ductal adenocarcinoma undergoing upfront surgery. Asian J Surg 2022; 46:1541-1549. [PMID: 36376184 DOI: 10.1016/j.asjsur.2022.09.156] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/13/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Positive resection margin indicates worse prognosis. The present study identified the independent risk factors of R1 resection in pancreaticoduodenectomy (PD) and distal pancreatosplenectomy (DP) for patients with pancreatic ductal adenocarcinoma (PDAC). METHOD Consecutive patients who were operated from 1st December 2017 to 30th December 2018 were analyzed retrospectively. A standardized pathological examination with digital whole-mount slide images (DWMSIs) was utilized for evaluation of resection margin status. R1 was defined as microscopic tumor infiltration within 1 mm to the resection margin. The potential risk factors of R1 resection for PD and DP were analyzed separately by univariate and multivariate logistic regression analyses. RESULTS For the 192 patients who underwent PD, and the 87 patients who underwent DP, the R1 resection rates were 31.8% and 35.6%, respectively. Univariate analysis on risk factors of R1 resection for PD were tumor location, lymphovascular invasion, N staging, and TNM staging; while those for DP were T staging and TNM staging. Multivariate logistic regression analysis showed the location of tumor in the neck and uncinate process, and N1/2 staging were independent risk factors of R1 resection for PD; while those for DP were T3 staging. CONCLUSIONS The clarification of the risk factors of R1 resection might clearly make surgeons take reasonable decisions on surgical strategies for different surgical procedures in patients with PDAC, so as to obtain the first attempt of R0 resection.
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Andersson R, Haglund C, Seppänen H, Ansari D. Pancreatic cancer - the past, the present, and the future. Scand J Gastroenterol 2022; 57:1169-1177. [PMID: 35477331 DOI: 10.1080/00365521.2022.2067786] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic cancer has been and still is associated with a very poor prognosis. This is due to a lack of major breakthroughs with respect to early diagnosis, prognostication, prediction, as well as novel, targeted therapies. The benefits of surgery and chemotherapy are evident, but the fact that only some 10% of all patients have early, localized disease highlights the unmet need for new early detection methods. An improved understanding of tumor biology and the development of molecular markers detectable both in the circulation and in cancer tissues may underlie the development of new tools for optimizing both diagnosis and treatment. MATERIAL AND METHODS Review of the literature. RESULTS AND CONCLUSION If we do not improve precision oncology for pancreatic ductal adenocarcinoma, the prognosis will still remain dismal and the" burden" on society will increase substantially.
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Affiliation(s)
- Roland Andersson
- Surgery, Department of Clinical Sciences Lund Lund University, Skåne University Hospital, Lund, Sweden
| | - Caj Haglund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Seppänen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Ansari
- Surgery, Department of Clinical Sciences Lund Lund University, Skåne University Hospital, Lund, Sweden
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20
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Pu N, Yin H, Chen Q, Wu W, Lou W. Commentary on "Nationwide Validation of the 8th American Joint Committee on Cancer TNM Staging System and Five Proposed Modifications for Resected Pancreatic Cancer". Ann Surg Oncol 2022; 29:7077-7078. [PMID: 35798891 DOI: 10.1245/s10434-022-12148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Ning Pu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hanlin Yin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiangda Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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21
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Holm MB, Verbeke CS. Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma. Curr Oncol 2022; 29:6551-6563. [PMID: 36135084 PMCID: PMC9498008 DOI: 10.3390/curroncol29090515] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.
