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Barreto SG, Shrikhande SV, Sirohi B. Neoadjuvant Therapy in Borderline Resectable Pancreatic Cancer. Indian J Surg Oncol 2024; 15:249-254. [PMID: 38817993 PMCID: PMC11133292 DOI: 10.1007/s13193-021-01361-1] [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: 12/21/2020] [Accepted: 05/31/2021] [Indexed: 12/09/2022] Open
Abstract
In this perspective, we present our assessment of all of the known accumulated evidence on the role of neoadjuvant therapy in the management of borderline resectable pancreatic cancer highlighting the gaps in the data, the current regimens used and providing a brief insight into the way forward.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia Australia
| | - Shailesh V. Shrikhande
- GI and HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra India
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu India
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Hackert T, Klaiber U, Hinz U, Strunk S, Loos M, Strobel O, Berchtold C, Kulu Y, Mehrabi A, Müller-Stich BP, Schneider M, Büchler MW. Portal Vein Resection in Pancreatic Cancer Surgery: Risk of Thrombosis and Radicality Determine Survival. Ann Surg 2023; 277:e1291-e1298. [PMID: 35793384 DOI: 10.1097/sla.0000000000005444] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the outcomes of pancreatic cancer [pancreatic ductal adenocarcinoma (PDAC)] surgery with concomitant portal vein resection (PVR), focusing on the PVR type according to the International Study Group of Pancreatic Surgery (ISGPS). BACKGROUND Surgery offers the only chance for cure in PDAC. PVR is often performed for borderline or locally advanced tumors. METHODS Consecutive patients with PDAC operated between January 2006 and January 2018 were included. Clinicopathologic characteristics and outcomes were analyzed and tested for survival prediction. RESULTS Of 2265 PDAC resections, 1571 (69.4%) were standard resections and 694 (30.6%) were resections with PVR, including 149 (21.5%) tangential resections with venorrhaphy (ISGPS type 1), 21 (3.0%) resections with patch reconstruction (type 2), 491 (70.7%) end-to-end anastomoses (type 3), and 33 (4.8%) resections with graft interposition (type 4). The 90-day mortality rate was 2.6% after standard resection and 6.3% after resection with PVR ( P <0.0001). Postoperative portal vein thrombosis and pancreas-specific surgical complications most frequently occurred after PVR with graft interposition (21.2% and 48.5%, respectively). In multivariable analysis, age 70 years and above, ASA stages 3/4, increased preoperative serum carbohydrate antigen 19-9, neoadjuvant treatment, total pancreatectomy, PVR, higher UICC stage, and R+ resections were significant negative prognostic factors for overall survival. Radical R0 (>1 mm) resection resulted in 23.3 months of median survival. CONCLUSIONS This is the largest single-center, comparative cohort study of PVR in PDAC surgery, showing that postoperative morbidity correlates with the reconstruction type. When radical resection is achieved, thrombosis risk is outweighed by beneficial overall survival times of nearly 2 years.
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Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Zhou Y, Chen FM. ASO Author Reflections: Estimation of Intraoperative Superior Mesenteric-Portal Vein Involvement in Pancreatic Ductal Adenocarcinoma on Preoperative CT-Radiomics Provides Better Performance. Ann Surg Oncol 2023; 30:1217-1218. [PMID: 36350457 DOI: 10.1245/s10434-022-12713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Yongping Zhou
- Department of Hepatobiliary Surgery, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Fang-Ming Chen
- Department of Radiology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, China.
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Soloff EV, Al-Hawary MM, Desser TS, Fishman EK, Minter RM, Zins M. Imaging Assessment of Pancreatic Cancer Resectability After Neoadjuvant Therapy: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:570-581. [PMID: 34851713 DOI: 10.2214/ajr.21.26931] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.
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Affiliation(s)
- Erik V Soloff
- Department of Radiology, University of Washington, Seattle, WA
| | - Mahmoud M Al-Hawary
- Department of Radiology and Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Terry S Desser
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Elliot K Fishman
- Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Marc Zins
- Department of Radiology, Groupe Hospitalier Paris Saint Joseph, 185 Rue R Losserand, Paris 75014, France
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Laface C, Laforgia M, Molinari P, Foti C, Ambrogio F, Gadaleta CD, Ranieri G. Intra-Arterial Infusion Chemotherapy in Advanced Pancreatic Cancer: A Comprehensive Review. Cancers (Basel) 2022; 14:cancers14020450. [PMID: 35053614 PMCID: PMC8774130 DOI: 10.3390/cancers14020450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pancreatic cancer has a very poor prognosis. The few available therapeutic options are characterized by low efficacy and high toxicity due to the intrinsic chemoresistance of this tumor type. To improve clinical results, some clinical trials have evaluated regional chemotherapy as a treatment option for PC. The pancreatic arterial infusion of chemotherapeutics has the aim of obtaining higher local concentrations of drugs and, at the same time, of limiting systemic toxicity. This therapeutic approach has already been successfully evaluated for the treatment of several types of tumors. Regarding advanced pancreatic cancers, only a few clinical studies have investigated the safety and efficacy of this treatment, with very promising results. Therefore, in this review, we summarize literature data on the clinical approaches to pancreatic arterial drug administration for the treatment of advanced PC to deepen knowledge on this topic. Abstract Advanced pancreatic cancer (PC) has a very poor prognosis due to its chemoresistant nature. Nowadays, only a few therapeutic options are available for PC, and the most effective ones are characterized by low response rates (RRs), short progression-free survival and overall survival, and severe toxicity. To improve clinical results, small series studies have evaluated loco-regional chemotherapy as a treatment option for PC, demonstrating its dose-dependent sensitivity towards the tumor. In fact, pancreatic arterial infusion (PAI) chemotherapy allows higher local concentrations of chemotherapeutic agents, sparing healthy tissues with a lower rate of adverse events compared to systemic chemotherapy. This therapeutic approach has already been evaluated in different types of tumors, especially in primary and metastatic liver cancers, with favourable results. With regard to advanced PC, a few clinical studies have investigated the safety and efficacy of PAI with promising results, especially in terms of RRs compared to systemic chemotherapy. However, clear evidence about its efficacy has not been established yet nor have the underlying mechanisms leading to its success. In this review, we aim to summarize the literature data on the clinical approaches to pancreatic arterial drug administration in terms of techniques, drug pharmacokinetics, and clinical outcomes for advanced PC.
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Affiliation(s)
- Carmelo Laface
- Interventional and Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy; (C.L.); (P.M.); (C.D.G.)
- Department of Biomedical Sciences and Clinical Oncology, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Mariarita Laforgia
- Pharmacy Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy;
| | - Pasquale Molinari
- Interventional and Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy; (C.L.); (P.M.); (C.D.G.)
| | - Caterina Foti
- Department of Biomedical Science and Human Oncology, Dermatological Clinic, University of Bari Aldo Moro, 70124 Bari, Italy; (C.F.); (F.A.)
| | - Francesca Ambrogio
- Department of Biomedical Science and Human Oncology, Dermatological Clinic, University of Bari Aldo Moro, 70124 Bari, Italy; (C.F.); (F.A.)
| | - Cosmo Damiano Gadaleta
- Interventional and Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy; (C.L.); (P.M.); (C.D.G.)
| | - Girolamo Ranieri
- Interventional and Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy; (C.L.); (P.M.); (C.D.G.)
