[S3-guideline exocrine pancreatic cancer]

Defining distal splenopancreatectomy by the mesopancreas

BACKGROUND

The implementation of the pathologic CRM (circumferential resection margin) staging system for pancreatic head ductal adenocarcinomas (hPDAC) resulted in a dramatic increase of R1 resections at the dorsal resection margin, presumably because of the high rate of mesopancreatic fat (MP) infiltration. Therefore, mesopancreatic excision (MPE) during pancreatoduodenectomy has recently been promoted and has demonstrated better local disease control, fueling the discussion of neoadjuvant downsizing regimes in MP + patients. However, it is unknown to what extent the MP is infiltrated in patients with distal pancreatic (tail/body) carcinomas (dPDAC). It is also unknown if the MP infiltration status affects surgical margin control in distal pancreatectomy (DP). The aim of our study was to histopathologically analyze MP infiltration and elucidate the influence of resection margin clearance on recurrence and survival in patients with dPDAC. Furthermore, the results were compared to a collective receiving MPE for hPDAC.

METHOD

Clinicopathological and survival parameters of 295 consecutive patients who underwent surgery for PDAC (n = 63 dPDAC and n = 232 hPDAC) were evaluated. The CRM evaluation was performed in a standardized fashion and the specimens were examined according to the Leeds pathology protocol (LEEPP). The MP area was histopathologically evaluated for cancerous infiltration.

RESULTS

In 75.4% of dPDAC patients the MP fat was infiltrated by vital tumor cells. The rates of MP infiltration and R0CRM- resections were similar between dPDAC and hPDAC patients (p = 0.497 and 0.453 respectively). MP- infiltration status did not correlate with CRM implemented resection status in dPDAC patients (p = 0.348). In overall survival analysis, resection status and MP status remained prognostic factors for survival. In follow up analysis. surgical margin clearance in dPDAC patients was associated with a significant improvement in local recurrence rates (5.2% in R0CRM- resected vs. 33.3 in R1/R0CRM + resected, p = 0.002).

CONCLUSION

While resection margin status was not affected by the MP status in dPDAC patients, the high MP infiltration rate, as well as improved survival in MP- dPDAC patients after R0CRM- resection, justify mesopancreatic excision during splenopancreatectomy. Larger scale studies are urgently needed to validate our results and to study the effect on neoadjuvant treatment in dPDAC patients.

[Gastrointestinal tumour prevention strategies]

Over the past few decades, substantial advancements have been achieved in the early detection and treatment of gastrointestinal oncological diseases. The survival rates of patients have significantly improved due to the expansion and enhancement of therapeutic and diagnostic options, leading to modifications in (neo-)adjuvant, perioperative, and palliative strategies, as well as the advent of personalized molecular therapy. Noteworthy progress has also been observed in primary, secondary, and tertiary prevention domains.Despite these advancements, gastrointestinal tumours continue to be a global health burden, with approximately 4 million new cases diagnosed annually. These constitute over a quarter of all tumour cases, with nearly one-third of all global tumour-related mortalities attributed to gastrointestinal tumours.Emerging evidence implicates aberrant differentiation of stem or progenitor cells in the pathogenesis of gastrointestinal tumour diseases. A confluence of clinically recognized risk factors, including high-fat diet, bile acid, microbiome alterations, and host factors, can instigate chronic inflammation. This disrupts stem cell homeostasis and precipitates malignant transformation. Consequently, environmental inflammation emerges as a critical risk factor warranting consideration in clinical cancer prevention and surveillance strategies.This review encapsulates the current understanding and recommendations in the prevention of selected gastrointestinal tumours, aiming to facilitate their integration into clinical practice. It underscores the need for continued research to further refine diagnostic and therapeutic strategies and improve patient outcomes.

[Cystic pancreatic lesions-indications, timing and reasons for surveillance]

BACKGROUND

Cystic pancreatic lesions are detected incidentally at an increasing rate. Often, the patients present asymptomatically. Hence, the resulting clinical consequences remain challenging and unsettling for both physicians and patients.

OBJECTIVES

Status of current recommendations in handling cystic pancreatic lesions.

MATERIALS AND METHODS

Selective literature search of PubMed while taking current guidelines into account.

RESULTS

Correct diagnostic classification of the cystic lesion is crucial since further action depends on the type of cystic lesion. Resection is generally recommended for mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN), and intraductal papillary mucinous neoplasms (IPMN) with relevant risk criteria such as prominent main-duct dilation. Surveillance is recommended for IPMN without risk criteria, as long as comorbidities and life expectancy of the patient will allow preventive resection over the years. SCNs are benign and only symptomatic SCNs require resection. Inflammatory pancreatic cysts should only be treated under certain circumstances.

The DEAD-box RNA helicase, DDX60, Suppresses immunotherapy and promotes malignant progression of pancreatic cancer

Excessive proliferation, invasion, metastasis, and immune resistance in pancreatic cancer (PC) makes it one of the most lethal malignant tumors. Recently, DDX60 was found to be involved in the development of various tumors and in immunotherapy. Therefore, we aimed to investigate whether DDX60 is a new factor involved in PC immunotherapy. The DDX60 mRNA was screened using transcriptome sequencing (RNA-seq). The Cox and survival analysis of DDX60 was performed using the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases. In addition, clinical and immune infiltration data in the databases were analyzed and plotted using the R language. Clinical samples and in vitro experiments were used to determine the molecular evolution of DDX60 during PC progression. We found that DDX60 was upregulated in PC tissues (P value = 0.0083) and was associated with poor prognosis and short survival time of patients with PC. Results of Gene Ontology, Kyoto Encyclopedia of Genes and Genomes, and gene set variation analyses showed that viral defense, tumor, and immune-related pathways were significantly enriched in samples with high DDX60 expression. The Pearson correlation test demonstrated that DDX60 expression correlated strongly with immune checkpoint and immune system-related metagene clusters. Our results indicated that DDX60 promoted cell proliferation, migration, and invasion and was related to poor prognosis and immune resistance. Therefore, DDX60 may be a promising novel target for PC immunotherapy.

Resected Early-Onset Pancreatic Cancer: Practices and Outcomes in an International Dual-Center Study

BACKGROUND

Early-onset pancreatic cancer (EOPC), defined as age ≤ 45 years at diagnosis, accounts for 3% of all pancreatic cancer cases. Although differences in tumor biology have been suggested, available data are sparse and specific treatment recommendations are lacking. This study explores the clinicopathological features and oncologic outcomes of resected EOPC.

PATIENTS AND METHODS

Patients with EOPC undergoing resection between 2002 and 2018 were identified from the Heidelberg University Hospital and Johns Hopkins University registries. Median overall survival (OS) and recurrence-free survival (RFS) were analyzed, and prognostic factors were identified.

RESULTS

The final cohort included 164 patients, most of whom had pancreatic ductal adenocarcinoma (PDAC, n = 136; 82.9%) or IPMN-associated pancreatic cancer (n = 17; 10.4%). Twenty (12.1%) patients presented with stage 1 disease, 42 (25.6%) with stage 2, 75 (45.7%) with stage 3, and 22 (13.4%) with oligometastatic stage 4 disease. Most patients underwent upfront resection (n = 113, 68.9%), whereas 51 (31.1%) individuals received preoperative treatment. Median OS and RFS were 26.0 and 12.4 months, respectively. Stage-specific median survival was 70.6, 41.8, 23.8, and 16.9 months for stage 1, 2, 3, and 4 tumors, respectively. Factors independently associated with shorter OS and RFS were R1 resections and AJCC stages 3 and 4. Notably, AJCC 3-N2 and AJCC 3-T4 tumors had a median OS of 20 months versus 29.5 months, respectively.

CONCLUSION

Despite frequently presenting with advanced disease, oncologic outcomes in EOPC patients are satisfactory even in locally advanced cancers, justifying aggressive surgical approaches. Further research is needed to tailor current guidelines to this rare population.

Analysis of the CONKO-001 trial: Is the validity of the study sufficient to recommend adjuvant chemotherapy for pancreatic cancer?

BACKGROUND

Since randomized controlled trials have indicated that adjuvant chemotherapy prolongs survival and reduces recurrence rates after surgical resection of pancreatic adenocarcinoma, a gemcitabine based chemotherapy has become part of the interdisciplinary treatment concept for pancreatic cancer in accordance to current guidelines.

OBJECTIVES

The aim of this project was to analyse the validity of the CONKO-001 trial as a basis for the recommendation of adjuvant chemotherapy in many international guidelines.

METHODS

We analysed the validity of the CONKO-001 trial regarding study design, recruitment period, participating institutions, patient selection, randomisation, stratification, standardization of surgical treatment and histological examination, statistical methods and interpretation of results. We additionally analysed the study regarding the risk of bias using the RoB 2 Tool. Finally we reviewed the influence of the pharmaceutical industry and potential conflicts of interest.