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Affiliation(s)
- Maia Blomhoff Holm
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
| | - Caroline Sophie Verbeke
- Department of Pathology, Faculty of Medicine, University of Oslo, 0372 Oslo, Norway
- Department of Pathology, Oslo University Hospital, 0424 Oslo, Norway
- Correspondence: ; Tel.: +47-405-578-36
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22
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Kelly KN, Macedo FI, Seaton M, Wilson G, Hammill C, Martin RC, Maduekwe UN, Kim HJ, Maithel SK, Abbott DE, Ahmad SA, Kooby DA, Merchant NB, Datta J. Intraoperative Pancreatic Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in the Era of Neoadjuvant Therapy: A Multi-institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2022; 29:6004-6012. [PMID: 35511392 DOI: 10.1245/s10434-022-11804-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 04/07/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Data regarding the survival impact of converting frozen-section (FS):R1 pancreatic neck margins to permanent section (PS):R0 by additional resection (i.e., converted-R0) during upfront pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) are conflicting. The impact of neoadjuvant therapy on this practice and its relationship with overall survival (OS) is incompletely understood. METHODS We reviewed PDAC patients (80% borderline resectable/locally advanced [BR/LA]) undergoing pancreaticoduodenectomy after neoadjuvant therapy at seven, academic, high-volume centers (2010-2018). Multivariable models examined the association of PS:R0, PS:R1, and converted-R0 margins with OS. RESULTS Of 272 patients receiving at least 2 (median 4) cycles of neoadjuvant chemotherapy (71% mFOLFIRINOX or gemcitabine/nab-paclitaxel) and undergoing pancreaticoduodenectomy with intraoperative frozen-section assessment of the transected pancreatic neck margin, PS:R0 (n = 220, 80.9%) was observed in a majority of patients; 18 patients (6.6%) had converted-R0 margins following additional resection, whereas 34 patients (12.5%) had persistently positive PS:R1 margins. At a median follow-up of 42 months, PS:R0 resection was associated with improved OS compared with either converted-R0 or PS:R1 resection (median 25 vs. 14 vs. 16 months, respectively; p = 0.023), with no survival difference between the converted-R0 and PS:R1 groups (p = 0.9). On Cox regression, SMA margin positivity (hazard ratio 2.2, p = 0.012), but not neck margin positivity (hazard ratio 1.2, p = 0.65), was associated with worse OS. CONCLUSIONS In this multi-institutional cohort of predominantly BR/LA PDAC patients undergoing pancreaticoduodenectomy following modern neoadjuvant therapy, pursuing a negative neck margin intraoperatively if the initial margin is positive does not appear to be associated with improved survival.
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Affiliation(s)
- Kristin N Kelly
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Surgery, Upstate Medical University, Syracuse, NY, USA
| | - Francisco I Macedo
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Surgery, University of Central Florida, Gainesville, FL, USA
| | - Max Seaton
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Gregory Wilson
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Chet Hammill
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert C Martin
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ugwuji N Maduekwe
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Hong J Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA.
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Schouten TJ, Daamen LA, van Santvoort HC, Molenaar IQ. Response to: Commentary on: "Nationwide Validation of the 8th American Joint Committee on Cancer TNM Staging System and Five Proposed Modifications for Resected Pancreatic Cancer". Ann Surg Oncol 2022; 29:7079-7080. [PMID: 35927598 DOI: 10.1245/s10434-022-12168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 11/18/2022]
Affiliation(s)
- T J Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.,Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
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Vuorela T, Vikatmaa P, Kokkola A, Mustonen H, Salmiheimo A, Eurola A, Aho P, Haglund C, Kantonen I, Seppänen H. Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques. Eur J Vasc Endovasc Surg 2022; 64:244-253. [PMID: 35462018 DOI: 10.1016/j.ejvs.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Roughly 10% - 20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction. METHODS This was a retrospective cohort study. A total of 1 375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumour infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end to end anastomosis, or a spiral graft from the great saphenous vein was performed. Next, 90 day and long term survival and outcomes across reconstruction techniques were analysed. RESULTS Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end to end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuro-endocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in hospital and one on post-operative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a Clavien-Dindo grade 5 complication. In addition, 50 (23%) patients had Clavien-Dindo grade 3 - 4 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected. CONCLUSION The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections.
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Affiliation(s)
- Tiina Vuorela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland.
