Optimal duration of the early and late recurrence of pancreatic cancer after pancreatectomy based on the difference in the prognosis

Futility of Up-Front Resection for Anatomically Resectable Pancreatic Cancer

Importance

There are currently no clinically relevant criteria to predict a futile up-front pancreatectomy in patients with anatomically resectable pancreatic ductal adenocarcinoma.

Objectives

To develop a futility risk model using a multi-institutional database and provide unified criteria associated with a futility likelihood below a safety threshold of 20%.

Design, Setting, and Participants

This retrospective study took place from January 2010 through December 2021 at 5 high- or very high-volume centers in Italy. Data were analyzed during April 2024. Participants included consecutive patients undergoing up-front pancreatectomy at the participating institutions.

Exposure

Standard management, per existing guidelines.

Main Outcomes and Measures

The main outcome measure was the rate of futile pancreatectomy, defined as an operation resulting in patient death or disease recurrence within 6 months. Dichotomous criteria were constructed to maintain the futility likelihood below 20%, corresponding to the chance of not receiving postneoadjuvant resection from existing pooled data.

Results

This study included 1426 patients. The median age was 69 (interquartile range, 62-75) years, 759 patients were male (53.2%), and 1076 had head cancer (75.4%). The rate of adjuvant treatment receipt was 73.7%. For the model construction, the study sample was split into a derivation (n = 885) and a validation cohort (n = 541). The rate of futile pancreatectomy was 18.9% (19.2% in the development and 18.6% in the validation cohort). Preoperative variables associated with futile resection were American Society of Anesthesiologists class (95% CI for coefficients, 0.68-0.87), cancer antigen (CA) 19.9 serum levels (95% CI, for coefficients 0.05-0.75), and tumor size (95% CI for coefficients, 0.28-0.46). Three risk groups associated with an escalating likelihood of futile resection, worse pathological features, and worse outcomes were identified. Four discrete conditions (defined as CA 19.9 levels-adjusted-to-size criteria: tumor size less than 2 cm with CA 19.9 levels less than 1000 U/mL; tumor size less than 3 cm with CA 19.9 levels less than 500 U/mL; tumor size less than 4 cm with CA 19.9 levels less than 150 U/mL; and tumor size less than 5 cm with CA 19.9 levels less than 50 U/mL) were associated with a futility likelihood below 20%. Both disease-free survival and overall survival were significantly longer in patients fulfilling the criteria.

Conclusions and relevance

In this study, a preoperative model (MetroPancreas) and dichotomous criteria to determine the risk of futile pancreatectomy were developed. This might help in selecting patients for up-front resection or neoadjuvant therapy.

Prognostic Factors for Early Recurrence After Resection of Pancreatic Cancer: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

More than half of pancreatic ductal adenocarcinomas (PDACs) recur within 12 months after curative-intent resection. This systematic review and meta-analysis was conducted to identify all reported prognostic factors for early recurrence in resected PDACs.

METHODS

After a systematic literature search, a meta-analysis was conducted using a random effects model. Separate analyses were performed for adjusted vs unadjusted effect estimates as well as reported odds ratios (ORs) and hazard ratios (HRs). Risk of bias was assessed using the Quality in Prognostic Studies tool, and evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation recommendations.

RESULTS

After 2903 abstracts were screened, 65 studies were included. Of these, 28 studies (43.1%) defined early recurrence as evidence of recurrence within 6 months, whereas 34 (52.3%) defined it as evidence of recurrence within 12 months after surgery. Other definitions were uncommon. Analysis of unadjusted ORs and HRs revealed 41 and 5 prognostic factors for early recurrence within 6 months, respectively. When exclusively considering adjusted data, we identified 25 and 10 prognostic factors based on OR and HR, respectively. Using a 12-month definition, we identified 38 (OR) and 15 (HR) prognostic factors from unadjusted data and 38 (OR) and 30 (HR) prognostic factors from adjusted data, respectively. On the basis of frequency counts of adjusted data, preoperative carbohydrate antigen 19-9, N status, nondelivery of adjuvant therapy, grading, and tumor size based on imaging were identified as key prognostic factors for early recurrence.

CONCLUSIONS

Reported prognostic factors of early recurrence vary considerably. Identified key prognostic factors could aid in the development of a risk stratification framework for early recurrence. However, prospective validation is necessary.

Prognostic Significance of Biologic Factors in Patients with a Modest Radiologic Response to Neoadjuvant Treatment for Resectable and Borderline Resectable Pancreatic Cancers: Impact of the Combination Index of Sialyl-Lewis Antigen-Related Tumor Markers

BACKGROUND

Appropriate re-evaluation after neoadjuvant treatment (NAT) is important for optimal treatment selection. Nonetheless, determining the operative eligibility of patients with a modest radiologic response remains controversial. This study aimed to assess the prognostic significance of biologic factors for patients showing a modest radiologic response to NAT and investigate the tumor markers (TMs), CA19-9 alone, DUPAN-II alone, and their combination, to create an index that combines these sialyl-Lewis antigen-related TMs associated with treatment outcomes.

METHODS

This study enrolled patients deemed to have a "stable disease" by RECIST classification with slight progression (tumor size increase rate, ≤20%) as their radiologic response after NAT. A sialyl-Lewis-related index (sLe index), calculated by adding one fourth of the serum DUPAN-II value to the CA19-9 value, was created. The prognostic significances of CA19-9, DUPAN-II, and the sLe index were assessed in relation to postoperative outcomes.

RESULTS

An sLe index lower than the cutoff value (45.25) was significantly associated with favorable disease-free survival. Moreover, the post-NAT sLe index had a higher area under the curve value for recurrence within 24 months than the post-NAT levels of CA19-9 or DUPAN-II alone. Multivariable analysis showed that a post-NAT sLe index higher than 45.25 was the single independent predictive factor for recurrence within 24 months.

CONCLUSIONS

Additional evaluation of biologic factors can potentially enhance patient selection, particularly for patients showing a limited radiologic response to NAT. The authors' index is a simple indicator for the biologic evaluation of multiple combined sialyl-Lewis antigen-related TMs and may offer a better predictive significance.

Nomogram model for predicting early recurrence for resectable pancreatic cancer: A multicenter study

Pancreatic cancer is a highly aggressive malignancy that is characterized by early metastasis, high recurrence, and therapy resistance. Early recurrence after surgery is one of the important reasons affecting the prognosis of pancreatic cancer. This study aimed to establish an accurate preoperative nomogram model for predicting early recurrence (ER) for resectable pancreatic adenocarcinoma. We retrospectively analyzed patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma between January 2011 and December 2020. The training set consisted of 604 patients, while the validation set included 222 patients. Survival was estimated using Kaplan-Meier curves. The factors influencing early recurrence of resectable pancreatic cancer after surgery were investigated, then the predictive model for early recurrence was established, and subsequently the predictive model was validated based on the data of the validation group. The preoperative risk factors for ER included a Charlson age-comorbidity index ≥ 4 (odds ratio [OR]: 0.628), tumor size > 3.0 cm on computed tomography (OR: 0.628), presence of clinical symptoms (OR: 0.515), carbohydrate antigen 19-9 > 181.3 U/mL (OR 0.396), and carcinoembryonic antigen > 6.01 (OR: 0.440). The area under the curve (AUC) of the predictive model in the training group was 0.711 (95% confidence interval: 0.669-0.752), while it reached 0.730 (95% CI: 0.663-0.797) in the validation group. The predictive model may enable the prediction of the risk of postoperative ER in patients with resectable pancreatic ductal adenocarcinoma, thereby optimizing preoperative decision-making for effective treatment.