RESULTS

We identified several shortcomings of the study concerning the study protocol, the participating clinics, the patient recruitment, the randomization pattern, the standardization of surgical treatment and histological examination, the statistical methods, the evaluation of the results and the influence of the pharmaceutical industry. According to the Cochrane RoB 2 Tool the study was judged to raise some concerns in three of the five risk domains for the outcome "overall survival".

CONCLUSIONS

Based on our review, the results of the CONKO-001-study should be revisited and critically reviewed. The recommendation to include adjuvant chemotherapy with gemcitabine deserves a critical appraisal.

Flexible semiparametric mode regression for time-to-event data

The distribution of time-to-event outcomes is usually right-skewed. While for symmetric and moderately skewed data the mean and median are appropriate location measures, the mode is preferable for heavily skewed data as it better represents the center of the distribution. Mode regression has been introduced for uncensored data to model the relationship between covariates and the mode of the outcome. Starting from nonparametric kernel density based mode regression, we examine the use of inverse probability of censoring weights to extend mode regression to handle right-censored data. We add a semiparametric predictor to add further flexibility to the model and we construct a pseudo Akaike's information criterion to select the bandwidth and smoothing parameters. We use simulations to evaluate the performance of our proposed approach. We demonstrate the benefit of adding mode regression to one's toolbox for analyzing survival data on a pancreatic cancer data set from a prospectively maintained cancer registry.

Präoperatives Ernährungsmanagement in der großen Tumorchirurgie des Bauchraumes an deutschen Kliniken. Eine explorative Strukturanalyse

Bis zu 80% der PatientInnen vor Tumorresektionen des oberen Gastrointestinaltrakts sind mangelernährt. Dabei hat schon der präoperative Ernährungszustand einen signifikanten Einfluss auf den perioperativen Verlauf. Ein adäquater präoperativer Ernährungszustand, der unter anderem die Komplikationsrate und die Krankenhausliegedauer reduzieren kann, ist daher erstrebenswert. Zwar empfehlen einschlägige Leitlinien Maßnahmen zur Erkennung und Behandlung einer Mangelernährung, jedoch fehlt es bislang an Vorschlägen zur Planung eines strukturieren präoperativen Ernährungsmanagements auf die BehandlerInnen zurückgreifen können. Innerhalb dieser Arbeit wurden 40 Krankenhäuser in Deutschland deshalb zu individuell vorhandenen Strukturen und Maßnahmen zum präoperativen Ernährungsmanagement von PatientInnen vor Tumorresektionen des oberen Gastrointestinaltrakts befragt. Die Befragungen zeigen, dass Maßnahmen zur Erkennung und Therapie einer präoperativen Mangelernährung mehrheitlich bekannt und akzeptiert sind. So befürworten 35 der 40 TeilnehmerInnen eine präoperative Ernährungstherapie bei mangelernährten PatientInnen, 26 TeilnehmerInnen erwägen hierfür sogar einen Aufschub der Operation. Eine flächendeckende Umsetzung an den Kliniken scheitere jedoch häufig an Hinderungsgründen, wie fehlender Sichtbarkeit der Ernährung als Therapiebaustein unter BehandlerInnen, labilen Verantwortlichkeiten sowie unzureichenden finanziellen und personellen Ressourcen. Mögliche Lösungsvorschläge zum Abbau der Hindernisse reichen von Refinanzierungsmöglichkeiten der klinischen Ernährungstherapie bis hin zu Forderungen auf gesundheitspolitischer Ebene. Aus den Erkenntnissen aktueller Studien und Leitlinien, sowie den Ergebnissen der Befragung, unterbreitet diese Arbeit einen Vorschlag zur Implementierung eines präoperativen Ernährungsmanagements. Dessen Umsetzbarkeit im klinischen Alltag sollte dabei durch wissenschaftliche Verfahren begleitet werden.

Delayed Gastric Emptying Does Not Influence Cancer-Specific Survival after Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma

Background: Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD). The present study investigates the influence of delayed gastric emptying on cancer-specific survival after PD. Methods: We included 267 patients who underwent PD between 2014 and 2021. They were analyzed regarding demographic factors, pre- and perioperative characteristics, surgical complications, and long-term survival. Results: Patients with a higher Charlson Comorbidity Index (CCI) or pre-existing pulmonary disease suffered significantly more from DGE. When experiencing PPH, a prolonged hospital stay, or major overall complications (Clavien-Dindo °III-V) were more common in the DGE group. Tumor size over 3 cm negatively affected survival. Conclusions: DGE has no influence on long-term survival in PDAC patients, although it prolongs hospital stay.

Isolated Gastric Metastases of Pancreatic Ductal Adenocarcinoma following Radical Resection—Impact of Endosonography-Guided Fine Needle Aspiration Tract Seeding

Background: Endosonography-guided fine needle aspiration biopsy (EUS-FNA)-associated metachronous gastric seeding metastases (GSM) of pancreatic ductal adenocarcinoma (PDAC) represent a serious condition with insufficient evidence. Methods: Retrospective analysis of PDAC resections with a curative-intent, proven pathological diagnosis of PDAC, preoperative EUS-FNA and post-resection follow-up of at least 60 months. The systematic literature search of published data was used for the GSM growth evaluation using Pearson correlation and the linear regression analyses. Results: The inclusion criteria met 59/134 cases, 16 (27%) had retained needle tract (15 following distal pancreatectomy, 1 following pylorus-sparing head resection). In total, 3/16 cases (19%) developed identical solitary GSM (10–26th month following primary surgery) and were radically resected. A total of 30 published cases of PDAC GSM following EUS-FNA were identified. Lesion was resected in 20 distal pancreatectomy cases with complete information in 14 cases. A correlation between the metastasis size and time (r = 0.612) was proven. The regression coefficient b = 0.72 expresses the growth of 0.72 mm per month. Conclusions: The GSM represent a preventable and curable condition. A remarkably high number of GSM following EUS-FNA was identified, leading to follow-up recommendation of EUS-FNA sampled patients. Multimodal management (gastric resection, adjuvant chemotherapy) may prolong survival.

[All about the Pancreas]

All about the Pancreas Abstract. Ultrasound has made tremendous progress with the use of contrast media and elastography, particularly in patients with small, solid pancreatic lesions (SPL) <20mm and cystic tumors (CPL) of any size. In the case of solid and cystic pancreatic lesions, the differential diagnosis must first be evaluated after detection in order to define the indications for radical surgery, strategies for preserving the pancreatic parenchyma or simply for control examinations. Contrast-enhanced transcutaneous (TUS, CEUS) and endoscopic (EUS, CE-EUS) ultrasound and elastography facilitate further characterization of SPL and ZPL. Pancreatic ductal adenocarcinomas (PDAC) show hypoenhancement in contrast-enhanced ultrasound. The majority of the important differential diagnoses, on the other hand, are multi-enhancing. PDAC are almost always harder than healthy pancreatic parenchyma. In contrast, elastographically soft SPL are - with very few exceptions - benign. This review provides an overview of the use of modern ultrasound techniques to detect and characterize solid and cystic pancreatic lesions.

Nutritional Interventions in Pancreatic Cancer: A Systematic Review

(1) Background: Pancreatic cancer (PaCa) is directly related to malnutrition, cachexia and weight loss. Nutritional interventions (NI) are used in addition to standard therapy. The aim of this systematic review is to provide an overview of the types of NI and their effects. (2) Methods: We included RCTs with at least one intervention group receiving an NI and compared them with a control group with no NI, placebo or alternative treatment on cachexia, malnutrition or weight loss in patients with PaCa. Any available literature until 12 August 2021 was searched in the Pubmed and Cochrane databases. RCTs were sorted according to NI (parenteral nutrition, enteral nutrition, dietary supplements and mixed or special forms). (3) Results: Finally, 26 studies with a total of 2720 patients were included. The potential for bias was mostly moderate to high. Parenteral nutrition is associated with a higher incidence of complications. Enteral nutrition is associated with shorter length of stay in hospital, lower rate and development of complications, positive effects on cytokine rates and lower weight loss. Dietary supplements enriched with omega-3 fatty acids lead to higher body weight and lean body mass. (4) Conclusions: Enteral nutrition and dietary supplements with omega-3 fatty acids should be preferred in nutritional therapy of PaCa patients.

Nationwide Provision of Radiologically-guided Interventional Measures for the Supportive Treatment of Tumor Diseases in Germany - An Analysis of the DeGIR Registry Data

PURPOSE

 In addition to direct oncologic therapy, interventional radiology plays an important supportive role in oncologic therapy primarily guided by other disciplines. These supporting measures include diagnostic punctures, drainages, biliary interventions, central venous access including port implantations, osteoplasties, pain therapies etc.). This study investigated the extent to which these radiologically guided supportive measures are available in Germany.