- Correspondence:
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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Gardi N, Ketkar M, McKinnon RA, Pandol SJ, Dutt S, Barreto SG. Down-regulation of metabolic pathways could offset the poor prognosis conferred by co-existent diabetes mellitus in pancreatic (head) adenocarcinoma. ANZ J Surg 2021; 91:2466-2474. [PMID: 34514690 DOI: 10.1111/ans.17194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) patients with diabetes mellitus (DM) have poor overall survival. Underlying mechanisms have not been fully clarified. This presents an opportunity for precision-oncology for which we systematically analysed publicly-available PDAC transcriptome data. METHODS PDAC TCGA RNASeq data were used. Analyses were restricted to only 'high purity' and 'head' as anatomical site. Patients were characterised by: (1) Gene expression classification, and (2) Weighted gene correlation network analysis (WGCNA) to identify co-expression patterns of genes. Newly identified gene signature subclasses of pancreatic head PDAC were associated with clinical and functional characteristics of patients. RESULTS Consensus clustering identified two patient subclasses within PDAC involving pancreatic head. WGCNA identified 11 distinct networks of gene expression patterns across two sub-classes. Class 1 patients demonstrated a significant upregulation of Module 5 and Module 6 gene expression compared to Class 2. Class 1 predominantly expressed the acinar, ductal and islet cell gene signatures. There were significantly less patients with DM in Class 1 subclass compared to Class 2 (p < 0.037). Patients with DM had significant downregulation of pathways involved in cellular metabolism, hormone secretion and paucity of islet cell markers with no reduced survival compared with non-diabetics. CONCLUSIONS A significant proportion of patients with PDAC of pancreatic head and DM exhibit downregulation of pathways involved in cellular metabolism, hormone secretion and signalling accompanied by a paucity of islet expression. Investigating the relationship between DM and gene expression profiles in patients with PDAC presents opportunities to improve overall survival in diabetics with PDAC.
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Affiliation(s)
- Nilesh Gardi
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Madhura Ketkar
- Homi Bhabha National Institute, Mumbai, India.,Shilpee Dutt Laboratory, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India
| | - Ross A McKinnon
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shilpee Dutt
- Homi Bhabha National Institute, Mumbai, India.,Shilpee Dutt Laboratory, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India
| | - Savio G Barreto
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
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Risk factors for early morbidity and mortality following pancreatoduodenectomy with concomitant vascular reconstruction. Ann Med Surg (Lond) 2021; 68:102587. [PMID: 34401114 PMCID: PMC8350451 DOI: 10.1016/j.amsu.2021.102587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/25/2021] [Indexed: 12/31/2022] Open
Abstract
Background Locally advanced pancreatic tumors may require vascular reconstruction for complete resection. However, pancreatoduodenectomy with vascular resection (PDVR) remains a subject of debate due to increased complications. Methods Patients were identified using the ACS NSQIP Participant User Data Files from 2014 to 2019. Results The 30-day mortality rate was 2.7%; major complications occurred in 32.2%. There is an increasing trend of PDVR in patients requiring pancreatectomy. There were no significant differences in mortality between PDVR with vein, artery, or venous and arterial resections. High BMI and postoperative biliary stent were risk factors for early complications. High BMI and COPD increased risk of early mortality. Chemotherapy and chemoradiotherapy were negative predictors for early morbidities and mortality, respectively. Conclusion This study identifies the predictors of early morbidity and mortality in PDVR. The results of this study may assist decision making in perioperative management to optimize overall survival and guide additional research. Pancreaticoduodenectomy with concomitant vascular reconstruction (PDVR) for carcinoma is increasing in frequency for locally advanced pancreatic neoplasms. Early morbidity and mortality rates are acceptable. Patients with elevated body mass index (BMI) and underlying COPD have a higher mortality. Elevated BMI and preoperative biliary stenting are associated with a higher incidence of early complications. Neoadjuvant chemotherapy and chemoradiation may also improve resectability and post-operative outcomes.
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Mikulic D, Mrzljak A. Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy. World J Clin Cases 2021; 9:5398-5407. [PMID: 34307593 PMCID: PMC8281399 DOI: 10.12998/wjcc.v9.i20.5398] [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: 01/27/2021] [Revised: 03/01/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
While pancreatic cancer is still characterized by early systemic spread and poor outcomes, the treatment of this disease has changed significantly in recent years due to major advancements in systemic therapy and advanced surgical techniques. Broader use of effective neoadjuvant approaches combined with aggressive surgical operations within a multidisciplinary setting has improved outcomes. Borderline resectable pancreatic cancer is characterized by tumor vascular invasion, and is a setting where the combination of potent neoadjuvant chemotherapy and aggressive surgical methods, including vascular resections and reconstructions, shows its full potential. Hopefully, this will lead to improved local control and curative treatment in a number of patients with this aggressive malignancy.
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Affiliation(s)
- Danko Mikulic
- Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
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Li D, Yang M, Liang M, Mei C, Lin Y, Yang F, Xiao Y, Chen Y, Wang F, Mao J, Su Z. c-Met-targeted near-infrared fluorescent probe for real-time depiction and dissection of perineural invasion and lymph node metastasis lesions in pancreatic ductal adenocarcinoma xenograft models. Biomater Sci 2021; 9:6737-6752. [PMID: 34254599 DOI: 10.1039/d1bm00674f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC), a fatal malignant tumour, has a high postoperative recurrence rate, mainly due to the difficulty of discerning occult lesions, including those related to perineural invasion (PNI) and lymph node metastasis (LNM). Cellular mesenchymal-epithelial transition factor (c-Met), an excellent imaging marker, is aberrantly expressed in the majority of PDACs. Thus, we plan to utilize a c-Met-targeted near-infrared fluorescent (NIRF) probe for real-time visualization and dissection of PDAC, and corresponding PNI and LNM lesions. Immunohistochemistry showed c-Met expression in PDAC, PNI and LNM reached 94.3% (100/106), 88.3% (53/60), and 71.4% (25/35), respectively, and its expression in PNI and LNM was significantly correlated with that in primary PDAC (r = 0.66, p < 0.0001 and r = 0.44, p < 0.01, respectively). SHRmAb-IR800 was successfully synthesized using an anti-c-Met antibody and a NIRF dye. The in vitro targeting ability of SHRmAb-IR800 was higher in CFPAC1 cells (c-Met positive) than in Miapaca-2 cells (c-Met negative) (p < 0.05). In vivo NIRF imaging of CFPAC1 subcutaneous tumours demonstrated higher accumulation of SHRmAb-IR800 than the control probe (p < 0.05). The signal-to-background ratio (TBR) of an orthotopic PDAC tumour was 3.38 ± 0.46, and imaging with SHRmAb-IR800 facilitated the resection of metastatic lesions with sensitivity and specificity values of 93.3% (56/60) and 87.1% (27/31), respectively. Furthermore, tiny PNI and LNM lesions in xenograft models were detected by NIRF imaging, with TBRs measuring 2.59 ± 0.19 and 2.88 ± 0.72, respectively. Therefore, the clinical translation of this probe might shed new light on NIRF-guided pancreatectomy and improve the surgical prognosis of PDAC patients.
