1
|
Wismans LV, Suurmeijer JA, van Dongen JC, Bonsing BA, Van Santvoort HC, Wilmink JW, van Tienhoven G, de Hingh IH, Lips DJ, van der Harst E, de Meijer VE, Patijn GA, Bosscha K, Stommel MW, Festen S, den Dulk M, Nuyttens JJ, Intven MPW, de Vos-Geelen J, Molenaar IQ, Busch OR, Koerkamp BG, Besselink MG, van Eijck CHJ. Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis. Surgery 2024; 175:1580-1586. [PMID: 38448277 DOI: 10.1016/j.surg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. METHODS All patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014-2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. RESULTS Overall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03-0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25-1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). CONCLUSION This nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.
Collapse
Affiliation(s)
- Leonoor V Wismans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, the Netherlands; Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/MarcBesselink
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
| |
Collapse
|
2
|
Mukai Y, Asukai K, Akita H, Kubo M, Hasegawa S, Wada H, Miyata H, Ohue M, Sakon M, Takahashi H. Assessing Intra-abdominal status for clinically relevant postoperative pancreatic fistula based on postoperative fluid collection and drain amylase levels after distal pancreatectomy. Ann Gastroenterol Surg 2024; 8:321-331. [PMID: 38455495 PMCID: PMC10914692 DOI: 10.1002/ags3.12741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/26/2023] [Accepted: 09/05/2023] [Indexed: 03/09/2024] Open
Abstract
Aim The aim of this study was to evaluate the intra-abdominal status related to postoperative pancreatic fistula by combining postoperative fluid collection and drain amylase levels. Methods We retrospectively reviewed the data of 203 patients who underwent distal pancreatectomy and classified their postoperative abdominal status into four groups based on postoperative fluid collection size and drain amylase levels. We also evaluated the incidence of clinically relevant postoperative pancreatic fistula in each group according to C-reactive protein values. Results The incidence of clinically relevant postoperative pancreatic fistula in the entire cohort (n = 203) was 28.1%. Multivariate analysis revealed that postoperative fluid collection, drain amylase levels, and C-reactive protein levels are considerable risk factors for clinically relevant postoperative pancreatic fistula. In the subgroup with large postoperative fluid collection and high drain amylase levels, 65.9% of patients developed clinically relevant postoperative pancreatic fistula. However, no significant difference was observed in C-reactive protein levels between patients with clinically relevant postoperative pancreatic fistula and those without it. In contrast, in the subgroup with a large postoperative fluid collection size or a high amylase level alone, a significant difference was observed in C-reactive protein values between the patients with clinically relevant postoperative pancreatic fistula and those without it. Conclusion Postoperative fluid collection status and the C-reactive protein value provide a more precise assessment of intra=abdominal status related to postoperative pancreatic fistula after distal pancreatectomy. This detailed analysis may be a clinically reasonable approach to individual drain management.
Collapse
Affiliation(s)
- Yosuke Mukai
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of SurgeryYao Municipal HospitalOsakaJapan
| | - Hirofumi Akita
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masahiko Kubo
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | | | - Hiroshi Wada
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayuki Ohue
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masato Sakon
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
- Department of Gastroenterological Surgery, Graduate School of MedicineOsaka UniversityOsakaJapan
| |
Collapse
|
3
|
Wu HY, Liu T, Zhong T, Zheng SY, Zhai QL, Du CJ, Wu TZ, Li JZ. Research trends and hotspots of neoadjuvant therapy in pancreatic cancer: a bibliometric analysis based on the Web of Science Core Collection. Clin Exp Med 2023; 23:2473-2485. [PMID: 36773211 DOI: 10.1007/s10238-023-01013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/26/2023] [Indexed: 02/12/2023]
Abstract
Neoadjuvant therapy (NAT) for pancreatic cancer (PC) has achieved certain results. This article was aimed to analyze the trends in NAT in PC over the past 20 years using bibliometric analysis and visualization tools to guide researchers in exploring future research hotspots. Articles related to NAT for PC were retrieved from the Web of Science Core Collection for the period 2002-2021. The information was analyzed and visualized using VOSviewer, Citespace, Microsoft Excel and R software. The number of articles per year has continued to increase over the past 20 years. Of the 1,598 eligible articles, the highest number was from the United States (760), and an analysis of institutions indicated that the University of Texas System (150) had the highest number of articles. Matthew H. G. Katz had the highest number of citations and the highest H-index. "Pancreatic cancer" (981), "Resection" (623), "Cancer" (553), "Neoadjuvant therapy" (509) and "Survival" (484) were the top five ranked keywords. Combined with the keywords-cluster analysis and citation burst analysis, current research hotspots were the optimal NAT regimen, NAT response assessment, NAT for resectable PC and management of complications. NAT has received increasing attention in the field of PC over the past 20 years, but greater collaboration between countries and additional multicenter randomized clinical trials are needed. Overall, we have revealed current research hotspots and provided valuable information for the choice of future research directions.
Collapse
Affiliation(s)
- Hong-Yu Wu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tao Liu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tao Zhong
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Si-Yuan Zheng
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Qi-Long Zhai
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Chang-Jie Du
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Tian-Zhu Wu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, No.76 Linjiang Road, Chongqing, 400010, Yuzhong District, People's Republic of China.
| |
Collapse
|
4
|
Wu HY, Li JW, Li JZ, Zhai QL, Ye JY, Zheng SY, Fang K. Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress. World J Gastrointest Surg 2023; 15:142-162. [PMID: 36896309 PMCID: PMC9988647 DOI: 10.4240/wjgs.v15.i2.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 02/27/2023] Open
Abstract
Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.
Collapse
Affiliation(s)
- Hong-Yu Wu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jin-Wei Li
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545000, Guangxi Province, China
| | - Jin-Zheng Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Qi-Long Zhai
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jing-Yuan Ye
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Si-Yuan Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Kun Fang
- Department of Surgery, Yinchuan Maternal and Child Health Hospital, Yinchuan 750000, Ningxia, China
| |
Collapse
|
5
|
Imamura H, Takahashi H, Akita H, Wada H, Mukai Y, Asukai K, Hasegawa S, Fujii Y, Sugase T, Yamamoto M, Takeoka T, Shinno N, Hara H, Kanemura T, Haraguchi N, Nishimura J, Matsuda C, Yasui M, Omori T, Miyata H, Ohue M, Sakon M. The clinical impact of modified transpancreatic mattress sutures with polyglactin 910 woven mesh on postoperative pancreatic fistula in distal pancreatectomy. Surgery 2022; 172:1220-1227. [PMID: 35773024 DOI: 10.1016/j.surg.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/08/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND We previously reported the stump closure method for the remnant pancreas in distal pancreatectomy, in which soft coagulation and polyglycolic acid felt attached with fibrin glue were utilized. Transpancreatic mattress suture with polyglactin 910 woven mesh was recently reported as a novel stump closure technique. We developed the modified transpancreatic mattress suture with polyglactin 910 woven mesh method, which combined our polyglycolic acid felt method with the transpancreatic mattress suture with polyglactin 910 woven mesh method. METHODS The polyglycolic acid felt group included patients undergoing distal pancreatectomy in whom the pancreatic stump was closed with the polyglycolic acid felt method from 2017 to 2018 (n = 54); whereas the modified transpancreatic mattress suture with polyglactin 910 woven mesh group included those whose stump was closed with the modified transpancreatic mattress suture with polyglactin 910 woven mesh method from 2019 to 2020 (n = 51). Perioperative parameters, including grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula), were assessed according to the stump closure method. RESULTS The incidence of clinically relevant postoperative pancreatic fistula was significantly lower in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group than in the polyglycolic acid felt group (7.8% vs 22.2%, P = .036). In multivariate analysis, the use of neoadjuvant chemoradiotherapy and the transpancreatic mattress suture with polyglactin 910 woven mesh method were independent factors for preventing clinically relevant postoperative pancreatic fistula (P = .011 and 0.0038, respectively). Moreover, in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group, the incidence of clinically relevant postoperative pancreatic fistula in patients with a thick pancreas (≥13 mm, 6.7%) was comparably as low as that in patients with a thin pancreas (<13 mm, 9.5%). CONCLUSION The modified transpancreatic mattress suture with polyglactin 910 woven mesh method is an effective stump closure technique to prevent clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Our results warrant further prospective investigation to evaluate the efficacy of the modified transpancreatic mattress suture with polyglactin 910 woven mesh method compared with other standard closure methods (eg, stapler closure or hand-sewn closure).
