Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients

Survival benefit associated with screening of patients at elevated risk for pancreatic cancer

BACKGROUND & OBJECTIVES: Screening for pancreatic cancer is recommended for individuals with a strong family history, certain genetic syndromes, or a neoplastic cyst of the pancreas. However, limited data supports a survival benefit attributable to screening these higher-risk individuals.

METHODS

All patients enrolled in screening at a High-Risk Pancreatic Cancer Clinic (HRC) from July 2013 to June 2020 were identified from a prospectively maintained institutional database and compared to patients evaluated at a Surgical Oncology Clinic (SOC) at the same institution during the same period. Clinical outcomes of patients selected for surgical resection, particularly clinicopathologic stage and overall survival, were compared.

RESULTS

Among 826 HRC patients followed for a median (IQR) of 2.3 (0.8-4.2) years, 128 were selected for surgical resection and compared to 402 SOC patients selected for resection. Overall survival was significantly longer among HRC patients (median survival: not reached vs. 2.6 years, p < 0.001). Among 31 HRC and 217 SOC patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC), the majority of HRC patients were diagnosed with stage 0 disease (carcinoma in situ), while the majority of SOC patients were diagnosed with stage II disease (p < 0.001). Overall survival after resection of invasive PDAC was also significantly longer among HRC patients compared to SOC patients (median survival 5.5 vs. 1.6 years, p = 0.002).

CONCLUSION

Patients at increased risk for PDAC and followed with guideline-based screening exhibited downstaging of disease and improved survival from PDAC in comparison to patients who were not screened.

Analysis of chemoresistance characteristics and prognostic relevance of postoperative gemcitabine adjuvant chemotherapy in pancreatic cancer

AIM

To investigate the relationship between chemoresistance in pancreatic cancer patients receiving postoperative gemcitabine adjuvant therapy and specific clinical/pathological characteristics, as well as its impact on patient prognosis.

METHODS

From June 2018 to June 2021, clinical and pathological data of 148 pancreatic cancer patients were collected, and 101 patients were followed up for tumor recurrence/metastasis and survival status. The correlation between chemoresistance and specific clinical/pathological characteristics or patient prognosis was retrospectively analyzed.

RESULTS

Of the 148 patients, 78 were in the chemoresistance group and 70 in the non-chemoresistance group. Univariate analysis showed that the development of chemoresistance may be related to patient age, combined diabetes, preoperative CA19-9 level, tumor size, AJCC stage, vascular invasion, and positive lymph node ratio. Furthermore, subsequent multivariate analysis incorporating these variables indicated that tumor size may be a key factor influencing chemoresistance (p < 0.001, OR = 1.584). Log-rank test showed patients in the chemoresistance group had worse overall survival (OS) (HR = 2.102, p = 0.018) and progression free survival (PFS) (HR = 3.208, p = 0.002) than patients in the non-chemoresistance group; and patients with smaller size tumors (diameter ≤3 cm) had significantly better OS (HR = 2.923, p < 0.001) and PFS (HR = 2.930, p = 0.003) than those with larger size tumors (diameter >3 cm).

CONCLUSIONS

Patients with pancreatic cancer receiving postoperative gemcitabine adjuvant therapy are more likely to develop chemoresistance when their tumor sizes are larger (diameter >3 cm). Development of chemoresistance exacerbates the prognosis of patients with pancreatic cancer, and larger tumor size is also a risk factor for poor prognosis in these patients.

The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

The Association of Oral Microbiome Dysbiosis with Gastrointestinal Cancers and Its Diagnostic Efficacy

BACKGROUND

The second leading mortality cause in the world is cancer, making it a critical issue that impacts human health. As a result, scientists are looking for novel biomarkers for cancer detection. The oral microbiome, made up of approximately 700 species-level taxa, is a significant source for discovering novel biomarkers. In this review, we aimed to prepare a summary of research that has investigated the association between the oral microbiome and gastrointestinal cancers.

METHODS

We searched online scientific datasets including Web of Science, PubMed, Scopus, and Google Scholar. Eligibility criteria included human studies that reported abundances of the oral microbiome, or its diagnostic/prognostic performance in patients with gastrointestinal cancers.

RESULTS

Some phyla of the oral microbiome have a relationship with cancers. Some particular phyla of the oral microbiome that may be related to gastrointestinal cancers consist of Firmicutes, Actinobacteria, Bacteroidetes, Proteobacteria, and Fusobacteria. Changes in the abundances of Porphyromonas, Fusobacterium, Prevotella, and Veillonella are correlated with carcinogenesis, and may be used for distinguishing cancer patients from healthy subjects. Oral, colorectal, pancreatic, and esophageal cancers are the most important cancers related to the oral microbiome.

CONCLUSION

The results of this study may help future research to select bacteria as an early diagnostic or prognostic biomarker of gastrointestinal cancer. Given the current state of our knowledge, additional research is required to comprehend the multiplex processes underlying the role of bacterial microbiota upon cancer progression and to characterize the complex microbiota-host interaction network.

Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy

Background

This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients.

Patients and methods

This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic.

Results

The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model.

Conclusion

The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.

Earlier Diagnosis of Pancreatic Cancer: Is It Possible?

Pancreatic ductal adenocarcinoma has a very high mortality rate which has been only minimally improved in the last 30 years. This high mortality is closely related to late diagnosis, which is usually made when the tumor is large and has extensively infiltrated neighboring tissues or distant metastases are already present. This is a paradoxical situation for a tumor that requires nearly 15 years to develop since the first founding mutation. Response to chemotherapy under such late circumstances is poor, resistance is frequent, and prolongation of survival is almost negligible. Early surgery has been, and still is, the only approach with a slightly better outcome. Unfortunately, the relapse percentage after surgery is still very high. In fact, early surgery clearly requires early diagnosis. Despite all the advances in diagnostic methods, the available tools for improving these results are scarce. Serum tumor markers permit a late diagnosis, but their contribution to an improved therapeutic result is very limited. On the other hand, effective screening methods for high-risk populations have not been fully developed as yet. This paper discusses the difficulties of early diagnosis, evaluates whether the available diagnostic tools are adequate, and proposes some simple and not-so-simple measures to improve it.

Surgical resection for liver recurrence after curative resection of pancreatic ductal adenocarcinoma

PURPOSE

This study aimed to evaluate the clinical significance of surgical resection for liver recurrence in patients with curatively resected pancreatic ductal adenocarcinoma.

METHODS

The medical records of patients with a liver recurrence after undergoing curative pancreatectomy for pancreatic ductal adenocarcinoma were retrospectively reviewed. Clinicopathological and prognostic factors were analyzed, as was the clinical impact of surgical resection for liver recurrence.