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Affiliation(s)
- Dan Li
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Meilin Yang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Mingzhu Liang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China and Center for Interventional Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China. and Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Chaoming Mei
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Yujing Lin
- Department of Pathology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Fan Yang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Yitai Xiao
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Yuechuan Chen
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China
| | - Fen Wang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province 510080, China.
| | - Junjie Mao
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China and Center for Interventional Medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
| | - Zhongzhen Su
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China and Department of Ultrasound, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong Province 519000, China.
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Shrikhande SV, Barreto S, Sirohi B, Bal M, Shrimali RK, Chacko RT, Chaudhari V, Bhatia V, Kulkarni S, Kaur T, Dhaliwal RS, Rath GK. Indian council of medical research consensus document for the management of pancreatic cancer. Indian J Med Paediatr Oncol 2021. [DOI: 10.4103/ijmpo.ijmpo_29_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | | | | | - Munita Bal
- Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Raj Kumar Shrimali
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju T Chacko
- Department of Medical Oncology, Division of Non-Communicable Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Vikram Bhatia
- Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanvir Kaur
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - R S Dhaliwal
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - Goura Kishor Rath
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
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Ausania F, Sanchez-Cabus S, Senra Del Rio P, Borin A, Ayuso JR, Bodenlle P, Espinoza S, Cuatrecasas M, Conill C, Saurí T, Ferrer J, Fuster J, García-Valdecasas JC, Melendez R, Fondevila C. Clinical impact of preoperative tumour contact with superior mesenteric-portal vein in patients with resectable pancreatic head cancer. Langenbecks Arch Surg 2021; 406:1443-1452. [PMID: 33475833 DOI: 10.1007/s00423-020-02065-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 12/15/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival. METHODS All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV. RESULTS Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis. CONCLUSION Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.
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Affiliation(s)
- Fabio Ausania
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Santiago Sanchez-Cabus
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Paula Senra Del Rio
- Department of HPB Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Alex Borin
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain.
| | - Juan Ramon Ayuso
- Department of Radiology, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Pilar Bodenlle
- Department of Radiology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Sofia Espinoza
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Miriam Cuatrecasas
- Department of Pathology, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Carlos Conill
- Department of Radiotherapy, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Tamara Saurí
- Department of Medical Oncology, Hospital Clinic and Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Joana Ferrer
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Josep Fuster
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Juan Carlos García-Valdecasas
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Reyes Melendez
- Department of HPB Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Constantino Fondevila
- Department of HPB and Transplant Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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13
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Navez J, Bouchart C, Lorenzo D, Bali MA, Closset J, van Laethem JL. What Should Guide the Performance of Venous Resection During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma with Venous Contact? Ann Surg Oncol 2021; 28:6211-6222. [PMID: 33479866 PMCID: PMC8460578 DOI: 10.1245/s10434-020-09568-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022]
Abstract
Complete surgical resection, most often associated with perioperative chemotherapy, is the only way to offer a chance of cure for patients with pancreatic cancer. One of the most important factors in determining survival outcome that can be influenced by the surgeon is the R0 resection. However, the proximity of mesenteric vessels in cephalic pancreatic tumors, especially the mesenterico-portal venous axis, results in an increased risk of vein involvement and/or the presence of malignant cells in the venous bed margin. A concomitant venous resection can be performed to decrease the risk of a positive margin. Given the additional technical difficulty that this implies, many surgeons seek a path between the tumor and the vein, hoping for the absence of tumor infiltration into the perivascular tissue on pathologic analysis, particularly in cases with administration of neoadjuvant therapy. The definition of optimal surgical margin remains a subject of debate, but at least 1 mm is an independent predictor of survival after pancreatic cancer surgical resection. Although preoperative radiologic assessment is essential for accurate planning of a pancreatic resection, intraoperative decision-making with regard to resection of the mesenterico-portal vein in tumors with a venous contact remains unclear and variable. Although venous histologic involvement and perivascular infiltration are not accurately predictable preoperatively, clinicians must examine the existing criteria and normograms to guide their surgical management according to the integration of new imaging techniques, preoperative chemotherapy use, tumor biology and molecular histopathology, and surgical techniques.
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Affiliation(s)
- Julie Navez
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Diane Lorenzo
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jean Closset
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc van Laethem
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Abstract
BACKGROUND In addition to the prognostically important systemic recurrence, a high rate of local recurrence is a relevant problem of pancreatic cancer surgery. Improvement of local control is a requirement for surgical resection as a prerequisite for a potentially curative treatment. OBJECTIVES Summary of the current evidence on frequency, relevance, and risk factors of local recurrence. Presentation of strategies for reduction of local recurrence with a special focus on surgical resection techniques. MATERIAL AND METHODS Analysis and appraisal of currently available scientific literature on the topic. RESULTS AND CONCLUSION Local recurrences occur as the first manifestation of tumor recurrence in 20-50% of patients after resection of pancreatic cancer. The considerable variations of reported local recurrence rates depend on the quality of surgery, regimens of (neo)adjuvant therapy as well as the design of surveillance and duration of follow-up. An R1 status is an important risk factor for local recurrence highlighting the relevance of a local radical resection. The majority of local recurrences consist of perivascular and lymph node recurrences. Therefore, lymphadenectomy, radical dissection directly at the celiac and mesenteric vessels including resection of the periarterial nerve plexus and vascular resection are starting points for improving surgical resection techniques. The safety and efficacy of radical resection techniques in the context of multimodal treatment of pancreatic cancer have to be further evaluated in prospective studies.
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15
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Barreto SG, D'Onise K. Pancreatic cancer in the Australian population: identifying opportunities for intervention. ANZ J Surg 2020; 90:2219-2226. [DOI: 10.1111/ans.16272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine Flinders Medical Centre Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Katina D'Onise
- Prevention and Population Health Wellbeing South Australia Australia
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16
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Giovinazzo F, Soggiu F, Jang JY, Versteijne E, van Tienhoven G, van Eijck CH, Han Y, Choi SH, Kang CM, Zalupski M, Ahmad H, Yentz S, Helton S, Rose JB, Takishita C, Nagakawa Y, Abu Hilal M. Gemcitabine-Based Neoadjuvant Treatment in Borderline Resectable Pancreatic Ductal Adenocarcinoma: A Meta-Analysis of Individual Patient Data. Front Oncol 2020; 10:1112. [PMID: 32850319 PMCID: PMC7431761 DOI: 10.3389/fonc.2020.01112] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Non-randomized studies have investigated multi-agent gemcitabine-based neo-adjuvant therapies (GEM-NAT) in borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC). Treatment sequencing and specific elements of neoadjuvant treatment are still under investigation. The present meta-analysis aims to assess the effectiveness of GEM-NAT on overall survival (OS) in BR-PDAC. Patients and Methods: A meta-analysis of individual participant data (IPD) on GEM-NAT for BR-PDAC were performed. The primary outcome was OS after treatment with GEM-based chemotherapy. In the Individual Patient Data analysis data were reappraised and confirmed as BR-PDAC on provided radiological data. Results: Six studies investigating GEM-NAT were included in the IPD metanalysis. The IPD metanalysis was conducted on 271 patients who received GEM-NAT. Pooled median patient-level OS was 22.2 months (95%CI 19.1–25.2). R0 rates ranged between 81 and 95% (I2 = 0%, p = 0.64), respectively. Median OS was 27.8 months (95%CI 23.9–31.6) in the patients who received NAT-GEM followed by resection compared to 15.4 months (95%CI 12.3–18.4) for NAT-GEM without resection and 13.0 months (95%CI 7.4–18.5) in the group of patients who received upfront surgery (p < 0.0001). R0 rates ranged between 81 and 95% (I2 = 0%, p = 0.64), respectively. Overall survival in the R0 group was 29.3 months (95% CI 24.3–34.2) vs. 16.2 months (95% CI 7·9–24.5) in the R1 group (p = 0·001). Conclusions: The present study is the first meta-analysis combining IPD from a number of international centers with BR-PDAC in a cohort that underwent multi-agent gemcitabine neoadjuvant therapy (GEM-NAT) before surgery. GEM-NAT followed by surgical resection improve survival and R0 resection in BR-PDAC. Also, GEM-NAT may result in a good palliative option in non-resected patients because of progressive disease after neoadjuvant treatment. Results from randomized controlled trials (RCTs) are awaited to validate these findings.