Collapse
Affiliation(s)
- Hiroki Imamura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hidenori Takahashi
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan.
| | - Hirofumi Akita
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hiroshi Wada
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Yosuke Mukai
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Kei Asukai
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Shinichiro Hasegawa
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Yoshiaki Fujii
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takahito Sugase
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masaaki Yamamoto
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Tomohira Takeoka
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Naoki Shinno
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hisashi Hara
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takashi Kanemura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Junichi Nishimura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Chu Matsuda
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masayoshi Yasui
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takeshi Omori
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hiroshi Miyata
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masato Sakon
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| |
Collapse
|
6
|
van Dongen JC, Wismans LV, Suurmeijer JA, Besselink MG, de Wilde RF, Groot Koerkamp B, van Eijck CHJ. The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies. HPB (Oxford) 2021; 23:1321-1331. [PMID: 34099372 DOI: 10.1016/j.hpb.2021.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer. METHODS This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models. RESULTS Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity. CONCLUSION Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
Collapse
Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Leonoor V Wismans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | |
Collapse
|
7
|
Wang L, Zhang X, Lu Y, Tian B. Letter to the editor: the nonnegligible effect of neoadjuvant therapy for patients with borderline resectable pancreatic ductal adenocarcinoma. Gland Surg 2021; 10:2340-2342. [PMID: 34422605 DOI: 10.21037/gs-21-379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/30/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Li Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Zhang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yanrong Lu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bole Tian
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
8
|
Nappo G, Donisi G, Zerbi A. Borderline resectable pancreatic cancer: Certainties and controversies. World J Gastrointest Surg 2021; 13:516-528. [PMID: 34194610 PMCID: PMC8223708 DOI: 10.4240/wjgs.v13.i6.516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.
Collapse
Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Greta Donisi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| |
Collapse
|
9
|
Self-assembling peptide hydrogel SPG-178 as a pancreatic fistula-preventing agent. Langenbecks Arch Surg 2021; 407:189-196. [PMID: 34100123 DOI: 10.1007/s00423-021-02226-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Pancreatic fistula (PF) is a common and challenging complication after pancreatic surgery. The aim of this study was to investigate the efficacy of a new method for preventing PF utilizing self-assembling peptide hydrogel SPG-178 as a preclinical study. METHODS The degradability of SPG-178 was confirmed by mixing it with protease. A PF rat model was then established to investigate the efficacy of SPG-178 at preventing PF. After transecting the pancreatic duct toward the spleen, SPG-178 was attached to both sides of the pancreatic stump. The levels of amylase and lipase in both the serum and ascites were measured and surgical specimens investigated pathologically. RESULTS The hardness of SPG-178 did not change when treated with protease over a short period. The ascitic amylase level was significantly lower in rats treated with SPG-178 than rats who were not 3 days after transection of the pancreatic duct toward the spleen. Pathological examination showed fewer inflammatory cells and presence of a structure body on the surface of the pancreatic stump in the SPG-178-treated group. SPG-178 remained on the surface and many cells that covered it formed fibrous tissue or mesothelium. CONCLUSION Self-assembling peptide hydrogel SPG-178 has potential as a tool for preventing PF.
Collapse
|
10
|
Yamada S, Fujii T, Sonohara F, Kawai M, Shibuya K, Matsumoto I, Fukuzawa K, Baba H, Aoki T, Unno M, Satoi S, Kishi Y, Hatano E, Uemura K, Horiguchi A, Sho M, Takeda Y, Shimokawa T, Kodera Y, Yamaue H. Safety of Combined Division vs Separate Division of the Splenic Vein in Patients Undergoing Distal Pancreatectomy: A Noninferiority Randomized Clinical Trial. JAMA Surg 2021; 156:418-428. [PMID: 33656542 PMCID: PMC7931136 DOI: 10.1001/jamasurg.2021.0108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Question In distal pancreatectomy, is combined division of the splenic vein safe compared with separate division of the splenic vein? Findings In this noninferiority randomized clinical trial, the proportion of grade B/C pancreatic fistula in the separate division group was 27.1% vs 28.6% in the combined division group, demonstrating noninferiority of the combined division of the splenic vein against separate division. Meaning The safety of combined division of the splenic vein in distal pancreatectomy was established, such that the approach could be recommended with more confidence. Importance In distal pancreatectomy (DP), the splenic vein is isolated from the pancreatic parenchyma prior to being ligated and divided to prevent intra-abdominal hemorrhage from the splenic vein stump with pancreatic fistula (PF). Conversely, dissecting the splenic vein with the pancreatic parenchyma is easy and time-saving. Objective To establish the safety of combined division of the splenic vein compared with separate division of the splenic vein. Design, Setting, and Participants This study was designed as a multicenter prospective randomized phase 3 trial. All results were analyzed using the modified intent-to-treat set. Patients undergoing DP for pancreatic body and tail tumors were eligible for inclusion. Patients were randomly assigned between August 10, 2016, and July 30, 2019. Interventions Patients were centrally randomized (1:1) to either separate division of the splenic vein or combined division of the splenic vein. Main Outcomes and Measures The primary end point was the incidence of grade B/C PF, and the incidence of intra-abdominal hemorrhage was included as one of the secondary end points. Results A total of 318 patients were randomly assigned, and 2 patients were excluded as ineligible. Of the 316 remaining patients, 150 (50.3%) were male. The modified intent-to-treat population constituted 159 patients (50.3%) in the separate division group and 157 patients (49.7%) in the combined division group. In the modified intent-to-treat set, the proportion of grade B/C PF in the separate division group was 27.1% (42 of 155) vs 28.6% (44 of 154) in the combined division group (adjusted odds ratio, 1.108; 95% CI, 0.847-1.225; P = .047), demonstrating noninferiority of the combined division of the splenic vein against separate division. The incidence of postoperative intra-abdominal hemorrhage in the 2 groups was identical at 1.3%. Conclusions and Relevance This study demonstrated noninferiority of the combined division of the splenic vein compared with separate division of the splenic vein regarding safety. Thus, isolating the splenic vein from the pancreatic parenchyma is deemed unnecessary. Trial Registration ClinicalTrials.gov Identifier: NCT02871804
Collapse
Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Sugitani, Toyama, Japan
| | - Fuminori Sonohara
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Kimiidera, Wakayama, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Sugitani, Toyama, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Ono-higashi, Osaka-Sayama, Japan
| | - Kengo Fukuzawa
- Department of Surgery, Oita Red Cross Hospital, Chiyo-machi, Oita, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Honjo, Chuo-ku, Kumamoto, Japan
| | - Takeshi Aoki
- Department of Gastroenterological and General Surgery, Showa University School of Medicine, Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Michiaki Unno
- Division of Hepato-Biliary Pancreatic Surgery, Tohoku University Graduate School of Medicine, Seiryo-cho, Aoba-ku, Sendai, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Shinmachi, Hirakata, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College, Namiki, Tokorozawa, Saitama, Japan
| | - Etsuro Hatano
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Mukogawa, Nishinomiya, Hyogo, Japan
| | - Kenichiro Uemura
- Department of Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Kasumi, Minami-ku, Hiroshima, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University Bantane Hospital, Otobashi, Nakagawa-ku, Nagoya, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University School of Medicine, Shijo-cho, Kashihara, Nara, Japan
| | - Yutaka Takeda
- Department of Surgery, Japan Organization of Occupational Health and Safety, Kansai Rosai Hospital, Inabaso, Amagasaki, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Kimiidera, Wakayama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Kimiidera, Wakayama, Japan
| |
Collapse
|
11
|
Hua J, Chen XM, Chen YJ, Lu BC, Xu J, Wang W, Shi S, Yu XJ. Development and multicenter validation of a nomogram for preoperative prediction of lymph node positivity in pancreatic cancer (NeoPangram). Hepatobiliary Pancreat Dis Int 2021; 20:163-172. [PMID: 33461937 DOI: 10.1016/j.hbpd.2020.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Neoadjuvant therapy is associated with nodal downstaging and improved oncological outcomes in patients with lymph node (LN)-positive pancreatic cancer. This study aimed to develop and validate a nomogram to preoperatively predict LN-positive disease. METHODS A total of 558 patients with resected pancreatic cancer were randomly and equally divided into development and internal validation cohorts. Multivariate logistic regression analysis was used to construct the nomogram. Model performance was evaluated by discrimination, calibration, and clinical usefulness. An independent multicenter cohort consisting of 250 patients was used for external validation. RESULTS A four-marker signature was built consisting of carbohydrate antigen 19-9 (CA19-9), CA125, CA50, and CA242. A nomogram was constructed to predict LN metastasis using three predictors identified by multivariate analysis: risk score of the four-marker signature, computed tomography-reported LN status, and clinical tumor stage. The prediction model exhibited good discrimination ability, with C-indexes of 0.806, 0.742 and 0.763 for the development, internal validation, and external validation cohorts, respectively. The model also showed good calibration and clinical usefulness. A cut-off value (0.72) for the probability of LN metastasis was determined to separate low-risk and high-risk patients. Kaplan-Meier survival analysis revealed a good agreement of the survival curves between the nomogram-predicted status and the true LN status. CONCLUSIONS This nomogram enables the identification of pancreatic cancer patients at high risk for LN positivity who may have more advanced disease and thus could potentially benefit from neoadjuvant therapy.
Collapse
Affiliation(s)
- Jie Hua
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
| | - Xue-Min Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First People's Hospital of Changzhou, Changzhou 213004, China
| | - Yun-Jie Chen
- Department of Minimally Invasive Hepatobiliary and Pancreatic Surgery, Ningbo No. 2 Hospital, Ningbo 315010, China
| | - Bao-Chun Lu
- Department of Hepatobiliary and Pancreatic Surgery, Shaoxing People's Hospital, Shaoxing 312000, China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
| | - Wei Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China
| | - Si Shi
- Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China.