RESULTS

Overall, 502 patients underwent curative pancreatic ductal adenocarcinoma resection. Of the 311 patients with recurrence after curative pancreatectomy, 71 (23%) had an initial recurrence in the liver, with 35 having solitary recurrence (11%). Patients with solitary, two or three, or more than four recurrences had median overall survival times of 28.5, 18.0, and 12.2 months, respectively (p < 0.001). Surgical indications for liver recurrence in our institution included solitary tumor, good disease control under chemotherapy after recurrence for > 6 months, and sufficient remnant liver function. Ten patients who met our institutional policy inclusion criteria underwent liver resection. Among 35 patients with initially solitary liver recurrence, those who underwent liver resection outlived those who did not (57.6 months vs. 20.1 months, p < 0.001). In multivariate analysis of overall survival, solitary liver recurrence and liver resection were independent favorable prognostic factors in patients with initial liver recurrence.

CONCLUSION

In selected patients with solitary liver recurrence after curatively resected pancreatic ductal adenocarcinoma, liver resection may be a treatment option.

Hepatopancreaticobiliary Surgical Outcomes at a Community Hospital

There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai'i with outcomes comparable to large tertiary centers.

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for advanced pancreatic and periampullary adenocarcinoma

Long term prognosis and 5-year survival for pancreatic adenocarcinoma (PDAC) remains suboptimal. Endoscopic ultrasound (EUS) guided RFA (EUS-RFA) is an emerging technology and limited data exist regarding safety and long-term outcomes. The aim of this study is to report safety-profile, feasibility and outcomes of EUS-RFA for advanced PDAC. Prospective review of patients with diagnosis of locally-advanced or metastatic PDAC undergoing EUS-RFA between October 2016 to March 2018 with long-term follow up (> 30 months). Study patients underwent a total of 1–4 RFA sessions. All patients were enrolled in longitudinal cohort study and received standard of care chemotherapy. 10 patients underwent EUS-RFA. Location of the lesions was in the head(4), neck(2), body(2), and tail(2). 22 RFA sessions were performed with a range of 1–4 sessions per patient. There were no major adverse events (bleeding, perforation, infection, pancreatitis) in immediate (up to 72 h) and short-term follow up (4 weeks). Mild worsening of existing abdominal pain was noted during post-procedure observation in 12/22 (55%) of RFA treatments. Follow-up imaging demonstrated tumor progression in 2 patients, whereas tumor regression was noted in 6 patients (> 50% reduction in size in 3 patients). Median survival for the cohort was 20.5 months (95% CI, 9.93–42.2 months). Currently, 2 patients remain alive at 61 and 81 months follow-up since initial diagnosis. One patient had 3 cm PDAC with encasement of the portal confluence, abutment of the celiac axis, common hepatic and superior mesenteric artery. This patient had significant reduction in tumor size and underwent standard pancreaticoduodenectomy. In our experience, EUS-RFA was safe, well-tolerated and could be concurrently performed with standard chemotherapy. In this select cohort, median survival was improved when compared to published survival based upon SEER database and clinical trials. Future prospective trials are needed to understand the role of EUS-RFA in overall management of PDAC.

Portal Vein Thrombosis After Venous Reconstruction During Pancreatectomy: Timing and Risks

BACKGROUND

Numerous studies have shown that portal vein resection during pancreatectomy can help achieve complete tumor clearance and long term-survival. While the safety of vascular resection during pancreatectomy is well documented, the risk of superior mesenteric vein/portal vein (SMV/PV) thrombosis after reconstruction remains unclear. This study aimed to describe the incidence and risk factors of SMV/PV thrombosis after vein reconstruction during pancreatectomy.

METHODS

All patients who underwent portal vein resection (PVR) during pancreatectomy (2007-2019) were identified from a single institution prospective clinical database. Demographic and clinical data, operative and pathological findings, and postoperative outcomes were analyzed.

RESULTS

Pancreatectomy with PVR was performed in 220 patients (mean age 65.1 years, male/female ratio 0.96). Thrombosis occurred in 36 (16.4%) patients after a median of 15.5 days [IQR 38.5, 1-786 days]. SMV/PV patency rates were 92.7% and 88.7% at 1 and 3 months, respectively. The rate of SMV/PV thrombosis varied according to SMV/PV reconstruction technique: 12.8% after venorrhaphy, 13.2% end-to-end anastomosis, 22.6% autologous vein, and 83.3% synthetic graft interposition (p < 0.0001). SMV/PV thrombosis was associated with increased 90-day mortality (16.7% vs 4.9%, p = 0.02) and overall 30-day complication rate (69.4% vs 42.9%, p = 0.006). Pancreatectomy type, neoadjuvant chemoradiation, pathologic tumor venous invasion, resection margin status, and manner of perioperative anticoagulation did not influence the incidence of PV thrombosis. SMV/PV thrombosis was associated with a nearly 5-times increased risk of postoperative sepsis after pancreatectomy.

CONCLUSION

Portal vein thrombosis developed in 16% of patients who underwent pancreatectomy with PVR at a median of 15 days. PVR with synthetic interposition graft carries the highest risk for thrombosis.

[Epidemiology and surgical treatment of pancreatic cancer in the State of Brandenburg : Analysis of 5418 cases]

BACKGROUND

Pancreatic cancer is the second most frequent cause of death among all forms of cancer in Germany with more than 19,000 deaths per year. The evaluation of the nationwide clinical cancer register aims to depict the reality of treatment and to improve the quality of treatment in the future by targeted analyses.

METHOD

The data from the clinical cancer register of Brandenburg-Berlin for the diagnosis years 2001-2017 were analyzed with respect to the treatment of pancreatic cancer. Data from patients resident in the State of Brandenburg were evaluated with respect to epidemiological and therapeutic parameters.

RESULTS

A total of 5418 patients with pancreatic cancer were documented in the register from 2001 to 2017 and 49.6% of the patients were diagnosed as having the Union for International Cancer Control (UICC) stage IV. A pancreas resection was carried out in 26.4% of the cases. In cases of cancer of the head of the pancreas the most frequent procedure was a pylorus-preserving resection with 51.8% and a pancreatectomy was carried out in 9.4%. The R0 resection rate of all pancreatic cancers in the period from 2014 to 2017 was 61.9%. After R0 resection the 5‑year survival was 19%. Relevant multivariate survival factors were age, UICC stage and the residual (R) tumor classification. The case numbers per hospital had no influence on the absolute survival of patients operated on in the State of Brandenburg.

CONCLUSION

The treatment reality in the State of Brandenburg for patients with pancreatic cancer corresponds to the results of international publications with respect to the key performance indicators investigated. A qualitative internationally comparable treatment of these patients is also possible in nonmetropolitan regions.