Uncovering the clinicopathological features of early recurrence after surgical resection of pancreatic cancer

To identify risk factors and biomarker for early recurrence in patients diagnosed with pancreatic cancer who undergo curative resection. Early recurrence after curative resection of pancreatic cancer is an obstacle to long-term survival. We retrospectively reviewed 162 patients diagnosed with pancreatic cancer who underwent curative resection. Early recurrence was defined as recurrence within 12 months of surgery. We selected S100A2 as a biomarker and investigated its expression using immunohistochemistry. Of the total, 79.6% (n = 129) of patients received adjuvant chemotherapy after surgery and 117 (72.2%) experienced recurrence, of which 73 (45.1%) experience early recurrence. In multivariate analysis, age < 60 years, presence of lymph node metastasis, and no adjuvant chemotherapy were significantly associated with early recurrence (all P < 0.05). The proportion of patients with high S100A2 expression (H-score > 5) was significantly lower in the early recurrence group (41.5% vs. 63.3%, P = 0.020). The cumulative incidence rate of early recurrence was higher in patients with an S100A2 H-score < 5 (41.5% vs. 63.3%, P = 0.012). The median overall survival of patients with higher S100A2 expression was longer than those with lower S100A2 expression (median 30.1 months vs. 24.2 months, P = 0.003). High-risk factors for early recurrence after surgery for pancreatic cancer include young age, lymph node metastasis, and no adjuvant therapy. Neoadjuvant treatment or intensive adjuvant therapy after surgery may improve the prognosis of patients with high-risk signatures. In patients who receive adjuvant therapy, high S100A2 expression is a good predictor.

Combined Therapy of Chemotherapy and Radiofrequency Ablation for Pancreatic Cancer Patients With Metachronous Hepatic Metastatic Lesions After Radical Pancreatic Resection

PURPOSE

Hepatic metastasis frequently occurs in patients who have undergone radical pancreatic resection for pancreatic cancer. Besides chemotherapy, various local treatment approaches targeting hepatic lesions have been explored. However, research on radiofrequency ablation (RFA) as a localized therapy for hepatic metastasis is limited. Therefore, we conducted this retrospective study to provide clinical evidence.

METHODS

This is a single-center, retrospective, cohort study. After radical pancreaticoduodenectomy, 32 patients developed metachronous hepatic metastasis with fewer than 3 lesions, the largest of which was less than 3 cm in diameter. These patients underwent combined treatment with chemotherapy and RFA. After 8 weeks of chemotherapy, patients received RFA for hepatic lesions. Additional chemotherapy was administered, and the patients' tumor status and survival were monitored. The primary endpoint of this study was overall survival (OS). Factors affecting OS were analyzed using the Cox risk model.

RESULTS

Among the 32 patients, the mean OS was 28.4 months. Univariate and multivariate Cox regression analysis revealed that the time (in months) of liver metastasis (HR = 0.04, 95% CI: 0.01 to 0.19; P < 0.001), the number of liver metastases (HR = 7.08, 95% CI: 1.85 to 27.08, P = 0.004), and PD (progressive disease) response to the second round of chemotherapy (HR = 29.50, 95% CI: 1.46 to 597.27; P = 0.027) were independent predictors of poorer survival.

CONCLUSION

Combined therapy with RFA and chemotherapy is safe in patients with hepatic metastasis after radical pancreaticoduodenectomy. Early recurrence (≤12 months), three liver metastatic lesions, and a poor response to the second round of chemotherapy were associated with poor survival.

A novel combined carbohydrate antigen 19-9 and lymphocyte-to-monocyte ratio score can predict early recurrence of resectable pancreatic ductal adenocarcinoma

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) often recurs early after radical resection, which causes a poor prognosis. This study aimed to establish a scoring model to assess the optimal treatment in patients who underwent surgery for PDAC.

METHODS

This single-center retrospective study included 127 patients who underwent radical resection for PDAC between 2005 and 2021. Early recurrence (ER) was defined as recurrence within 12 months after resection. The predictive effect for ER was evaluated using receiver operating characteristic (ROC) curves of preoperative parameters.

RESULTS

ER occurred in 43 (33.9%) patients. The ER group had a significantly worse prognosis than the non-ER group (p < 0.0001). The carbohydrate antigen 19-9 (CA19-9) level and lymphocyte-to-monocyte ratio (LMR) were the strongest diagnostic factors (areas under the ROC curves: 0.74 and 0.68, respectively). The ER prediction score was calculated using optimal cutoff values. A higher CA19-9-LMR score was associated with a worse prognosis in terms of the overall and recurrence-free survival (p = 0.0017 and p < 0.0001, respectively). A multivariate analysis identified a high CA19-9-LMR score as an independent predictor of ER.

CONCLUSIONS

The CA19-9-LMR scoring model can predict ER after surgery and is applicable for risk stratification in the assessment of patients with resectable PDAC.

Risk factors for early recurrence in patients with pancreatic ductal adenocarcinoma who underwent curative resection

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers, and surgical resection is the only potentially curative approach. However, the rate of recurrence remains high, particularly within the first 6 months, and is associated with a poor prognosis. The present study evaluated the clinical characteristics and risk factors for early recurrence in pancreatic ductal adenocarcinoma (PDAC) patients who underwent curative resection, regardless of the use of neoadjuvant chemotherapy, to identify predictive factors associated with early recurrence and poor outcomes as well as to determine the optimal treatment strategy for patients at high risk of early recurrence after surgical resection.

METHODS

Patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2021 were included in this study. We investigated the clinicopathological features of patients in groups: those with recurrence within 6 months, recurrence between 6 and 12 months, and recurrence beyond 12 months or no recurrence. A logistic regression analysis identified covariates associated with early recurrence at 6 and 12 months.

RESULTS

The study included 403 patients with a median follow-up of 25.7 months. Recurrence was observed in 279 patients, with 14.6% recurring within 6 months, 23.3% within 6-12 months, and 62% after 12 months or not at all. The preoperative CA19-9 level, modified Glasgow prognostic score (mGPS), and positive peritoneal cytology were significant risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant risk factors for recurrence within 12 months. For patients who received preoperative chemotherapy or chemoradiotherapy, the preoperative CA19-9 level, mGPS, and positive peritoneal cytology were significant independent risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant independent risk factors for recurrence within 12 months. The study concluded that the overall survival after surgical resection for potentially resectable PDAC worsened according to the number of risk factors present in the patient.