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China.
| |
Collapse
|
12
|
Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis. J Gastrointest Surg 2021; 25:747-756. [PMID: 32253648 DOI: 10.1007/s11605-020-04581-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/23/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) drives morbidity and mortality following pancreatectomy. Use of neoadjuvant chemotherapy (NAC) has recently increased in the treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC). This study examined the effect of NAC on POPF rates and postoperative outcomes in PDAC. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset was queried to identify PDAC patients who underwent curative-intent pancreatectomies. Propensity score matching was used to stratify patients by receipt of NAC. Postoperative outcomes were compared and logistic regression applied to identify POPF predictors. RESULTS Six thousand eight hundred sixty-three patients met the inclusion criteria; of those, 1908 (27.8%) received NAC and 4955 (72.2%) did not (NNAC). Two thousand sixty-two patients were matched 1:1 from each group. NAC patients had significantly lower POPF rates (9.0% vs. 14.5%; P < 0.001); the majority were categorized as grade A (5.1% vs. 9.5%). Overall 30-day morbidity was lower with NAC (40.4% vs. 49.5%; P < 0.001). Specifically, pneumonia (2.3% vs. 4.1%), organ space infections (7.9% vs. 13.2%), sepsis (5.2% vs. 8.0%), and delayed gastric emptying (10.1% vs. 14.8%) occurred less frequently in the NAC group. Postoperative mortality and unplanned reoperations were similar. On multivariate analysis, receipt of NAC was an independent predictor of decreased POPF rates (HR, 0.73 [0.56-0.94]; P = 0.016). Other factors included gland texture, duct size, male gender, and lower BMI. CONCLUSIONS In this propensity-matched, population-based cohort study of PDAC patients, NAC was associated with lower POPF rates and overall major complications. Those findings suggest a modest protective effect of NAC from POPF.
Collapse
|
13
|
Rykina-Tameeva N, Nahm CB, Mehta S, Gill AJ, Samra JS, Mittal A. Neoadjuvant therapy for pancreatic cancer changes the composition of the pancreatic parenchyma. HPB (Oxford) 2020; 22:1631-1636. [PMID: 32247587 DOI: 10.1016/j.hpb.2020.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/16/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a prominent complication following pancreatic cancer resections. The primary aim of this study was to evaluate the histological changes that occur in the pancreas due to neoadjuvant therapy (NAT) by comparing the acinar, collagen and fat scores in resected PDAC specimens of patients who did and did not receive NAT. Secondary aims included (1) the difference in rates of POPF in PDAC patients who received NAT versus upfront resection; and (2) the association between acinar/collagen/fat scores and the development of POPF. METHODS Consecutive patients who underwent pancreaticoduodenectomy for PDAC, with and without NAT were included for analysis. Acinar, collagen and fat scores were determined from histology slides of the pancreatic resection margin. RESULTS One hundred and thirty-four patients were included. There was a significant decrease in the median acinar score (48 vs 23, p = 0.003) and increase in the collagen score (28 vs 50, p = 0.011) for patients who received NAT and a significant correlation with the number of cycles of NAT. This study found no statistical difference between NAT and the development of POPF. CONCLUSION The use of NAT in the treatment of PDAC changes the composition of the pancreas.
Collapse
Affiliation(s)
- Nadya Rykina-Tameeva
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia
| | - Shreya Mehta
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia.
| | - Anthony J Gill
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia; Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, NSW, Australia; Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| |
Collapse
|
14
|
Han IW, Cho K, Ryu Y, Shin SH, Heo JS, Choi DW, Chung MJ, Kwon OC, Cho BH. Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence. World J Gastroenterol 2020; 26:4453-4464. [PMID: 32874057 PMCID: PMC7438201 DOI: 10.3748/wjg.v26.i30.4453] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.
AIM To develop a risk prediction platform for POPF using an AI model.
METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.
RESULTS The number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.
CONCLUSION This study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.
Collapse
Affiliation(s)
- In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Kyeongwon Cho
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Myung Jin Chung
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Oh Chul Kwon
- Artificial Intelligence Research Center, Medical DataBase Incorporated, Seoul 06048, South Korea
| | - Baek Hwan Cho
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| |
Collapse
|
15
|
Kusafuka T, Kato H, Iizawa Y, Noguchi D, Gyoten K, Hayasaki A, Fujii T, Murata Y, Tanemura A, Kuriyama N, Azumi Y, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy. BMC Surg 2020; 20:129. [PMID: 32527310 PMCID: PMC7291550 DOI: 10.1186/s12893-020-00785-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/31/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon's hand. METHODS Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT. RESULTS In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (1.5%). According to multivariate analysis, a high pancreas-visceral fat CT value ratio (p = 0.002), serrated-type contour (p = 0.02) and no history of chemoradiotherapy (p = 0.019) were identified as independent risk factors for POPF grade B/C. Even in patients with soft pancreas, the incidence of POPF grade B/C was 0% (0/57) in patients with a pancreas-visceral fat CT value ratio of less than - 0.4 and smooth-type contour, whereas the incidence was markedly high (45.0%, 9/20) in patients with a pancreas-visceral fat CT value ratio of - 0.4 or greater and serrated-type contour, indicating that patients with soft pancreas should be categorized into POPF high-risk and low-risk groups according to preoperative CT scan results. CONCLUSIONS The pancreas-visceral fat CT value ratio and serrated-type pancreas are useful markers to preoperatively identify true POPF high-risk groups in patients undergoing PD, regardless of the pancreatic texture judged intraoperatively.
Collapse
Affiliation(s)
- Tomoki Kusafuka
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshinori Azumi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| |
Collapse
|
16
|
Kamarajah SK, Bundred JR, Boyle C, Oo J, Pandanaboyana S, Loveday B. Impact of neoadjuvant therapy on post-operative pancreatic fistula: a systematic review and meta-analysis. ANZ J Surg 2020; 90:2201-2210. [PMID: 32418344 DOI: 10.1111/ans.15885] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing, although its impact on post-operative pancreatic fistula (POPF) is variably reported. This systematic review and meta-analysis aimed to assess the impact of NAT on POPF. METHODS A systematic literature search until October 2019 identified studies reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy) versus upfront resection. The primary outcome was overall POPF. Secondary outcomes included grade B/C POPF, delayed gastric emptying (DGE), post-operative pancreatic haemorrhage (PPH) and overall and major complications. RESULTS The search identified 24 studies: pancreatoduodenectomy (PD), 19 studies (n = 19 416) and distal pancreatectomy (DP), five studies (n = 477). Local staging was reported in 17 studies, with borderline resectable and locally advanced disease comprising 6% (0-100%) and 1% (0-33%) of the population, respectively. For PD, any NAT was significantly associated with lower rates of overall POPF (OR: 0.57, P < 0.001) and grade B/C POPF (OR: 0.55, P < 0.001). In DP, NAT was not associated with significantly lower rates of overall or grade B/C POPF. CONCLUSION NAT is associated with significantly lower rates of POPF after PD but not after DP. Further studies are required to determine whether NAT should be added to POPF risk calculators.
Collapse
Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, Newcastle, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Charles Boyle
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - June Oo
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Benjamin Loveday
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand
| |
Collapse
|
17
|
Lof S, Korrel M, van Hilst J, Alseidi A, Balzano G, Boggi U, Butturini G, Casadei R, Dokmak S, Edwin B, Falconi M, Keck T, Malleo G, de Pastena M, Tomazic A, Wilmink H, Zerbi A, Besselink MG, Abu Hilal M. Impact of Neoadjuvant Therapy in Resected Pancreatic Ductal Adenocarcinoma of the Pancreatic Body or Tail on Surgical and Oncological Outcome: A Propensity-Score Matched Multicenter Study. Ann Surg Oncol 2019; 27:1986-1996. [PMID: 31848815 PMCID: PMC7210228 DOI: 10.1245/s10434-019-08137-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several studies have suggested a survival benefit of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head. Data concerning NAT for PDAC located in pancreatic body or tail are lacking. METHODS Post hoc analysis of an international multicenter retrospective cohort of distal pancreatectomy for PDAC in 34 centers from 11 countries (2007-2015). Patients who underwent resection after NAT were matched (1:1 ratio), using propensity scores based on baseline characteristics, to patients who underwent upfront resection. Median overall survival was compared using the stratified log-rank test. RESULTS Among 1236 patients, 136 (11.0%) received NAT, most frequently FOLFIRINOX (25.7%). In total, 94 patients receiving NAT were matched to 94 patients undergoing upfront resection. NAT was associated with less postoperative major morbidity (Clavien-Dindo ≥ 3a, 10.6% vs. 23.4%, P = 0.020) and pancreatic fistula grade B/C (9.6% vs. 21.3%, P = 0.026). NAT did not improve overall survival [27 (95% CI 14-39) versus 31 months (95% CI 19-42), P = 0.277], as compared with upfront resection. In a sensitivity analysis of 251 patients with radiographic tumor involvement of splenic vessels, NAT (n = 37, 14.7%) was associated with prolonged overall survival [36 (95% CI 18-53) versus 20 months (95% CI 15-24), P = 0.049], as compared with upfront resection. CONCLUSION In this international multicenter cohort study, NAT for resected PDAC in pancreatic body or tail was associated with less morbidity and pancreatic fistula but similar overall survival in comparison with upfront resection. Prospective studies should confirm a survival benefit of NAT in patients with PDAC and splenic vessel involvement.