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Arto Kokkola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Harri Mustonen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Aino Salmiheimo
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Annika Eurola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Pekka Aho
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Caj Haglund
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Ilkka Kantonen
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Hanna Seppänen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
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Shi H, Chen Z, Dong S, He R, Du Y, Qin Z, Zhou W. A nomogram for predicting survival in patients with advanced (stage III/IV) pancreatic body tail cancer: a SEER-based study. BMC Gastroenterol 2022; 22:279. [PMID: 35658912 PMCID: PMC9164315 DOI: 10.1186/s12876-022-02362-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Pancreatic body tail carcinoma (PBTC) is a relatively few pancreatic cancer in clinical practice, and its specific clinicopathological features and prognosis have not been fully described. In this study, we aimed to create a nomogram to predict the overall survival (OS) of patients with advanced PBTC. METHODS We extracted clinical and related prognostic data of advanced PBTC patients from 2000 to 2018 from the Surveillance, Epidemiology, and End Results database. Independent prognostic factors were selected using univariate and multivariate Cox analyses, and a nomogram was constructed using R software. The C-index, area under the curve (AUC) of receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA) were used to assess the clinical utility of the nomogram. Finally, OS was assessed using the Kaplan-Meier method. RESULTS A total of 1256 patients with advanced PBTC were eventually included in this study. Age, grade, N stage, M stage, surgery, and chemotherapy were identified as independent risk factors using univariate and multivariate Cox regression analyses (p < 0.05). In the training cohort, the calibration index of the nomogram was 0.709, while the AUC values of the nomogram, age, grade, N stage, M stage, surgery, and chemotherapy were 0.777, 0.562, 0.621, 0.5, 0.576, 0.632, and 0.323, respectively. Meanwhile, in the validation cohort, the AUC values of the nomogram, age, grade, N stage, M stage, surgery, and chemotherapy were 0.772, 0.551, 0.629, 0.534, 0.577, 0.606, and 0.639, respectively. Good agreement of the model in the training and validation cohorts was demonstrated in the calibration and DCA curves. Univariate survival analysis showed a statistically significant effect of age, grade, M stage, and surgery on prognosis (p < 0.05). CONCLUSION Age, grade, M stage, and surgery were independently associated with OS, and the established nomogram was a visual tool to effectively predict OS in advanced PBTC patients.
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Affiliation(s)
- Huaqing Shi
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Zhou Chen
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Shi Dong
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Ru He
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yan Du
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Zishun Qin
- School of Stomatology, Lanzhou University, Lanzhou, China
| | - Wence Zhou
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, 730000, China.
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Eurola A, Mustonen H, Mattila N, Lassila R, Haglund C, Seppänen H. Preoperative oncologic therapy and the prolonged risk of venous thromboembolism in resectable pancreatic cancer. Cancer Med 2022; 11:1605-1616. [PMID: 35148464 PMCID: PMC8986147 DOI: 10.1002/cam4.4397] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/24/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Pancreatic cancer is one of the most prothrombotic cancers. Among patients receiving preoperative chemotherapy followed by surgery, chemotherapy and surgery represent a compound risk for venous thromboembolism (VTE), rendering the postoperative time a period of interest. We aimed to analyze whether preoperative oncologic therapy increases the risk for VTE after surgery and identify which characteristics associate with VTE. METHODS We first identified patients surgically treated for pancreatic cancer at Helsinki University Hospital between 2000 and 2017, collecting the following data: gender, age at surgery, preoperative medication, body mass index (BMI), preoperative chemo(radio)therapy, tumor size, positive node ratio, perineural and perivascular invasion, tumor grade, surgical technique, postoperative anticoagulation, adjuvant therapy, time of VTE, time of local disease recurrence, time of distant metastasis, and time of death. With a follow-up period of at least 2 years or until death, we compared a total of 93 preoperative oncologic therapy and 291 upfront surgery patients (n = 384, median age 66.5 years). RESULTS Preoperative oncologic therapy increased the risk for thrombosis after surgery (hazard ratio [HR] 1.61; 95% confidence interval [CI] 1.03-2.53). The VTE incidence rate remained high for up to 2 years after surgery. BMI ≥30 kg/m2 , prior anticoagulation, and disease recurrence (p < 0.05, respectively) associated with VTE. VTE is also associated with shorter overall survival (HR 3.25; 95% CI 2.36-4.44). In 71.6% (95% CI 60.5-81.1) of patients, VTE was diagnosed after disease recurrence. CONCLUSIONS Preoperative oncologic therapy represents an independent risk factor for VTE, not only during the immediate postoperative period but up to 2 years after surgery. VTE is associated with obesity, prior anticoagulation, and disease recurrence and diminishes overall survival.