MATERIAL AND METHODS

 All interventional procedures documented in the DeGIR-registry (excluding transhepatic portosystemic shunts) of the years 2018 and 2019 were recorded (DeGIR-module C). A breakdown of the documented interventions was performed based on federal states as well as 40 individual regions (administrative districts and former administrative districts).

RESULTS

 A total of 136,328 procedures were recorded at 216 centers in DeGIR Module C in 2018 and 2019. On average, 389 cases were documented per hospital in 2018 and 394 cases in 2019; the increase per hospital from 2019 is not statistically significant but is relevant in the aggregate when new participating centers are included, with an overall increase of 10 % (6,554 more cases than the previous year). Normalized to one million inhabitants, an average of 781 procedures took place across Germany in 2018 and 860 in 2019. Districts with no registered procedures are not found for Module C.Indications for Module C interventions were mostly interdisciplinary in 2018 and 2019. In this context, the quality of outcome was very high; for the procedures drain placement, marking and biopsy the technical success was 99 %, while the complication rate was lower than 1 %.

CONCLUSION

 The structural analysis of this work concludes that in Germany there is good nationwide availability of radiologically guided supportive measures in oncological therapy. Accordingly, the training situation for prospective interventional radiologists is good, as the distribution to centers with high experience is excellent. In addition, the overall outcome quality of radiology-guided interventions is very high.

KEY POINTS

· In Germany, there is good nationwide coverage of radiologically guided supportive interventions in oncological therapy.. · The training situation for prospective interventional radiologists is good, as the distribution to centers with high experience is excellent.. · The overall outcome quality of radiology-guided interventions is very high..

CITATION FORMAT

· Nadjiri J, Schachtner B, Bücker A et al. Nationwide Provision of Radiologically-guided Interventional Measures for the Supportive Treatment of Tumor Diseases in Germany - An Analysis of the DeGIR Registry Data. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1735-3615.

The clinical impact of preoperative biliary drainage on isolated infectious complications (iiC) after pancreatic head resection—a retrospective study

Background

The perioperative morbidity after pancreatoduodenectomy (PD) is mostly influenced by intraabdominal complications which are often associated with infections. In patients with preoperative biliary drainage (PBD), the risk for postoperative infections may be even elevated. The aim of this study is to explore if isolated infectious complications without intraabdominal focus (iiC) can be observed after PD and if they are associated to PBD and antibiotic prophylaxis with potential conclusions for their treatment.

Methods

During a 10-year period from 2009 to 2019, all consecutive PD were enrolled prospectively in a database and analyzed retrospectively. Bacteriobilia (BB) and Fungibilia (FB) were examined by intraoperatively acquired smears. A perioperative antibiotic prophylaxis was performed by Ampicillin/Sulbactam. For this study, iiC were defined as postoperative infections like surgical site infection (SSI), pneumonia, unknown origin etc. Statistics were performed by Fisher’s exact test and Mann Whitney U test.

Results

A total of 426 PD were performed at the Vivantes Humboldt-hospital. The morbidity was 56% (n = 238). iiC occurred in 93 patients (22%) and accounted for 38% in the subgroup of patients with postoperative complications. They were not significantly related to BB and PBD but to FB. The subgroup of SSI, however, had a significant relationship to BB and FB with a poly microbial profile and an accumulation of E. faecalis, E. faecium, Enterobacter, and Candida. BB was significantly more frequent in longer lay of PBD. Resistance to standard PAP and co-existing resistance to broad spectrum antibiotics is frequently found in patients with iiC. The clinical severity of iiC was mostly low and non-invasive therapy was adequate. Their treatment led to a significant prolongation of the hospital stay.

Conclusions

iiC are a frequent problem after PD, but only in SSI a significant association to BB and FB can be found in our data. Therefore, the higher resistance of the bacterial species to routine PAP, does not justify broad spectrum prophylaxis. However, the identification of high-risk patients with BB and PBD (length of lay) is recommended. In case of postoperative infections, an early application of broad-spectrum antibiotics and adaption to microbiological findings from intraoperatively smears may be advantageous.

Concepts and Outcomes of Perioperative Therapy in Stage IA-III Pancreatic Cancer-A Cross-Validation of the National Cancer Database (NCDB) and the German Cancer Registry Group of the Society of German Tumor Centers (GCRG/ADT)

(1) Background: The aim of this study is to assess perioperative therapy in stage IA-III pancreatic cancer cross-validating the German Cancer Registry Group of the Society of German Tumor Centers-Network for Care, Quality, and Research in Oncology, Berlin (GCRG/ADT) and the National Cancer Database (NCDB). (2) Methods: Patients with clinical stage IA-III PDAC undergoing surgery alone (OP), neoadjuvant therapy (TX) + surgery (neo + OP), surgery+adjuvantTX (OP + adj) and neoadjuvantTX + surgery + adjuvantTX (neo + OP + adj) were identified. Baseline characteristics, histopathological parameters, and overall survival (OS) were evaluated. (3) Results: 1392 patients from the GCRG/ADT and 29,081 patients from the NCDB were included. Patient selection and strategies of perioperative therapy remained consistent across the registries for stage IA-III pancreatic cancer. Combined neo + OP + adj was associated with prolonged OS as compared to neo + OP alone (17.8 m vs. 21.3 m, p = 0.012) across all stages in the GCRG/ADT registry. Similarly, OS with neo + OP + adj was improved as compared to neo + OP in the NCDB registry (26.4 m vs. 35.4 m, p < 0.001). (4) Conclusion: The cross-validation study demonstrated similar concepts and patient selection criteria of perioperative therapy across clinical stages of PDAC. Neoadjuvant therapy combined with adjuvant therapy is associated with improved overall survival as compared to either therapy alone.

MR-guided adaptive stereotactic body radiotherapy (SBRT) of primary tumor for pain control in metastatic pancreatic ductal adenocarcinoma (mPDAC): an open randomized, multicentric, parallel group clinical trial (MASPAC)

Background

Pain symptoms in the upper abdomen and back are prevalent in 80% of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC), where the current standard treatment is a systemic therapy consisting of at least doublet-chemotherapy for fit patients. Palliative low-dose radiotherapy is a well-established local treatment option but there is some evidence for a better and longer pain response after a dose-intensified radiotherapy of the primary pancreatic cancer (pPCa). Stereotactic body radiation therapy (SBRT) can deliver high radiation doses in few fractions, therefore reducing chemotherapy-free intervals. However, prospective data on pain control after SBRT of pPCa is very limited. Therefore, we aim to investigate the impact of SBRT on pain control in patients with mPDAC in a prospective trial.

Methods

This is a prospective, double-arm, randomized controlled, international multicenter study testing the added benefit of MR-guided adaptive SBRT of the pPca embedded between standard of care-chemotherapy (SoC-CT) cycles for pain control and prevention of pain in patients with mPDAC. 92 patients with histologically proven mPDAC and at least stable disease after initial 8 weeks of SoC-CT will be eligible for the trial and 1:1 randomized in 3 centers in Germany and Switzerland to either experimental arm A, receiving MR-guided SBRT of the pPCa with 5 × 6.6 Gy at 80% isodose with continuation of SoC-CT thereafter, or control arm B, continuing SoC-CT without SBRT. Daily MR-guided plan adaptation intents to achieve good target coverage, while simultaneously minimizing dose to organs at risk. Patients will be followed up for minimum 6 and maximum of 18 months. The primary endpoint of the study is the “mean cumulative pain index” rated every 4 weeks until death or end of study using numeric rating scale.

Discussion

An adequate long-term control of pain symptoms in patients with mPDAC is an unmet clinical need. Despite improvements in systemic treatment, local complications due to pPCa remain a clinical challenge. We hypothesize that patients with mPDAC will benefit from a local treatment of the pPCa by MR-guided SBRT in terms of a durable pain control with a simultaneously favorable safe toxicity profile translating into an improvement of quality-of-life.

Trial registration

German Registry for Clinical Trials (DRKS): DRKS00025801. Meanwhile the study is also registered at ClinicalTrials.gov with the Identifier: NCT05114213.

Neoadjuvant Treatment Lowers the Risk of Mesopancreatic Fat Infiltration and Local Recurrence in Patients with Pancreatic Cancer

Simple Summary

After the implementation of an in-depth histopathological pancreas protocol, curative resection rates for pancreatic head cancers have drastically dropped. Standardized extended resections using embryo-anatomic landmarks (MPE), have recently been prooved to increase margin-negative resection rates. The mesopancreatic fat, excised during these extended resections, was infiltrated in the majority of the patients. Neoadjuvant treatment is an emerging topic of interest for pancreatic cancer patients. It remains unclear if these extended resections are still warranted in patients after neoadjuvant treatment. Neoadjuvant treatment lowered the risk for mesopancreatic fat infiltration and patients were less prone to local recurrence and margin positive resections when compared to patients after upfront surgery. However, the majority of the patients are yet diagnosed with mesopancreatic fat infiltration, justifying this extended approach synergistically with the treatment strategies for colorectal cancer.