Collapse
Affiliation(s)
- Sanne Lof
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Gianpaolo Balzano
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | | | - Riccardo Casadei
- Department of Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Safi Dokmak
- Department of Surgery, Hospital of Beaujon, Clichy, France
| | - Bjørn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Tobias Keck
- Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Hanneke Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University Hospital, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK. .,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
| | | |
Collapse
|
18
|
Jiang L, Ning D, Chen X. Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions. Front Med 2019; 14:251-261. [PMID: 31840199 DOI: 10.1007/s11684-019-0727-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/12/2019] [Indexed: 02/08/2023]
Abstract
Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.
Collapse
Affiliation(s)
- Li Jiang
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Deng Ning
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| |
Collapse
|
19
|
Hank T, Sandini M, Ferrone CR, Rodrigues C, Weniger M, Qadan M, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy. JAMA Surg 2019; 154:943-951. [PMID: 31411659 PMCID: PMC6694396 DOI: 10.1001/jamasurg.2019.2272] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/17/2019] [Indexed: 01/05/2023]
Abstract
Importance In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited. Objective To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential associations with OS. Design, Setting, and Participants This retrospective cohort study was conducted on data from patients who underwent pancreatic resection for PDAC at the Massachusetts General Hospital from January 1, 2007, to December 31, 2017. Exposures Pancreatic cancer surgery with or without NAT. Main Outcomes and Measures Overall morbidity and CR-POPF rates were compared between NAT and upfront resection. Factors associated with CR-POPF were assessed with univariate and multivariate analysis. Survival data were analyzed by Kaplan-Meier curves and a Cox proportional hazards regression model. Results Of 753 patients, 364 were men (48.3%); median (interquartile range) age was 68 (61-75) years. A total of 346 patients (45.9%) received NAT and 407 patients (54.1%) underwent upfront resection. At pathologic examination, NAT was associated with smaller tumor size (mean [SD], 26.0 [15.3] mm vs 32.7 [14.4] mm; P < .001), reduced nodal involvement (102 [25.1%] vs 191 [55.2%]; P < .001), and higher R0 rates (257 [74.3%] vs 239 [58.7%]; P < .001). There were no significant differences in severe complication rate or 90-day mortality. The rate of CR-POPF was 3.6-fold lower in patients receiving NAT vs upfront resection (13 [3.8%] vs 56 [13.8%]; P < .001). In addition, factors associated with CR-POPF changed after NAT, and only soft pancreatic texture was associated with a higher risk of CR-POPF (38.5% vs 6.3%; P < .001). Survival analysis showed no differences between patients with or without CR-POPF after upfront resection (26 vs 25 months; P = .66), but after NAT, a worse overall survival rate was observed in patients with CR-POPF (17 vs 34 months; P = .002). This association was independent of other established predictors of overall survival by multivariate analysis (hazard ratio, 2.80; 95% CI, 1.44-5.45; P < .002). Conclusions and Relevance Neoadjuvant therapy may be associated with a significant reduction in the rate of CR-POPF. In addition, standard factors associated with CR-POPF appear to be no longer applicable following NAT. However, once CR-POPF occurs, it is associated with a significant reduction in long-term survival. Patients with CR-POPF may require closer follow-up and could benefit from additional therapy.
Collapse
Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
20
|
Pouypoudat C, Buscail E, Cossin S, Cassinotto C, Terrebonne E, Blanc JF, Smith D, Marty M, Dupin C, Laurent C, Dabernat S, Chiche L, Vendrely V. FOLFIRINOX-based neoadjuvant chemoradiotherapy for borderline and locally advanced pancreatic cancer: A pilot study from a tertiary centre. Dig Liver Dis 2019; 51:1043-1049. [PMID: 31000479 DOI: 10.1016/j.dld.2019.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy, potentially relevant to increase resection rate in pancreatic cancer, is still debated. AIMS To assess tolerance, resection rate and outcomes of patients with non-metastatic pancreatic ductal adenocarcinoma treated by concomitant chemoradiotherapy. METHODS This monocentric study included all consecutive patients treated from 2010 to 2014 for non-metastatic pancreatic adenocarcinoma. Chemotherapy was followed by chemoradiotherapy in operable patients, surgical resectability being assessed by CT-scan. RESULTS Seventy-nine patients were included: 41 patients had borderline and 38 locally advanced tumours. All patients were treated by chemotherapy (FOLFIRINOX), followed by chemoradiotherapy (median dose: 59 Gy, range 45-66 Gy) for 94% of patients. Thirty-seven patients (47%) could subsequently benefit from surgery with a complete R0 resection in 94% of cases, with a postoperative mortality of 5%. Median overall survival was 21.5 months (median follow-up: 48.8 months). Local control, overall and disease-free survival were significantly higher for patients who underwent resection compared to others, with 89.2% vs 59.5% (p = 0.01), 49.7 vs 17.4 months (p < 0.01) and 25.5 vs 9.2 months (p < 0.01), respectively. CONCLUSION Neoadjuvant treatment consisting of FOLFIRINOX chemotherapy followed by chemoradiotherapy is an efficient strategy for patients with borderline and locally advanced pancreatic cancer, resulting in a 43% rate of secondary complete surgical resection associated with high local control, overall and disease-free survival.
Collapse
Affiliation(s)
| | - Etienne Buscail
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | | | | | | | - Denis Smith
- CHU Bordeaux, Department of Oncology, Bordeaux, France
| | - Marion Marty
- CHU Bordeaux, Department of Pathology, Bordeaux, France
| | - Charles Dupin
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France
| | - Christophe Laurent
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | | | - Laurence Chiche
- Bordeaux University, INSERM U1035, Bordeaux, France; CHU Bordeaux, Department of Surgery, Bordeaux, France
| | - Véronique Vendrely
- CHU Bordeaux, Department of Radiotherapy, Bordeaux, France; Bordeaux University, INSERM U1035, Bordeaux, France.
| |
Collapse
|
21
|
Use of Machine-Learning Algorithms in Intensified Preoperative Therapy of Pancreatic Cancer to Predict Individual Risk of Relapse. Cancers (Basel) 2019; 11:cancers11050606. [PMID: 31052270 PMCID: PMC6562932 DOI: 10.3390/cancers11050606] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Although surgical resection is the only potentially curative treatment for pancreatic cancer (PC), long-term outcomes of this treatment remain poor. The aim of this study is to describe the feasibility of a neoadjuvant treatment with induction polychemotherapy (IPCT) followed by chemoradiation (CRT) in resectable PC, and to develop a machine-learning algorithm to predict risk of relapse. Methods: Forty patients with resectable PC treated in our institution with IPCT (based on mFOLFOXIRI, GEMOX or GEMOXEL) followed by CRT (50 Gy and concurrent Capecitabine) were retrospectively analyzed. Additionally, clinical, pathological and analytical data were collected in order to perform a 2-year relapse-risk predictive population model using machine-learning techniques. Results: A R0 resection was achieved in 90% of the patients. After a median follow-up of 33.5 months, median progression-free survival (PFS) was 18 months and median overall survival (OS) was 39 months. The 3 and 5-year actuarial PFS were 43.8% and 32.3%, respectively. The 3 and 5-year actuarial OS were 51.5% and 34.8%, respectively. Forty-percent of grade 3-4 IPCT toxicity, and 29.7% of grade 3 CRT toxicity were reported. Considering the use of granulocyte colony-stimulating factors, the number of resected lymph nodes, the presence of perineural invasion and the surgical margin status, a logistic regression algorithm predicted the individual 2-year relapse-risk with an accuracy of 0.71 (95% confidence interval [CI] 0.56–0.84, p = 0.005). The model-predicted outcome matched 64% of the observed outcomes in an external dataset. Conclusion: An intensified multimodal neoadjuvant approach (IPCT + CRT) in resectable PC is feasible, with an encouraging long-term outcome. Machine-learning algorithms might be a useful tool to predict individual risk of relapse. A small sample size and therapy heterogeneity remain as potential limitations.