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Affiliation(s)
- Annika Eurola
- Department of SurgeryTranslational Cancer Medicine Research ProgramFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Harri Mustonen
- Department of SurgeryTranslational Cancer Medicine Research ProgramFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Nora Mattila
- Department of SurgeryTranslational Cancer Medicine Research ProgramFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Riitta Lassila
- Department of Coagulation DisordersFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
- HUSLAB Laboratory ServicesClinical ChemistryHelsinkiFinland
| | - Caj Haglund
- Department of SurgeryTranslational Cancer Medicine Research ProgramFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Hanna Seppänen
- Department of SurgeryTranslational Cancer Medicine Research ProgramFaculty of MedicineUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Alva-Ruiz R, Yohanathan L, Yonkus JA, Abdelrahman AM, Gregory LA, Halfdanarson TR, Mahipal A, McWilliams RR, Ma WW, Hallemeier CL, Graham RP, Grotz TE, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. Neoadjuvant Chemotherapy Switch in Borderline Resectable/Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2022; 29:1579-1591. [PMID: 34724125 PMCID: PMC8810469 DOI: 10.1245/s10434-021-10991-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/06/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is an integral part of preoperative treatment for patients with borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). The identification of a chemotherapeutic regimen that is both effective and tolerable is critical for NAC to be of oncologic benefit. After initial first-line (FL) NAC, some patients have lack of response or therapeutic toxicities precluding further treatment with the same regimen; optimal decision making regarding this patient population is unclear. Chemotherapy switch (CS) may allow for a larger proportion of patients to undergo curative-intent resection after NAC. METHODS We reviewed our surgical database for patients undergoing combinatorial NAC for BR/LA PDAC. Variant histologic exocrine carcinomas, intraductal papillary mucinous neoplasm-associated PDAC, and patients without research consent were excluded. RESULTS Overall, 468 patients with BR/LA PDAC receiving FL chemotherapy were reviewed, of whom 70% (329/468) continued with FL chemotherapy followed by surgical resection. The remaining 30% (139/468) underwent CS, with 72% (100/139) of CS patients going on to curative-intent surgical resection. Recurrence-free survival (RFS) and overall survival (OS) were not significantly different between the resected FL and CS cohorts (30.0 vs. 19.1 months, p = 0.13, and 41.4 vs. 36.4 months, p = 0.94, respectively) and OS was significantly worse in those undergoing CS without subsequent resection (19 months, p < 0.0001). On multivariable analysis, carbohydrate antigen (CA) 19-9 and pathologic treatment responses were predictors of RFS and OS. CONCLUSION CS in patients undergoing NAC for BR/LA pancreatic cancer does not incur oncologic detriment. The incorporation of CS into NAC treatment sequencing may allow a greater proportion of patients to proceed to curative-intent surgery.
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Affiliation(s)
- Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lavanya Yohanathan
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amro M Abdelrahman
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey A Gregory
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Wen Wee Ma
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.
