Potential role of surgical resection for pancreatic cancer in the very elderly

The survival in octogenarians undergoing surgery for pancreatic cancer and its association with the nutritional status

PURPOSES

This study explored the association between the nutritional status and survival outcomes after pancreatic cancer surgery and reconsidered surgical indications in octogenarians.

METHODS

Three hundred and ninety-three consecutive pancreatic cancer patients who underwent resection were analyzed and grouped according to age (< 70 years old; septuagenarians [70-79 years old], and octogenarians [80-89 years old]). The Charlson age comorbidity index and nutritional parameters were recorded. Survival outcomes and their association with nutritional parameters and prognostic factors were examined.

RESULTS

The overall survival was worse in the octogenarians than in other patients. The median overall survivals in the < 70 years old group, septuagenarians, and octogenarians were 27.2, 26.4, and 15.3 months, respectively (P = 0.0828). DUPAN-2 ≥ 150 U/mL, borderline resectable/unresectable tumors, blood loss volume ≥ 500 mL, and blood transfusion were predictors of the overall survival among octogenarians. Nutritional parameter values were worse in the octogenarians than in other patients. The octogenarian age group was not an independent predictor of postoperative complications in a univariate analysis.

CONCLUSIONS

Survival outcomes were poor in octogenarians. However, an age ≥ 80 years old alone should not be considered a contraindication for pancreatic cancer surgery. The maintenance of perioperative nutritional status is an important factor associated with the survival.

Prognosis of pancreaticoduodenectomy in octogenarians for pancreatic ductal adenocarcinoma with propensity score matched analysis

BACKGROUND

This retrospective study investigates factors affecting surgical and oncological outcome after performing pancreaticoduodenectomy in octogenarian patients diagnosed with pancreatic ductal adenocarcinoma.

METHODS

From January 2009 to December 2018, patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were included. Data were analysed by comparing clinicopathological characteristics, complications, survival, recurrence, adjuvant treatment between octogenarians and the younger group. Propensity score matched analysis was performed due to the small size of the octogenarian group.

RESULTS

A total of 666 patients were included in this study and 24 (3.6%) were included in the octogenarian group. Short term complication rates (P = 0.119) and hospital stay (P = 0.839) did not differ between two groups. Overall survival between the two groups showed significant difference (<80 median 25 months versus ≥80 median 13 months, P = 0.045). However, after propensity score matched analysis, the two groups did not differ in overall survival (<80 median 18 months versus ≥80 median survival 16 months, P = 0.565) or disease-free survival (P = 0.471). Among the octogenarians, six patients survived longer than 24 months even without satisfying all favourable prognostic factors.

CONCLUSION

Considering the general condition of octogenarians diagnosed with pancreatic ductal adenocarcinoma, select patients should be treated more aggressively for the best chance of receiving curative treatment.

Risks and benefits of pancreaticoduodenectomy in patients aged 80 years and over

PURPOSE

The frequency of pancreaticoduodenectomy is increasing in oldest old patients owing to population aging. We aimed to clarify the clinical significance of pancreaticoduodenectomy in patients aged ≥ 80 years with multiple underlying diseases.

METHODS

A total of 649 consecutive patients who underwent pancreaticoduodenectomy from April 2010 to March 2021 in our institute were divided into two groups according to their age: ≥ 80 years (51) and ≤ 79 years (598). We compared mortality and morbidity between the groups. The age-related prognosis was analyzed in 302 patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma treatment.