Collapse
|
22
|
Dokmak S, Ftériche FS, Meniconi RL, Aussilhou B, Duquesne I, Perrone G, Romdhani C, Belghiti J, Lévy P, Soubrane O, Sauvanet A. Pancreatic fistula following laparoscopic distal pancreatectomy is probably unrelated to the stapler size but to the drainage modality and significantly decreased with a small suction drain. Langenbecks Arch Surg 2019; 404:203-212. [DOI: 10.1007/s00423-019-01756-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
|
23
|
Splenic vein resection together with the pancreatic parenchyma versus separated resection after isolation of the parenchyma during distal pancreatectomy (COSMOS-DP trial): study protocol for a randomised controlled trial. Trials 2018; 19:369. [PMID: 29996884 PMCID: PMC6042420 DOI: 10.1186/s13063-018-2756-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/20/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In distal pancreatectomy (DP), it is customary to ligate and divide the splenic vein after isolating it from the pancreatic parenchyma. This is considered essential to prevent disruption of the stump of the splenic vein and consequent intra-abdominal haemorrhage in the event of pancreatic fistula (PF). However, this procedure can be technically demanding, especially when the vein is firmly embedded in the pancreatic parenchyma. The objective of the COSMOS-DP trial is to confirm the non-inferiority of resection of the splenic vein embedded in the pancreatic parenchyma compared with the conventional technique of isolating the splenic vein before resection during DP using a mechanical stapler. METHODS Patients with diseases of the pancreatic body and tail whose pancreatic parenchyma and splenic vein can be divided concurrently during open or laparoscopic DP are considered eligible for inclusion. This study is designed as a multicentre prospective randomised phase III trial. Eligible patients will be centrally randomised to either Arm A (resection of the splenic vein after isolation from the pancreatic parenchyma) or Arm B (co-resection of the vein together with the pancreas). This study aims to establish the non-inferiority of the safety of Arm B compared with that of Arm A; the primary endpoint is the incidence of PF (ISGPF grade B/C). DISCUSSION The COSMOS-DP trial will establish the safety of this procedure, such that it can be recommended with more confidence. The use of this procedure will likely result in significant reductions in operative time and blood loss during DP. TRIAL REGISTRATION ClinicalTrials.gov, NCT02871804 . Registered on 27 July 2016.
Collapse
|
24
|
Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11:105-118. [PMID: 29588609 PMCID: PMC5858541 DOI: 10.2147/ceg.s120217] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.
Collapse
Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia
| | - Saxon J Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
| |
Collapse
|
25
|
Blair AB, Rosati LM, Rezaee N, Gemenetzis G, Zheng L, Hruban RH, Cameron JL, Weiss MJ, Wolfgang CL, Herman JM, He J. Postoperative complications after resection of borderline resectable and locally advanced pancreatic cancer: The impact of neoadjuvant chemotherapy with conventional radiation or stereotactic body radiation therapy. Surgery 2018; 163:1090-1096. [PMID: 29395234 DOI: 10.1016/j.surg.2017.11.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The impact of neoadjuvant stereotactic body radiation therapy on postoperative complications for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma remains unclear. Limited studies have compared neoadjuvant stereotactic body radiation therapy versus conventional chemoradiation therapy. A retrospective study was performed to determine if perioperative complications were different among patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma receiving neoadjuvant stereotactic body radiation therapy or chemoradiation therapy. METHODS Patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma who underwent neoadjuvant chemotherapy with stereotactic body radiation therapy or chemoradiation therapy followed by pancreatectomy at the Johns Hopkins Hospital between 2008 and 2015 were included. Predictive factors for severe complications (Clavien grade ≥ III) were assessed by univariate and multivariate analyses. RESULTS A total of 168 patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma underwent neoadjuvant chemotherapy and RT followed by pancreatectomy. Sixty-one (36%) patients underwent stereotactic body radiation therapy and 107 (64%) patients received chemoradiation therapy. Compared with the chemoradiation therapy cohort, the neoadjuvant stereotactic body radiation therapy cohort was more likely to have locally advanced pancreatic ductal adenocarcinoma (62% vs 43% P = .017) and require a vascular resection (54% vs 37%, P = .027). Multiagent chemotherapy was used more commonly in the stereotactic body radiation therapy cohort (97% vs 75%, P < .001). Postoperative complications (Clavien grade ≥ III 23% vs 28%, P = .471) were similar between stereotactic body radiation therapy and chemoradiation therapy cohort. No significant difference in postoperative bleeding or infection was noted in either group. CONCLUSION Compared with chemoradiation therapy, neoadjuvant stereotactic body radiation therapy appears to offer equivalent rates of perioperative complications in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma despite a greater percentage of locally advanced disease and more complex operative treatment.
Collapse
Affiliation(s)
- Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lauren M Rosati
- The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Neda Rezaee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Georgios Gemenetzis
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lei Zheng
- The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ralph H Hruban
- The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA; The Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA; The Sol Goldman Pancreatic Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA.
| |
Collapse
|
26
|
Should functional renal scans be obtained prior to upper abdominal IMRT for pancreatic cancer? Pract Radiat Oncol 2017; 7:e449-e455. [PMID: 28886941 DOI: 10.1016/j.prro.2017.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/08/2017] [Accepted: 06/26/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Upper abdominal irradiation for pancreatic cancer is administered in close proximity to the radiation-sensitive kidneys. There is difficulty in defining dose-volume parameters to predict late renal toxicity after partial kidney irradiation. Less than 10% of the general population is estimated to have asymmetrical kidney function; however, there are no studies that examine this in patients with pancreatic cancer. The primary purpose of this study was to determine the prevalence of asymmetrical kidney function in patients with pancreatic cancer. A secondary aim was to determine if asymmetrical kidney function was associated with abnormal laboratory values or kidney size on computed tomography scans. Finally, we aimed to develop recommendations for when a functional renal scan in patients with pancreatic cancer should be ordered. METHODS AND MATERIALS We performed a retrospective review of patients with resectable, borderline resectable, and locally advanced pancreatic cancer who received abdominal radiation therapy and had preradiation functional renal scans between 2009 and 2015. Asymmetrical kidney function was defined as a difference between the 2 kidneys that was ≥60%/40% on a functional renal scan. Serum studies (blood urea nitrogen [BUN], creatinine [Cr], and glomerular filtration rate [GFR]) and abdominal computed tomography scans were routinely obtained before simulation. RESULTS Of the 204 patients examined, 23 (11.2%) had asymmetrical kidney function that was identified on preradiation functional renal scans. Elevated Cr or BUN, a GFR <60, or a medical history that suggested abnormal renal function were not significantly associated with asymmetrical kidney function. Only 6 of 23 patients (26%) with asymmetrical kidney function had a notable difference in kidney size. CONCLUSIONS In our series, approximately 11% of patients with pancreatic cancer have asymmetrical kidney function that was not identified by kidney size, serum BUN, Cr, GFR, or a significant medical history. These data suggest that in cases in which renal radiation doses exceed a V18 of 20% to 30% or there is concern about baseline renal function, a functional renal scan should be considered.
Collapse
|
27
|
Mirkin KA, Hollenbeak CS, Gusani NJ, Wong J. Trends in utilization of neoadjuvant therapy and short-term outcomes in resected pancreatic cancer. Am J Surg 2017; 214:80-88. [DOI: 10.1016/j.amjsurg.2016.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/17/2016] [Accepted: 08/23/2016] [Indexed: 12/22/2022]
|
28
|
Mikamori M, Gotoh K, Takahashi H, Akita H, Tomokuni A, Kobayashi S, Ohue M, Fujiwara Y, Yano M, Ishikawa O, Sakon M. Novel intraoperative use of the "Tensipresser" to assess factors predictive of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2017; 47:1201-1207. [PMID: 28324164 DOI: 10.1007/s00595-017-1509-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
PURPOSES Pancreatic fistula (PF) is a challenging complication of pancreaticoduodenectomy (PD). 'Soft pancreas' is reported as a risk factor for PF; however, palpation by the surgeon is not an objective method of evaluating pancreatic texture. We conducted this study to investigate whether a texture analyzer called a "Tensipresser" can be used to quantify pancreatic tissue hardness and predict the development of postoperative PF. METHODS We assessed pancreatic texture in 85 patients who underwent PD. After surgeons assessed the texture of the pancreas subjectively, the physical properties were measured on the pancreatic margin intraoperatively, by the two-bite method using the "Tensipresser". The incidence and severity of PF were based on the definitions of the International Study Group on Pancreatic Fistula. RESULTS Symptomatic PF (grade B and C) developed in 16% of the patients. Patients were divided into two groups based on the Tensipresser measurement: those with a soft and fragile pancreas with hardness < 2070 gw/cm2 and cohesiveness < 0.65 (SF group); and all other patients (non-SF group). In the univariate and multivariate analysis, a small pancreatic duct diameter (<4 mm), no conduction of preoperative chemoradiation therapy, and inclusion in the SF group were significant predictors of PF. CONCLUSION The Tensipresser can evaluate pancreatic texture objectively, helping to define intraoperatively, those at risk of the development of PF.
Collapse
Affiliation(s)
- Manabu Mikamori
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
- Department of Gastroenterological Surgery, Graduate School of Medicine Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Kunihito Gotoh
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan.