Analysis of the Pancreatic Cancer Microbiome Using Endoscopic Ultrasound-Guided Fine-Needle Aspiration-Derived Samples

OBJECTIVES

Most previous studies have analyzed bacteria in tumors using resected pancreatic cancer (PC) tissues, because it is difficult to obtain tissue samples from unresectable advanced PC. We aimed to determine whether minimal tissue obtained by endoscopic ultrasound-guided fine-needle aspiration is useful for microbiome analysis.

METHODS

Thirty PC and matched duodenal and stomach tissues (N = 90) were prospectively collected from 30 patients who underwent endoscopic ultrasound-guided fine-needle aspiration. Bacterial DNA was extracted, and 16S rRNA sequencing was performed. The primary outcome was the success rate of bacterial detection in tumors. Bacterial diversity and structure were investigated.

RESULTS

The bacterial detection rates were 80%, 100%, and 97% in PC, gastric, and duodenal samples, respectively. Pancreatic cancer tissues showed a lower α-diversity and a significantly different microbial structure than stomach and duodenal tissues. Proteobacteria were more abundant, whereas Firmicutes, Bacteroidetes, and Fusobacteria were less abundant in PC tissues than in stomach and duodenal tissues. Acinetobacter was more abundant in PC tissues than in stomach and duodenal tissues, and Delftia was more frequently detected in resectable PC.

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle aspiration samples were valuable for PC microbiome analysis, revealing that the bacterial composition of PC is different from that of the stomach and duodenum.

Peptide Signatures for Prognostic Markers of Pancreatic Cancer by MALDI Mass Spectrometry Imaging

Despite the overall poor prognosis of pancreatic cancer there is heterogeneity in clinical courses of tumors not assessed by conventional risk stratification. This yields the need of additional markers for proper assessment of prognosis and multimodal clinical management. We provide a proof of concept study evaluating the feasibility of Matrix-assisted laser desorption/ionization (MALDI) mass spectrometry imaging (MSI) to identify specific peptide signatures linked to prognostic parameters of pancreatic cancer. On 18 patients with exocrine pancreatic cancer after tumor resection, MALDI imaging analysis was performed additional to histopathological assessment. Principal component analysis (PCA) was used to explore discrimination of peptide signatures of prognostic histopathological features and receiver operator characteristic (ROC) to identify which specific m/z values are the most discriminative between the prognostic subgroups of patients. Out of 557 aligned m/z values discriminate peptide signatures for the prognostic histopathological features lymphatic vessel invasion (pL, 16 m/z values, eight proteins), nodal metastasis (pN, two m/z values, one protein) and angioinvasion (pV, 4 m/z values, two proteins) were identified. These results yield proof of concept that MALDI-MSI of pancreatic cancer tissue is feasible to identify peptide signatures of prognostic relevance and can augment risk assessment.

Surgical Resection or Ablation for Recurrent Pancreatic Ductal Adenocarcinoma: An Analysis of Oncologic Outcomes According to the Recurrence Type

Objective

To evaluate the survival benefits of curative-intent treatment (CIT, including surgery or ablation) for recurrent pancreatic ductal adenocarcinoma (PDAC) depending on the recurrence type and compared the survival outcomes with other treatment modalities.

Background

The treatment for recurrent PDAC is mostly chemotherapy or best supportive care (BSC). Still, the role of CIT for recurrent PDAC is not well established.

Methods

PDAC patients who underwent pancreatectomy between 2004 and 2019 were included. Recurrences were categorized as locoregional (LR), distant, or disseminated. Recurrent PDAC management was classified as CIT, chemotherapy ± radiation therapy (CTX ± RTX), or BSC. The survival after recurrence (SAR) rate was measured from the first day of recurrence to the date of death or last follow-up.

Results

Two hundred eighteen patients had recurrent PDAC and were analyzed (27 CIT, 128 CTX ± RTX, 63 BSC). The 1-, 3-, and 5-year SAR rates were 65.4%, 11.5%, and 11.5% for CIT, 42.1%, 4.0%, and 0% for CTX ± RTX, and 15.9%, 1.6%, and 0% for BSC, respectively. Subgroup analysis indicated the SAR rate was significantly better in the CIT group than in the CTX ± RTX and BSC groups in LR type (P = 0.027) and distant type (P < 0.001). In multivariate analysis, the albumin level at recurrence (hazard ratio, 2.14; 95% confidence interval, 1.15-18.3, P = 0.038) and operation time of the second operation (hazard ratio, 0.98; 95% confidence interval, 0.97-0.99, P = 0.021) were associated with a favorable prognosis of SAR in the CIT group.

Conclusions

CIT should be considered in recurrent PDAC for LR and distant metastases in selected patients.

AGITG MASTERPLAN: a randomised phase II study of modified FOLFIRINOX alone or in combination with stereotactic body radiotherapy for patients with high-risk and locally advanced pancreatic cancer

Background

Among patients with non-metastatic pancreatic cancer, 80% have high-risk, borderline resectable or locally advanced cancer, with a 5-year overall survival of 12%. MASTERPLAN evaluates the safety and activity of stereotactic body radiotherapy (SBRT) in addition to chemotherapy in these patients.

Methods and design

MASTERPLAN is a multi-centre randomised phase II trial of 120 patients with histologically confirmed potentially operable pancreatic cancer (POPC) or inoperable pancreatic cancer (IPC). POPC includes patients with borderline resectable or high-risk tumours; IPC is defined as locally advanced or medically inoperable pancreatic cancer. Randomisation is 2:1 to chemotherapy + SBRT (investigational arm) or chemotherapy alone (control arm) by minimisation and stratified by patient cohort (POPC v IPC), planned induction chemotherapy and institution. Chemotherapy can have been commenced ≤28 days prior to randomisation. Both arms receive 6 × 2 weekly cycles of modified FOLFIRINOX (oxaliplatin (85 mg/m² IV), irinotecan (150 mg/m²), 5-fluorouracil (2400 mg/m² CIV), leucovorin (50 mg IV bolus)) plus SBRT in the investigational arm. Gemcitabine+nab-paclitaxel is permitted for patients unsuitable for mFOLFIRINOX. SBRT is 40Gy in five fractions with planning quality assurance to occur in real time. Following initial chemotherapy ± SBRT, resectability will be evaluated. For resected patients, adjuvant chemotherapy is six cycles of mFOLFIRINOX. Where gemcitabine+nab-paclitaxel was used initially, the adjuvant treatment is 12 weeks of gemcitabine and capecitabine or mFOLFIRINOX. Unresectable or medically inoperable patients with stable/responding disease will continue with a further six cycles of mFOLFIRINOX or three cycles of gemcitabine+nab-paclitaxel, whatever was used initially. The primary endpoint is 12-month locoregional control. Secondary endpoints are safety, surgical morbidity and mortality, radiological response rates, progression-free survival, pathological response rates, surgical resection rates, R0 resection rate, quality of life, deterioration-free survival and overall survival. Tertiary/correlative objectives are radiological measures of nutrition and sarcopenia, and serial tissue, blood and microbiome samples to be assessed for associations between clinical endpoints and potential predictive/prognostic biomarkers. Interim analysis will review rates of locoregional recurrence, distant failure and death after 40 patients complete 12 months follow-up. Fifteen Australian and New Zealand sites will recruit over a 4-year period, with minimum follow-up period of 12 months.