RESULTS

There were no significant differences in morbidity (Clavien-Dindo classification grade III or higher; P = 0.1300), mortality (P = 0.0786), or postoperative hospital stay (P = 0.5763) between the groups. Patients aged ≥ 80 years, who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, had shorter overall survival than those aged ≤ 79 years (median survival time, 16.7 months vs. 32.7 months; P = 0.0206). However, the overall survival of patients aged ≥ 80 years who received perioperative chemotherapy was comparable to that of patients aged ≤ 79 years (P = 0.9795). In the multivariate analysis, the absence of perioperative chemotherapy was identified as an independent prognostic factor, while age ≥ 80 years was not. Perioperative chemotherapy was the sole independent prognostic factor in patients aged ≥ 80 years who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

CONCLUSIONS

Pancreaticoduodenectomy is safe for patients aged ≥ 80 years. The survival benefits of pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma aged ≥ 80 years might be limited to those who can receive perioperative chemotherapy.

Therapeutic efficacy of dose-reduced adjuvant chemotherapy with S-1 in patients with pancreatic cancer: a retrospective study

BACKGROUND

S-1 adjuvant chemotherapy is the standard treatment in Asia for resectable pancreatic ductal adenocarcinoma. The relative dose intensity of adjuvant chemotherapy influences survival in pancreatic cancer but does not precisely reflect treatment schedule modifications. We investigated the effects of total dose intensity of S-1 adjuvant chemotherapy on the survival of patients with pancreatic cancer and the permissible dose reduction.

METHODS

Patients who underwent surgical resection during 2011-2019 for pancreatic cancer were selected. We determined the total dose intensity cut-off value that predicted tumor recurrence within 2 years postoperatively using receiver operating characteristic curves and compared the outcomes between the high and low total dose intensity groups.

RESULTS

Patients with total dose intensity ≥ 62.5% (n = 53) showed significantly better overall survival than those with total dose intensity < 62.5% (n = 16) (median survival time: 53.3 vs. 20.2 months, P < 0.001). The median survival of patients without adjuvant chemotherapy (total dose intensity = 0, n = 28) was 24.8 months. Univariate analysis identified lymphatic involvement (P = 0.035), lymph node metastasis (P = 0.034), and total dose intensity (P < 0.001) as factors affecting survival. On multivariate analysis, total dose intensity (P < 0.001) was an independent predictor of worse survival.

CONCLUSIONS

Maintaining a total dose intensity of at least 60% in S-1 adjuvant chemotherapy seems important to achieve a long postoperative survival in patients with pancreatic cancer.

Mortality and Survival Among Octogenarians with Localized Pancreatic Head Cancer: a National Cancer Database Analysis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has historically poor outcomes. Difficult decisions must be made by patients and providers, especially in the elderly for whom treatment morbidities may not be tolerable. Herein, we report treatment-dependent outcomes of octogenarians with localized PDAC.

METHODS

The National Cancer Database identified patients ≥60 years with localized PDAC of the pancreatic head (2011-2016). Patients were grouped by age (60-79 and ≥80 years) and categorized by treatment regimen: no treatment, chemotherapy, pancreaticoduodenectomy, pancreaticoduodenectomy with perioperative chemotherapy, or pancreaticoduodenectomy with adjuvant chemotherapy. Postoperative outcomes and survival were analyzed.

RESULTS

A total of 35,409 patients were included, 8745 (24.7%) of which were ≥80 years. Over 52% of octogenarians did not receive any treatment, compared to 19.1% of younger patients (p<0.001). Patients ≥80 years who underwent a pancreaticoduodenectomy had a significantly greater 90-day mortality rate compared to patients 60-79 years (11.0% vs. 6.7%, p<0.001). Only 42.2% of octogenarians who underwent upfront pancreatectomy received adjuvant chemotherapy. Median survival for octogenarians was 3.3 months without any treatment, 9.7 months with chemotherapy, 12.0 months with pancreaticoduodenectomy, and greater than 20 months with either perioperative or adjuvant chemotherapy in addition to pancreaticoduodenectomy. Age ≥80 was associated with poor survival relative to ages 60-79 when adjusting for treatment regimen (HR=1.19, p<0.001).