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29
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Shah MM, Datta J, Merchant NB, Kooby DA. Landmark Series: Importance of Pancreatic Resection Margins. Ann Surg Oncol 2022; 29:1542-1550. [PMID: 34985731 DOI: 10.1245/s10434-021-11168-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/26/2021] [Indexed: 12/24/2022]
Abstract
An important goal of cancer surgery is to achieve negative surgical margins and remove all disease completely. For pancreatic neoplasms, microscopic margins may remain positive despite gross removal of the palpable mass, and surgeons must then consider extending resection, even to the point of completion pancreatectomy, an option that renders the patient with significant adverse effects related to exocrine and endocrine insufficiency. Counterintuitively, extending resection to ensure clear margins may not improve patient outcome. Furthermore, the goal of improving survival by extending the resection may not be achieved, as an initial positive margin may indicate more aggressive underlying tumor biology. There is a growing body of literature on this topic, and this landmark series review will examine the key publications that guide our management for resection of pancreatic ductal adenocarcinoma, intraductal papillary mucinous neoplasms, and pancreatic neuroendocrine tumors.
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Affiliation(s)
- Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA.
| | - Jashodeep Datta
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
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van Dam MA, Vuijk FA, Stibbe JA, Houvast RD, Luelmo SAC, Crobach S, Shahbazi Feshtali S, de Geus-Oei LF, Bonsing BA, Sier CFM, Kuppen PJK, Swijnenburg RJ, Windhorst AD, Burggraaf J, Vahrmeijer AL, Mieog JSD. Overview and Future Perspectives on Tumor-Targeted Positron Emission Tomography and Fluorescence Imaging of Pancreatic Cancer in the Era of Neoadjuvant Therapy. Cancers (Basel) 2021; 13:6088. [PMID: 34885196 PMCID: PMC8656821 DOI: 10.3390/cancers13236088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite recent advances in the multimodal treatment of pancreatic ductal adenocarcinoma (PDAC), overall survival remains poor with a 5-year cumulative survival of approximately 10%. Neoadjuvant (chemo- and/or radio-) therapy is increasingly incorporated in treatment strategies for patients with (borderline) resectable and locally advanced disease. Neoadjuvant therapy aims to improve radical resection rates by reducing tumor mass and (partial) encasement of important vascular structures, as well as eradicating occult micrometastases. Results from recent multicenter clinical trials evaluating this approach demonstrate prolonged survival and increased complete surgical resection rates (R0). Currently, tumor response to neoadjuvant therapy is monitored using computed tomography (CT) following the RECIST 1.1 criteria. Accurate assessment of neoadjuvant treatment response and tumor resectability is considered a major challenge, as current conventional imaging modalities provide limited accuracy and specificity for discrimination between necrosis, fibrosis, and remaining vital tumor tissue. As a consequence, resections with tumor-positive margins and subsequent early locoregional tumor recurrences are observed in a substantial number of patients following surgical resection with curative intent. Of these patients, up to 80% are diagnosed with recurrent disease after a median disease-free interval of merely 8 months. These numbers underline the urgent need to improve imaging modalities for more accurate assessment of therapy response and subsequent re-staging of disease, thereby aiming to optimize individual patient's treatment strategy. In cases of curative intent resection, additional intra-operative real-time guidance could aid surgeons during complex procedures and potentially reduce the rate of incomplete resections and early (locoregional) tumor recurrences. In recent years intraoperative imaging in cancer has made a shift towards tumor-specific molecular targeting. Several important molecular targets have been identified that show overexpression in PDAC, for example: CA19.9, CEA, EGFR, VEGFR/VEGF-A, uPA/uPAR, and various integrins. Tumor-targeted PET/CT combined with intraoperative fluorescence imaging, could provide valuable information for tumor detection and staging, therapy response evaluation with re-staging of disease and intraoperative guidance during surgical resection of PDAC. METHODS A literature search in the PubMed database and (inter)national trial registers was conducted, focusing on studies published over the last 15 years. Data and information of eligible articles regarding PET/CT as well as fluorescence imaging in PDAC were reviewed. Areas covered: This review covers the current strategies, obstacles, challenges, and developments in targeted tumor imaging, focusing on the feasibility and value of PET/CT and fluorescence imaging for integration in the work-up and treatment of PDAC. An overview is given of identified targets and their characteristics, as well as the available literature of conducted and ongoing clinical and preclinical trials evaluating PDAC-targeted nuclear and fluorescent tracers.