Discussion

MASTERPLAN evaluates SBRT in both resectable and unresectable patients with pancreatic ductal adenocarcinoma.

Trial registration

Australia New Zealand Clinical Trials Registry ACTRN12619000409178, 13/03/2019.

Protocol version: 2.0, 19 May 2019

Contemporary indications for upfront total pancreatectomy

Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.

Qualitative diagnostic signature for pancreatic ductal adenocarcinoma based on the within-sample relative expression orderings

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) accounts for about 90% of pancreatic cancer, which is one of the most aggressive malignant neoplasms with a 9.3% five-year survival rate. The pathological biopsy is the current golden standard for confirming suspicious lesions of PDAC, but it is not entirely reliable because of the insufficient sampling amount and inaccurate sampling location. Therefore, developing a robust signature to aid the accurate diagnosis of PDAC is critical.

METHODS

Based on the within-sample relative expression orderings of gene pairs, we identified a qualitative signature to discriminate both PDAC and adjacent samples from both chronic pancreatitis and normal samples in the training datasets and validated it in other independent datasets produced by different laboratories with different measuring platforms.

RESULTS

A six-gene-pair signature was identified in the training data and validated in eight independent datasets. For surgical samples, 96.63% of 356 PDAC tissues, 100% of 11 pancreatitis tissues of non-cancer patients, and 23 of 24 normal pancreatic tissues were correctly classified. Especially, 59 of 60 cancer-adjacent normal tissues of PDAC patients were correctly identified as PDAC. For biopsy samples, all of 11 PDAC biopsy tissues were correctly classified as PDAC.

CONCLUSION

The signature can distinguish both PDAC and PDAC-adjacent normal tissues from both chronic pancreatitis and normal tissues of non-cancer patients even when the sampling locations are inaccurate, which can aid the diagnosis of PDAC.

Contemporary Reappraisal of Intraoperative Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Review

Importance

Although margin-negative (R0) resection is the gold standard for surgical management of localized pancreatic ductal adenocarcinoma (PDAC), the question of how to manage the patient with a microscopically positive intraoperative neck margin (IONM) during pancreaticoduodenectomy remains controversial.

Observations

In the absence of randomized clinical trials, we critically evaluated high-quality retrospective studies examining the oncologic utility of re-resecting positive IONMs during pancreaticoduodenectomy for PDAC (2000-2019). Several studies have concluded that additional pancreatic resection to achieve an R0 margin in IONM-positive cases does not influence survival. The largest is a multi-institutional study of 1399 patients undergoing pancreaticoduodenectomy, which demonstrated that in comparison with patients undergoing R0 resection (n = 1196; median survival, 21 months), those with either final R1 resections (n = 131) or undergoing margin conversion from IONM-positive to R0 resection on permanent section (n = 72) demonstrated similar median survival times (13.7 and 11.9 months, respectively). Conversely, recent reports suggest that the conversion of IONM to R0 resection with additional resection or even total pancreatectomy may be associated with improved survival. The discordance between these conflicting studies could be explained in part by the influence of biologic and physiologic selection on the association of IONM re-resection and survival. Since most studies did not include patients receiving modern combination chemotherapy regimens, the intersection between margin status, tumor biology, and chemoresponsiveness remains unclear. Furthermore, there are no dedicated data to guide surgical management in IONM-positive pancreaticoduodenectomy for patients receiving neoadjuvant chemotherapy.

Conclusions and Relevance

Although data regarding the oncologic utility of additional resection to achieve a tumor-free margin following initial IONM positivity during pancreaticoduodenectomy for PDAC are conflicting, they suggest that IONM positivity may be a surrogate for biologic aggressiveness that is unlikely to be mitigated by the extent of surgical resection. The complex relationship between margin status and chemoresponsiveness warrants exploration in studies including patients receiving increasingly effective neoadjuvant chemotherapy.

Impact of completeness of adjuvant gemcitabine, relapse pattern, and subsequent therapy on outcome of patients with resected pancreatic ductal adenocarcinoma - A pooled analysis of CONKO-001, CONKO-005, and CONKO-006 trials

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) represents one of the most fatal malignancies worldwide. It is suggested that survival in PDAC depends, among other things, on pattern of disease recurrence.

PATIENTS AND METHODS

We performed a pooled analysis of the adjuvant therapy studies CONKO-001, CONKO-005, and CONKO-006, including a total of 912 patients with regard to prognostic factors in patients with recurrent disease. Overall survival from disease recurrence (OS 2) and disease-free survival (DFS) from the day of surgery were expressed by Kaplan-Meier method and compared using log-rank testing and Cox regression.

RESULTS

Of 912 patients treated within the previously mentioned CONKO trials, we identified 689 patients with disease recurrence and defined site of relapse. In multivariable analysis, the presence of isolated pulmonary metastasis, low tumour grading, and low postoperative level of CA 19-9 remained significant factors for improved OS 2 and DFS. Furthermore, completeness of adjuvant gemcitabine-based treatment (OS 2: P = 0.006), number of relapse sites (OS 2: P = 0.015), and type of palliative first-line treatment (OS 2: P < 0.001) significantly affected overall survival after disease recurrence in PDAC.

CONCLUSIONS

Determining tumour subgroups using prognostic factors may be helpful to stratify PDAC patients for future clinical trials. In case of disease recurrence, the site of relapse may have a prognostic impact on subsequent survival. Further investigations are needed to identify differences in tumour biology, reflecting relapse patterns and the differing survival of PDAC patients.

Survival after Margin-Positive Resection in the Era of Modern Chemotherapy for Pancreatic Cancer: Do Patients Still Benefit?

BACKGROUND

R0 resection for pancreatic cancer is considered standard of care, but is not always achieved. This study looks at R1/R2 resection outcomes compared with chemotherapy alone. Our hypothesis is that patients with margin-positive disease have better outcomes than those receiving chemotherapy alone.

STUDY DESIGN

Stage II pancreatic cancer patients who underwent R1/R2 surgery with/without neoadjuvant chemotherapy, from the National Cancer Database (NCDB) 2010 to 2017 were identified and compared with similar staged patients who received chemotherapy alone. The surgical group was then analyzed by subset based on receipt of chemotherapy: upfront surgery (+/- adjuvant therapy) and neoadjuvant therapy followed by surgery (+/- adjuvant therapy).