CONCLUSION

Increasing age is associated with worse overall survival in PDAC, but select octogenarians can achieve reasonable survival with multimodal therapy. Given the poor survival and increased perioperative mortality of octogenarians, patient selection for surgery and consideration of neoadjuvant therapy may be increasingly important.

Skeletal Muscle Loss and Octogenarian Status Are Associated with S-1 Adjuvant Therapy Discontinuation and Poor Prognosis after Pancreatectomy

Simple Summary

Significant advances in surgical techniques and perioperative care, together with adjuvant chemotherapy, have contributed to the increasing number of patients with pancreatic cancer undergoing surgery. However, the results of some studies suggest that the postoperative complications and mortality might be higher in elderly patients undergoing pancreatectomy. We aimed to identify the utility of S-1 adjuvant chemotherapy in elderly patients with resected pancreatic cancer. In our cohort of 80 patients, including 16 octogenarians, univariate and multivariate analyses revealed that S-1 adjuvant chemotherapy was associated with improved prognosis in patients with pancreatic cancer. However, we also observed that skeletal muscle loss and age of 80 years or older predicted the failure to complete adjuvant chemotherapy with S-1. We propose that evaluation of skeletal muscle mass should be considered as a useful preoperative assessment approach for determining feasibility of adjuvant chemotherapy in elderly patients.

Abstract

The efficacy and prognosis of adjuvant chemotherapy for resected pancreatic cancer remain unclear. We investigated the utility and risk factors of S-1 adjuvant chemotherapy in patients with pancreatic cancer undergoing pancreatectomy. This study comprised 80 patients, including 58 patients who received S-1 adjuvant chemotherapy. Skeletal muscle loss was defined using cutoff values of skeletal muscle mass index. In total, 16 (20%) octogenarian patients underwent pancreatectomy. Skeletal muscle loss was present in 56 (70%) patients. The entire course of S-1 adjuvant chemotherapy for 6 months was completed in 33 patients (41%). S-1 adjuvant chemotherapy <6 months was an independent prognostic indicator of poor overall survival. Patients who completed S-1 adjuvant chemotherapy exhibited significantly longer overall and relapse-free survival rates than those did not complete the chemotherapy (p < 0.0001 and p = 0.0003, respectively). Being an octogenarian and skeletal muscle loss were independent variables associated with the discontinuation of S-1 adjuvant chemotherapy. Finally, the S-1 adjuvant chemotherapy rates were 6.3% (1/16) and 28.6% (16/56) in octogenarian patients and those with skeletal muscle loss, respectively. S-1 adjuvant chemotherapy completion was associated with improved prognosis in patients with pancreatic cancer. Skeletal muscle loss and octogenarian status predicted the failure of S-1 adjuvant chemotherapy completion.

Survival benefit of surgery for very elderly patients with pancreatic cancer: what extent of pancreatectomy is acceptable?

The purpose of this study is to clarify the survival benefit and acceptable extent of surgery for very elderly patients with pancreatic cancer. Patients (n=55) ≥80 years with resectable pancreatic cancer were studied. 29 underwent pancreatectomy, 16 underwent chemotherapy, and 10 received best supportive care. Uni and multivariate analysis were performed to explore predictive factors for overall survival (OS) with surgery and chemotherapy (n=45). Postoperative survival of PD (pancreatoduodenectomy) and DP (distal pancreatectomy) and of PD-PVR (PD with portal vein resection) and PD were compared. OS was equivalent with surgery and chemotherapy (median survival time [MST]; 685 vs. 626 days, respectively; p=0.057); 6 patients surivived ≥3 years after surgery. Pancreatectomy was not a prognostic factor. Survival was significantly worse with PD-PVR than with PD, but equivalent with PD and DP. Within 2 years after PD-PVR, 8 patients have died. Surgery was not a positive prognostic factor for very elderly patients with pancreatic cancer, but was the sole chance for survival ≥3 years. Indication for PD-PVR for very elderly patients should be determined more cautiously compared with that for non-elderly patients.

Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer

BACKGROUND

Pancreaticoduodenectomy (PD) is more challenging in the elderly.

METHODS

Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL).

RESULTS

Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients.

CONCLUSION

Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.

Evaluation of the validity of pancreatectomy for very elderly patients with pancreatic ductal adenocarcinoma

PURPOSE

The role of pancreatectomy for very elderly patients with pancreatic adenocarcinoma is controversial. This study aimed to clarify the validity of pancreatic resection in octogenarian patients with pancreatic ductal adenocarcinoma.

METHODS

We compared 31 patients aged ≥ 80 years and 548 patients aged < 80 years who underwent pancreatectomy for pancreatic ductal adenocarcinoma and evaluated the relationship between age, clinicopathological factors, recurrence, and outcomes.

RESULTS

Postoperative mortality, morbidity, and completion of adjuvant chemotherapy rates did not differ between groups. There were no significant differences in median recurrence-free survival, disease-specific survival, and overall survival between groups (1.0, 2.3, and 2.2 years in patients ≥ 80 years and 1.2, 2.8, and 2.7 years in patients < 80 years; P = 0.67, 0.47, and 0.46, respectively). The median time from recurrence to death of octogenarian patients was significantly shorter than that of younger patients (0.6 vs. 1.1 years, P = 0.0070). In multivariate analysis, age ≥ 80 years (hazard ratio, 1.5), resection of other organs (hazard ratio, 1.8), pathological grade 2/3 (hazard ratio, 1.6), and failure to implement of treatment after recurrence (hazard ratio, 3.6) were independent risk factors for a short time from recurrence to death. Furthermore, age ≥ 80 years (odds ratio, 0.32) was an independent risk factor for the implementation of treatment after recurrence.

CONCLUSIONS

Pancreatectomy for octogenarians may be acceptable, but median survival time from recurrence to death was shorter due to lower rates of implementation of treatment after recurrence in octogenarian patients.

Age-Related Differences in the Prognosis of Pancreatic Cancer According to Perioperative Systemic Therapy

OBJECTIVES

In this study, we retrospectively assessed the feasibility and prognostic efficacy of perioperative chemo(radio)therapy for pancreatic cancer (PC) patients according to age.

METHODS

A total of 556 consecutive patients who underwent curative-intent pancreatectomy for PC between 2000 and 2018 were enrolled.

RESULTS

Of the 556 patients who underwent resection, 95 (17%) were elderly (age, ≥75 years). Postoperative complications did not significantly differ between the 2 age groups, and postoperative prognoses were also similar (recurrence-free survival [RFS], P = 0.68; overall survival [OS], P = 0.28). In this cohort, 103 patients (19%) underwent preoperative chemo(radio)therapy, and 417 (77%) underwent postoperative chemotherapy. Perioperative therapy was found to be significantly beneficial for younger patients (preoperative therapy: RFS, P = 0.006; OS, P < 0.001; postoperative therapy: RFS, P < 0.001; OS, P < 0.001). Conversely, no significant survival benefit of perioperative therapy was found for the elderly (preoperative therapy: RFS, P = 0.28; OS, P = 0.44; postoperative therapy: RFS, P = 0.77; OS, P = 0.08).

CONCLUSIONS

This study demonstrated that, although perioperative therapy is feasible for selected elderly patients with PC, this approach might not be as beneficial as it is for younger PC patients.

Does Major Pancreatic Surgery Have Utility in Nonagenarians with Pancreas Cancer?

OBJECTIVE

This study aims to define the role of surgery and assess different therapies for nonagenarians with localized, nonmetastatic pancreatic adenocarcinoma (PDAC).

METHODS

The National Cancer Database (NCDB) was queried for patients ≥ 90 years of age with nonmetastatic, localized PDAC from 2004-2016. Postoperative mortality was assessed at 30 and 90 days in patients receiving pancreatoduodenectomy or total pancreatectomy. Overall survival (OS) was compared between three treatment groups: surgery alone, chemotherapy alone, and chemoradiation (chemoRT) alone.