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Affiliation(s)
- Martijn A. van Dam
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Floris A. Vuijk
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Judith A. Stibbe
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Ruben D. Houvast
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Saskia A. C. Luelmo
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | | | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, University Medical Center Leiden, 2333 ZA Leiden, The Netherlands;
- Biomedical Photonic Imaging Group, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Cornelis F. M. Sier
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Percuros B.V., 2333 CL Leiden, The Netherlands
| | - Peter J. K. Kuppen
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | | | - Albert D. Windhorst
- Department of Radiology, Section of Nuclear Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands;
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Centre for Human Drug Research, 2333 CL Leiden, The Netherlands
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
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Kooby DA. Invited Commentary. J Am Coll Surg 2021; 232:413-415. [PMID: 33771298 DOI: 10.1016/j.jamcollsurg.2020.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 10/21/2022]
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Varghese C, Wells CI, Lee S, Pathak S, Siriwardena AK, Pandanaboyana S. Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery. Surgery 2021; 171:490-497. [PMID: 34417025 DOI: 10.1016/j.surg.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown. METHODS MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak. RESULTS Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies. CONCLUSION The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/chrisvarghese98
| | - Cameron Iain Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/drcamwells
| | - Shiela Lee
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Samir Pathak
- Department of Oncology and Surgery, St James Hospital, Leeds, UK. https://twitter.com/Drsampathak
| | - Ajith K Siriwardena
- Department of Hepatobiliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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Reconsideration of the Appropriate Dissection Range Based on Japanese Anatomical Classification for Resectable Pancreatic Head Cancer in the Era of Multimodal Treatment. Cancers (Basel) 2021; 13:cancers13143605. [PMID: 34298818 PMCID: PMC8303207 DOI: 10.3390/cancers13143605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with resectable pancreatic cancer are considered to already have micro-distant metastasis, because most of the recurrence patterns postoperatively are distant metastases. Multimodal treatment dramatically improves prognosis; thus, micro-distant metastasis is considered to be controlled by chemotherapy. The survival benefit of "regional lymph node dissection" for pancreatic head cancer remains unclear. We reviewed the literature that could be helpful in determining the appropriate resection range. Regional lymph nodes with no suspected metastases on preoperative imaging may become areas treated with preoperative and postoperative adjuvant chemotherapy. Many studies have reported that the R0 resection rate is associated with prognosis. Thus, "dissection to achieve R0 resection" is required. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Therefore, it is possible to simulate the dissection range to achieve R0 resection preoperatively. However, it is often difficult to distinguish between areas of inflammatory changes and cancer infiltration during resection. Even if the "dissection to achieve R0 resection" range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of anatomical landmarks to determine the appropriate dissection range during surgery.
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Kinny-Köster B, Habib JR, Javed AA, Shoucair S, van Oosten AF, Fishman EK, Lafaro KJ, Wolfgang CL, Hackert T, He J. Technical progress in robotic pancreatoduodenectomy: TRIANGLE and periadventitial dissection for retropancreatic nerve plexus resection. Langenbecks Arch Surg 2021; 406:2527-2534. [PMID: 34240247 DOI: 10.1007/s00423-021-02261-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE The resection of retropancreatic nerve plexuses for pancreatic head cancer became standard of care during open pancreatoduodenectomy to minimize local recurrences. Since more surgical centers are progressing on the learning curve, robotically-assisted pancreatoduodenectomy is now increasingly performed with decreasing anatomic exclusion criteria. To achieve comparable and favorable oncologic outcomes, advanced surgical techniques should be transferred and implemented when performing robotic resections. METHODS The nomenclature and anatomic principles of retropancreatic nerve plexuses and three different levels of dissections are utilized based on established definitions. RESULTS The en bloc dissection in the "TRIANGLE" area (triangular-shaped retropancreatic space enclosed by the common hepatic artery, superior mesenteric artery, and superior mesenteric vein/portal vein) and the periadventitial dissection of arteries for non-tunica media-invading tumors were executed robotically. Both can be utilized to achieve a radical dorsal and medial margin. Video recordings are provided to illustrate varying TRIANGLE dissections. CONCLUSION To accomplish oncologic non-inferiority, established principles from open pancreatic resections can be incorporated precisely and safely, overcoming the lack of haptic feedback while exploiting the technological advantages of the robotically-assisted platform.