RESULTS

There were 11,699 Stage II pancreatic cancer patients included, 9,521 (81.4%) of whom were treated with chemotherapy alone, 15.7% (n = 1,836) had upfront surgery, and 2.9% (n = 342) had neoadjuvant therapy with surgery. R1/R2 neoadjuvant patients had the best overall survival at a mean of 19.75 months (95% CI 17.91, 22.28) compared with the upfront surgery group (17.77 months, 95% CI 15.64, 19.55) and the chemotherapy alone group (10.12 months, 95% CI 8.97, 11.50) (hazard ratio [HR] 0.46 upfront surgery and 0.32 neoadjuvant group, respectively, p < 0.0001). Even with R2 resection, survival was better in surgical patients compared with patients who underwent chemotherapy only (15.76 mo vs 10.22 mo, p = 0.06). Patients with R1/R2 resections had improved survival if they received neoadjuvant/adjuvant chemotherapy, though the survival rates were significantly lower than those with standard R0 resections (n = 16,129).

CONCLUSIONS

R1 resection has benefit over chemotherapy alone in pancreatic cancer. Pancreatic cancer patients who are left with microscopic R1 disease have better survival than without surgery, particularly in the setting of neoadjuvant therapy.

Detection of Circulating Tumor Cells in Resectable Pancreatic Ductal Adenocarcinoma: A Prospective Evaluation as a Prognostic Marker

Circulating tumor cells (CTCs) are useful biomarkers of many solid tumors, but are infrequently detected in early stage pancreatic ductal adenocarcinomas (PDACs). The first drainage of pancreatic venous blood flow come to portal vein and pass through the liver, and they finally go out for peripheral blood. We thought that comparing CTCs from portal vein and peripheral blood could enable us to understand the clinical meaning of CTCs from each different site in PDACs. Therefore, we aimed to determine 1) whether CTCs could be reliably identified in early stages (operable) of PDACs, 2) if there are any differences in the detected number of CTC in portal vein blood and peripheral blood, and 3) whether CTCs can be sensitive biomarkers for the prognosis of resectable PDAC patients. Newly diagnosed PDAC patients who underwent operation with curative intention between 2013 and 2015 were prospectively enrolled. Blood draws from portal and peripheral vein ran through the microfabricated porous filter, and anti-epithelial cell adhesion molecule (EpCAM) and anti-Plectin-1 antibodies were used for CTC identification. Baseline clinical characteristics, tumor characteristics, treatment, and clinical outcomes were assessed. The clinical stages of the 32 enrolled patients were as follows: IA/IB 1 (3.1%); IIA 9 (28.1%); IIB 17 (53.1%); III 5 (15.6%). Twenty-seven patients (84.4%) received R0 resection, while five patients (15.6%) received R1 resection. EpCAM+ CTCs were detected in 20 portal blood (62.5%) and 22 peripheral blood (68.8%). Plectin-1+ CTCs were identified in 14 portal blood (43.8%) and 16 peripheral blood (50%). Plectin-1-expressing CTCs were picked from CTC platform (microfabricated porous filter) and we could find out all KRAS mutation. Patients with detectable EpCAM+ CTC less than one in peripheral blood showed longer overall survival (OS) compared to patients with detectable CTCs more than one (35.5 months vs. 16.0 months). EpCAM and Plectin-1 successfully identified CTCs at the early stage of PDACs. Also, the number of CTCs could be a prognostic marker for survival in resectable PDACs.

Intraoperative Radiation Mitigates the Effect of Microscopically Positive Tumor Margins on Survival Among Pancreatic Adenocarcinoma Patients Treated with Neoadjuvant FOLFIRINOX and Chemoradiation

BACKGROUND

Microscopically positive margins (R1) negatively impact survival in pancreatic ductal adenocarcinoma (PDAC). For patients with close/positive margins, intraoperative radiotherapy (IORT) can improve local control. The prognostic impact of an R1 resection in patients who receive total neoadjuvant therapy (TNT; FOLFIRINOX with chemoradiation) and IORT is unknown.

METHODS

Clinicopathologic data were retrospectively collected for borderline/locally advanced (BR/LA) PDAC patients who received TNT and underwent resection between 2011 and 2019. Disease-free (DFS) and overall survival (OS) measured from time of diagnosis were compared between groups.

RESULTS

Two hundred one patients received TNT and were resected, with a median DFS and OS of 24 months and 47 months, respectively. Eighty-eight patients (44%) received IORT; of these, 69 (78%) underwent an R0 and 19 (22%) an R1 resection. There was no significant difference in clinicopathologic factors between the IORT and no-IORT groups, except for resectability status (LA: IORT 69%, no-IORT 53%, p = 0.021) and surgeons' concern for a positive/close margin. R1 resection was associated with worse DFS and OS in the no-IORT population. However, among patients who received IORT, there was no difference in DFS (R0: 29 months, IQR 14-47 vs R1: 20 months, IQR 15-28; p = 0.114) or OS (R0: 48 months, IQR 25-not reached vs R1: 37 months, IQR 30-47; p = 0.307) between patients who underwent R0 vs R1 resection. In multivariate analysis, within the IORT group, R1 resection was not associated with DFS or OS.

CONCLUSION

IORT may mitigate the adverse effect of an R1 resection on DFS and OS in BR/LA PDAC patients receiving TNT.

Whipple Procedure: A Five-Year Clinical Experience in Tertiary Care Center

Introduction: Whipple procedure is one of the major surgeries performed in tertiary care centers. Once considered a high mortality procedure is now being practicing with mortality declining to less than 5%. This study describes our five-year experience of the Whipple procedure in terms of preoperative, operative, and postoperative parameters of patients undergoing surgery in a local tertiary care setting.

Material and Methods: This was a non-randomized interventional study that was conducted at the Surgical Department of Services Hospital Lahore from January 2014 to December 2018. A total of 57 Whipple procedures were performed during this period. Demographic data, presenting symptoms, physical signs, past medical history, preoperative stenting details, intra-operative duration of surgery, postoperative course and complications, pathology, and causes of postoperative death were collected on a pre-designed questionnaire. Data were entered and analyzed by using SPSS 22 (IBM Corp., Armonk, USA).

Results: Out of 57 patients, 19 were females and 38 were males. The mean age of patients was 53±05 years. The most common presenting symptom was jaundice 39 (68.4%), followed by abdominal pain 32 (56.1%). The mean size of the tumor on CT-scan was 2.8±1.4 cm, the mean operation time was 315±38.3 min, mean blood loss during surgery was 500±130 ml, and mean hospital stay was 10±6 days. The major postoperative complication was the pancreatic fistula (12%). Twenty-one out of 39 patients presented with jaundice had undergone preoperative biliary stenting by endoscopic retrograde biliary stenting. The most common histological diagnosis was adenocarcinoma of pancreas 19 (33.3%). Out of 57 patients, nine (15.8%) patients expired in the first 30 days and the most frequent cause of mortality was septic shock.