CONCLUSIONS

We clarified that preoperative CA19-9, positive peritoneal cytology, and the lack of adjuvant chemotherapy were consistent predictors for early recurrence within 6 and 12 months. In addition, an increased number of risk factors affecting the patient was associated with a poorer overall survival after potentially curable resection. Calculating the number of risk factors for early recurrence may be an essential predictive factor when considering treatment strategies.

Early Recurrence After Resection of Locally Advanced Pancreatic Cancer Following Induction Therapy: An International Multicenter Study

OBJECTIVE

To establish an evidence-based cutoff and predictors for early recurrence in patients with resected locally advanced pancreatic cancer (LAPC).

BACKGROUND

It is unclear how many and which patients develop early recurrence after LAPC resection. Surgery in these patients is probably of little benefit.

METHODS

We analyzed all consecutive patients undergoing resection of LAPC after induction chemotherapy who were included in prospective databases in The Netherlands (2015-2019) and the Johns Hopkins Hospital (2016-2018). The optimal definition for "early recurrence" was determined by the post-recurrence survival (PRS). Patients were compared for overall survival (OS). Predictors for early recurrence were evaluated using logistic regression analysis.

RESULTS

Overall, 168 patients were included. After a median follow-up of 28 months, recurrence was observed in 118 patients (70.2%). The optimal cutoff for recurrence-free survival to differentiate between early (n=52) and late recurrence (n=66) was 6 months ( P <0.001). OS was 8.4 months [95% confidence interval (CI): 7.3-9.6] in the early recurrence group (n=52) versus 31.1 months (95% CI: 25.7-36.4) in the late/no recurrence group (n=116) ( P <0.001). A preoperative predictor for early recurrence was postinduction therapy carbohydrate antigen (CA) 19-9≥100 U/mL [odds ratio (OR)=4.15, 95% CI: 1.75-9.84, P =0.001]. Postoperative predictors were poor tumor differentiation (OR=4.67, 95% CI: 1.83-11.90, P =0.001) and no adjuvant chemotherapy (OR=6.04, 95% CI: 2.43-16.55, P <0.001).

CONCLUSIONS

Early recurrence was observed in one third of patients after LAPC resection and was associated with poor survival. Patients with post-induction therapy CA 19-9 ≥100 U/mL, poor tumor differentiation and no adjuvant therapy were especially at risk. This information is valuable for patient counseling before and after resection of LAPC.

Development and validation of a radiomics model of magnetic resonance for predicting liver metastasis in resectable pancreatic ductal adenocarcinoma patients

BACKGROUND

Nearly one fourth of patients with pancreatic ductal adenocarcinoma (PDAC) occur to liver metastasis after surgery, and liver metastasis is a risk factor for prognosis for those patients with surgery therapy. However, there is no effective way to predict liver metastasis post-operation.

METHOD

Clinical data and preoperative magnetic resonance imaging (MRI) of PDAC patients diagnosed between July 2010 and July 2020 were retrospectively collected from three hospital centers in China. The significant MRI radiomics features or clinicopathological characteristics were used to establish a model to predict liver metastasis in the development and validation cohort.

RESULTS

A total of 204 PDAC patients from three hospital centers were divided randomly (7:3) into development and validation cohort. Due to poor predictive value of clinical features, MRI radiomics model had similar receiver operating characteristics curve (ROC) value to clinical-radiomics combing model in development cohort (0.878 vs. 0.880, p = 0.897) but better ROC in validation dataset (0.815 vs. 0.732, p = 0.022). Radiomics model got a sensitivity of 0.872/0.750 and a specificity of 0.760/0.822 to predict liver metastasis in development and validation cohort, respectively. Among 54 patients randomly selected with post-operation specimens, fibrosis markers (α-smooth muscle actin) staining was shown to promote radiomics model with ROC value from 0.772 to 0.923 (p = 0.049) to predict liver metastasis.

CONCLUSION

This study developed and validated an MRI-based radiomics model and showed a good performance in predicting liver metastasis in resectable PDAC patients.

DUPAN-2 as a Risk Factor of Early Recurrence After Curative Pancreatectomy for Patients With Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Several patients with pancreatic ductal adenocarcinoma (PDAC) experience postoperative early recurrence (ER). We evaluated PDAC patients to identify the risk factors for postoperative ER (≤6 months), including preoperative serum DUPAN-2 level.

METHODS

We retrospectively evaluated 74 PDAC patients who underwent pancreatectomy with curative intent. Clinicopathological factors including age, sex, body mass index, postoperative complications, pathological factors, preoperative C-reactive protein/albumin ratio, neutrophil/lymphocyte ratio, modified Glasgow prognostic score, preoperative tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, SPAN-1, and DUPAN-2), and history of adjuvant chemotherapy were investigated. Early recurrence risk factors were determined using multivariate logistic regression analysis.

RESULTS

Recurrence and ER occurred in 52 (70.3%) and 23 (31.1%) patients, respectively. Univariate analysis revealed that postoperative complications, C-reactive protein/albumin ratio ≥0.02, neutrophil/lymphocyte ratio ≥3.01, carbohydrate antigen 19-9 ≥ 92.3 U/mL, SPAN-1 ≥ 69 U/mL, DUPAN-2 ≥ 200 U/mL, and absence of adjuvant chemotherapy were significant risk factors for ER. In multivariate analysis, DUPAN-2 ≥ 200 U/mL (P = 0.04) and absence of adjuvant chemotherapy (P = 0.02) were identified as independent risk factors for ER.

CONCLUSIONS

A higher level of preoperative DUPAN-2 was an independent risk factor for ER. For patients with high DUPAN-2 level, neoadjuvant therapies might be required to avoid ER.

Clinical Implications of FDG-PET in Pancreatic Ductal Adenocarcinoma Patients Treated with Neoadjuvant Therapy

PURPOSE

To evaluate the clinical significance of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy.

METHODS

Among 285 consecutive patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma between 2015 and 2021, 86 who underwent preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography after completion of neoadjuvant treatment were reviewed. Among preoperative factors, including post-treatment maximum standardized uptake value, predictors of early recurrence and poor prognosis were identified using multivariate analysis for decision making in surgery.

RESULTS

Nineteen (22%) patients with pancreatic ductal adenocarcinoma demonstrated high maximum standardized uptake (≥ 4.5). High post-treatment maximum standardized uptake (≥ 4.5) predicted early recurrence within 6 months after surgery and correlated with shorter recurrence-free survival. Elevated post-treatment CA19-9 level (> 37 U/ml) and maximum standardized uptake ≥ 4.5 were independent prognostic factors. Post-treatment, a high maximum standardized uptake value indicated a poorer prognosis than a low maximum standardized uptake value in both patients with elevated CA19-9 and normal CA19-9 levels. The median overall survival in patients with elevated post-treatment CA19-9 and high maximum standardized uptake was only 17 months; 67% experienced early recurrence. Dynamic changes in maximum standardized uptake during neoadjuvant therapy were correlated with pathological response to neoadjuvant therapy, but not with radiological response or change in CA19-9 level.