RESULTS

Of 380,524 patients with PDAC, 98 patients ≥ 90 years of age underwent curative-intent resection; 55% were female and 75% had a Charlson-Deyo comorbidity score of 0. A total of 17% received postoperative chemotherapy, 51.1% had poorly differentiated tumors with a median tumor size of 3 cm, 55.1% had positive lymph nodes, and 19.4% had positive resection margins. Postoperative median length of stay was 11 days. Postoperative 30- and 90-day mortality was 10.0% and 18.9%, respectively. Median OS for the surgery alone group was 11.6 months compared with 20.4 months in those receiving adjuvant therapy (p = 0.01). Among nonoperative PDAC patients, median OS in patients receiving chemotherapy only (n = 207) was 7.2 months, while chemoRT only (n = 100) was similar to surgery only (11 versus 11.6 months, p = 0.97).

CONCLUSIONS

Even in well-selected nonagenarians, pancreatoduodenectomy or total pancreatectomy carries a high mortality rate. While adjuvant therapy after resection provides the best survival, it is seldom achieved, and chemoRT alone affords identical survival statistics as surgery alone. These data suggest it is reasonable to consider chemoRT as initial therapy, then reassess candidacy for resection if performance status allows.

Optimal Treatment for Octogenarians With Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: A Multicenter Retrospective Study

OBJECTIVES

The objective of this study was to clarify the role of pancreatectomy for patients with resectable and borderline resectable pancreatic ductal adenocarcinoma aged 80 years or older using a nationwide audit by the Japan Pancreas Society.

METHODS

Data were collected from 39 institutions from 2007 to 2014. The primary endpoint was overall survival, and secondary endpoints were surgical outcomes and predictive factors for prognosis.

RESULTS

Data were obtained from 556 octogenarians who underwent pancreatectomy (n = 369, 66%), chemo(radio)therapy (n = 99, 18%), and palliative therapy (n = 88, 16%). Median survival times were 20.6, 18.6, and 8.8 months in each group, respectively. Even after propensity score matching, median survival time in the surgery group (22.8 months) was significantly higher than that in the chemotherapy group (18.5 months; hazard ratio, 0.64 [95% confidence interval, 0.44-0.93]; P = 0.020). Significant independent prognostic factors were body mass index, lymph node metastasis, and tumor diameter in the surgery group, and serum albumin level, American Society of Anesthesiologists classification, body mass index, modified Glasgow prognostic score, second-line chemotherapy, and tumor diameter in the chemotherapy group.

CONCLUSIONS

Octogenarians with resectable/borderline resectable pancreatic ductal adenocarcinoma can be recommended for pancreatectomy according to mental and physical fitness for surgical procedures.

Pancreatic resections in elderly patients with high American Society of Anesthesiologists' risk score: a view from a tertiary care center

BACKGROUND

More than 60% of patients affected by pancreatic cancer are ≥ 65 years of age. Surgery represents the only potentially curative treatment for malignant pancreatic neoplasia and a useful treatment for benign diseases.

AIM

To evaluate outcomes in elderly patients with ASA risk score 4 who underwent pancreatic resection compared to younger patients and elderly patients with lower anesthesiological risk.

METHODS

A consecutive series of 345 patients underwent pancreatic resection between 2010 and 2017 was reviewed. We compared three groups based on age at the time of surgery: < 65 years (group A), 65-74 years (group B), and ≥ 75 years (group C). Patients in group C were split into two subgroups, ASA 1-3 versus ASA 4, and compared.