Abstract

Background: Survival following surgical treatment of ductal adenocarcinoma of the pancreas (PDAC) remains poor. The recent implementation of the circumferential resection margin (CRM) into standard histopathological evaluation lead to a significant reduction in R0 rates. Mesopancreatic fat infiltration is present in ~80% of PDAC patients at the time of primary surgery and recently, mesopancreatic excision (MPE) was correlated to complete resection. To attain an even higher rate of R0(CRM−) resections in the future, neoadjuvant therapy in patients with a progressive disease seems a promising tool. We analyzed radiographic and histopathological treatment response and mesopancreatic tumor infiltration in patients who received neoadjuvant therapy prior to MPE. The aim of our study was to evaluate the need for MPE following neoadjuvant therapy and if multi-detector computed tomographically (MDCT) evaluated treatment response correlates with mesopancreatic (MP) infiltration. Method: Radiographic, clinicopathological and survival parameters of 27 consecutive patients who underwent neoadjuvant therapy prior to MPE were evaluated. The mesopancreatic fat tissue was histopathologically analyzed and the 1 mm-rule (CRM) was applied. Results: In the study collective, both the rate of R0 resection R0(CRM−) and the rate of mesopancreatic fat infiltration was 62.9%. Patients with MP infiltration showed a lower tumor response. Surgical resection status was dependent on MP infiltration and tumor response status. Patients with MDCT-predicted tumor response were less prone to MP infiltration. When compared to patients after upfront surgery, MP infiltration and local recurrence rate was significantly lower after neoadjuvant treatment. Conclusion: MPE remains warranted after neoadjuvant therapy. Mesopancreatic fat invasion was still evident in the majority of our patients following neoadjuvant treatment. MDCT-predicted tumor response did not exclude mesopancreatic fat infiltration.

Evaluation of the Hamburg-Glasgow Classification in Pancreatic Cancer: Preoperative Staging by Combining Disseminated Tumor Load and Systemic Inflammation

This study aims to compare the Hamburg Glasgow Classification (HGC) to Union for International Cancer Control (UICC) classification in patients with pancreatic ductal adenocarcinoma (PDAC). As adequate tumor classification is only possible after tumor resection and histological evaluation, only 20% of patients with PDAC receive accurate tumor staging. Thus, an accurate preoperative staging system is still missing but urgently needed. Systemic inflammation and tumor dissemination are important factors regarding the oncological outcome. HGC integrates both into a preoperative staging system, by combining C-reactive protein (CRP), albumin, and disseminated tumor cells (DTC) in the bone marrow. In this prospective study, 109 patients underwent surgical exploration for suspected PDAC. All patients underwent a preoperative bone marrow aspiration for DTC detection. HGC showed significant preoperative risk stratification for overall survival (OS) (p-value < 0.001) and progression-free survival (PFS) (p-value < 0.001). These results were comparable to the UICC survival stratification for OS and PFS (p-value = 0.001 and 0.006). Additionally, in non-metastatic PDAC, HGC III-IV was associated with shorter OS and PFS (p-value < 0.001, respectively) when compared to HGC I-II. Therefore, the HGC is a promising preoperative prognostic staging classification for accurate and simple outcome stratification in patients with PDAC.

Study protocol of an open-label, single arm phase II trial investigating the efficacy, safety and quality of life of neoadjuvant chemotherapy with liposomal irinotecan combined with Oxaliplatin and 5-fluorouracil/Folinic acid followed by curative surgical resection in patients with hepatic Oligometastatic adenocarcinoma of the pancreas (HOLIPANC)

BACKGROUND

According to current guidelines, treatment of patients with hepatic oligometastasis in pancreatic cancer is not reflected and systemic chemotherapy is recommended in those patients. Retrospective data suggest beneficial outcomes in patients with hepatic oligometastasis, though prospective data from clinical trials addressing this particular patient group is not available.

METHODS

In this single arm, phase-2 trial, survival data from patients receiving neoadjuvant chemotherapy followed by R0/R1 resection will be compared to historic data from patients with oligometastatic adenocarcinoma of the pancreas. The clinical trial will focus on a well-defined patient collective with metastatic load limited to the liver as target organ with a maximum of five metastases. The combination of liposomal irinotecan (nal-IRI), oxaliplatin (OX) and 5-fluouracil (5-FU)/folinic acid (FA) (nal-IRI + OX+ 5-FU/FA, NAPOX) was chosen as neoadjuvant chemotherapy; the choice was based on an ongoing clinical study in which NAPOX appeared manageable, with promising anti-tumor activity in first-line treatment of patients with metastatic pancreatic adenocarcinoma. In total 150 patients will be enrolled for this trial with an aim of 55 patients receiving a complete macroscopic synchronous tumor and metastatic resection.

DISCUSSION

This is the first clinical study to prospectively evaluate the value of multimodality therapy concepts in oligometastatic pancreatic cancer.

TRIAL REGISTRATION NUMBERS

EudraCT 2019-002734-37 ; NCT04617457 .

[Complete response after neoadjuvant therapy : How certain is the pathology?]

Histopathologic evaluation of tumors after neoadjuvant therapy is performed by tumor regression grading (TRG) systems, which reflect the proportion of vital residual primary tumor in relation to the previous total tumor. The World Health Organization (WHO) tumor grading is replaced by TRG in tumor classification. The histopathological work-up of a tumor is based on the criteria of the TNM classification even after neoadjuvant therapy. A uniform TRG does not exist. For various tumors TRGs based on the tumor entity have been established, consisting of a 3-stage or 5‑stage grading system. Complete histopathological tumor regression is only present if no vital tumor cells are detectable in the histopathological examination of the primary surgical specimens (primary tumor and accompanying locoregional lymph nodes) and there are no distant metastases.

[Prevention of gastrointestinal cancer]

Throughout the past decades, considerable progress has been made in the (early) diagnosis and treatment of gastrointestinal cancers. However, the prognosis for advanced stages of gastrointestinal tumors remains limited for many patients and approximately one third of all tumor patients die as a result of gastrointestinal tumors. The prevention and early detection of gastrointestinal tumors is therefore of great importance.For this reason, we summarize the current state of knowledge and recommendations for the primary, secondary and tertiary prevention of esophageal, stomach, pancreas, liver and colorectal cancer in the following.

[Surgery for periampullary pancreatic cancer]

Periampullary neoplasms are a heterogeneous group of different tumor entities arising from the periampullary region, of which pancreatic ductal adenocarcinoma (PDAC) is the most common subgroup with 60-70%. As typical for pancreatic adenocarcinomas, periampullary pancreatic cancer is characterized by an aggressive growth and early systemic progression. Due to the anatomical location in close relationship to the papilla of Vater symptoms occur at an earlier stage of the disease, so that treatment options and prognosis are overall more favorable compared to pancreatic carcinomas at other locations. Nevertheless, the principles of treatment for periampullary pancreatic cancer are not substantially different from the standards for pancreatic cancer at other locations. A potentially curative approach for non-metastatic periampullary pancreatic cancer is a multimodal therapy concept, which includes partial pancreatoduodenectomy as a radical oncological resection in combination with a systemic adjuvant chemotherapy. As a result, long-term survival can be achieved in patients with favorable prognostic factors. In addition, with the continous development of surgery and systemic treatment potentially curative treatment concepts for advanced initially nonresectable tumors were also established, after completion of neoadjuvant treatment. This article presents the current surgical principles of a radical oncological resection for periampullary pancreatic cancer in the context of a multimodal treatment concept with an outlook for future developments of treatment.

Pre-Operative MDCT Staging Predicts Mesopancreatic Fat Infiltration-A Novel Marker for Neoadjuvant Treatment?

The rates of microscopic incomplete resections (R1/R0CRM+) in patients receiving standard pancreaticoduodenectomy for PDAC remain very high. One reason may be the reported high rates of mesopancreatic fat infiltration. In this large cohort study, we used available histopathological specimens of the retropancreatic fat and correlated high resolution CT-scans with the microscopic tumor infiltration of this area. We found that preoperative MDCT scans are suitable to detect cancerous infiltration of this mesopancreatic tissue and this, in turn, was a significant indicator for both incomplete surgical resection (R1/R0CRM+) and worse overall survival. These findings indicate that a neoadjuvant treatment in PDAC patients with CT-morphologically positive infiltration of the mesopancreas may result in better local control and thus improved resection rates. Mesopancreatic fat stranding should thus be considered in the decision for neoadjuvant therapy. Background: Due to the persistently high rates of R1 resections, neoadjuvant treatment and mesopancreatic excision (MPE) for ductal adenocarcinoma of the pancreatic head (hPDAC) have recently become a topic of interest. While radiographic cut-off for borderline resectability has been described, the necessary extent of surgery has not been established. It has not yet been elucidated whether pre-operative multi-detector computed tomography (MDCT) staging reliably predicts local mesopancreatic (MP) fat infiltration and tumor extension. Methods: Two hundred and forty two hPDAC patients that underwent MPE were analyzed. Radiographic re-evaluation was performed on (1) mesopancreatic fat stranding (MPS) and stranding to peripancreatic vessels, as well as (2) tumor diameter and anatomy, including contact to peripancreatic vessels (SMA, GDA, CHA, PV, SMV). Routinely resected mesopancreatic and perivascular (SMA and PV/SMV) tissue was histopathologically re-analyzed and histopathology correlated with radiographic findings. A logistic regression of survival was performed. Results: MDCT-predicted tumor diameter correlated with pathological T-stage, whereas presumed tumor contact and fat stranding to SMA and PV/SMV predicted and correlated with histological cancerous infiltration. Importantly, mesopancreatic fat stranding predicted MP cancerous infiltration. Positive MP infiltration was evident in over 78%. MPS and higher CT-predicted tumor diameter correlated with higher R1 resection rates. Patients with positive MP stranding had a significantly worse overall survival (p = 0.023). Conclusions: A detailed preoperative radiographic assessment can predict mesopancreatic infiltration and tumor morphology and should influence the decision for primary surgery, as well as the extent of surgery. To increase the rate of R0CRM- resections, MPS should be considered in the decision for neoadjuvant therapy.