CONCLUSIONS

Post-treatment assessment using maximum standardized uptake value is useful for stratifying patients with pancreatic ductal adenocarcinoma who will benefit from surgery. Instead of subsequent curative resection, additional neoadjuvant therapy should be considered in patients with a persistently high maximum standardized uptake value.

Serum exosomal and serum glypican-1 are associated with early recurrence of pancreatic ductal adenocarcinoma

Background

The diagnostic performance and prognostic value of serum exosomal glypican 1 (GPC-1) in pancreatic ductal adenocarcinoma (PDAC) remain controversial. In this study, we detected serum exosomal GPC-1 using enzyme-linked immunosorbent assay (ELISA) and determined whether it serves as a predictor of diagnosis and recurrence for early-stage PDAC.

Methods

Serum samples were obtained from patients with 50 PDAC, 6 benign pancreatic tumor (BPT), or 9 chronic pancreatitis (CP) and 50 healthy controls (HCs). Serum exosomes were isolated using an exosome isolation kit. Exosomal and serum GPC-1 levels were measured using ELISA. The freeze–thaw process was carried out to analyze the stability of GPC-1. Receiver operating characteristic (ROC) analysis was employed to assess the diagnostic value of GPC-1. Kaplan–Meier and multivariate Cox analyses were used to evaluate the prognostic value of GPC-1.

Results

The average concentrations of serum exosomal and serum GPC-1 were 1.5 and 0.8 ng/ml, respectively. GPC-1 expression levels were stable under repeated freezing and thawing (d1-5 freeze–thaw cycles vs. d0 P > 0.05). Serum exosomal and serum GPC-1 were significantly elevated in patients with PDAC compared with HCs (P < 0.0001) but were slightly higher compared with that in patients with CP and BPT (P > 0.05). The expression levels of exosomal and serum GPC-1 were elevated 5 days after surgery in patients with PDAC, CP, and BPT (P < 0.05). Patients with high levels of exosomal and serum GPC-1 had a shorter relapse-free survival (RFS) (P = 0.006, and P = 0.010). Multivariate analyses showed that serum exosomal and serum GPC-1 were independent prognostic indicators for early RFS (P = 0.008, and P = 0.041).

Conclusion

ELISA is an effective and sensitive method to detect exosomal and serum GPC-1. The detection of GPC-1 was stable under repeated freezing and thawing cycles and could distinguish early-stage PDAC from HCs but not CP and BPT. Exosomal and serum GPC-1 may be good independent predictors of early recurrence in early-stage PDAC.

Impact of radiologic splenic vessel invasion in resectable left-sided pancreatic ductal adenocarcinoma: predictor of early systemic recurrence following upfront surgery

BACKGROUND

The aim of this study is to identify prognostic factors and the best candidates for neoadjuvant therapy among patients with resectable left-sided pancreatic ductal adenocarcinoma (PDAC) by analyzing the timing and pattern of recurrence following upfront surgery.

METHODS

This single-center retrospective study included patients with resectable left-sided PDAC who underwent upfront distal pancreatectomy from 2005 to 2015. A minimum P value approach was used to evaluate the optimal cutoff of early recurrence. The predictors of recurrence were assessed with Cox regression analysis.

RESULTS

Among 311 included patients, 241 (77.5%) had a recurrence at a median follow-up of 29.3 months. Systemic recurrence occurred in 194 patients (80.5%) and isolated local recurrence in 47 patients (19.5%). A recurrence-free survival cutoff of 12 months was selected to distinguish between early and late recurrence. The patients with early recurrence had a shorter median overall survival (16.1 vs. 39.9 months, P<0.001) and post-recurrence survival (9.6 vs. 17.2 months, P<0.001) than those with late recurrence. The patients with systemic recurrence had a shorter median overall survival (19.6 vs. 29.1 months, P=0.007) and post-recurrence survival (11.0 vs. 15.3 months, P=0.024) than those with an isolated local recurrence. In multivariable analysis, preoperative CA 19-9 ≥500 U/mL [odd ratio (OR) 2.037, P=0.035], radiologic splenic vessels invasion (OR 5.014, P<0.001), positive radial resection margin (OR 2.638, P<0.001), and no adjuvant chemotherapy (OR 2.084, P=0.001) were predictors of an early systemic recurrence.

CONCLUSIONS

Radiologic splenic vessels invasion may be considered to indicate a biologically borderline status in patients with anatomically resectable left-sided PDAC. Future clinical trials of neoadjuvant therapy targeting these patients should be conducted.

Prognostic Analysis of Distal Pancreatectomy for Pancreatic Body and/or Tail Cancer Involving the Portal Vein: Is Pancreatic Body and/or Tail Cancer Involving the Portal Vein Resectable?

OBJECTIVES

To the best of our knowledge, the prognostic impact of distal pancreatectomy (DP) for pancreatic body and/or tail cancer involving portal vein (PV) has not been analyzed.

METHODS

A total of 155 patients with pancreatic body and/or tail cancer who were eligible candidates for resection between 2002 and 2017 were analyzed.

RESULTS

Twenty-seven patients had PV contact ≤180°. Fifteen patients underwent preoperative treatment; finally, 132 patients underwent DP, and 21 underwent DP with celiac axis resection. The overall survival (OS) of the PV contact group (n = 27, median survival time [MST], 25.6 months) was worse than the non-PV contact group (n = 128; MST, 58.4 months; P = 0.002); however, it was better than the unresectable group (MST, 14.2 months; P = 0.011). The OS of the PV contact with preoperative chemotherapy group (MST, not available) was comparable to the non-PV contact group and better than the PV contact without preoperative chemotherapy group (MST, 13.4 months; P = 0.017). The multivariate analysis identified PV contact ( P = 0.046) as one of the independent prognostic factors of OS.

CONCLUSIONS

Pancreatic body and/or tail cancer contact with PV ≤180° should be considered borderline resectable because of poor survival.

Predictive risk factors for early recurrence in patients with localized pancreatic ductal adenocarcinoma who underwent curative-intent resection after preoperative chemoradiotherapy

Background

The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a subject of debate for patients with pancreatic ductal adenocarcinoma (PDAC) because early recurrence often occurs even after curative-intent resection. The present study aimed to identify perioperative risk factors of early recurrence for patients with PDAC who underwent curative-intent resection after preoperative CRT.

Methods

Two hundred three patients with PDAC who underwent curative-intent resection after preoperative CRT from February 2005 to December 2018 were retrospectively analyzed. The optimal threshold for differentiating between early and late recurrence was determined by the minimum p-value approach. Multivariate regression analysis was performed to identify predictive factors for early recurrence.