- Department of Gastroenterological Surgery, Graduate School of Medicine Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidenori Takahashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Hirofumi Akita
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Akira Tomokuni
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Shogo Kobayashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masahiko Yano
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Osamu Ishikawa
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masato Sakon
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| |
Collapse
|
29
|
Preoperative Chemoradiation for Pancreatic Adenocarcinoma Does Not Increase 90-Day Postoperative Morbidity or Mortality. J Gastrointest Surg 2016; 20:1975-1985. [PMID: 27730398 DOI: 10.1007/s11605-016-3286-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of preoperative chemoradiation on postoperative morbidity and mortality of patients with pancreatic adenocarcinoma remains controversial. METHODS Consecutive pancreatectomies for adenocarcinoma performed between 2011 and 2015 were prospectively monitored for 90 days by using a previously reported surveillance system to determine the association between preoperative chemoradiation and adverse events, pancreatic fistulae, readmissions, and mortality. RESULTS Among 209 consecutive patients who underwent pancreatectomy, 159 (76 %) experienced at least one adverse event within 90 postoperative days. Patients who received preoperative chemoradiation (n = 137, 66 %) were more likely to have borderline resectable/locally advanced tumors, to have received induction chemotherapy, and to require vascular resection at pancreatectomy than those who did not receive chemoradiation (all P < 0.05). Nonetheless, there were no significant differences in the rates of severe complications, readmission, or mortality between these groups (all P > 0.05). Among patients who underwent pancreatoduodenectomy, the rate of pancreatic fistula was similar between those who received chemoradiation and those who did not (P = 0.96). In contrast, those who received chemoradiation prior to distal pancreatectomy had a lower rate of pancreatic fistula (P < 0.01). CONCLUSION Preoperative chemoradiation is not associated with an increase in 90-day morbidity or mortality, and it may reduce the rate of pancreatic fistula following distal pancreatectomy.
Collapse
|
30
|
de Geus SWL, Eskander MF, Bliss LA, Kasumova GG, Ng SC, Callery MP, Tseng JF. Neoadjuvant therapy versus upfront surgery for resected pancreatic adenocarcinoma: A nationwide propensity score matched analysis. Surgery 2016; 161:592-601. [PMID: 28341441 DOI: 10.1016/j.surg.2016.08.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/23/2016] [Accepted: 08/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage. METHODS A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method. RESULTS In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer (n = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank P < .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I (n = 3,149; median survival, 26.2 vs 25.7 months; P = .4418) and II (n = 5,065; median survival, 23.5 vs 23.0 months; P = .7751) disease after matching. CONCLUSION The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.
Collapse
Affiliation(s)
- Susanna W L de Geus
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mariam F Eskander
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lindsay A Bliss
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark P Callery
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F Tseng
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
31
|
Tsai S, Erickson BA, Dua K, Ritch PS, Tolat P, Evans DB. Evolution of the Management of Resectable Pancreatic Cancer. J Oncol Pract 2016; 12:772-8. [DOI: 10.1200/jop.2016.015818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In pancreatic cancer, as with many other solid tumors, a commonly held surgical adage—a chance to cut is a chance to cure—has been promulgated throughout the years. Following such reasoning, surgical extirpation of a localized tumor would prevent tumor dissemination and metastatic tumor progression. However, decades of surgical experience have demonstrated that surgical resection alone provides a limited median survival benefit. Despite the optimization of surgical technique and perioperative management over the past three decades, little progress has been made to improve the limited survival of patients with localized pancreatic cancer who receive surgery. In this article, we discuss the rationale for a novel management strategy for patients with resectable pancreatic cancer, which may improve patient selection and the delivery of multimodality therapy.
Collapse
Affiliation(s)
- Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | | | | |
Collapse
|
32
|
Preoperative chemoradiotherapy does not compromise the feasibility of adjuvant chemotherapy for patients with pancreatic ductal adenocarcinoma. Surg Today 2016; 47:218-226. [PMID: 27586014 DOI: 10.1007/s00595-016-1405-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/10/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Preoperative chemoradiotherapy (CRT) is a novel, emerging treatment strategy for pancreatic ductal adenocarcinoma (PDAC), but it remains unclear whether post-surgery adjuvant chemotherapy is feasible following preoperative CRT. This retrospective study evaluates the feasibility of adjuvant therapy after preoperative CRT. METHODS The subjects of this study were 99 consecutive patients who underwent pancreatectomy for PDAC between January, 2007 and February, 2013 in our hospital. Sixty patients received preoperative CRT: as gemcitabine (GEM) and 40 Gy radiation in 28 (G-CRT group), and as GEM, S-1, and 50.4 Gy radiation in 32 (GS-CRT group). We also evaluated 39 patients who underwent surgery alone (SA group). We investigated adjuvant chemotherapy induction and completion rates and the frequency of adverse events rated ≥grade 3, based on Common Terminology Criteria for Adverse Events (version 4.0) in all three groups. RESULTS In the G-CRT, GS-CRT, and SA groups, the induction rates were 78 % (22/28), 78 % (25/32), and 72 % (28/39), respectively; completion rates were 86 % (19/22), 88 % (22/25), and 82 % (23/28), respectively; and adverse event frequencies were 36 % (8/22), 28 % (7/25), and 43 % (12/28), respectively. No significant difference was found among the three groups. CONCLUSION Preoperative CRT was demonstrated to be safe and did not compromise the feasibility of adjuvant chemotherapy.
Collapse
|
33
|
Kim SS, Nakakura EK, Wang ZJ, Kim GE, Corvera CU, Harris HW, Kirkwood KS, Hirose R, Tempero MA, Ko AH. Preoperative FOLFIRINOX for borderline resectable pancreatic cancer: Is radiation necessary in the modern era of chemotherapy? J Surg Oncol 2016; 114:587-596. [PMID: 27444658 DOI: 10.1002/jso.24375] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND No consensus exists regarding the optimal neoadjuvant treatment paradigm for patients with borderline resectable pancreatic cancer (BRPC), including the respective roles of chemotherapy and radiation. METHODS We performed a retrospective analysis, including detailed pathologic and radiologic review, of pancreatic cancer patients undergoing FOLFIRINOX, with or without radiation therapy (RT), prior to surgical resection at a high-volume academic center over a 4-year period. RESULTS Of 26 patients meeting inclusion criteria, 22 (84.6%) received FOLFIRINOX alone without RT (median number of treatment cycles = 9). The majority of patients met formal radiographic criteria for BRPC, with the superior mesenteric vein representing the most common vessel involved. R0 resection rate was 90.9%, with 12 patients (54.5%) requiring vascular reconstruction. Treatment response was classified as moderate or marked in 16 patients (72.7%) according to the College of American Pathologists grading system. Estimated median disease-free and overall survival rates are 22.6 months and not reached (NR), respectively. CONCLUSIONS This is one of the largest series to describe the use of neoadjuvant FOLFIRINOX, without radiation therapy, in patients with BRPC undergoing surgical resection. Given the high R0 resection rates and favorable clinical outcomes with chemotherapy alone, this strategy should be further assessed in prospective study design. J. Surg. Oncol. 2016;114:587-596. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Sunhee S Kim
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Eric K Nakakura
- Department of Surgery, University of California San Francisco, San Francisco, California.
| | - Zhen J Wang
- Department of Radiology, University of California San Francisco, San Francisco, California
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Carlos U Corvera
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Hobart W Harris
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Margaret A Tempero
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Andrew H Ko
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California.
| |
Collapse
|
34
|
Christians KK, Heimler JW, George B, Ritch PS, Erickson BA, Johnston F, Tolat PP, Foley WD, Evans DB, Tsai S. Survival of patients with resectable pancreatic cancer who received neoadjuvant therapy. Surgery 2016; 159:893-900. [PMID: 26602840 DOI: 10.1016/j.surg.2015.09.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/20/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enthusiasm for neoadjuvant therapy is growing from the emerging consensus that pancreatic cancer is a systemic disease at the time of diagnosis. Those who remain in favor of upfront surgery often cite the lack of reported data to support alternative treatment sequencing. We therefore report the results of all patients treated outside of a clinical trial under the direction of a multidisciplinary pancreatic cancer working group. METHODS We reviewed all patients with resectable pancreatic cancer treated with neoadjuvant therapy (NeoTx) from 2009 to 2013; we excluded those patients treated on prospective clinical trials as they will be the subject of subsequent reports. Data regarding demographics, NeoTx, operative outcomes, pathology, and survival data were abstracted from a prospective database. RESULTS NeoTx was initiated in 69 patients; median age was 65 years (interquartile range [IQR]: 11) and median carbohydrate antigen 19-9 at diagnosis was 96.5 (IQR 210). NeoTx consisted of chemotherapy alone (n = 10, 14%), chemotherapy and radiation (chemoradiation, n = 53, 77%), or both (n = 6, 9%). Median carbohydrate antigen 19-9 after NeoTx was 39 (IQR 104) corresponding to a median decrease of 60%. Operative resection was completed in 60 (87%) of the 69 patients. At restaging after NeoTx, 5 (7%) of 69 patients were not considered candidates for surgery because of the development of metastatic disease (n = 4) or an inadequate performance status (n = 1). At the time of surgery, 4 (6%) of 64 patients had metastatic disease found at laparoscopy. Of the 60 patients who underwent surgical resection, a complete pathologic response was observed in 2 (3%) patients; 20 (33%) had positive lymph nodes, and the median number of positive lymph nodes was 2 (IQR 3). R0 resections were achieved in 58 (97%) of the 60 patients. Additional postoperative adjuvant therapy was administered to 37 (62%) of the 60 patients. Median survival of all 69 patients was 31.5 months; 44.9 months for the 60 patients who completed all NeoTx and resection compared with 8.1 months for the 9 patients who were not resected (log rank P < .001). CONCLUSION NeoTx for resectable pancreatic cancer was associated with a median overall survival of 32 months; something not reported for patients treated with surgery first if based on intent-to-treat analysis. Treatment sequencing may provide an oncologic benefit beyond that of the selection bias afforded surgery after a period of induction therapy.