[Standardized diagnosis of pancreatic head carcinoma]

Most pancreatic ductal adenocarcinomas are localized in the pancreatic head. Due to the complex anatomic relationships with the surrounding organs and vascular structures in the retroperitoneal space and to the presence of numerous transection margins and dissection planes, pancreatic head resections belong to the most complex specimens concerning grossing and sampling for histopathologic analysis.Here we discuss current guidelines for standardized grossing and reporting of pancreatic cancer, with special reference to the assessment of the resection margin status. The importance of standardized reporting for the sake of completeness, comprehensibility, comparability, and quality control as well as for the integration of pathology reports in interdisciplinary digital workflows and artificial intelligence applications will be emphasized.

Surgical margin clearance and extended chemotherapy defines survival for synchronous oligometastatic liver lesions of the ductal adenocarcinoma of the pancreas

Background

The role of surgery for circumscribed synchronous hepatic lesions of the pancreatic ductal adenocarcinoma (PDAC) remains controversial. Thus, the aim of our study was to compare survival outcome (OS) after surgery of patients with hepatic metastases (M1surg) to patients with only localized disease.

Methods

Correlation analysis of clinicopathological data and OS after resection of M1surg patients and patients with localized PDACs (M0) was performed. Patients were included for survival analysis only if a complete staging including perineural, venous and lymphatic invasion was available.

Results

Out of the study collective, 35 patients received extended surgery (M1surg), whereas 131 patients received standardized surgery for localized disease (M0). Length of hospitalization and mortality was similar in both groups. FOLFIRNOX as an adjuvant treatment regime was administered in ~ 23 and ~ 8% of M1surg and M0 patients, respectively. In subgroup analysis of R0 resected patients and in multivariate analysis of the total cohort, there was no difference in overall survival between both groups. Only the resection status (R1 vs R0) and venous invasion (V1) were identified as independent prognostic factors. Site of recurrence in R0 resected M1surg patients and in M0 patients were homogenously distributed.

Conclusion

This is the first study demonstrating a survival benefit after extended surgery for synchronously hepatic-metastasized PDACs. We found no difference in survival outcome of metastasized patients when compared to patients with localized disease. FOLFIRINOX as an adjuvant treatment regime for resected M1surg presumably is worthwhile. Larger multicenter studies are still needed to validate our results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10147-021-01961-5.

[Definition and treatment of superior mesenteric artery revascularization and dissection-associated diarrhea (SMARD syndrome) in Germany]

Hintergrund

Die A. mesenterica superior (AMS) wird im Rahmen von Pankreasresektionen (PR) und mesenterialen Gefäßeingriffen (MG) freigelegt und disseziert. Eine dadurch entstandene Schädigung des umliegenden ex- und intrinsischen vegetativen Nervenplexus kann zu einer passageren oder therapierefraktären Diarrhö führen.

Fragestellung

Die vorliegende Studie soll einen Überblick über den derzeitigen Stellenwert der AMS-Revaskularisations- und -Dissektions-assoziierten Diarrhö („superior mesenteric artery revascularisation and dissection-associated diarrhea“[SMARD]-Syndrom) in Deutschland geben.

Material und Methoden

Nach selektiver Literaturrecherche (SLR) mit der Fragestellung, ob und wie häufig eine postoperativ neu aufgetretene Diarrhö nach PR und MG vorkommt, wurde eine Onlineumfrage versendet.

Ergebnisse

Die SLR (n = 4) bestätigte, dass eine postoperativ neu aufgetretene Diarrhö eine häufige Komplikation nach Präparation zur Revaskularisation (RV) bzw. Dissektion (DIS) der AMS ist (Inzidenz ca. 62 %). Therapierefraktäre Verläufe sind selten 14 %. 54 von 159 Zentren beteiligten sich an der Umfrage. 63 % gaben an, eine AMS-RV/-DIS im Rahmen von PR oder MG durchzuführen. Der Durchschnitt an PR pro Zentrum lag 2018 bei 47 und bei 49 im Jahr 2019. Fünf MG erfolgten durchschnittlich in beiden Jahren pro Zentrum. Drei Patienten litten durchschnittlich am SMARD-Syndrom.

Diskussion

Diese Umfrage erfasst erstmals den derzeitigen Stellenwert des SMARD-Syndroms in Deutschland. Bisher fehlen Empfehlungen zur Therapie einer solchen Diarrhö. Die Ergebnisse zeigen, dass zunächst eine symptomatische Therapie erfolgen sollte. Aufgrund der Komplexität der Pathophysiologie sind kausale Therapieansätze bislang nicht entwickelt.

Late recurrences of pancreatic cancer in patients with long-term survival after pancreaticoduodenectomy

BACKGROUND

Pancreatic cancer remains a relevant clinical problem due to poor prognosis. Even after curative pancreaticoduodenectomy tumor recurrences occur in up to 80%. Risk factors for postoperative tumor recurrences have been identified before, but data on risk factors for tumor recurrences in patients with long-term-survival is scarce.

METHODS

In this retrospective study consecutive long-term survival-patients (defined as at least 60 months survival) undergoing pancreaticoduodenectomy for pancreatic cancer from 2007-2014 were identified in the 2nd largest pancreatic surgery center in Germany. Clinical, pathohistological and laboratory values were analyzed to identify risk factors for tumor recurrence.

RESULTS

Thirty-four of one-hundred-sixty-seven patients were identified as long-term-survival-patients in the study period. Of those, 10 patients (29.4%) suffered from tumor recurrence. Lymph vessel invasion was identified as an independent risk factor (P=0.031, hazard ratio 13.127, 95% confidence interval: 1.270-135.698). Median postoperative time to tumor recurrence in long-term-survival-patients was 49 months. Overall survival after diagnosis of tumor recurrence was 33 months. 80% (N=8) of the patients were asymptomatic. Half of the patients (N=5) suffered from local disease, with 40% undergoing curative tumor resection. CA 19-9 levels were significantly elevated at 57 U/mL (normal <27 U/mL).

CONCLUSIONS

Tumor recurrence in long-term-survival-patients is typically asymptomatic. Especially long-term-survival-patients with lymph vessel invasion are more likely to develop tumor recurrence. Therefore, a structured follow-up program including CT-scans and CA 19-9 surveillance must be continued in all patients undergoing pancreaticoduodenectomy even in cases of long-term-survival.

Can Patients with Pancreatic Cancer and Liver Metastases Obtain Survival Benefit from Surgery? A Population-Based Study

Background: Surgery for pancreatic cancer with liver metastases (PCL) is not recommended in the international guidelines, and investigation of its clinical significance in patients with PCL is very limited. This study explored whether surgery, especially synchronous resection of the primary tumor and liver metastases (SPL), could improve survival in PCL.

Methods: Data of 14,248 patients with PCL from Surveillance, Epidemiology, and End Results database was analyzed. Patients were divided into following groups: SPL, synchronous primary site, and other resection (SPO), single resection of the primary site (SPS), and no resection (NR).

Results: In this study, only 93 (0.7%) underwent SPL, 88 (0.6%) for SPO, and 232 (1.6%) for SPS. Multivariate Cox analysis showed surgical procedures of both the primary site and other sites were independent protective prognostic factors for pancreatic cancer cause-specific survival (PCSS) (all P < 0.001). Patients in the SPL group showed the most survival benefit, with a significant and gradually increased difference as compared with the SPO, SPS, and NR groups (median survival: 54, 34, 15, and 3 months, respectively, all P < 0.001). Compared with the NR group, mortalities were significant and gradually declining in the SPS, SPO, and SPL groups, with hazard ratio 0.329 (95% confidence interval [CI], 0.281 to 0.386), 0.220 (95% CI, 0.164 to 0.294), and 0.162 (95% CI, 0.118 to 0.222), respectively (all P < 0.001).