Results

In 130 patients who developed recurrence after resection, 52 who had an initial recurrence within 12 months were defined as the early recurrence group, and the remaining 78 were defined as the late recurrence group. The incidence of hepatic recurrence was significantly higher in the early recurrence group than in the late recurrence group (39.7 vs. 15.4%). The early recurrence group had significantly lower 3-year rates of post-recurrence and overall survival than the late recurrence group (4.0 and 10.7% vs. 9.8 and 59.0%, respectively). Serum level of CA19-9 before surgery ≥56.8 U/ml was identified as an independent risk factor for early recurrence (OR:3.07, 95%CI:1.65–5.73, p<0.001) and associated with a significantly higher cumulative incidence rate of hepatic recurrence and lower rates of recurrence-free and overall survival.

Conclusion

Serum level of CA19-9 before surgery after preoperative CRT was a strong predictive factor for early recurrence.

Preoperative serum carbohydrate antigen 19-9 levels predict early recurrence after the resection of early-stage pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a serious disease with a poor prognosis. Only a minority of patients undergo surgery due to the advanced stage of the disease, and patients with early-stage disease, who are expected to have a better prognosis, often experience recurrence. Thus, it is important to identify the risk factors for early recurrence and to develop an adequate treatment plan.

AIM

To evaluate the predictive factors associated with the early recurrence of early-stage PDAC.

METHODS

This study enrolled 407 patients with stage I PDAC undergoing upfront surgical resection between January 2000 and April 2016. Early recurrence was defined as a diagnosis of recurrence within 6 mo of surgery. The optimal cutoff values were determined by receiver operating characteristic (ROC) analyses. Univariate and multivariate analyses were performed to identify the risk factors for early recurrence.

RESULTS

Of the 407 patients, 98 patients (24.1%) experienced early disease recurrence: 26 (26.5%) local and 72 (73.5%) distant sites. In total, 253 (62.2%) patients received adjuvant chemotherapy. On ROC curve analysis, the optimal cutoff values for early recurrence were 70 U/mL and 2.85 cm for carbohydrate antigen 19-9 (CA 19-9) levels and tumor size, respectively. Of the 181 patients with CA 19-9 level > 70 U/mL, 59 (32.6%) had early recurrence, compared to 39 (17.4%) of 226 patients with CA 19-9 level ≤ 70 U/mL (P < 0.001). Multivariate analysis revealed that CA 19-9 level > 70 U/mL (P = 0.006), tumor size > 2.85 cm (P = 0.004), poor differentiation (P = 0.008), and non-adjuvant chemotherapy (P = 0.025) were significant risk factors for early recurrence in early-stage PDAC.

CONCLUSION

Elevated CA 19-9 level (cutoff value > 70 U/mL) can be a reliable predictive factor for early recurrence in early-stage PDAC. As adjuvant chemotherapy can prevent early recurrence, it should be recommended for patients susceptible to early recurrence.

Resectable, borderline, and locally advanced pancreatic cancer-"the good, the bad, and the ugly" candidates for surgery?

The possibility of surgical resection strongly overrules medical oncologic treatment and is the only modality, causa sine qua non, long-term survival can be achieved in patients with pancreatic cancer. For this reason, the clinical classification of local resectability, subdividing tumors into resectable, borderline resectable, and locally advanced cancer, that is very technical in nature, is the one most widely used and accepted. As multimodality treatment with potent agents, particularly in the neoadjuvant setting, seems to be stepping forward as the new standard of treatment of pancreatic cancer, the established technical surgical landmarks tend to get challenged. This review aims to highlight the grey zones in the current classifications for local tumor involvement with respect to the observed patient outcome in the current multimodality treatment era. It summarizes the latest reported series on the outcome of resected primary resectable, borderline and locally advanced pancreatic cancer, and particularly vascular resections during pancreatectomy, in the background of different types of neoadjuvant therapy. It also hints what the new horizons of cancer biology tend to reveal whenever the technical hinders start being pushed aside. The current calls for the necessity of re-classification of the clinical categories of pancreatic cancer, from technically oriented to biology-focused individualized approach, are being elucidated.

Prediction of Early Distant Recurrence in Upfront Resectable Pancreatic Adenocarcinoma: A Multidisciplinary, Machine Learning-Based Approach

Simple Summary

If pancreatic adenocarcinoma is assessed to be technically resectable, curative surgery is still suggested as the primary treatment option; however, the recurrence rate can be very high even in this selected population. The aim of our retrospective study was to develop a preoperative model to accurately stratify upfront resectable patients according to the risk of early distant disease relapse after surgery (<12 months from index procedure). Through a machine learning-based approach, we identified one biochemical marker (serum level of CA19.9), one radiological finding (necrosis) and one radiomic feature (SurfAreaToVolumeRatio), all significantly associated with the early resurge of distant recurrence. A model composed of these three variables only allowed identification of those patients at high risk for early distant disease relapse (50% chance of developing metastases within 12 months after surgery), who would benefit from neoadjuvant chemotherapy instead of upfront surgery.

Abstract

Despite careful selection, the recurrence rate after upfront surgery for pancreatic adenocarcinoma can be very high. We aimed to construct and validate a model for the prediction of early distant recurrence (<12 months from index surgery) after upfront pancreaticoduodenectomy. After exclusions, 147 patients were retrospectively enrolled. Preoperative clinical and radiological (CT-based) data were systematically evaluated; moreover, 182 radiomics features (RFs) were extracted. Most significant RFs were selected using minimum redundancy, robustness against delineation uncertainty and an original machine learning bootstrap-based method. Patients were split into training (n = 94) and validation cohort (n = 53). Multivariable Cox regression analysis was first applied on the training cohort; the resulting prognostic index was then tested in the validation cohort. Clinical (serum level of CA19.9), radiological (necrosis), and radiomic (SurfAreaToVolumeRatio) features were significantly associated with the early resurge of distant recurrence. The model combining these three variables performed well in the training cohort (p = 0.0015, HR = 3.58, 95%CI = 1.98–6.71) and was then confirmed in the validation cohort (p = 0.0178, HR = 5.06, 95%CI = 1.75–14.58). The comparison of survival curves between low and high-risk patients showed a p-value <0.0001. Our model may help to better define resectability status, thus providing an actual aid for pancreatic adenocarcinoma patients’ management (upfront surgery vs. neoadjuvant chemotherapy). Independent validations are warranted.

Upregulated HSPA2 predicts early relapse of pancreatic cancer after surgery

Background

Heat shock protein A2 (HSPA2) is known to relate to the pathogenesis and progress of cancer. This study aimed to investigate the connection between HSPA2 and early postsurgical relapse of pancreatic cancer (PC).