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Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Fiammetta Soggiu
- Hepato-Pancreato-Biliary and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Youngmin Han
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Seong Ho Choi
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chang Moo Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Mark Zalupski
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Hasham Ahmad
- Department of Surgery, University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Sarah Yentz
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, United States
| | - J Bart Rose
- Section of Surgical Oncology, University of Alabama, Birmingham, AL, United States
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, United Kingdom.,Depatment of Surgery, Fondazione Poliambulanza Istituto Ospedaliero Multispecialistico, Brescia, Italy
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17
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Geers J, Topal H, Jaekers J, Topal B. 3D-laparoscopic pancreaticoduodenectomy with superior mesenteric or portal vein resection for pancreatic cancer. Surg Endosc 2020; 34:5616-5624. [PMID: 32749613 DOI: 10.1007/s00464-020-07847-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy with synchronous vein resection for pancreatic cancer is controversial. The aim of this study was to evaluate outcomes and describe the surgical technique of 3d-laparoscopic pylorus-resecting pancreaticoduodenectomy (3dLPD) with venous resection for pancreatic cancer. METHODS A retrospective cohort analysis was performed with 26 patients [male/female 11/15; median age 68 (range 45-83) years] who underwent 3dLPD with stented pancreaticogastrostomy and superior mesenteric or portal vein resection for pancreatic adenocarcinoma between November 2016 and June 2019. Median follow-up time after surgery was 12 months (range 3-32). RESULTS Median operating time was 340 min (range 240-420) and intra-operative blood loss was 100 mL (range 0-1000). Type of venous resection and reconstruction was wedge-resection with primary closure (n = 22), wedge-resection with reconstruction using a peritoneal patch (n = 3), and segmental resection with primary end-to-end reconstruction (n = 1). Laparoscopy was converted to open surgery in 4 (15%) patients. Postoperative complications occurred in 10 (38%) patients including severe complications (Clavien-Dindo grade > 2) in 4 (15%). Postoperative mortality was zero. R0 resection was achieved in 21 (81%) patients. Median number of lymph nodes retrieved was 25 (range 10-45). Venous patency was observed in 23 (88%) patients with a median patency duration of 11 months (range 0-31). CONCLUSIONS 3dLPD with simultaneous venous resection for pancreatic cancer results in acceptable reconstruction patency and adequacy of surgical oncology without compromising clinical outcomes.
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Affiliation(s)
- Joachim Geers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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18
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Yang F, Wang X, Jin C, He H, Fu D. Pancreatectomy with Hepatic Artery Resection for Pancreatic Head Cancer. World J Surg 2020; 43:2909-2919. [PMID: 31396672 DOI: 10.1007/s00268-019-05106-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To report our experiences and outcome of pancreatectomy with hepatic artery resection (PT-HAR) for advanced pancreatic head cancer. METHODS A retrospective study of clinical data from 14 patients with advanced pancreatic ductal adenocarcinoma undergoing PT-HAR in a tertiary academic center between March 2010 and June 2017 was performed. Furthermore, a comparison in a match-pair analysis (1:3) with patients received standard pancreatectomy during the same period was conducted to evaluate the clinical outcome. RESULTS The PT-HAR cohort included pancreaticoduodenectomy (n = 11) and total pancreatectomy (n = 3). Of them, six underwent portal/superior mesenteric vein resection and reconstruction and three underwent hepatic artery reconstruction. Four patients without arterial reconstruction developed liver perfusion failure. No perioperative mortality occurred, with a median postoperative hospital stay of 10.5 days (range 6-39). The median overall survival was 30 months (95% confidence interval 9.8-50.2 months), with the 1-, 2-, and 3-year survival rates of 81.8%, 63.6%, and 42.4%, respectively. The matched-pair data analysis showed no significant differences between PT-HAR and standard pancreatectomy, except that liver perfusion failure occurred more frequently after PT-HAR. CONCLUSIONS PT-HAR can be performed with acceptable morbidity, mortality, and survival for advanced pancreatic head cancer. Considering the potential risk of liver perfusion failure, only highly selected patients are eligible for PT-HAR without reconstruction.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China.
| | - Xiaoyi Wang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Hang He
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China.
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19
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Barreto SG, Kleeff J. Synchronous arterial resections in pancreatic cancer - still a matter of debate? Eur J Surg Oncol 2020; 47:480-482. [PMID: 32586727 DOI: 10.1016/j.ejso.2020.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 01/08/2023] Open
Abstract
Surgery remains the cornerstone of a multimodality approach aimed at cure in pancreatic cancer (PC). To improve outcomes in PC and widen the indications for surgical resection, surgeons have targeted borderline-resectable (BR) and locally advanced (LA) tumours having demonstrated the feasibility of synchronous arterial (SAR) and venous resections (SVR). However, the true benefit of SARs in PC in terms of improving overall survival has not been fully realised. One of the reasons for this lies in the fact that once the tumour involves the artery, it has already spread along the perineural autonomic plexus that surround it, resulting in early extended local and distant cancer dissemination. Thus, before advocating for the performance of routine SARs in PC, it is important to critically analyse the evidence and develop a structured framework to test if these operations truly hold a beacon of hope for patients with LAPC.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, South Australia, Australia.
| | - Jorg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Saxony-Anhalt, Germany.