Conclusions: Surgical procedures for both primary site and other sites improved survival. SPL, particularly, showed a considerable survival benefit in well-selected patients with PCL.

Hepatic artery reconstruction after extended resection for borderline resectable pancreatic head cancer: A case report

Pancreatic head cancer is frequently associated with invasion of the surrounding vascular structures, such cases being considered for a long period of time as unresectable. Improvement of the vascular surgery techniques allowed association of extended vascular resections and reconstructions, increasing in this way the percentage of patients benefiting from radical surgery. We present the case of a 47-year-old male patient with no significant medical history diagnosed with a large pancreatic head tumor invading the common and proper hepatic artery as well as the portal vein. The venous reconstruction was performed using a synthetic prosthesis while the left hepatic artery was sutured to the left gastric artery; meanwhile the right hepatic artery was reconstructed using the splenic artery. In conclusion, extended hepatic artery resection followed by arterial reconstruction in association with portal vein resection and prosthetic replacement might be needed in cases presenting large pancreatic head tumors with vascular invasion.

[Intraoperative rapid frozen section-when meaningful, when necessary?]

Intraoperative frozen sections can significantly improve the results of numerous visceral surgical operations. For this a close cooperation between surgery and pathology is a basic prerequisite. The main indications are the diagnostics of unclear intraoperative findings and the assessment of resection margins. Just as in any other procedure, there are also limiting factors to be considered in frozen section examinations.

[Surgery of pancreatic cancer: techniques to avoid local recurrence]

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.

Advanced Pancreatic Ductal Adenocarcinoma: Moving Forward

Globally, the death rate of pancreatic ductal adenocarcinoma (PDAC) has doubled over 30 years and is likely to further increase, making PDAC a leading cause of cancer-related death in the coming years. PDAC is typically diagnosed at an advanced stage, and modified FOLFIRINOX or nab-paclitaxel and gemcitabine are the mainstay of systemic therapy. For elderly patients with good performance status, low-dose treatment can preserve quality of life without compromising cancer control or survival. Maintenance therapy should be considered in PDAC patients achieving disease control with systemic therapy. In particular, olaparib has demonstrated a progression-free survival benefit of 3.6 months in a subgroup of PDAC patients with germline BRCA1/2 mutations (ca. 10% of all PDAC). Pancreatic enzyme replacement therapy is often omitted in the treatment of patients with PDAC, with possibly deleterious consequences. Small intestinal bacterial overgrowth is highly prevalent in patients with PDAC and should be considered in the diagnostic algorithm of PDAC patients with bloating and diarrhea. Rivaroxaban has been associated with a reduced risk of thrombosis without an increase in major bleeding events, and its use should be considered in every patient with advanced PDAC undergoing systemic therapy.

Systematic Analysis of Accuracy in Predicting Complete Oncological Resection in Pancreatic Cancer Patients-Proposal of a New Simplified Borderline Resectability Definition

Background: Borderline resectability in pancreatic cancer (PDAC) is currently debated. Methods: Patients undergoing pancreatic resections for PDAC were identified from a prospectively maintained database. As new borderline criteria, the presence of any superior mesenterico-portal vein alteration (SMPV) and perivascular stranding of the superior mesenteric artery (SMA) was evaluated in preoperative imaging. The accuracy of established radiological borderline criteria as compared to the new borderline criteria in predicting R status (sensitivity/negative predictive value) and overall survival was assessed. (3) Results: 118 patients undergoing pancreatic resections for PDAC from 2013 to 2018 were identified. Forty-three (36.4%) had radiological perivascular SMA stranding and 55 (46.6%) had SMPV alterations. Interrater reliability was 90% for SMA stranding and 87% for SMPV alterations. The new borderline definition including SMPV alterations and perivascular SMA stranding was the best predictor of conventional R status (p = 0.040, sensitivity 53%, negative predictive value 81%) and Leeds/Wittekind circumferential margin status (p = 0.050, sensitivity 73%, negative predictive value 79%) as compared to established borderline resectability definition criteria. Perivascular SMA stranding qualified as an independent negative prognostic parameter (HR 3.066, 95% CI 1.078-5.716, p = 0.036). Conclusion: The radiological evaluation of any SMPV alteration and perivascular SMA stranding predicts R status and overall survival in PDAC patients, and may serve to identify potential candidates for neoadjuvant therapy.

Modern ultrasound imaging of pancreatic tumors

In patients with solid pancreatic lesions (SPLs), the differential diagnosis must be evaluated to determine whether radical surgery, pancreatic parenchyma-saving strategies, or follow-up is indicated. Contrast-enhanced (endoscopic) ultrasonography and elastography facilitate the further characterization of SPLs. The majority of cases of pancreatic ductal adenocarcinoma exhibit hypoenhancement with contrast-enhanced ultrasonography. Elastographically soft SPLs are benign with very few exceptions, whereas stiffer SPLs can be malignant or benign. This article reviews the current use of modern ultrasound imaging techniques, including contrast-enhanced ultrasonography and elastography, for the detection and characterization of SPLs. In particular, the unexcelled diagnostic potential of multiparametric endoscopic ultrasonography to detect and characterize small SPLs is highlighted.

Pancreatic cancer-derived organoids - a disease modeling tool to predict drug response

BACKGROUND

Organotypic cultures derived from pancreatic ductal adenocarcinoma (PDAC) termed pancreatic ductal cancer organoids (PDOs) recapitulate the primary cancer and can be derived from primary or metastatic biopsies. Although isolation and culture of patient-derived pancreatic organoids were established several years ago, pros and cons for individualized medicine have not been comprehensively investigated to date.

METHODS

We conducted a feasibility study, systematically comparing head-to-head patient-derived xenograft tumor (PDX) and PDX-derived organoids by rigorous immunohistochemical and molecular characterization. Subsequently, a drug testing platform was set up and validated in vivo. Patient-derived organoids were investigated as well.

RESULTS

First, PDOs faithfully recapitulated the morphology and marker protein expression patterns of the PDXs. Second, quantitative proteomes from the PDX as well as from corresponding organoid cultures showed high concordance. Third, genomic alterations, as assessed by array-based comparative genomic hybridization, revealed similar results in both groups. Fourth, we established a small-scale pharmacotyping platform adjusted to operate in parallel considering potential obstacles such as culture conditions, timing, drug dosing, and interpretation of the results. In vitro predictions were successfully validated in an in vivo xenograft trial. Translational proof-of-concept is exemplified in a patient with PDAC receiving palliative chemotherapy.

CONCLUSION

Small-scale drug screening in organoids appears to be a feasible, robust and easy-to-handle disease modeling method to allow response predictions in parallel to daily clinical routine. Therefore, our fast and cost-efficient assay is a reasonable approach in a predictive clinical setting.

High mobility group AT-hook 2 and c-MYC as potential prognostic factors in pancreatic ductal adenocarcinoma

The present study investigated if c-MYC and high mobility group AT-hook 2 (HMGA2) expression was associated with prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). A total of 102 patients undergoing surgery for PDAC were retrospectively reviewed. Immunohistochemistry was used to detect c-MYC and HMGA2 protein expression in PDAC and peritumoral tissue samples. Expression of c-MYC and HMGA2 was associated with clinicopathological characteristics and prognoses of patients with PDAC using multivariate analysis. HMGA2 and c-MYC protein expression was significantly higher in PDAC tissues compared with peritumoral tissue (P<0.001). HMGA2 and c-MYC expression was also significantly higher in patients with PDAC who had lymph node metastasis, invasion of regional tissues and tumor node metastasis (TNM) stage III or IV disease compared with those who had no lymph node metastasis, no invasion of regional tissues and TNM stage I or II disease (P<0.001). Multivariate logistic regression analysis was used to identify TNM stage (P=0.007) and invasion (P=0.003) as significant independent predictors of c-MYC expression (model AUC=0.8201), and lymph node metastasis (P=0.002) and invasion (P=0.003) as significant independent predictors of HMGA2 expression (model AUC=0.7638). Cox multivariate analysis showed that expression of c-MYC (P=0.019) and HMGA2 (P<0.001), TNM stage (P=0.014) and lymph node metastasis (P=0.032) were associated with reduced overall survival time. HMGA2 and c-MYC may be important biological markers and potential therapeutic targets involved in the tumorigenesis, metastasis, invasion and prognosis of PDAC.

Maintenance Therapy with FOLFIRI after FOLFIRINOX for Advanced Pancreatic Ductal Adenocarcinoma: A Retrospective Single-Center Analysis

Objectives

Patients with pancreatic ductal adenocarcinoma (PDA) receiving FOLFIRINOX often develop oxaliplatin-induced polyneuropathy, which limits the continuation of this therapy. We evaluated the efficacy and safety of FOLFIRI maintenance treatment after FOLFIRINOX induction in a retrospective single-center study.

