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Nakai Y, Smith Z, Chang KJ, Dua KS. Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction. Surg Oncol Clin N Am 2021; 30:639-656. [PMID: 34511187 DOI: 10.1016/j.soc.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.
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Affiliation(s)
- Yousuke Nakai
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Zachary Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, Digestive Health Institute, University of California, Irvine, 101 The City Drive, Building 22C, Orange, CA, USA
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, USA.
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Ausania F, Sanchez-Cabus S, Senra Del Rio P, Borin A, Ayuso JR, Bodenlle P, Espinoza S, Cuatrecasas M, Conill C, Saurí T, Ferrer J, Fuster J, García-Valdecasas JC, Melendez R, Fondevila C. Clinical impact of preoperative tumour contact with superior mesenteric-portal vein in patients with resectable pancreatic head cancer. Langenbecks Arch Surg 2021; 406:1443-1452. [PMID: 33475833 DOI: 10.1007/s00423-020-02065-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/15/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival. METHODS All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV. RESULTS Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis. CONCLUSION Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.
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Affiliation(s)
- Fabio Ausania
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Santiago Sanchez-Cabus
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Paula Senra Del Rio
- Department of HPB Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Alex Borin
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain.
| | - Juan Ramon Ayuso
- Department of Radiology, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Pilar Bodenlle
- Department of Radiology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Sofia Espinoza
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Miriam Cuatrecasas
- Department of Pathology, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Carlos Conill
- Department of Radiotherapy, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Tamara Saurí
- Department of Medical Oncology, Hospital Clinic and Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Joana Ferrer
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Josep Fuster
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Juan Carlos García-Valdecasas
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Reyes Melendez
- Department of HPB Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Constantino Fondevila
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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Mattevi C, Garnier J, Marchese U, Ewald J, Gilabert M, Poizat F, Piana G, Delpero JR, Turrini O. Has the non-resection rate decreased during the last two decades among patients undergoing surgical exploration for pancreatic adenocarcinoma? BMC Surg 2020; 20:176. [PMID: 32758203 PMCID: PMC7430808 DOI: 10.1186/s12893-020-00835-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose To determine if improvement in imaging reduces the non-resection rate (NRR) among patients with pancreatic ductal adenocarcinoma (PDAC). Methods From 2000 to 2019, 751 consecutive patients with PDAC were considered eligible for a intention-to-treat pancreatectomy and entered the operating room. In April 2011, our institution acquired a dual energy spectral computed tomography (CT) scanner and liver diffusion weighted magnetic resonance imaging (DW-MRI) was included in the imaging workup. We consequently considered 2 periods of inclusion: period #1 (February 2000–March 2011) and period #2 (April 2011–August 2019). Results All patients underwent a preoperative CT scan with a median delay to surgery of 18 days. Liver DW-MRI was performed among 407 patients (54%). Median delay between CT and surgery decreased (21 days to 16 days, P < .01), and liver DW-MRI was significantly most prescribed during period #2 (14% vs 75%, P < .01). According to the intraoperative findings, the overall NRR was 24.5%, and remained stable over the two periods (25% vs 24%, respectively). While vascular invasion, liver metastasis, and carcinomatosis rates remained stable, para-aortic lymph nodes invasion rate (0.4% vs 4.6%; P < 0.001) significantly increased over the 2 periods. The mean size of the bigger extra pancreatic tumor significantly decrease (7.9 mm vs 6.4 mm (P < .01), respectively) when the resection was not done. In multivariate analysis, CA 19–9 < 500 U/mL (P < .01), and liver DW-MRI prescription (P < .01) favoured the resection. Conclusions Due to changes in our therapeutic strategies, the NRR did not decrease during two decades despite imaging improvement.
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Affiliation(s)
- C Mattevi
- Departement of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - J Garnier
- Departement of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - U Marchese
- Departement of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - J Ewald
- Departement of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - M Gilabert
- Departement of Oncology, Institut Paoli-Calmettes, Marseille, France
| | - F Poizat
- Departement of Pathology, Institut Paoli-Calmettes, Marseille, France
| | - G Piana
- Departement of Radiology, Institut Paoli-Calmettes, Marseille, France
| | - J R Delpero
- Departement of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - O Turrini
- Departement of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, 232 boulevard Sainte Marguerite, 13009, Marseille, France.
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Gemenetzis G, Groot VP, Blair AB, Ding D, Thakker SS, Fishman EK, Cameron JL, Makary MA, Weiss MJ, Wolfgang CL, He J. Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma. J Surg Oncol 2018; 118:1277-1284. [PMID: 30380143 DOI: 10.1002/jso.25288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/13/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The incidence of occult metastatic disease (OMD) in pancreatic ductal adenocarcinoma (PDAC) and associated risk factors are largely unknown. METHODS We identified all patients with PDAC, who had an aborted oncologic operation due to OMD within a 10-year period. The cases were matched to a cohort of resected PDAC patients on a 1:3 ratio, based on age and sex, for comparison of preoperative clinical characteristics and potential risk factors for OMD. RESULTS In the studied period, 117 patients with OMD were identified in 1423 pancreatectomies performed for PDAC (8%). Liver metastases were the most common finding (79%) followed by peritoneal implants (16%). When compared with non-OMD cases, patients with OMD presented more often with abdominal pain (P < 0.001), and higher preoperative carbohydrate antigen 19-9 (CA 19-9) values ( P = 0.007). Additionally, indeterminate liver lesions on preoperative computed tomography (CT) were identified in 40% of OMD versus 17% of non-OMD patients ( P < 0.001). Multivariable analysis distinguished four independent predictors for OMD: indeterminate lesions on preoperative CT, tumor size > 30 mm, abdominal pain, and preoperative CA 19-9 > 192 U/mL. CONCLUSIONS Occurrence of OMD in PDAC accounts for 8% of cases. Preoperative CA 19-9 > 192 U/mL, primary tumor size > 30 mm, and identification of indeterminate lesions in preoperative CT may indicate the need for diagnostic laparoscopy.
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Affiliation(s)
- Georgios Gemenetzis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vincent P Groot
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alex B Blair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sameer S Thakker
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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