Methods

Expression of HSPA2 in 85 pairs of cancerous and matched noncancerous samples was determined by immunostaining method. The relationship between HSPA2 expression and early postsurgical recurrence was assessed using logistic regression. The performance and potential application of HSPA2 expression to predict early postsurgical recurrence was evaluated by receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

Results

HSPA2 expression in tumor specimens was markedly elevated compared with non-tumor specimens. Logistic regression analysis indicated that HSPA2 upregulation was an independent risk marker for early postsurgical recurrence of PC. ROC curve analysis and DCA demonstrated that both the area under the curve (AUC) and the net benefit of HSPA2 expression were higher than those of other clinicopathologic features in predicting early postsurgical relapse of PC. The combination of HSPA2 expression with other malignant clinicopathologic characteristics had greater AUC and net benefit relative to them alone in predicting early postsurgical recurrence.

Conclusions

Upregulated HSPA2 independently predicts early postsurgical recurrence of PC and has superior predictive performance and potential application value when combined with malignant clinicopathologic features. Our findings reveal that HSPA2 is a promising predictor for early postoperative relapse of PC.

Nomogram and competing risk model to predict recurrence after curative surgical resection of PDAC

BACKGROUND

Surgical resection remains the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC). However, a number of patients get disease recurred in a short time post-operation. Few studies have focused on the predictors of different recurrence patterns of PDAC.

OBJECTIVE

To try to establish and verify a nomogram to predict recurrence free survival (RFS) in PDAC patients, and to distinguish the risk factors of local recurrence first and distant metastasis first via competing risk model.

METHODS

Patients who underwent radical pancreatectomy for PDAC in our center from 2010 to 2018 were reviewed retrospectively. Kaplan-Meier methods and multivariate Cox regression analyses were used to identify the clinicopathological predictors of recurrence post-operation. And then, a nomogram was constructed and validated. Competing risk regression model was used to compare the predictors between local recurrence group and distant metastasis group.

RESULTS

A total of 200 patients were included into the final analysis, and 153 patients got disease relapsed post-operation. CA19-9 level, vascular resection, tumor differentiation, lymph node ratio (LNR) and adjuvant chemotherapy were identified as independent risk factors for recurrence free survival (RFS) and incorporated into the nomogram. The C-index of the nomogram was 0.650. Competing risk model indicated that the status of lymph-node metastasis was significantly associated the patterns of first relapse.

CONCLUSIONS

Nomogram and competing risk model were constructed to quantify the risk of recurrence following surgery for PDAC. Our findings may be useful for predicting RFS and recurrence pattern in clinical work.

Predictors of early recurrence following a curative resection in patients with a carcinoma of the ampulla of Vater

Purpose

Ampulla of Vater (AoV) carcinoma has a relatively good prognosis. The 5-year recurrence rate for AoV is still around 40%–50% however, and most recurrences occur in the early period. The aim of this study was to identify predictors of an early recurrence in AoV patients following a curative resection.

Methods

The clinicopathological data for 501 consecutive patients that underwent a resection for AoV in our institute between January 2000 and December 2015 were retrospectively reviewed. The characteristics of any recurrences and early recurrence patients were analyzed accordingly. Early recurrence was defined as occurring within one year of resection.

Results

There were 170 diagnosed recurrences in our study population, 57.1% of whom were men, with a mean age of 60.1 years (range, 30–94 years). Almost all of the study patients underwent a pancreaticoduodenectomy, and 9% underwent minimally invasive surgery. Of the 170 recurrent cases, 107 were diagnosed with an early recurrence and had 1-, 3-, and 5-year overall survival rates of 77.7%, 18.4%, 10.5%, respectively. The factors that significantly influenced early recurrences, determined by multivariate analysis, lymphovascular invasion (LVI), lymph node ratio (LNR), and poor differentiation were found to be independent determinants of a recurrence within 1 year.

Conclusion

An early recurrence in AoV patients is ultimately lethal even though this cancer has a good prognosis. LVI, LNR, and poor differentiation are powerful predictors of an early recurrence in AoV. Hence, intensive surveillance and new therapeutic strategies should be considered for AoV patients with these predictors following a curative resection.

Defining and predicting early recurrence in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy

BACKGROUND

The definition of "early recurrence (ER)" after rectal cancer surgery is currently unclear.

OBJECTIVE

To determine an evidence-based cut-off to distinguish early and late recurrence (LR) for patients with rectal cancer and compare the clinicopathological factors between the two groups.

METHODS

Patients who underwent neoadjuvant chemoradiotherapy (nCRT) and radical resection for locally advanced rectal cancer were included. A minimum p-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into ER and LR groups based on overall survival. A logistic regression model was used to assess risk factors for ER.

RESULTS

A total of 763 patients were included, of which 167 (21.9%) experienced recurrence. The optimal cut-off value of recurrence-free survival to differentiate between ER (n = 125, 74.9%) and LR (n = 42, 25.1%) was 24 months (P = 0.000001). The median postrecurrence survival of ER and LR was 12 months and 22 months, respectively (p = 0.028). The most common recurrent sites in patients with ER and LR were lung metastases, the incidence of liver metastases, however, differed considerably in ER and LR (27.2% vs 9.5%, P = 0.019). Risk factors including elevated preoperative carcinoembryonic antigen (CEA), higher ypTNM stage, positive circumferential resection margin (CRM), and perineural invasion were significantly associated with ER.

CONCLUSION

A recurrence-free interval of 24 months is the optimal cut-off value for defining ER versus LR. Elevated preoperative CEA, higher ypTNM staging, positive CRM, and perineural invasion were associated with ER of locally advanced rectal cancer.

A preoperative risk model for early recurrence after radical resection may facilitate initial treatment decisions concerning the use of neoadjuvant therapy for patients with pancreatic ductal adenocarcinoma

BACKGROUND

Neoadjuvant chemotherapy may benefit patients with pancreatic ductal adenocarcinoma with resectable and borderline disease. Inappropriate use of neoadjuvant therapy, however, may lead to the loss of therapeutic opportunities. Until an effective prediction model of individual drug sensitivity is established, no accurate model exists to help surgeons decide on the appropriate use of neoadjuvant chemotherapy. We hypothesized that early recurrence in patients undergoing upfront, early resection may be an indication for neoadjuvant chemotherapy. Therefore, we aimed to use preoperative clinical parameters to establish a model of early recurrence to select patients at high risk for neoadjuvant chemotherapy.

METHODS

Patients who underwent resection for pancreatic ductal adenocarcinoma between January 2014 and November 2017 were analyzed retrospectively. After the minimum P-value approach, the patients were divided into three groups: early recurrence, middle recurrence, and late/non-recurrence. Preoperative clinicopathologic factors that could predict early recurrence were included in a Cox proportional hazards regression model for univariate and multivariate analyses. The factors related to early recurrence were included to establish nomogram and decision tree models, which were then validated in 68 patients.