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Affiliation(s)
- Benedict Kinny-Köster
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Floortje van Oosten
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock 665, Baltimore, MD, 21287, USA.
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Osawa I, Okamoto K, Ikeda M, Otani A, Wakimoto Y, Yamashita M, Shinohara T, Kanno Y, Jubishi D, Kurano M, Harada S, Okugawa S, Yatomi Y, Moriya K. Dynamic changes in fibrinogen and D-dimer levels in COVID-19 patients on nafamostat mesylate. J Thromb Thrombolysis 2021; 51:649-656. [PMID: 32920751 PMCID: PMC7486975 DOI: 10.1007/s11239-020-02275-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 02/06/2023]
Abstract
Critical illnesses associated with coronavirus disease 2019 (COVID-19) are attributable to a hypercoagulable status. There is limited knowledge regarding the dynamic changes in coagulation factors among COVID-19 patients on nafamostat mesylate, a potential therapeutic anticoagulant for COVID-19. First, we retrospectively conducted a cluster analysis based on clinical characteristics on admission to identify latent subgroups among fifteen patients with COVID-19 on nafamostat mesylate at the University of Tokyo Hospital, Japan, between April 6 and May 31, 2020. Next, we delineated the characteristics of all patients as well as COVID-19-patient subgroups and compared dynamic changes in coagulation factors among each subgroup. The subsequent dynamic changes in fibrinogen and D-dimer levels were presented graphically. All COVID-19 patients were classified into three subgroups: clusters A, B, and C, representing low, intermediate, and high risk of poor outcomes, respectively. All patients were alive 30 days from symptom onset. No patient in cluster A required mechanical ventilation; however, all patients in cluster C required mechanical ventilation, and half of them were treated with venovenous extracorporeal membrane oxygenation. All patients in cluster A maintained low D-dimer levels, but some critical patients in clusters B and C showed dynamic changes in fibrinogen and D-dimer levels. Although the potential of nafamostat mesylate needs to be evaluated in randomized clinical trials, admission characteristics of patients with COVID-19 could predict subsequent coagulopathy.
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Affiliation(s)
- Itsuki Osawa
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Mahoko Ikeda
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Amato Otani
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuji Wakimoto
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Marie Yamashita
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takayuki Shinohara
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yoshiaki Kanno
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Daisuke Jubishi
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Makoto Kurano
- Department of Clinical Laboratory, The University of Tokyo Hospital, Tokyo, Japan
| | - Sohei Harada
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yutaka Yatomi
- Department of Clinical Laboratory, The University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
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Swami A, Varshney VK. Outcomes of Margin Status on Survival in Pancreatic Ductal Adenocarcinoma Receiving Neoadjuvant Therapy. J Am Coll Surg 2021; 232:1022-1023. [PMID: 33722463 DOI: 10.1016/j.jamcollsurg.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
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He J, Schmocker R. Neoadjuvant Treatment and Surgical Resection Are Associated with Survival in Pancreatic Cancer. J Am Coll Surg 2021; 232:1023-1024. [PMID: 33722461 DOI: 10.1016/j.jamcollsurg.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
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