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20
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Barreto SG. Pancreatic cancer in Australia: is not it time we address the inequitable resource problem? Future Oncol 2020; 16:1385-1392. [PMID: 32412798 DOI: 10.2217/fon-2020-0109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The present study reviewed the geographical variations in the delivery of pancreatic cancer therapy and whether this impacts overall survival. The evidence suggests a difference in the accessibility of pancreatic cancer care to patients in rural as compared with urban Australia. While centralization of pancreatic surgery is essential to deliver high quality care to patients, it may be interfering with the ease of access of this form of care to patients in regional areas. Access to chemotherapy in regional Australia is also limited. There is need for a concerted effort to improve the overall care and uptake of medical services to patients in metropolitan and remote Australia with the overarching aim of improving survival and meaningful quality of life.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.,College of Medicine & Public Health, Flinders University, South Australia, Australia
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21
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Pancreatoduodenectomy With Arterial Resection for Locally Advanced Pancreatic Cancer of the Head: A Systematic Review. Pancreas 2020; 49:621-628. [PMID: 32433398 DOI: 10.1097/mpa.0000000000001551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The development of increasingly effective chemotherapy regimens and increasing tumor necrosis is allowing radical pancreatectomy to be re-evaluated. This systematic review examines the outcome of patients with locally advanced cancer of the pancreatic head after pancreatectomy with arterial resection. Electronic searches were performed on PubMed and Medline databases between January 2000 and December 2018. The end points were to determine the safety and overall survival after arterial resection in pancreatectomy. Thirteen studies with 467 patients were included. Celiac, hepatic, mesenteric, and splenic arteries were resected across all studies. The median overall morbidity was 52% (range, 37%-100%) and with major complications occurring in a median of 25% (range, 12%-54%) of patients. The median 90-day mortality was 5% (range, 0%-17%). R0 was achieved in 66% (range, 43%-100%) and R1 in 31% (range, 0%-74%). The median survival was 17 (range, 7-29) months with a 1- and 3-year survival of 59% (range, 16%-92%) and 17% (range, 0%-13%), respectively. Pancreatectomy with arterial resection may be safely performed in high-volume centers with acceptable survival results in highly selected patients. Pooling of data through a multi-institutional registry will allow a more accurate assessment of the safety and efficacy of this treatment strategy.
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22
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Barreto SG, Michael MZ, Keating DJ. Islets and pancreatic ductal adenocarcinoma - An opportunity for translational research from the 'Bench to the Bedside'. Pancreatology 2020; 20:385-390. [PMID: 32057682 DOI: 10.1016/j.pan.2020.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/15/2020] [Accepted: 02/01/2020] [Indexed: 02/06/2023]
Abstract
The islet-acinar axis is of prime importance to the optimal functioning of the human pancreas. Not only is this inter-relationship important for normal physiological processes, it is also relevant in diseased states, including chronic pancreatitis and pancreatic ductal adenocarcinoma (PDAC). Early experiments, nearly 4 decades ago, explored the role of islets in the development and progression of PDAC. These led to further studies that provided compelling evidence to support the role of islets and their hormones in PDAC. This association presents oncologists with therapeutic options not only for managing, but potentially preventing PDAC, a cancer that is well known for its poor patient outcomes. This review will discuss the accumulated evidence regarding the role of islets and their hormones in PDAC and highlight areas for future research.
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Affiliation(s)
- Savio G Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, South Australia, Australia.
| | - Michael Z Michael
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Damien J Keating
- College of Medicine and Public Health, Flinders University, South Australia, Australia
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23
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Delpero JR, Sauvanet A. Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019. Front Oncol 2020; 10:40. [PMID: 32117714 PMCID: PMC7010716 DOI: 10.3389/fonc.2020.00040] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019). Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system. Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion). Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.
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Affiliation(s)
- Jean Robert Delpero
- Institut Paoli-Calmettes (IPC), Marseille, France.,Faculté de Médecine, Aix Marseille Université, Marseille, France
| | - Alain Sauvanet
- Hôpital Beaujon, Clichy, France.,Université Paris VII - Denis Diderot, Paris, France
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24
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Affiliation(s)
- Savio George Barreto
- Division of Surgery & Perioperative Medicine Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.,College of Medicine & Public Health, Flinders University, Adelaide, South Australia, Australia
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25
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Pandé R, Roberts KJ. Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit? Front Oncol 2019; 9:1060. [PMID: 31681596 PMCID: PMC6811510 DOI: 10.3389/fonc.2019.01060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.
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Affiliation(s)
- Rupaly Pandé
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith J Roberts
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Department of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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26
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Bolm L, Petrova E, Weitz J, Rückert F, Wittel UA, Makowiec F, Lapshyn H, Bronsert P, Rau BM, Khatkov IE, Bausch D, Keck T, Wellner UF, Distler M. Prognostic relevance of preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 in a multicenter subset analysis of 179 patients with distal cholangiocarcinoma. HPB (Oxford) 2019; 21:1513-1519. [PMID: 30956162 DOI: 10.1016/j.hpb.2019.03.363] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Distal cholangiocarcinoma (DCC) is a rare malignancy and validated prognostic markers remain scarce. We aimed to evaluate the role of serum CA19-9 as a potential biomarker in DCC. METHODS Patients operated for DCC at 6 high-volume surgical centers from 1994 to 2015 were identified from prospectively maintained databases. Patient baseline characteristics, surgical and histopathological parameters, as well as overall survival after resection were assessed for correlation with preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 (CA19-9). Preoperative CA19-9 to bilirubin ratio (CA19-9/BR) was classified as elevated (≥ 25 U/ml/mg/dl) according to the upper serum normal values of CA19-9 (37 U/ml) and bilirubin (1.5 mg/dl) giving a cut-off at ≥ 25 U/ml/mg/dl. RESULTS In total 179 patients underwent resection for DCC during the study period. High preoperative CA19-9/BR was associated with advanced age and regional lymph node metastases. Median overall survival after resection was 27 months. Elevated preoperative serum CA19-9/bilirubin ratio (HR 1.6, p = 0.025), T3/4 stage (HR 1.8, p = 0.022), distant metastasis (HR 2.5, p = 0.007), tumor grade (HR 1.9, p = 0.001) and R status (HR 1.7, p = 0.023) were identified as independent negative prognostic factors following multivariable analysis. CONCLUSION Elevated preoperative bilirubin-adjusted serum CA19-9 correlates with regional lymph node metastases and constitutes a negative independent prognostic factor after resection of DCC.
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Affiliation(s)
- Louisa Bolm
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ekaterina Petrova
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jürgen Weitz
- Dept. for Visceral, Thoracic and Vascular Surgery at the University Hospital, Technical University Dresden, Dresden, Germany
| | - Felix Rückert
- Dept. of Surgery, University Medical Center Mannheim, Mannheim, Germany
| | - Uwe A Wittel
- Dept. of General and Visceral Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - Frank Makowiec
- Dept. of General and Visceral Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - Hryhoriy Lapshyn
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Germany; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - Bettina M Rau
- Dept. of General, Visceral, and Thoracic Surgery, Municipal Hospital of Neumarkt, Neumarkt i.d.OPf., Germany; Dept. of General, Thoracic, Vascular, and Transplantation Surgery, University of Rostock, Rostock, Germany
| | | | - Dirk Bausch
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich F Wellner
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marius Distler
- Dept. for Visceral, Thoracic and Vascular Surgery at the University Hospital, Technical University Dresden, Dresden, Germany.
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Abstract
Pancreatic ductal adenocarcinoma represents the most common malignant tumor of the pancreas. Despite substantial research efforts and gradual diagnostic and therapeutic improvements, its prognosis remains dismal. In accordance with the current German, European, and US guidelines, this CME-article provides a comprehensive review of the disease. In addition, selected up-to-date aspects of epidemiology, etiopathology, genetics, and basic principles of diagnostics and therapy including potential future therapeutic options are discussed.