RESULTS

We found that 235 (72.5%) of 324 patients had recurrence with a median recurrence-free survival of 210 days. The early recurrence, middle recurrence, and late/non-recurrence groups differed in preoperative carbohydrate antigen 19-9 and carcinoembryonic antigen levels, "resectability" on cross-sectional imaging, resection requiring a vascular resection, T stage, tumor size, and adjuvant chemotherapy. The best cutoff value of early recurrence was the first 162 days postoperatively. Univariate and multivariate analyses showed that selected preoperative chief complaints, lymph node enlargement and resectability on cross-sectional imaging, preoperative carbohydrate antigen 19-9 levels >210 kU/L, and a neutrophil/lymphocyte ratio >4.2 were independent predictors for early recurrence.

CONCLUSION

We have successfully built a prediction model of early recurrence of patients with pancreatic ductal adenocarcinoma with the optimal cutoff early-recurrence value of 162 days. Our nomogram and decision tree models may be used to select those at high risk for early recurrence to guide preoperative decision-making concerning the use of neoadjuvant therapy in those patients who have "resectable" disease and not only the more classic criteria of borderline resectability.

Defining and Predicting Early Recurrence in 957 Patients With Resected Pancreatic Ductal Adenocarcinoma

OBJECTIVES

To establish an evidence-based cut-off to differentiate between early and late recurrence and to compare clinicopathologic risk factors between the two groups.

SUMMARY BACKGROUND DATA

A clear definition of "early recurrence" after pancreatic ductal adenocarcinoma resection is currently lacking.

METHODS

Patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma between 2000 and 2013 were included. Exclusion criteria were neoadjuvant therapy and incomplete follow-up. A minimum P-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into early and late recurrence cohorts based on subsequent prognosis. Potential risk factors for early recurrence were assessed with logistic regression models.

RESULTS

Of 957 included patients, 204 (21.3%) were recurrence-free at last follow-up. The optimal length of recurrence-free survival to distinguish between early (n = 388, 51.5%) and late recurrence (n = 365, 48.5%) was 12 months (P < 0.001). Patients with early recurrence had 1-, and 2-year post-recurrence survival rates of 20 and 6% compared with 45 and 22% for the late recurrence group (both P < 0.001). Preoperative risk factors for early recurrence included a Charlson age-comorbidity index ≥4 (OR 1.65), tumor size > 3.0 cm on computed tomography (OR 1.53) and CA 19-9 > 210 U/mL (OR 2.30). Postoperative risk factors consisted of poor tumor differentiation grade (OR 1.66), microscopic lymphovascular invasion (OR 1.70), a lymph node ratio > 0.2 (OR 2.49), and CA 19-9 > 37 U/mL (OR 3.38). Adjuvant chemotherapy (OR 0.28) and chemoradiotherapy (OR 0.29) were associated with a reduced likelihood of early recurrence.

CONCLUSION

A recurrence-free interval of 12 months is the optimal threshold for differentiating between early and late recurrence, based on subsequent prognosis.

Development of a Novel Multiparametric MRI Radiomic Nomogram for Preoperative Evaluation of Early Recurrence in Resectable Pancreatic Cancer

Background

In pancreatic cancer, methods to predict early recurrence (ER) and identify patients at increased risk of relapse are urgently required.

Purpose

To develop a radiomic nomogram based on MR radiomics to stratify patients preoperatively and potentially improve clinical practice.

Study Type

Retrospective.

Population

We enrolled 303 patients from two medical centers. Patients with a disease‐free survival ≤12 months were assigned as the ER group (n = 130). Patients from the first medical center were divided into a training cohort (n = 123) and an internal validation cohort (n = 54). Patients from the second medical center were used as the external independent validation cohort (n = 126).

Field Strength/Sequence

3.0T axial T₁‐weighted (T₁‐w), T₂‐weighted (T₂‐w), contrast‐enhanced T₁‐weighted (CET₁‐w).

Assessment

ER was confirmed via imaging studies as MRI or CT. Risk factors, including clinical stage, CA19‐9, and radiomic‐related features of ER were assessed. In addition, to determine the intra‐ and interobserver reproducibility of radiomic features extraction, the intra‐ and interclass correlation coefficients (ICC) were calculated.

Statistical Tests

The area under the receiver‐operator characteristic (ROC) curve (AUC) was used to evaluate the predictive accuracy of the radiomic signature in both the training and test groups. The results of decision curve analysis (DCA) indicated that the radiomic nomogram achieved the most net benefit.

Results

The AUC values of ER evaluation for the radiomics signature were 0.80 (training cohort), 0.81 (internal validation cohort), and 0.78 (external validation cohort). Multivariate logistic analysis identified the radiomic signature, CA19‐9 level, and clinical stage as independent parameters of ER. A radiomic nomogram was then developed incorporating the CA19‐9 level and clinical stage. The AUC values for ER risk evaluation using the radiomic nomogram were 0.87 (training cohort), 0.88 (internal validation cohort), and 0.85 (external validation cohort).

Data Conclusion

The radiomic nomogram can effectively evaluate ER risks in patients with resectable pancreatic cancer preoperatively, which could potentially improve treatment strategies and facilitate personalized therapy in pancreatic cancer.

Level of Evidence: 4

Technical Efficacy: Stage 4

J. Magn. Reson. Imaging 2020;52:231–245.

Meta-analysis of recurrence pattern after resection for pancreatic cancer

Background

Initial recurrence mapping of resected pancreatic ductal adenocarcinoma (PDAC) could help in stratifying patient subpopulations for optimal postoperative follow-up. The aim of this systematic review and meta-analysis was to investigate the initial recurrence patterns of PDAC and to correlate them with clinicopathological factors.

Methods

MEDLINE and Web of Science databases were searched systematically for studies reporting first recurrence patterns after PDAC resection. Data were extracted from the studies selected for inclusion. Pooled odds ratios (ORs) and 95 per cent confidence intervals were calculated to determine the clinicopathological factors related to the recurrence sites. The weighted average of median overall survival was calculated.

Results

Eighty-nine studies with 17 313 patients undergoing PDAC resection were included. The weighted median rates of initial recurrence were 20·8 per cent for locoregional sites, 26·5 per cent for liver, 11·4 per cent for lung and 13·5 per cent for peritoneal dissemination. The weighted median overall survival times were 19·8 months for locoregional recurrence, 15·0 months for liver recurrence, 30·4 months for lung recurrence and 14·1 months for peritoneal dissemination. Meta-analysis revealed that R1 (direct) resection (OR 2·21, 95 per cent c.i. 1·12 to 4·35), perineural invasion (OR 5·19, 2·79 to 9·64) and positive peritoneal lavage cytology (OR 5·29, 3·03 to 9·25) were significantly associated with peritoneal dissemination as initial recurrence site. Low grade of tumour differentiation was significantly associated with liver recurrence (OR 4·15, 1·71 to 10·07).

Conclusion

Risk factors for recurrence patterns after surgery could be considered for specific surveillance and treatments for patients with pancreatic cancer.

Isolated pulmonary recurrence after resection of pancreatic cancer: the effect of patient factors and treatment modalities on survival

BACKGROUND

The literature suggests favorable survival for patients with isolated pulmonary recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) as compared to other recurrence patterns. Within this cohort, it remains unclear what factors are associated with improved survival.