Conclusion: In this study, the most common presentation of patients undergoing Whipple procedure was obstructive jaundice, the most frequent operative complication was pancreatic fistula, and the most prevalent histopathology was carcinoma of the pancreas. Perioperative parameters such as mean operative time, mean blood loss during surgery, and mean length of hospital stay were comparable with other studies. However, mortality in this study was slightly higher. It can be concluded that with meticulous surgical technique, securing hemostasis strictly and standard critical care postoperatively can decrease morbidity and mortality after the Whipple procedure.

Time interval-based indication for liver resection of metastasis from pancreatic cancer

Background

Surgical indications for liver metastases from pancreatic ductal adenocarcinoma (PDAC) are lacking because outcomes are usually poor. However, liver resection and the recent progress in perioperative chemotherapy have been observed to improve survival.

Methods

We performed liver resection for liver metastases from PDAC only under the following criteria: (1) liver-only metastasis, (2) up to three tumors, and (3) no increase in the number of metastases during the 3-month observation period. No limitations were placed on the location or size of liver metastasis. In this study, we aimed to validate our surgical criteria and analyze factors affecting survival in patients with PDAC.

Results

Seventy-nine patients underwent curative resection for PDAC between 2005 and 2015. Seventy-one patients experienced recurrence, with liver-only recurrence in 17 patients. Among these, nine patients underwent liver resection and eight did not. The median survival time was significantly better for patients who underwent liver resection (55 months) than for those with other recurrences (17.5 months, p = 0.016). The median survival after liver recurrence was significantly better in the liver resection group (31 months) than in the non-liver resection group (7 months, p = 0.0008). The median disease-free interval (DFI) after pancreatectomy was significantly longer in the liver resection group (21 months; range, 3–44 months) than in the non-liver resection group (3 months; range, 2–7 months; p = 0.02).

Conclusion

Good indications for liver metastases from PDAC include solitary metachronous tumors and longer DFIs.

Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Adjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma.

METHODS

Patients with stage I-III pancreatic head adenocarcinoma in the 2006-2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6-12-weeks, and 12-24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy.

RESULTS

Of 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6-12 weeks, and 1194 (8.9%) within 12-24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6-12-weeks: 0.744, and 12-24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens.

CONCLUSIONS

For patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.

Characterization of Oral Microbiome and Exploration of Potential Biomarkers in Patients with Pancreatic Cancer

Pancreatic cancer (PC) is highly malignant and lacks an effective therapeutic schedule, hence that early diagnosis is of great importance to achieve a good prognosis. Oral bacteria have been proved to be associated with pancreatic cancer, but the specific mechanism has not been comprehensively illustrated. In our study, thirty-seven saliva samples in total were collected with ten from PC patients, seventeen from benign pancreatic disease (BPD) patients, and ten from healthy controls (HC). The oral bacterial community of HC, PC, and BPD groups was profiled by 16S rDNA high-throughput sequencing and bioinformatic methods. As shown by Simpson, Inverse Simpson, Shannon and Heip, oral microbiome diversity of HC, BPD and PC groups is in increasing order with the BPD and PC groups significantly higher than the HC group. Principal coordinate analysis (PCoA) suggested that grouping by PC, BPD and HC was statistically significant. The linear discriminant analysis effect size (LEfSe) identified high concentrations of Fusobacterium periodonticum and low concentrations of Neisseria mucosa as specific risk factors for PC. Furthermore, predicted functions showed changes such as RNA processing and modification as well as the pathway of NOD-like receptor signaling occurred in both PC and HC groups. Conclusively, our findings have confirmed the destruction of oral bacterial community balance among patients with PC and BPD and indicated the potential of Fusobacterium periodonticum and Neisseria mucosa as diagnostic biomarkers of PC.

Molecular targets for diagnostic and intraoperative imaging of pancreatic ductal adenocarcinoma after neoadjuvant FOLFIRINOX treatment

Neoadjuvant systemic treatment is increasingly being integrated in the standard treatment of pancreatic ductal adenocarcinoma (PDAC) patients to improve oncological outcomes. Current available imaging techniques remain unreliable in assessing response to therapies, as they cannot distinguish between (vital) tumor tissue and therapy induced fibrosis (TIF). Consequently, resections with tumor positive margins and subsequent early post-operative recurrences occur and patients eligible for potential radical resection could be missed. To optimize patient selection and monitor results of neoadjuvant treatment, PDAC-specific diagnostic and intraoperative molecular imaging methods are required. This study aims to evaluate molecular imaging targets for PDAC after neoadjuvant FOLFIRINOX treatment. Expression of integrin α_vβ₆, carcinoembryonic antigen cell adhesion molecule 5 (CEACAM5), mesothelin, prostate-specific membrane antigen (PSMA), urokinase-type plasminogen activator receptor, fibroblast activating receptor, integrin α5 subunit and epidermal growth factor receptor was evaluated using immunohistochemistry. Immunoreactivity was determined using the semiquantitative H-score. Resection specimens from patients after neoadjuvant FOLFIRINOX treatment containing PDAC (n = 32), tumor associated pancreatitis (TAP) and TIF (n = 15), normal pancreas parenchyma (NPP) (n = 32) and tumor positive (n = 24) and negative (n = 56) lymph nodes were included. Integrin α_vβ₆, CEACAM5, mesothelin and PSMA stainings showed significantly higher expression in PDAC compared to TAP and NPP. No expression of α_vβ₆, CEACAM5 and mesothelin was observed in TIF. Integrin α_vβ₆ and CEACAM5 allow for accurate metastatic lymph node detection. Targeting integrin α_vβ₆, CEA, mesothelin and PSMA has the potential to distinguish vital PDAC from fibrotic tissue after neoadjuvant FOLFIRINOX treatment. Integrin α_vβ₆ and CEACAM5 detect primary tumors and tumor positive lymph nodes.

First report on the feasibility of a permanently implantable uni-directional planar low dose rate brachytherapy sheet for patients with resectable or borderline resectable pancreatic cancer

BACKGROUND

Margin negative resection in pancreatic cancer remains the only curative option but is challenging, especially with the retroperitoneal margin. Intraoperative radiation therapy (IORT) can improve rates of local control but requires specially designed facilities and equipment. This retrospective review describes initial results of a novel implantable mesh of uni-directional low dose rate (LDR) Pd-103 sources (sheet) used to deliver a focal margin-directed high-dose boost in patients with concern for close or positive margins.