Methods

Patients with advanced PDA treated with FOLFIRI as maintenance therapy after achieving disease control under FOLFIRINOX according to the local operating procedure between 2011 and 2016 were identified. Medical records of this group were evaluated retrospectively.

Results

Overall, 22 patients with PDA were treated with FOLFIRI (mean age 59 years, 55% female, 45% male). Before receiving FOLFIRI, all patients were treated with FOLFIRINOX for a median of 4 months. The median progression-free survival (PFS) under FOLFIRI maintenance therapy was 8 months. Side effects grade 3-4 (CTCAE v4.0) were observed in 18% of patients receiving FOLFIRI. Considering together FOLFIRINOX induction and subsequent FOLFIRI maintenance therapy, the median PFS was 11 months. The median overall survival (OS) from the beginning of palliative treatment was estimated at 46 months.

Conclusions

In the selected group of PDA patients achieving disease control with FOLFIRINOX, FOLFIRI maintenance therapy was feasible, safe, and effective, with some patients achieving long-term disease stabilization.

[Pancreatic ductal adenocarcinoma]

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.

Protocol of a prospective, monocentric phase I/II feasibility study investigating the safety of multimodality treatment with a combination of intraoperative chemotherapy and surgical resection in locally confined or borderline resectable pancreatic cancer: the combiCaRe study

INTRODUCTION

Pancreatic cancer is a devastating disease with an exceptionally poor prognosis. Complete resection of the primary tumour followed by adjuvant chemotherapy is the current standard treatment for patients with resectable disease and the only curative treatment option. However, long-term survival remains rare. Tumour cell dissemination due to manipulation during surgery may increase the rate of future metastases and local recurrence, and perioperative chemotherapy might diminish local, distant and circulating minimal residual disease. Yet, safety and feasibility of systemic chemotherapeutic treatments during pancreatic cancer resection have to be evaluated in a first instance.

METHODS AND ANALYSIS

This is a prospective, single-centre phase I/II feasibility study to investigate the safety and tolerability of a combination of intraoperative chemotherapy and surgical resection in pancreatic cancer. Forty patients with locally confined or borderline resectable pancreatic cancer, meeting all proposed criteria will be included. Participants will receive 400 mg/m2 calcium folinate over 2 hours and 2000 mg/m2 5-fluorouracil over 48 hours, started on the day before pancreatic surgery and thus continuing during surgery. Participants will be followed until 60 days after surgery. The primary endpoint is the 30-day overall complication rate according to the Clavien-Dindo classification. Secondary endpoints comprise toxicity and treatment associated complications. Patients receiving perioperative chemotherapy will be compared with a propensity score matched contemporary control group of 70 patients with pancreatic cancer receiving the standard treatment. This trial also contains an ancillary translational study to analyse disseminated tumour cells and effects of pharmacological interventions in pancreatic cancer.

ETHICS AND DISSEMINATION

CombiCaRe has been approved by the German Federal Institute for Drugs and Medical Devices (reference number 4042787) and the Medical Ethics Committee of Heidelberg University (reference number AFmo-269/2018). The results of this trial will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00015766).

Optimizing the outcomes of pancreatic cancer surgery

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.

[Oligometastasis in pancreatic cancer : Current state of knowledge and spectrum of local therapy]

BACKGROUND

Several case series reported results of surgical resection in patients with pancreatic ductal adenocarcinoma in a metastasized stage.

AIM

A summarized overview of the current state of knowledge and a summary of the results of currently available studies.

MATERIAL AND METHODS

A systematic search was carried out in MEDLINE and PubMed with respect to metastasized pancreatic cancer and surgical resection.

RESULTS

The evidence level for surgical resection in the metastasized stage is weak and so far no prospective trials are available. The largest single-arm trial included 85 patients with hepatic metastasis. In cases of hepatic oligometastasis an overall survival of 11-14 months was observed. In the presence of pulmonary metastasis, overall survival seems to be prolonged compared to intra-abdominal metastasis, although the evidence level is relatively weak.

CONCLUSION

According to the available results, a general recommendation for surgical resection in a metastasized stage cannot be given; however, the results show a possible benefit for some well-selected patient subgroups. Prospective trials must validate these data and investigate the use of combined surgical and systemic treatments in the case of resectable metastatic pancreatic cancer.

Etiology and Risk Factors of Acute and Chronic Pancreatitis

Based on the recognition of common etiological and genetic risk factors, acute and chronic pancreatitis are increasingly regarded as a continuum of the same disease, with a significant overlap of clinical manifestations and phenotypes but distinct morphological and imaging appearances. Recent population-based and cohort studies have found that tobacco smoke conveys a greater risk than immoderate alcohol consumption for the development of chronic pancreatitis, and hypertriglyceridemia has been identified as a risk factor for acute pancreatitis - even when plasma levels are only mildly elevated. Hereditary pancreatitis, in its autosomal dominant form, is associated with mutations in the cationic trypsinogen gene (PRSS1), whereas a number of germline variations in other genes have been found to represent risk factors for chronic as well as acute pancreatitis. For now, most of these involve the pancreatic digestive protease/antiprotease system. Oftentimes, affected patients are burdened with multiple or accumulating risk factors, and genetic traits when combined with environmental toxins compound the chance of developing the disease. Determining the underlying etiology of pancreatitis is worth the effort since formerly intractable varieties such as autoimmune pancreatitis are now becoming increasingly treatable, and subtype-specific therapeutic modalities may become available.

A Blood-Based Multi Marker Assay Supports the Differential Diagnosis of Early-Stage Pancreatic Cancer

The most frequent malignancy of the pancreas is the pancreatic ductal adenocarcinoma (PDAC). Despite many efforts PDAC has still a dismal prognosis. Biomarkers for early disease stage diagnosis as a prerequisite for a potentially curative treatment are still missing. Novel blood-based markers may help to overcome this limitation.

Methods: Prior to surgery plasma levels of thrombospondin-2 (THBS2), which was recently published as a novel biomarker, and CA19-9 from 52 patients with histologically proven PDAC were determined, circulating cell-free (cfDNA) was quantified. 15 patients with side-branch IPMNs without worrisome features and 32 patients with chronic pancreatitis served for comparison. Logit (logistic regression) models were used to test the performance of single biomarkers and biomarker combinations.

Results: CA19-9 and THBS2 alone showed comparable c-statistics of 0.80 and 0.73, respectively, improving to 0.87 when combining these two markers. The c-statistic was further increased to 0.94 when combining CA19-9 and THBS2 with cfDNA quantification. This marker combination performed best for all PDAC stages but also for PDACs grouped by stage. The greatest improvement over CA19-9 was seen in the group of stage I PDAC, from 0.69 to 0.90 for the three marker combination.

Conclusion:These data establish the combination of CA19-9, THBS2 and cfDNA as a composite liquid biomarker for non-invasive diagnosis of early-stage PDAC.

Radical pancreatic cancer surgery-with arterial resection

Extended surgery with arterial resection in pancreatic cancer remains a controversial topic. Although not recommended as a standard procedure, arterial resection may be feasible in selected patients and with the availability of new multimodal treatment approaches it may gain increasing impact in pancreatic cancer therapy as a complete tumor removal is still the only opportunity to achieve long-term survival for this disease. With regard to the surgical approach, one must differentiate between resection and reconstruction of the celiac axis and the hepatic artery as its most important branch, and resection/reconstruction of the superior mesenteric artery. Both procedures are technically possible and require a distinct level of surgical experience as well as interdisciplinary management for preoperative diagnosis and treatment of postoperative complications to achieve good outcomes. Besides arterial resection followed by reconstruction, there are specific situations when arteries may be resected without reconstruction, e.g., during distal pancreatectomy with celiac axis resection. In addition, in some cases arterial resections can be avoided despite a suspected tumor attachment by sharp dissection on the adventitial layer of the respective artery, especially after neoadjuvant therapy which is increasingly performed for borderline resectable and locally advanced tumor findings. This review summarizes definitions, diagnostics, technical aspects and outcomes of arterial resection in pancreatic cancer surgery in the context of the current literature and evidence.

Neoadjuvant plus adjuvant or only adjuvant nab-paclitaxel plus gemcitabine for resectable pancreatic cancer - the NEONAX trial (AIO-PAK-0313), a prospective, randomized, controlled, phase II study of the AIO pancreatic cancer group

BACKGROUND

Even clearly resectable pancreatic cancer still has an unfavorable prognosis. Neoadjuvant or perioperative therapies might improve the prognosis of these patients. Thus, evaluation of perioperative chemotherapy in resectable pancreatic cancer in a prospective, randomized trial is warranted. A substantial improvement in overall survival of patients with metastatic pancreatic cancer with FOLFIRINOX and nab-paclitaxel/gemcitabine vs standard gemcitabine has been demonstrated in phase III-trials. Indeed nab-paclitaxel/gemcitabine has a more favorable toxicity profile compared to the FOLFIRINOX protocol and appears applicable in a perioperative setting.