Collapse
Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI.
| | - Jonathan W Heimler
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Ben George
- Department of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Ritch
- Department of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Beth A Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Fabian Johnston
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Parag P Tolat
- Department of Diagnostic Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - William D Foley
- Department of Diagnostic Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas B Evans
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
35
|
Akahori T, Sho M, Tanaka T, Kinoshita S, Nagai M, Nishiwada S, Nishiofuku H, Ohbayashi C, Kichikawa K, Nakajima Y. Factors associated with failure to complete adjuvant chemotherapy in pancreatic cancer. Am J Surg 2016; 211:787-92. [DOI: 10.1016/j.amjsurg.2015.10.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 10/15/2015] [Accepted: 10/27/2015] [Indexed: 02/07/2023]
|
36
|
Closure method for thick pancreas stump after distal pancreatectomy: soft coagulation and polyglycolic acid felt with fibrin glue. Langenbecks Arch Surg 2015; 400:843-8. [PMID: 26345639 DOI: 10.1007/s00423-015-1339-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/31/2015] [Indexed: 12/30/2022]
Abstract
PURPOSE Pancreatic fistula (PF) remains an obstacle to safe distal pancreatectomy (DP). A thick pancreatic parenchyma is a major risk factor for PF. In this paper, we elucidate the feasibility of the new closure method using soft coagulation and polyglycolic acid felt with fibrin glue. METHODS In 2009-2013, 96 patients underwent DP with a novel closure method for pancreatic stump that utilized soft coagulation and polyglycolic acid felt with fibrin glue. We evaluated amylase levels in drainage fluid on postoperative days (POD) 1 and 3 and the incidence of postoperative PF according to International Study Group of Pancreatic Fistula (ISGPF) definitions. RESULTS Drain amylase levels on POD1 and POD3 were 275 and 241 U/L, respectively, and ISGPF-defined Grade B/C PF rates were 16.7%. No clinical factors were significantly associated with PF. Average pancreatic parenchymal thicknesses were similar in PF-positive and PF-negative patients (10.4 ± 2.6 mm vs. 10.1 ± 2.2 mm, P = 0.639). There was no significant difference in the postoperative PF rate between patients with thick (≥12 mm) and thin (<12 mm) pancreas (11.1 vs. 18.8%, P = 0.544). CONCLUSION Our novel pancreatic stump closure method appears to be simple and effective, particularly in patients with thick pancreas.
Collapse
|
37
|
Fathi A, Christians KK, George B, Ritch PS, Erickson BA, Tolat P, Johnston FM, Evans DB, Tsai S. Neoadjuvant therapy for localized pancreatic cancer: guiding principles. J Gastrointest Oncol 2015; 6:418-29. [PMID: 26261728 PMCID: PMC4502155 DOI: 10.3978/j.issn.2078-6891.2015.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/27/2015] [Indexed: 12/17/2022] Open
Abstract
The management of localized pancreatic cancer (PC) remains controversial. Historically, patients with localized disease have been treated with surgery followed by adjuvant therapy (surgery-first approach) under the assumption that surgical resection is necessary, even if not sufficient for cure. However, a surgery-first approach is associated with a median overall survival of only 22-24 months, suggesting that a large proportion of patients with localized PC have clinically occult metastatic disease. As a result, adjuvant therapy has been recommended for all patients with localized PC, but in actuality, it is often not received due to the high rates of perioperative complications associated with pancreatic resections. Recognizing that surgery may be necessary but usually not sufficient for cure, there has been growing interest in neoadjuvant treatment sequencing, which benefits patients with both localized and metastatic PC by ensuring the delivery of oncologic therapies which are commensurate with the stage of disease. For patients who have clinically occult metastatic disease, neoadjuvant therapy allows for the early delivery of systemic therapy and avoids the morbidity and mortality of a surgical resection which would provide no oncologic benefit. For patients with truly localized disease, neoadjuvant therapy ensures the delivery of all components of the multimodality treatment. This review details the rationale for a neoadjuvant approach to localized PC and provides specific recommendations for both pretreatment staging and treatment sequencing for patients with resectable and borderline resectable (BLR) disease.
Collapse
|
38
|
Optimal indication of neoadjuvant chemoradiotherapy for pancreatic cancer. Langenbecks Arch Surg 2015; 400:477-85. [PMID: 25929828 DOI: 10.1007/s00423-015-1304-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/20/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Much attention has been paid to preoperative treatment as a new strategy especially for borderline resectable pancreatic cancer (BRPC). The purpose of this study was to define the optimal indication of neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer. METHODS We analyzed consecutive 184 patients who had undergone pancreatic resection in Nara Medical University Hospital. Resectability status was classified by NCCN guidelines. Full-dose gemcitabine with concurrent radiation was used as NACRT. We evaluated 85 patients treated with NACRT in comparison with 99 patients without NACRT as control. RESULTS The regimen of NACRT was well tolerated and feasible. The perioperative outcomes were almost comparable. The postoperative complications were significantly less frequent in NACRT group than non-NACRT group. The pathological effects on both resectable and borderline tumors were favorable in NACRT group compared to non-NACRT group. The overall survival of resectable pancreatic cancer was significantly better than that of BRPC regardless of whether the patients were treated with or without NACRT. The prognosis of the patients with NACRT in resectable tumors was significantly better than without, while there was no significant difference in BRPC. Furthermore, multivariate analysis of various factors in the patients with NACRT identified resectability status and completion of adjuvant chemotherapy as independent prognostic factors. CONCLUSIONS NACRT did not improve the prognosis of the patients with BRPC, although it induced substantial pathological antitumor effect. In contrast, the prognosis of resectable pancreatic cancer treated with NACRT was favorable. Therefore, resectable pancreatic cancer may be good indication for multimodal treatment including NACRT.
Collapse
|
39
|
Sho M, Akahori T, Tanaka T, Kinoshita S, Nagai M, Tamamoto T, Ohbayashi C, Hasegawa M, Kichikawa K, Nakajima Y. Importance of resectability status in neoadjuvant treatment for pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:563-70. [PMID: 25921623 DOI: 10.1002/jhbp.258] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Much attention has been paid to neoadjuvant treatment (NAT) as a new strategy especially for borderline resectable pancreatic cancer (BRPC). However, the optimal indication of NAT remains undetermined. METHODS We analyzed 248 patients with pancreatic cancer (PC). One hundred resectable tumors were classified as R group. Sixty-nine tumors with venous involvement were classified as BR-P group, while 31 tumors with arterial involvement were classified as BR-A group. Ninety-nine patients received NAT. Furthermore, 48 unresectable locally advanced PC served as controls (LAPC group). Among them, 11 patients received adjuvant surgery afterwards (Ad-surg group). RESULTS The overall median survival time in the R, BR-P and BR-A groups was 45.3, 24.8 and 16.8 months. In the R and BR-P groups, patients treated with NAT had a better prognosis than those without. In contrast, NAT had no impact on prognosis in the BR-A group. Patients treated with NAT in the BR-P, but not BR-A group, had a better prognosis than patients in the LAPC group. Furthermore, patients in the Ad-surg group had a significantly better prognosis than patients in the BR-A group. CONCLUSIONS Borderline resectable pancreatic cancer with venous involvement, but without arterial involvement, may be a good indication for NAT. Our data highlight the importance of preoperative resectability assessment to evaluate the indication and efficacy of NAT.
Collapse
Affiliation(s)
- Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoichi Kinoshita
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Chiho Ohbayashi
- Department of Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | | |
Collapse
|
40
|
Takahashi H, Akita H, Gotoh K, Kobayashi S, Marubashi S, Miyoshi N, Sugimura K, Motoori M, Kishi K, Noura S, Fujiwara Y, Ohue M, Ohigashi H, Yano M, Sakon M, Ishikawa O. Preoperative gemcitabine-based chemoradiation therapy for pancreatic ductal adenocarcinoma of the body and tail: impact of splenic vessels involvement on operative outcome and pattern of recurrence. Surgery 2015; 157:484-95. [PMID: 25444512 DOI: 10.1016/j.surg.2014.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/12/2014] [Accepted: 09/16/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among the various multimodal treatment strategies for pancreatic ductal adenocarcinoma (PDA), preoperative chemoradiation therapy (CRT) and subsequent operation is a promising strategy. The aim of this study is to evaluate the outcome of preoperative gemcitabine-based CRT for PDA of the body and tail, focusing on the associations among splenic vessel involvement, surgical outcomes, and pattern of recurrence. METHODS A total of 99 patients with PDA of the body and tail received preoperative CRT. The status of tumor involvement of the splenic artery (SA) and vein (SV) were evaluated based on radiographical findings obtained before the initiation of preoperative CRT. We assessed the following in association with the status of SA and SV involvement: (1) resection rate, (2) survival, and (3) pattern of recurrence. RESULTS The resection rate of SA-positive cases (71%) was significantly lesser than that of SA-negative cases (94%; P = .004), whereas SV involvement was not associated with the resection rate. The 5-year survival rates of the resected SA-negative and SA-positive cases were 76% and 20%, respectively (P < .001). The 5-year cumulative incidence of distant recurrence was significantly higher in the SA-positive patients than in the SA-negative patients (74% vs. 17%; P < .001). CONCLUSION In preoperative CRT for PDA of the body and tail, positive SA involvement was associated with a lesser resection rate, and the survival rate for the patients with SA-positive tumors was lesser than that for patients with SA-negative tumors because of the greater incidence of distant recurrence in SA-positive patients.