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Xie ZB, Li J, Gu JC, Jin C, Zou CF, Fu DL. Pancreatoduodenectomy with portal vein resection favors the survival time of patients with pancreatic ductal adenocarcinoma: A propensity score matching analysis. Oncol Lett 2019; 18:4563-4572. [PMID: 31611964 PMCID: PMC6781555 DOI: 10.3892/ol.2019.10822] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/18/2019] [Indexed: 01/27/2023] Open
Abstract
Portal vein (PV) involvement is common in patients with pancreatic ductal adenocarcinoma (PDAC). To the best of our knowledge, pancreatectomy combined with PV resection (PVR) is the only radical therapy for patients with PV involvement. However, there remains a debate on whether patients with PV involvement could benefit from PVR or not. The present study aimed to compare the survival outcomes between patients receiving pancreatoduodenectomy (PD) with PVR and those receiving PD alone. A total of 377 patients with PDAC were enrolled, 138 patients with PV involvement were placed in the PVR group, while the other 239 patients were in the non-PVR group. To reduce selection bias and estimate the causal effect, 123 pairs of propensity score matched (PSM) patients were selected and compared for the survival outcomes. Before PSM, the survival of patients in the PVR group was worse compared with those in the non-PVR group (mean survival, 25.1 vs. 29.3 months; P=0.038). After balancing the baseline characteristics using the PSM method, the significant survival difference between the two groups was insignificant (mean survival, 25.9 vs. 31.2 months; P=0.364). Tumor stage, body mass index, serum albumin, R1 resection, lymph node metastasis, carbohydrate antigen (CA)125 and CA19-9 were significant independent prognostic factors. The incidence of serious postoperative complications was similar between the two groups. PVR is safe and effective for patients with PDAC. Patients with PV involvement could achieve the similar survival outcome as patients without PV involvement, through radical resection combined with PVR, without increasing the risk of serious complications.
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Affiliation(s)
- Zhi-Bo Xie
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Ji-Chun Gu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Cai-Feng Zou
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
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29
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Abstract
Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.
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30
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Is it time to reconsider the principles of pancreatic cancer surgery? Pancreatology 2019; 19:204-205. [PMID: 30553775 DOI: 10.1016/j.pan.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/11/2022]
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31
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Wang X, Cai Y, Zhao W, Gao P, Li Y, Liu X, Peng B. Laparoscopic pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition graft: Case series. Medicine (Baltimore) 2019; 98:e14204. [PMID: 30653175 PMCID: PMC6370126 DOI: 10.1097/md.0000000000014204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/18/2018] [Accepted: 12/25/2018] [Indexed: 02/05/2023] Open
Abstract
RATIONALE With the development of laparoscopic techniques, laparoscopic pancreatoduodenectomy was applied in various indications including pancreatic cancer. Here, we share our experience of venous resection and reconstruction with interposition graft in laparoscopic pancreatoduodenectomy in these patients. PATIENT CONCERNS We reviewed data of laparoscopic pancreatoduodenectomy with venous resection and reconstruction in patients with pancreatic cancer between the dates of October 2010 and November 2017. OUTCOMES Ten patients underwent laparoscopic pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction with interposition graft. The mean operative time was 547 min. The mean blood loss was 435 ml. The mean length of venous defect after resection was 5.4 cm. R0 resection was achieved in nine patients (90%). There was one patient who suffered from severe postoperative complication. There was no 30-day mortality in this study. The long-term patency was achieved in all patients. CONCLUSION In this study, we demonstrate the initial experience of laparoscopic pancreaticoduodenectomy with long venous resection and reconstruction. Although applied in small number of patients, it could be another option for well-selected patients with reasonable morbidity and mortality as well as long-term outcomes in experienced minimally invasive surgical team.
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Affiliation(s)
- Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yunqiang Cai
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
| | - Wei Zhao
- Department of Pediatrics, Qingdao Municipal Hospital, Qingdao, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
| | - Yongbin Li
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
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32
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Hong SB, Lee SS, Kim JH, Kim HJ, Byun JH, Hong SM, Song KB, Kim SC. Pancreatic Cancer CT: Prediction of Resectability according to NCCN Criteria. Radiology 2018; 289:710-718. [PMID: 30251929 DOI: 10.1148/radiol.2018180628] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose To evaluate the diagnostic performance of CT in the determination of pancreatic cancer resectability according to the National Comprehensive Cancer Network (NCCN) criteria to predict R0 resection. Materials and Methods Structured reports of pancreatic CT clinically prepared by board-certified abdominal radiologists from January 2014 to March 2017 were retrospectively reviewed to assess resectability (resectable, borderline resectable, or unresectable) according to NCCN criteria (version 1.2017) in 616 patients (369 men, 247 women; mean age, 63 years ± 10 [standard deviation]) with pancreatic cancer. Negative resection margin (R0) rates were assessed based on CT resectability status in patients who underwent upfront surgery. R0 resection-associated factors were identified by using logistic regression analysis. Results In 371 patients who underwent surgery, R0 resection rates were 73% (171 of 235), 55% (57 of 104), and 16% (five of 32) for resectable, borderline resectable, and unresectable disease, respectively (P < .001). At multivariable analysis, tumor diameter larger than 4 cm (P < .001) and abutment to the portomesenteric vein (P < .001) were significantly associated with margin-positive resection in patients with resectable disease at CT. R0 resection rates were 80% (123 of 154) for resectable disease without portomesenteric vein abutment, 59% (48 of 81) for resectable disease with portomesenteric vein abutment, 83% (57 of 69) for resectable disease 2 cm or smaller, and 29% (five of 17) for tumors larger than 4 cm. Conclusion CT resectability is used to stratify patients with pancreatic cancer according to the possibility of R0 resection. Larger tumor size and tumor abutment to the portomesenteric vein are associated with margin-positive resection in patients with resectable pancreatic cancer. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Fowler in this issue.
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Affiliation(s)
- Seung Baek Hong
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Seung Soo Lee
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Jin Hee Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Hyoung Jung Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Jae Ho Byun
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Seung Mo Hong
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Ki-Byung Song
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Song Cheol Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
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Barreto SG. Pancreatic cancer: let us focus on cachexia, not just sarcopenia! Future Oncol 2018; 14:2791-2794. [PMID: 30192167 DOI: 10.2217/fon-2018-0369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Savio George Barreto
- Division of Surgery & Perioperative Medicine Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.,College of Medicine & Public Health, Flinders University, South Australia, Australia
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34
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Cherukuru R, Govil S, Vij M, Rela M. Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection. Ann Hepatobiliary Pancreat Surg 2018; 22:261-268. [PMID: 30215048 PMCID: PMC6125268 DOI: 10.14701/ahbps.2018.22.3.261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims En-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality. Methods A retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome. Results The study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status. Conclusions Venous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.