METHODS

Eleven consecutive patients from a single institution with resectable or borderline resectable pancreatic cancer with concern for positive margins were selected for sheet placement and retrospectively reviewed. Procedural outcomes, including the time to implant the device and complications, and clinical outcomes, including survival and patterns of failure, are reported. A dosimetric comparison of the LDR sheet with hypothetical stereotactic body radiotherapy (SBRT) boost is reported.

RESULTS

One patient had a resectable disease, and 10 patients had a borderline resectable disease and underwent neoadjuvant treatment. Sheet placement added 15 min to procedural time with no procedural or sheet-related complications. At a median follow up of 13 months, 64% (n = 7) of patients are alive and 55% (n = 6) are disease-free. Compared to a hypothetical SBRT boost, the LDR sheet delivered a negligible dose to kidneys, liver, and spinal cord with a 50% reduction in max dose to the small bowel.

CONCLUSION

This is the first report of the use of an implantable uni-directional LDR brachytherapy sheet in patients with resected pancreatic cancer with concern for margin clearance, with no associated toxicity and favorable clinical outcomes.

Long-term outcomes following en bloc resection for pancreatic ductal adenocarcinoma of the head with portomesenteric venous invasion

BACKGROUND

The aim of this study is to clarify the prognostic influence of venous resection of the portal vein (PV) or superior mesenteric vein (SMV) on long-term outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) of the head with suspected vascular invasion.

METHODS

From May 1995 to December 2014, a total of 557 patients underwent surgery with curative intent for pancreatic cancer of the head.

RESULTS

Among 557 patients, 106 (19%) underwent pancreaticoduodenectomy (PD) with PV-SMV resection and 89 (75.5%) of these patients were confirmed to have true pathological invasion. The 5-year overall survival rate in patients underwent PV-SMV resection was significantly lower compared with those who did not (18.7% versus 24.3%; p = 0.002). Patients with negative resection margins who underwent PV-SMV resection had a better prognosis than those with positive resection margins who did not undergo PV-SMV resection with positive resection margins (17% versus 6.3% in 5-year overall survival rate; p = 0.003). The overall morbidity rate was not significantly different between PV-SMV resection group and no PV-SMV resection group (p = 0.064). On multivariate analysis, margin status, advanced T stage (3 or 4), lymph node metastasis, and adjuvant therapy were independent prognostic factors for survival.

CONCLUSION

PV-SMV resection was related to lower overall survival. However, on multivariate analysis, margin status was a more important prognostic factor than PV-SMV resection and true pathological invasion for survival. Therefore, en bloc PV-SMV resection should be performed when PV-SMV invasion is suspected to achieve R0 resection.

Undertreatment of Pancreatic Cancer: Role of Surgical Pathology

BACKGROUND

Current guidelines recommend treatment of early-stage pancreatic cancer with surgical resection and chemotherapy. Undertreatment can occur after resection when patients fail to receive adjuvant chemotherapy. Final pathologic results have the potential to bias providers to omit adjuvant chemotherapy, however, the association of surgical pathology and adjuvant chemotherapy is unknown.

METHODS

Data from the National Cancer Database identified patients who underwent surgery for stage I or II pancreatic cancer. Chi-square tests and logistic regression were used to determine differences between patients receiving surgery followed by chemotherapy and those who had resection alone. Survival analysis of subgroups with favorable pathology (node-negative disease, tumor size ≤ 2 cm, well-differentiated histology) was performed by the Kaplan-Meier method and the Cox proportional hazards model.

RESULTS

Of the 22,131 patients included in this study, 28% were considered undertreated (surgery alone). Favorable pathologic traits of negative lymph nodes, tumor 2 cm in size or smaller, and well-differentiated histology were associated with a 15-35% lower probability that adjuvant chemotherapy would be given than less favorable pathologic results (p < 0.001). Multivariable survival analysis showed significantly lower odds of mortality for patients who received resection and chemotherapy than for those who were undertreated among two subgroups: patients with node-negative disease (hazard ratio [HR] 0.774) and those with a tumor 2 cm in size or smaller (HR 0.771).

CONCLUSION

The patients who had early-stage pancreatic cancer with favorable pathology after pancreatectomy were less likely than those with unfavorable pathology to receive adjuvant chemotherapy. This omission had significant survival consequences for subgroups with node-negative disease and tumors 2 cm in size or smaller. Recognition of patients with favorable pathology as an undertreated group is required for efforts to be directed toward encouraging guideline-concordant care and to combat undertreatment of pancreatic cancer.

Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging

BACKGROUND

Lymph node staging of ductal adenocarcinoma of the pancreatic head (PDAC) by cross-sectional imaging is limited. The aim of this study was to determine the diagnostic accuracy of expanded criteria in nodal staging in PDAC patients.

METHODS

Sixty-six patients with histologically confirmed PDAC that underwent primary surgery were included in this retrospective IRB-approved study. Cross-sectional imaging studies (CT and/or MRI) were evaluated by a radiologist blinded to histopathology. Number and size of lymph nodes were measured (short-axis diameter) and characterized in terms of expanded morphological criteria of border contour (spiculated, lobulated, and indistinct) and texture (homogeneous or inhomogeneous). Sensitivities and specificities were calculated with histopathology as a reference standard.

RESULTS

Forty-eight of 66 patients (80%) had histologically confirmed lymph node metastases (pN+). Sensitivity, specificity, and Youden's Index for the criterion "size" were 44.2%, 82.4%, and 0.27; for "inhomogeneous signal intensity" 25.6%, 94.1%, and 0.20; and for "border contour" 62.7%, 52.9%, and 0.16, respectively. There was a significant association between the number of visible lymph nodes on preoperative CT and lymph node involvement (pN+, p = 0.031).

CONCLUSION

Lymph node staging in PDAC is mainly limited due to low sensitivity for detection of metastatic disease. Using expanded morphological criteria instead of size did not improve regional nodal staging due to sensitivity remaining low. Combining specific criteria yields improved sensitivity with specificity and PPV remaining high.

Margin-Positive Pancreatic Ductal Adenocarcinoma during Pancreaticoduodenectomy: Additional Resection Does Not Improve Survival

BACKGROUND

The impact of resecting positive margins during pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA) remains debated. Additionally, the survival benefit of resecting multiple positive margins is unknown.

METHODS

We identified patients with PDA who underwent PD from 2006 to 2015. Pancreatic neck, bile duct, and uncinate frozen section margins were assessed before and after resection of positive margins. Survival curves were compared with log-rank tests. Multivariable Cox regression assessed the effect of margin status on overall survival.