Collapse
Affiliation(s)
- Hidenori Takahashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan.
| | - Hirofumi Akita
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Kunihito Gotoh
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Shogo Kobayashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Shigeru Marubashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Norikatsu Miyoshi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Keijiro Sugimura
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Kentaro Kishi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Shingo Noura
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Hiroaki Ohigashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Masahiko Yano
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Masato Sakon
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| | - Osamu Ishikawa
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka City, Japan
| |
Collapse
|
41
|
Does the use of neoadjuvant therapy for pancreatic adenocarcinoma increase postoperative morbidity and mortality rates? J Gastrointest Surg 2015; 19:80-6; discussion 86-7. [PMID: 25091851 PMCID: PMC4289101 DOI: 10.1007/s11605-014-2620-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 07/23/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The impact of neoadjuvant therapy on postpancreatectomy complications is inadequately described. METHODS Data from the NSQIP Pancreatectomy Demonstration Project (11/2011 to 12/2012) was used to identify patients with pancreatic adenocarcinoma who did and did not receive neoadjuvant therapy. Neoadjuvant therapy was classified as chemotherapy alone or radiation ± chemotherapy. Outcomes in the neoadjuvant vs. surgery first groups were compared. RESULTS Of 1,562 patients identified at 43 hospitals, 199 (12.7%) received neoadjuvant therapy (99 chemotherapy alone and 100 radiation ± chemotherapy). Preoperative biliary stenting (57.9 vs. 44.7%, p = 0.0005), vascular resection (41.5 vs. 17.3%, p < 0.0001), and open resections (94.0 vs. 91.4%, p = 0.008) were more common in the neoadjuvant group. Thirty-day mortality (2.0 vs. 1.5%, p = 0.56) and postoperative morbidity rates (56.3 vs. 52.8%, p = 0.35) were similar between groups. Neoadjuvant therapy patients had fewer organ space infections (3.0 vs. 10.3%, p = 0.001), and neoadjuvant radiation patients had fewer pancreatic fistulas (7.3 vs. 15.4%, p = 0.03). CONCLUSIONS Despite evidence for more extensive disease, patients receiving neoadjuvant therapy did not experience more complications. Neoadjuvant radiation was associated with lower pancreatic fistula rates. These data provide evidence against higher postoperative complication rates in patients with pancreatic cancer who are treated with neoadjuvant therapy.
Collapse
|
42
|
Paye F, Micelli Lupinacci R, Bachellier P, Boher JM, Delpero JR. Distal pancreatectomy for pancreatic carcinoma in the era of multimodal treatment. Br J Surg 2014; 102:229-36. [PMID: 25533421 DOI: 10.1002/bjs.9708] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent publications have suggested improvements in the outcome of distal pancreatectomy (DP) for cancer, but the series were small and heterogeneous. The aim of the present study was to assess perioperative and long-term outcomes of DP for pancreatic adenocarcinoma in the era of multimodal treatment in a major European country. METHODS This was a nationwide study of all patients undergoing DP for pancreatic adenocarcinoma between 2004 and 2009 in 28 centres in France. Postoperative and long-term outcomes were assessed retrospectively and outcome predictors were explored by multivariable analysis. RESULTS A total of 278 patients were enrolled. Multivisceral resections were performed in 58 patients (20·9 per cent), venous resections in 33 (11·9 per cent) and arterial resections in 11 (4·0 per cent). Neoadjuvant chemoradiotherapy was used in 20 patients. Postoperative complications occurred in 96 patients (34·5 per cent) and pancreatic fistulas developed in 76 (27·3 per cent). The postoperative 90-day mortality rate was 5·0 per cent. In univariable analysis, multivisceral resection was the only factor associated with postoperative morbidity (P = 0·048). Age 65 years or less, body mass index of at least 30 kg/m(2) and absence of preoperative chemoradiotherapy were associated with an increased risk of pancreatic fistula in multivariable analysis. Overall survival rates at 3 and 5 years were 44·9 and 29·5 per cent respectively. In multivariable analysis, only the presence of lymph node metastases was associated with poorer overall survival. CONCLUSION Postoperative morbidity and mortality associated with pancreatic fistula remain considerable after DP, but both short- and long-term survival have improved markedly.
Collapse
Affiliation(s)
- F Paye
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France; Université Pierre et Marie Curie Paris 06, Paris, France
| | | | | | | | | | | |
Collapse
|
43
|
Abstract
Treatment of pancreatic cancer is increasingly multimodal, with patients receiving chemotherapy, radiation, and surgical extirpation in hope of long-term cure. There is ongoing debate over the timing, sequence, and necessity of these treatments as they pertain to the spectrum of local-regional disease. Current guidelines support a neoadjuvant strategy in patients with locally advanced and borderline resectable disease. Although there is currently no high-level evidence to recommend neoadjuvant therapy for all patients, there are data to suggest that wider application of neoadjuvant therapy may be beneficial. Random-assignment prospective trials are ongoing. In this review we examine the literature addressing a neoadjuvant approach to potentially resectable, borderline resectable, and locally advanced pancreatic cancer and highlight the outcomes of preoperative emergence of latent metastatic disease, attempted resection rates, margin negative resection rates, and pathologic response to treatment.
Collapse
Affiliation(s)
- Megan Winner
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | | | - John A Chabot
- Division of Gastrointestinal/Endocrine Surgery, Pancreas Center, and Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY.
| |
Collapse
|
44
|
Sutton JM, Abbott DE. Neoadjuvant therapy for pancreas cancer: Past lessons and future therapies. World J Gastroenterol 2014; 20:15564-15579. [PMID: 25400440 PMCID: PMC4229521 DOI: 10.3748/wjg.v20.i42.15564] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/21/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma remains a most deadly malignancy, with an overall 5-year survival of 5%. A subset of patients will be diagnosed with potentially resectable disease, and while complete surgical resection provides the only chance at cure, data from trials of postoperative chemoradiation and/or chemotherapy demonstrate a modest survival advantage over those patients who undergo resection alone. As such, most practitioners believe that completion of multimodality therapy is the optimal treatment. However, the sequence of surgery, chemotherapy and radiation therapy is frequently debated, as patients may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to resection. Here we review the rationale for neoadjuvant therapy, which includes a higher rate of completion of multimodality therapy, minimizing the risk of unnecessary surgical resection for patients who develop early metastatic disease, improved surgical outcomes and the potential for longer overall survival. However, there are no prospective, randomized studies of the neoadjuvant approach compared to a surgery-first strategy; the established and ongoing investigations of neoadjuvant therapy for pancreatic cancer are discussed in detail. Lastly, as the future of therapeutic regimens is likely to entail patient-specific genetic and molecular analyses, and the treatment that is best applied based on those data, a review of clinically relevant biomarkers in pancreatic cancer is also presented.
Collapse
|
45
|
Pathological and clinical impact of neoadjuvant chemoradiotherapy using full-dose gemcitabine and concurrent radiation for resectable pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:197-205. [PMID: 22766692 DOI: 10.1007/s00534-012-0532-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/PURPOSE The therapeutic options available as preoperative strategies for resectable pancreatic cancer have received worldwide attention. We have recently introduced neoadjuvant chemoradiotherapy (NACRT) to achieve local control and possibly complete cure. In this study, we have retrospectively evaluated its impact on pathology and the perioperative clinical course in addition to its safety. METHODS Sixty-one patients who received full-dose gemcitabine (1000 mg/m(2)) preoperatively with concurrent radiation (50 or 54 Gy) were evaluated. Seventy-one patients who received no preoperative therapy served as controls. Perioperative outcomes, postoperative complications, immunonutritional status, and the performance of adjuvant chemotherapy were compared. RESULTS Fifty-nine patients (97 %) completed NACRT. Toxicity was acceptable and the regimen was feasible as outpatient treatment. The perioperative outcomes were closely comparable to control. The rate of pancreatic fistula was lower and hospital stay was shorter in the NACRT group. The rate of lymph node metastasis and stage was lower in the NACRT group. Furthermore, R0 resection could be achieved in 92 % of patients treated with NACRT. Nutritional status decreased after NACRT and further deteriorated during adjuvant chemotherapy. The initiation of postoperative chemotherapy was delayed in the NACRT group. CONCLUSIONS Our current protocol of neoadjuvant chemoradiotherapy is feasible and substantially improves the pathology. However, it has some detrimental effects on postoperative nutritional status and performance of adjuvant chemotherapy. Furthermore, it should be noted that there is a possibility of arterial complications.
Collapse
|
46
|
|
47
|
Oláh A. [Pancreatic surgery]. Magy Seb 2012; 65:154-9. [PMID: 22717970 DOI: 10.1556/maseb.65.2012.3.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|