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Affiliation(s)
| | - Sanjay Govil
- Gleneagles Global Hospital and Health City, Chennai, India
| | - Mukul Vij
- Gleneagles Global Hospital and Health City, Chennai, India
| | - Mohamed Rela
- Gleneagles Global Hospital and Health City, Chennai, India.,Institute of Liver Studies, King's College Hospital, London, UK
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35
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Barreto SG, Loveday B, Windsor JA, Pandanaboyana S. Detecting tumour response and predicting resectability after neoadjuvant therapy for borderline resectable and locally advanced pancreatic cancer. ANZ J Surg 2018; 89:481-487. [PMID: 30117669 DOI: 10.1111/ans.14764] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/27/2018] [Accepted: 06/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND This systematic review aimed to determine the accuracy of imaging modalities to predict resectability and R0 resection for borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC) after neoadjuvant therapy (NAT). METHODS A systematic search of major databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Fifteen studies identified 995 patients of which 683 had BRPC and 312 LAPC. Computed tomography (CT) scan was the most common modality for re-staging (n = 14), followed by positron emission tomography (PET)-CT (n = 3) and endosonography (EUS) (n = 2). Stable disease on RECIST criteria was found in 67% of patients (range 53-80%) with 20% demonstrating reduction in tumour size. A total of 60% of patients underwent surgery post-NAT (range 31-85%) with a R0 rate of 88% (range 57-100%). Accuracy for predicting R0 resectability and T-stage on CT scan was 71 and 49%. A reduction in SUVmax on PET-CT and reduction of tumour stiffness on EUS elastography positively correlated with resectability. CONCLUSIONS More than half the patients undergo resection post-NAT for LAPC and BRPC. Stable, or reduction of, tumour disease may predict resectability. Reduction in tumour SUVmax on PET-CT and decreased tumour stiffness on EUS elastography may be potential markers of NAT response and resectability.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Benjamin Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - John A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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36
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Goel N, D'Souza JW, Ruth KJ, Milestone B, Karachristos A, Nagarathinam R, Cooper H, Hoffman J, Reddy S. The Utility of Preoperative Vascular Grading in Patients Undergoing Surgery First for Pancreatic Cancer: Does Radiologic Arterial or Venous Involvement Predict Pathologic Margin Status? JOURNAL OF ONCOLOGY 2018; 2018:7675262. [PMID: 30186324 PMCID: PMC6110012 DOI: 10.1155/2018/7675262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022]
Abstract
Controversy exists on accurately grading vascular involvement on preoperative imaging for pancreatic ductal adenocarcinoma. We reviewed the association between preoperative imaging and margin status in 137 patients. Radiologists graded venous involvement based on the Ishikawa classification system and arterial involvement based on preoperative imaging. For patients with both classifications recorded, we categorized vascular involvement as "None," "Arterial only," "Venous only," or "Both" and examined the association of vascular involvement and pathologic margin status. Of 134 patients with Ishikawa classifications, 63%, 17%, 11%, and 9% were graded as I, II, III, and IV, respectively. Of 96 patients with arterial staging, 74%, 16%, and 10% were categorized as stages i, ii, and iii, respectively. Of 93 patients with both stagings, 61% had no vascular involvement, 7% had arterial only, 14% had venous only, and 17% had both involved. Ishikawa classification was strongly associated with a positive SMA and SMV margin (p<0.001). However, for arterial staging, there was no association with SMA or SMV margin. Overall, Ishikawa grading was more predicative of arterial involvement and remained significant on multivariate analysis. The use of diagnostic imaging in predicting positive margins is more accurate when using a venous grading system.
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Affiliation(s)
- Neha Goel
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Jimson W. D'Souza
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Karen J. Ruth
- Department of Biostatistics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Barton Milestone
- Department of Radiology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Andreas Karachristos
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Rajeswari Nagarathinam
- Department of Pathology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Harry Cooper
- Department of Pathology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - John Hoffman
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Sanjay Reddy
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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37
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How to treat borderline resectable pancreatic cancer: current challenges and future directions. Jpn J Clin Oncol 2018; 48:205-213. [DOI: 10.1093/jjco/hyx191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/18/2017] [Indexed: 01/08/2023] Open
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38
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Abstract
Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.
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39
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Malleo G, Maggino L, Marchegiani G, Feriani G, Esposito A, Landoni L, Casetti L, Paiella S, Baggio E, Lipari G, Capelli P, Scarpa A, Bassi C, Salvia R. Pancreatectomy with venous resection for pT3 head adenocarcinoma: Perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration. Pancreatology 2017; 17:847-857. [PMID: 28843714 DOI: 10.1016/j.pan.2017.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/20/2017] [Accepted: 08/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The outcomes of pancreatectomy with superior mesenteric vein (SMV) or portal vein (PV) resection have been mixed. This study investigated the morbidity and mortality profile after SMV-PV resection in comparison with standard pancreatectomy. Furthermore, we assessed whether tumors with histologically proven SMV-PV infiltration differ from other pT3 neoplasms in terms of recurrence pattern and survival. METHODS All patients with a pT3 head adenocarcinoma resected from 2000 to 2013 were analyzed retrospectively. In the SMV-PV resection group, information on venous wall status was obtained through pathologic reports. Standard statistical methods were used for data analysis. RESULTS The study population consisted of 651 patients, of whom 81 (12.4%) underwent synchronous SMV-PV resection. Venous resection was not associated with a higher rate of postoperative complications (60.5% versus 50.2%) and mortality (1.2% versus 1.1%) in comparison with standard pancreatectomy. Vascular infiltration was confirmed pathologically in 56/81 patients (69.1%). The median disease-specific survival of the entire population was 27 months (95% CI 24.6-29.3), with a 5-year survival rate of 20.5%. The median recurrence-free survival was 18 months (95% CI 15.0-20.9). On multivariate analysis, ASA score, preoperative pain, Ca 19-9 levels, tumor grade, R-status, lymph-vascular invasion, N-status, and adjuvant therapy resulted to be survival predictors. Similarly, Ca 19.9 levels, R-status, and N-status were predictors of recurrence. SMV-PV infiltration was not a significant prognostic factor. CONCLUSION Morbidity and mortality rates of pancreatectomy with SMV-PV resection are comparable with standard pancreatectomy. Pancreatic head adenocarcinoma with histologically confirmed SMV-PV infiltration does not segregate prognostically from other pT3 tumors.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy.
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Feriani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elda Baggio
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Giovanni Lipari
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy; ARC-NET Research Center, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
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40
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Barreto SG, Pandanaboyana S, Ironside N, Windsor JA. Does revision of resection margins based on frozen section improve overall survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma? A meta-analysis. HPB (Oxford) 2017; 19:573-579. [PMID: 28420560 DOI: 10.1016/j.hpb.2017.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/19/2017] [Accepted: 03/01/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Margin status is the main surgical determinant of long-term outcome in pancreatic cancer. Intraoperative frozen section (IOFS) detects microscopic positive margins at a stage when margin revision is possible. The aim of this study was to determine if IOFS driven-revision of pancreatic resection margin(s) improves overall survival (OS) in pancreatic cancer. METHODS A systematic review of major reference databases was undertaken. Patients were divided into 3 groups based on initial FS (FSR0 for negative margin and FSR1 for positive microscopic margin) and final Permanent Section report (PSR0 for negative margin and PSR1 for positive microscopic margin): Group 1 (FSR0 → PSR0), Group 2 (FSR1 → PSR0), and Group 3 (FSR1 → PSR1). Patients in Groups 2 and 3 had surgical revision of the FSR1 margin. Data was meta-analysed. RESULTS 4 studies included in the final analysis. No difference in OS and incidence of lymph node metastases between Groups 2 and 3 (P = 0.590 and P = 0.410). CONCLUSIONS IOFS-based revision of R1 pancreatic resection margin does not improve OS, even when it results in an R0 margin. This suggests that any benefit of margin revision based on FS is over-ridden by markers of more advanced or aggressive disease.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia; School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, South Australia, Australia.