METHODS

NEONAX is an interventional, prospective, randomized, controlled, open label, two sided phase II study with an unconnected analysis of the results in both experimental arms against a fixed survival probability (38% at 18 months with adjuvant gemcitabine), NCT02047513. NEONAX will enroll 166 patients with resectable pancreatic ductal adenocarcinoma (≤ cT3, N0 or N1, cM0) in two arms: Arm A (perioperative arm): 2 cycles nab-paclitaxel (125 mg/m2)/gemcitabine (1000 mg/m2, d1, 8 and 15 of an 28 day-cycle) followed by tumor surgery followed by 4 cycles nab-paclitaxel/gemcitabine, Arm B (adjuvant arm): tumor surgery followed by 6 cycles nab-paclitaxel/gemcitabine. The randomization (1:1) is eminent to avoid allocation bias between the groups. Randomization is stratified for tumor stage (ct1/2 vs. cT3) and lymph node status (cN0 vs. cN1). Primary objective is disease free survival (DFS) at 18 months after randomization. Key secondary objectives are 3-year overall survival (OS) rate and DFS rate, progression during neoadjuvant therapy, R0 and R1 resection rate, quality of life and correlation of DFS, OS and tumor regression with pharmacogenomic markers, tumor biomarkers and molecular analyses (ctDNA, transcriptome, miRNA-arrays). In addition, circulating tumor-DNA will be analyzed in patients with the best and the worst responses to the neoadjuvant treatment. The study was initiated in March 2015 in 26 centers for pancreatic surgery in Germany.

DISCUSSION

The NEONAX trial is an innovative study on resectable pancreatic cancer and currently one of the largest trials in this field of research. It addresses the question of the role of intensified perioperative treatment with nab-paclitaxel plus gemcitabine in resectable pancreatic cancers to improve disease-free survival and offers a unique potential for translational research.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02047513, 08/13/2014.

First reported case of a collision tumor composed of pancreatic adenocarcinoma and retroperitoneal liposarcoma: a case report

BACKGROUND

Collision tumors are rare cases with two different tumor entities growing synchronously. While adenocarcinoma of the pancreas is the most common pancreatic tumor with an incidence of 10 per 100.000, retroperitoneal liposarcoma remains very rare. This is the first report of a collision tumor between these two tumor entities.

CASE PRESENTATION

Demographic details: The tumor was diagnosed in a 64 male Caucasian patient. Besides atrial fibrillation, arterial hypertension and a hypothyroidism there is no relevant medical history especially no history of cancer. Clinical details: During a routine check-up an unclassified tumor of the pancreatic tail was diagnosed. The lab showed no pathologies. Tumor markers were negative for carbohydrate antigen 19-9 and 72-4 (CA 19-9, CA 72-4) and carcinoembryonic antigen (CEA). Alpha-fetoprotein (AFP) and neuron specific enolase (NSE) were both elevated (AFP 97kU/l, (< 5,8kU/l) and NSE 30,0 μg/l (16,4 μg/l)). A computed tomography-guided core needle biopsy was performed which revealed a low-grade liposarcoma (G1). A CT scan showed no metastases. A surgical resection was recommended by the interdisciplinary tumor board.

INTERVENTIONS

A systematic left sided retroperitoneal compartment resection including en-bloc-left sided pancreatectomy, splenectomy, nephrectomy, hemicolectomy, adrenalectomy, partial gastrectomy and partial resection of the diaphragm was performed. Pathology revealed a collision tumor consisting of pancreatic adenocarcinoma that was classified pT3, pN2 (11/33 ece+) L1 V0 Pn0, R0; G2 [UICC Stage III] and a liposarcoma pT2, pN0 (0/33) L0 V0 Pn0, G1 [UICC Stage Ib]. The postoperative tumor board recommended an adjuvant chemotherapy with gemcitabine and capecitabine for the locally advanced pancreatic adenocarcinoma.

OUTCOME

At the latest follow-up (1 year after surgery) the patient was in good clinical condition and without evidence of tumor recurrence.

CONCLUSION

Collision tumors are rare and difficult to diagnose. This is the first description of a collision tumor composed of pancreatic adenocarcinoma and retroperitoneal liposarcoma. The reported case demonstrates that inconsistent diagnostic results (e.g. imaging and pathology) should raise suspicion concerning the diagnosis. Awareness of these rare cases might protect us from underdiagnosing patients and therefore leading to better patient care. There is evolving evidence that will lead to more personalized treatment options for somatic BRCA mutated pancreatic cancer.

Combined Systemic Chemotherapy and CT-Guided High-Dose-Rate Brachytherapy for Isolated Local Manifestation of Pancreatic Cancer after Surgical Resection

BACKGROUND

Prospective data on the optimal management of patients with pancreatic ductal adenocarcinoma (PDA) and isolated local manifestation (ILM) after surgery are lacking. Hence, no statements with respect to this entity have been released from most international guidelines including European Society for Medical Oncology, National Comprehensive Cancer Network, and American Society for Clinical Oncology.

METHODS

We report for the first time a case-series of 3 patients with PDA and ILM receiving combined systemic chemotherapy and CT-guided high-dose-rate interstitial brachytherapy (CT-HDRBT).

RESULTS

CT-HDRBT allowed in all patients with pronounced chemotherapy-induced side effects either a pause of cytostatic treatment or de-escalation to a "maintenance" therapy (dose reduction, interval prolongation, scheme modification with withdrawal of most toxic drugs).

CONCLUSION

Combining CT-HDRBT to systemic chemotherapy in patients with PDA and ILM is feasible and safe. As for patients with PDA and ILM no standard of care exists, designing an appropriate randomized prospective trial for this highly selected group of patients is challenging.

The Indications for Laparoscopic Pancreatectomy

BACKGROUND

Laparoscopic pancreatectomy is not yet established as a routine procedure everywhere in Germany or in other countries. Few data are available on its short- and long-term outcomes.

METHODS

From 2008 onward, a working group initiated by 10 centers and currently comprising 34 centers has gathered data on all cases of laparoscopic pancreatectomy. Procedures in which laparoscopy was converted to open surgery are also included.

RESULTS

The registry now contains 550 data sets representing 267 cases of benign disease, 244 malignancies, and 39 borderline tumors. The most common procedure was laparoscopic left pancreatectomy, followed by resection of the head of the pancreas and tumor enucleation. The most common intraoperative complication was hemorrhage, with a frequency of 3%. The rate of conversion to open surgery was 35%; if minilaparotomies are excluded, the conversion rate was only 16%. 39% of patients developed a pancreatic fistula after surgery (usually grade A or B, with 1.5% grade C) and 3% underwent reoperation because of postoperative hemorrhage. The procedure-related mortality was 1.3%. 91% of the patients reported only very mild postoperative pain. 6.7% newly developed diabetes mellitus after the procedure.

CONCLUSION

The patient cohort in the registry consists of persons who were selected to undergo laparoscopic pancreatectomy by the participating hospital teams, and the data are thus inherently affected by selection bias. The operative procedures that they underwent reflect the current practice of laparoscopic pancreatectomy in Germany. The complication rates are similar to those of open surgery. Selection bias can be avoided only by a randomized trial.

Discriminating chronic pancreatitis from pancreatic cancer: Contrast-enhanced EUS and multidetector computed tomography in direct comparison

BACKGROUND AND OBJECTIVES

To compare the ability of multidetector computed tomography (MDCT) and contrast-enhanced EUS to discriminate chronic pancreatitis (CP) from pancreatic ductal adenocarcinoma (PDAC).

SUBJECTS AND METHODS

A total of 215 patients (age: 62 ± 15 years, sex: f/m 80/135) were included in this retrospective study. All patients were examined by conventional endoscopic B-mode and contrast-enhanced high mechanical index EUS (CEHMI-EUS). CELMI-EUS was performed in 159 patients and endoscopic sonoelastography (ESE) in 210 patients. MDCT was carried out in 131 patients as part of their clinical work-up. Radiological reports were retrospectively analyzed. Final diagnosis was achieved by biopsy and evaluation of cytological specimens collected was performed by EUS-FNA, surgery, or follow-up of 12 months or more in patients with benign findings. In a subgroup of 100 patients, all diagnostic five methods were performed, and head-to-head analysis was performed.

RESULTS

Sensitivity and specificity for MDCT were 89% and 70% and for CEHMI-EUS were 96% and 91%, respectively. Sensitivities and specificities for EUS were 92% and 63% for B-Mode EUS, 96% and 38% for ESE, and 82% and 76% for CELMI-EUS, respectively. In the head-to-head analysis, each modality had shown lower numbers for specificity than shown in the overall group analysis because of high drop-out rate. EUS-FNA for PDAC had a sensitivity of 96% and a specificity of 100%.

CONCLUSIONS

Contrast-enhanced EUS is a reliable tool in discriminating PDAC from CP.