RESULTS

Group A consisted of 117 (34%) patients, group B 128 (37%) patients, and group C 100 (29%) patients. Group C had a significantly higher incidence of comorbidity and ASA 4 status (p < 0.05), and of overall post-operative complications (p < 0.01), because of the higher incidence of post-operative medical complications. No differences in terms of overall surgical complications and post-operative mortality were reported. The mean overall survival was significantly lower for group C (p < 0.01), with no difference in mortality for cancer. Within group C, no differences were reported regarding surgical complications (p = 0.59), mortality (p = 0.34), and mean overall survival (p = 0.53) between ASA 1-3 and ASA 4 patients.

CONCLUSIONS

Advanced age should not preclude elderly patients with pancreatic diseases from being treated surgically, and ASA 4 in subjects aged ≥ 75 years should not be an absolute contraindication.

Short- and long-term outcomes of pancreaticoduodenectomy in elderly patients with periampullary cancer

Purpose

Pancreaticoduodenectomy (PD) is recently performed in older cancer patients. The complication rate of PD is high. The present study was to compare the postoperative short- and long-term outcomes of PD in between older patients and younger patients.

Methods

Between 2000 and 2014, patients who underwent PD due to periampullary cancers were enrolled. Patients aged 75 years or over were included in the older group.

Results

Total 1,249 patients were enrolled in this study and 168 patients (13.5%) were included in the older group. Postoperative complication rates, duration of postoperative hospital stay, and 30-day mortality were comparable between the 2 groups, although the admission rate of intensive care unit postoperatively was higher in the older adult group (20.8% vs. 10.5%, P < 0.001). In terms of long-term outcomes, 5-year overall survival rate was lower in the older group (23.4% vs. 41.8%, P < 0.001), and 5-year cumulative recurrence rate was higher in the older group without statistical significance (63.9% vs. 57.9%, P = 0.095). However, there were no statistical differences of cumulative recurrence in pancreatic cancer patients (81.5% vs. 82.5%, P = 0.805).

Conclusion

PD for periampullary cancer is a safe and feasible treatment in the older patients. The treatment modality for obtaining better survival outcomes will be investigated.

Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years

BACKGROUND

The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival.

METHODS

A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied.

RESULTS

A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005).

CONCLUSION

Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

The Management of Older Adults with Pancreatic Adenocarcinoma

Pancreatic cancer is the eleventh most common cancer, yet it is the third leading cause of mortality. It is also largely a disease of older adults, with the median age of 71 at diagnosis in the US, with <1% of diagnoses occurring prior to age 50. Current NCCN guidelines recommend surgery for localized disease, followed by adjuvant therapy and/or consideration of enrollment in a clinical trial. For metastatic disease, current guidelines recommend clinical trial enrollment or systemic chemotherapy based on results from the landmark ACCORD-11 and MPACT trials. However, these trials focused heavily on younger, more fit patients, with the ACCORD-11 trial excluding patients over age 75 and the MPACT trial having 92% of its patients with a Karnofsky performance score >80. This article summarizes the available evidence in current literature in regards to the best treatment options for older adults, who represent the majority of pancreatic cancer diagnoses.

Prognostic significance of Wilms' tumor 1 expression in patients with pancreatic ductal adenocarcinoma