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Natasha Ironside
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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Mizumoto T, Goto T, Toyama H, Sofue K, Asari S, Terai S, Tanaka M, Kido M, Ajiki T, Fukumoto T, Ku Y. Pancreatic ductal adenocarcinoma with inferior vena cava invasion: a report of three resected cases. Surg Case Rep 2017; 3:72. [PMID: 28537015 PMCID: PMC5442030 DOI: 10.1186/s40792-017-0348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) often infiltrates to the adjacent major vasculatures; however, direct invasion of PDAC to the inferior vena cava (IVC) is uncommon. Case presentation We report our experience with three cases of PDAC directly invading the IVC wall. All three patients underwent pancreatoduodenectomy along with wedge resection of the IVC wall without severe postoperative complications. Histopathological studies revealed tumor infiltration to the adventitia of the IVC. All patients achieved negative surgical margins. One patient was still alive 26 months after surgery without tumor recurrence. Two patients experienced recurrence; one patient experienced liver metastasis but was still alive and in a stable condition without further tumor progression 12 months after surgery. Another patient experienced multiple liver metastasis 10 months after surgery and died 26 months after surgery. Conclusions Pancreatoduodenectomy along with wedge resection of the IVC wall for patients with PDAC directly invading the adventitia of the IVC can be performed safely. Further accumulation of cases is needed to elucidate the prognostic impact of IVC invasion.
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Affiliation(s)
- Takuya Mizumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Tadahiro Goto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan.
| | - Keitaro Sofue
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Sadaki Asari
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Sachio Terai
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Motofumi Tanaka
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Masahiro Kido
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Tetsuo Ajiki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
| | - Yonson Ku
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Hyogo, Japan
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Hoshimoto S, Hishinuma S, Shirakawa H, Tomikawa M, Ozawa I, Wakamatsu S, Hoshi S, Hoshi N, Hirabayashi K, Ogata Y. Reassessment of the clinical significance of portal-superior mesenteric vein invasion in borderline resectable pancreatic cancer. Eur J Surg Oncol 2017; 43:1068-1075. [PMID: 28427822 DOI: 10.1016/j.ejso.2017.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/21/2017] [Accepted: 03/29/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The principal objective of this study is to clarify the prognostic significance of borderline resectable pancreatic cancer (BRPC). The second objective is to evaluate the prognostic impact of the depth of pathological venous invasion. METHODS The study included 122 pancreatic cancer patients who underwent curative surgery. All computed tomography scans of the patients were retrospectively interpreted and classified according to the NCCN guidelines, version 1.2016, as resectable (-) or borderline resectable (+) in each arterial (BR-A) and venous (BR-PV) involvement. RESULTS The overall survival (OS) rate was significantly higher in BR-A(-) patients (n = 94) than in BR-A(+) patients (n = 28) (P = 0.001), whereas there was no difference between BR-PV(-) (n = 101) and BR-PV(+) patients (n = 21) (P = 0.257). In a multivariate analysis, the independent predictors of OS included BR-A(+) (P = 0.002), lymph node metastasis (P = 0.008), pathological venous invasion (P = 0.003), and adjuvant chemotherapy (P = 0.001). Of 39 patients who underwent venous resection, no significant difference was observed between BR-PV(-) (n = 20) and BR-PV(+) patients (n = 19) in resection rate, lymph node metastasis, the presence of extrapancreatic nerve invasion, recurrence rate, frequency of initial recurrence at a liver or local site, and OS. Pathological venous invasion was significantly deeper in BR-PV(+) patients. However, the depth of invasion was not associated with OS. CONCLUSION The definition of venous involvement in the current guidelines predicted the depth of pathological venous invasion but not OS in BRPC patients. Further prospective, randomized studies are needed to establish treatment strategies for BRPC patients with isolated venous involvement.
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Affiliation(s)
- S Hoshimoto
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - S Hishinuma
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - H Shirakawa
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - M Tomikawa
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - I Ozawa
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - S Wakamatsu
- Department of Pathology, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - S Hoshi
- Department of Pathology, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - N Hoshi
- Department of Pathology, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - K Hirabayashi
- Department of Pathology, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
| | - Y Ogata
- Department of Hepato-Biliary-Pancreatic Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya, Tochigi, 320-0834, Japan.
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Miyazaki M, Yoshitomi H, Takano S, Shimizu H, Kato A, Yoshidome H, Furukawa K, Takayashiki T, Kuboki S, Suzuki D, Sakai N, Ohtuka M. Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer. Langenbecks Arch Surg 2017; 402:447-456. [PMID: 28361216 DOI: 10.1007/s00423-017-1578-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. METHODS Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. RESULTS Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. CONCLUSIONS Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan.
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Hiroaki Shimizu
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Atsushi Kato
- International University of Health & Welfare Mita Hospital, Tokyo, Japan
| | - Hiroyuki Yoshidome
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Katunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Masayuki Ohtuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
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Barreto SG, Singh A, Perwaiz A, Singh T, Singh MK, Chaudhary A. Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability! Future Oncol 2017; 13:799-807. [PMID: 28266246 DOI: 10.2217/fon-2016-0536] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems. AIM To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity. PATIENTS & METHODS Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors. RESULTS A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity. CONCLUSION Optimization of MSBOS protocols for PD is required for more judicious use of blood products.
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Affiliation(s)
- Savio G Barreto
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India.,Hepatobiliary & Oesophagogastric Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.,School of Medicine, Faculty of Medicine, Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Amanjeet Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Azhar Perwaiz
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Tanveer Singh
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Adarsh Chaudhary
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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Windsor JA, Barreto SG. The concept of 'borderline resectable' pancreatic cancer: limited foundations and limited future? J Gastrointest Oncol 2017; 8:189-193. [PMID: 28280624 DOI: 10.21037/jgo.2016.12.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is traditionally treated by a surgery-first approach. The development and adoption of the concept of borderline resectable PDAC, which extends the role of surgery, is based on the proposition that neoadjuvant therapy (NAT) will increase the resection rate, margin negative rate and overall survival. There are a number of issues with this concept and a critical review of these suggests that it is based on limited foundations and likely has a limited future.
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Affiliation(s)
- John A Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand;; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
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Bell R, Ao BT, Ironside N, Bartlett A, Windsor JA, Pandanaboyana S. Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival. Surg Oncol 2017; 26:53-62. [PMID: 28317585 DOI: 10.1016/j.suronc.2016.12.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/21/2016] [Accepted: 12/29/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival. METHOD An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness. RESULTS Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome. CONCLUSION On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients.
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Affiliation(s)
- Richard Bell
- Department of HPB and Transplant Surgery, St James Hospital, Leeds, UK
| | - Braden Te Ao
- Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand
| | - Natasha Ironside
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand
| | - Adam Bartlett
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy – Author's reply. Lancet Oncol 2016; 17:e178. [DOI: 10.1016/s1470-2045(16)30036-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
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Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17:e177-8. [PMID: 27301040 DOI: 10.1016/s1470-2045(16)30037-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 01/22/2023]
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