METHODS

Patients who developed pulmonary recurrence after pancreatectomy were selected from a prospective database. Predictors for post-recurrence survival (PRS) were analyzed using a multivariable Cox regression model.

RESULTS

Ninety-six patients were included. Median recurrence-free survival (RFS), PRS and overall survival (OS) were 16.3, 18.8 and 39.6 months, respectively. Further systemic treatment and/or metastasectomy (n = 64, 67%) was associated with significantly improved PRS and OS when compared to best supportive care (n = 35, 22%) (26.3 vs. 5.3 and 48.1 vs. 18.4, respectively; both P < 0.001). Patients who were able to undergo metastasectomy (n = 19) achieved a PRS and OS of 35.0 and 68.9 months, respectively. More than 5 pulmonary lesions, symptoms and CA 19-9 ≥100 U/mL at time of recurrence were predictive of decreased PRS. A recurrence-free interval of >16 months and treatment for recurrence were independently associated with improved PRS.

CONCLUSIONS

Isolated pulmonary recurrence occurs in 13% of patients with recurrent PDAC and is associated with a median OS of 40 months. Aggressive treatment in highly selected patients was correlated with improved survival.

Predictive factors of early recurrence after R0 resection of hilar cholangiocarcinoma: A single institution experience in China

Prediction of early postoperative recurrence is of great significance for follow‐up treatment. However, there are few studies available that focus on high‐risk factors of early postoperative recurrence or even the definition the exact time of early recurrence for hilar cholangiocarcinoma. Thus, we aimed to examine the optimal cut‐off value for defining the early in patients with R0 resection of hilar cholangiocarcinoma and to investigate prognostic factors associated with early recurrence. Two hundred and fifty‐eight patients with R0 resection of hilar cholangiocarcinoma between 2000 and 2015 were included. The minimum P value approach was used to define the optimal cut‐off of early recurrence. The prognostic factors associated with early recurrence were investigated. The optimal cut‐off value for dividing patients into early and non‐early recurrence groups after R0 resection of hilar cholangiocarcinoma was 12 months. Sixty‐two patients were recorded as early recurrence, and the remaining 196 patients were labeled as non‐early recurrence. Multivariate logistic regression analysis indicated lymph node metastasis (OR = 2.756, 95% CI 1.409‐5.393; P = 0.003), poor differentiation (OR = 1.653; 95% CI 1.040‐2.632; P = 0.034), increased postoperative CA 19‐9 levels (OR = 1.965, 95% CI 1.282‐3.013; P = 0.002), neutrophil‐to‐lymphocyte ratio > 3.41 (OR = 5.125, 95% CI 2.419‐10.857; P < 0.001) and age > 60 years (OR = 2.018, 95% CI 1.032‐3.947; P = 0.040) were independent determinants of early and non‐early recurrence. Poor differentiation (HR = 2.609, 95% CI 1.600‐4.252; P < 0.001), Bismuth classification type III/IV (HR = 2.510, 95% CI 1.298‐4.852; P = 0.006) and perineural invasion (HR=2.380, 95% CI 1.271‐4.457; P = 0.007) were independent factors of overall survival in the subgroup of patients who developed early recurrence. The optimal cut‐off value for dividing early recurrence after R0 resection of hilar cholangiocarcinoma was 12 months. Tumor differentiation, Bismuth classification, and perineural invasion were independent factors of overall survival in the subgroup of patients with early recurrence. Patients with risk factors should be monitored closely after curative surgery.

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.

Microscopic Venous Invasion in Pancreatic Cancer

BACKGROUND

Microscopic venous invasion (MVI) and the subsequent peripheral blood circulation of cancer cells are considered to be the primary route for systemic dissemination of pancreatic cancer.

METHODS

Patients who underwent pancreatectomy for invasive ductal carcinoma of the pancreas between January 2007 and December 2015 were retrospectively reviewed. The prognostic significance of MVI was analyzed.

RESULTS

A total of 352 patients underwent pancreatectomy for invasive ductal carcinoma of the pancreas. A pathologic examination showed MVI in 228 (64.5%) of the patients. The median survival time (MST) was 21 months for the patients with MVI and 58 months for those without MVI (p < 0.001). A multivariate analysis showed the following to be significant prognostic factors: non-administration of adjuvant chemotherapy [hazard ratio (HR) 2.37; p < 0.001], lymph node metastasis (HR 2.95; p = 0.001), CA19-9 value of 300 U/ml or higher (HR 1.70; p = 0.018), and MVI (HR 1.84; p = 0.011). The overall survival was clearly stratified into three groups; favorable (MST not reached in stage 1 or 2A without MVI; p = 0.867), moderate (30 months in stage 2A with MVI and 30 months in stage 2B without MVI; p = 0.528), and poor (19 months in stage 2B with MVI and 17 months in stage 4; p = 0.322). The differences between these three groups all were significant.

CONCLUSIONS

Approximately two-thirds of patients with radiologically resectable pancreatic cancer had MVI and were considered to have potentially systemic disease. This study identified MVI as one of the significant factors for a poor prognosis and a valuable complement of tumor-node-metastasis staging.

Prognostic value of carbohydrate antigen 19-9 in patients undergoing resection of biliary tract cancer

BACKGROUND

The clinical significance of abnormally high levels of carbohydrate antigen (CA) 19-9 after resection of biliary tract cancer (BTC) is not well established. The aim of this study was to determine the prognostic value of CA19-9 normalization in patients undergoing resection of BTC with curative intent.

METHODS

Patients with BTC undergoing resection with curative intent (1996-2015) were divided into those with normal preoperative CA19-9 level (normal CA19-9 group), those with an abnormally high preoperative CA19-9 level (over 37 units/ml) and normal postoperative CA19-9 level (normalization group), and those with an abnormally high preoperative CA19-9 level and abnormally high postoperative CA19-9 level (non-normalization group). Overall survival (OS) was analysed and predictors of OS were determined.

RESULTS

The normal CA19-9 group (180 patients) and normalization group (74) had better OS than the non-normalization group (58) (3-year OS rate 70·4, 73 and 31 per cent respectively; both P < 0·001). The normal CA19-9 and normalization groups had equivalent OS (P = 0·880). On multivariable analysis, factors associated with worse OS were lymph node metastases (hazard ratio (HR) 1·78; P = 0·014) and abnormally high postoperative CA19-9 level (HR 3·16; P < 0·001). In the normalization group, OS did not differ after R0 versus R1 resection (3-year OS rate 69 versus 62 per cent respectively; P = 0·372); in the non-normalization group, patients with R1 resection had worse OS (3-year OS rate 36 and 20 per cent for R0 and R1 respectively; P = 0·032).

CONCLUSION

Non-normalization of CA19-9 level after resection of BTC with curative intent was associated with worse OS. R1 resection was associated with a particularly poor prognosis when CA19-9 levels did not normalize.