The only current curative treatment for patients with pancreatic ductal adenocarcinoma (PDA) is surgical resection, and certain patients still succumb to disease shortly after complete surgical resection. Wilms' tumor 1 (WT1) serves an oncogenic role in various types of tumors; therefore, in the present study, WT1 protein expression in patients with PDA was analyzed and the association with overall survival (OS) and disease-free survival (DFS) time in patients with PDA was assessed following surgical resection. A total of 50 consecutive patients with PDA who received surgical resection between January 2005 and December 2015 at the Jikei University Kashiwa Hospital (Kashiwa, Chiba, Japan) were enrolled. WT1 protein expression in PDA tissue was measured using immunohistochemical staining. Furthermore, laboratory parameters were measured within 2 weeks of surgery, and systemic inflammatory response markers were evaluated. WT1 protein expression was detected in the nucleus and cytoplasm of all PDA cells and in tumor vessels. WT1 exhibited weak staining in the nuclei of all PDA cells; however, the cytoplasmic expression of WT1 levels was classified into four groups: Negative (n=0), weak (n=19), moderate (n=23) and strong (n=8). In patients with PDA, it was demonstrated that the OS and DFS times of patients with weak cytoplasmic WT1 expression were significantly prolonged compared with those of patients with moderate-to-strong cytoplasmic WT1 expression, as determined by log-rank test (P=0.0005 and P=0.0001, respectively). Furthermore, an association between the density of WT1-expressing tumor vessels and worse OS/DFS times was detected. Multivariate analysis also indicated a significant association between the overexpression of WT1 in PDA tissue and worse OS/DFS times. To the best of our knowledge, the present study is the first to demonstrate that moderate-to-strong overexpression of WT1 in the cytoplasm of PDA cells is significantly associated with worse OS/DFS times. Therefore, overexpression of WT1 in the cytoplasm of PDA cells may impact the recurrence and prognosis of patients with PDA following surgical resection. The results further support the development of WT1-targeted therapies to prolong survival in all patients with PDA.

Impact of Patient Age on the Postoperative Survival in Pancreatic Head Cancer

BACKGROUND

Some reports have stated that pancreatoduodenectomy for elderly patients have comparable morbidity and mortality to that of young patients. However, the long-term outcomes of these patients have not been fully evaluated, especially for pancreatic head cancer.

METHODS

A total of 227 patients who underwent pancreatoduodenectomy for pancreatic head cancer between 2007 and 2014 were included. They were stratified according to age: young (<70 years), elderly (70 to <80 years), and very elderly (≥80 years). The short- and long-term outcomes were evaluated.

RESULTS

There were no significant differences in terms of morbidity among the three groups. The median disease-free survival times were 15 months in the young, 11 months in the elderly, and 7 months in the very elderly. The disease-free survival of the young patients was significantly better than that in both the elderly and the very elderly (p = 0.012 and p = 0.016). The median overall survival times were 30 months in the young, 20 months in the elderly, and 14 months in the very elderly. The overall survival of the young patients was significantly better than that in both the elderly and the very elderly (p = 0.007 and p < 0.001). The difference was marginal between the elderly and the very elderly (p = 0.053). Multivariate analysis revealed that lymph node metastasis (p < 0.001), age ≥80 years (p = 0.013), lack of adjuvant chemotherapy (p = 0.003), blood transfusion (p = 0.015), and CA 19-9 ≥300 U/ml (p = 0.040) were significant prognostic factors.

CONCLUSIONS

Patient age influenced the survival after pancreatoduodenectomy for pancreatic cancer.

Pancreatic resection in very elderly patients: A critical analysis of existing evidence

The aging of the population results in a rise of number of elderly patients (aged 80 years and older) with pancreatic or periampullary cancer, and more pancreatectomies could eventually be performed in such complex patients. However, early and long-term results after pancreatic resection in octogenarians are still controversial, and may trouble the surgeon when approaching this type of population. Evaluation of reported experiences shows that for almost all Authors, pancreatectomy can be performed safely in elderly population, although overall morbidity and mortality rates were 34.9% and 13.2% respectively, with a mean length of hospital stay of 18 d. These features appear higher in older patients compared to the younger counterpart. Less than 50% of patients underwent adjuvant therapy after operation. Long-term survival is reported not significantly different in aged 80 years and older patients, with a median overall survival time of 17.6 mo. The quality of life after pancreatic resection is only sporadically evaluated but, when considered, it highlights the need of health facility service after operation for these “frail” patients. Prospective studies on the quality of life of pancreatectomized octogenarians are welcome. Proper selection of patients, geriatric assessment with multidisciplinary approach, centralization of pancreatic surgery in high-volume centres and rehabilitation programs after surgery appear to be crucial points in order to improve surgical treatments of pancreatic tumors in very elderly patients.