RESULTS

Of 501 patients identified, 17.3%, 5.3%, and 19.7% had an initially positive uncinate, bile duct, or neck margin, respectively. Among initially positive bile duct and neck margins, 77.8% and 67.0% were resected, respectively. Although median survival was decreased among patients with any positive margins (15.6 vs. 20.9 months; p = 0.006), it was similar among patients with positive bile duct or neck margins with or without R1 to R0 resection (17.0 vs. 15.6 months; p = 0.20). Median survival with and without positive uncinate margins was 13.8 vs. 19.7 months (p = 0.04). Uncinate margins were never resected. Resection of additional margins when the uncinate was concurrently positive was not associated with improved survival (p = 0.37). Patients with positive margins who received adjuvant therapy had improved survival, regardless of margin resection (p = 0.03). Adjuvant therapy was independently protective against death (hazard ratio 0.6, 95% CI 0.5-0.7).

CONCLUSIONS

Positive PD margins at any position are associated with reduced overall survival; however, resection of additional margins may not improve survival, particularly with concurrently positive uncinate margins. Adjuvant chemotherapy improves survival with positive margins, regardless of resection.

Stromal expression of hemopexin is associated with lymph-node metastasis in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is one of the most aggressive types of cancer. Certain proteins in the tumor microenvironment have attracted considerable attention owing to their association with tumor invasion and metastasis. Here, we used proteomics to identify proteins associated with lymph-node metastasis, which is one of the prognostic factors. We selected lymph node metastasis-positive and -negative patients (n = 5 each) who underwent pancreatectomy between 2005 and 2015 and subjected to comprehensive proteomic profiling of tumor stroma. A total of 490 proteins were detected by mass spectrometry. Software analysis revealed that nine of these proteins were differentially expressed between the two patient groups. We focused on hemopexin and ferritin light chain based on immunohistochemistry results. We assessed the clinicopathological data of 163 patients and found that hemopexin expression was associated with UICC N2 (p = 0.0399), lymph node ratio (p = 0.0252), venous invasion (p = 0.0096), and lymphatic invasion (p = 0.0232). Notably, in vitro assays showed that hemopexin promotes invasion of the pancreatic cancer cells. Our findings suggest that hemopexin is a lymph node metastasis-associated protein that could potentially serve as a useful therapeutic target or biomarker of pancreatic ductal adenocarcinoma.

The impact of neoadjuvant and adjuvant immunotherapy on the survival of pancreatic cancer patients: a retrospective analysis

Background

Immunotherapy has become an essential part of cancer treatment after showing great efficacy in various malignancies. However, its effectiveness in pancreatic ductal adenocarcinoma (PDAC), especially in resectable pancreatic cancer, has not been studied. The primary objective of this study is to compare the OS impact of immunotherapy between PDAC patients who receive neoadjuvant immunotherapy and patients who receive adjuvant immunotherapy. The secondary objective is to investigate the impact of neoadjuvant and adjuvant immunotherapy in combination with chemotherapy and chemoradiation by performing subset analyses of these two groups.

Methods

Patients diagnosed with PDAC between 2004 and 2016 were identified from the National Cancer Database (NCDB). Multivariable Cox proportional hazard analysis was performed to examine the effect of neoadjuvant and adjuvant immunotherapy in combination with chemotherapy and chemoradiation on the OS of the patients. The multivariable analysis was adjusted for essential factors such as the age at diagnosis, sex, race, education, income, place of living insurance status, hospital type, comorbidity score, and year of diagnosis.

Results

Overall, 526 patients received immunotherapy. Among whom, 408/526 (77.57%) received neoadjuvant immunotherapy, and the remaining 118/526 (22.43%) received adjuvant immunotherapy. There was no significant difference in OS between neoadjuvant and adjuvant immunotherapy (HR: 1.06, CI: 0.79–1.41; p < 0.714) in the multivariable analysis. In the univariate neoadjuvant treatment subset analysis, immunotherapy was associated with significantly improved OS compared to no immunotherapy (HR: 0.88, CI: 0.78–0.98; p < 0.026). This benefit disappeared in the multivariable analysis. However, after patients were stratified by educational level, the multivariable Cox regression analysis revealed that neoadjuvant immunotherapy was associated with significantly improved OS (HR: 0.86, CI: 0.74–0.99; p < 0.04) compared to no immunotherapy only in patients with high-level of education, but not in patients with low-level of education.

Conclusion

In this study, no difference in the OS between patients who received neoadjuvant immunotherapy and patients who received adjuvant immunotherapy was noticed. Future studies comparing neoadjuvant adjuvant immunotherapy combined with chemotherapy, radiation therapy, and chemoradiation are needed.

Three Curative Pancreatectomies for the Metachronous Appearance of Pancreatic Invasive Ductal Adenocarcinoma

We report a rare case of a patient who underwent 3 successful curative operations for the metachronous appearance of pancreatic cancer. In July 2007, a 54-year-old woman underwent pylorus-preserving pancreaticoduodenectomy. In March 2010, a tumor measuring 9 mm in diameter was detected in the tail of the pancreas on computed tomography (CT) and magnetic resonance imaging. The pancreas tail was subsequently resected while preserving the pancreatic body. In February 2011, CT revealed a cystic tumor measuring 2.5 cm in diameter in the remnant pancreatic body without any metastasis; therefore, total resection of the residual pancreas was performed in April 2011. The first resected tumor was histopathologically diagnosed as undifferentiated adenocarcinoma with osteoclast-like giant cells. Additionally, the third resected tumor had similar undifferentiated components. Contrarily, the second resected tumor was diagnosed as a well-differentiated tubular adenocarcinoma. We consider that the tumor from the third operation was an intra-pancreatic metastasis of the primary cancer and that the tumor from the second operation was the second primary cancer. The patient responded well with good control of surgical diabetes for 92 months since the last pancreatectomy. This case suggested that aggressive repeated resection for recurrent pancreatic invasive ductal adenocarcinoma is beneficial in limited cases.

Immunotherapy and radiation therapy for gastrointestinal malignancies: hope or hype?

Immunotherapy represents the newest pillar in cancer care. Although there are increasing data showing the efficacy of immunotherapy there is a spectrum of response across unselected populations of cancer patients. In fact, response rates can be poor even among patients with immunogenic tumors for reasons that remain poorly understood. A promising clinical strategy to improve outcomes, which is supported by an abundance of preclinical data, is combining immunotherapy with radiation therapy. Here we review the existing evidence and future directions for combining immunotherapy and radiation therapy for patients with gastrointestinal cancers.

Impact of resection margin status on survival in pancreatic cancer patients after neoadjuvant treatment and pancreatoduodenectomy

BACKGROUND

Resection margin status has been recognized as an independent prognostic factor on overall survival in pancreatic cancer patients undergoing surgical resection. However, its impact after neoadjuvant treatment remains uncertain.

METHODS

We analyzed 305 patients with resectable or borderline resectable pancreatic cancer treated with neoadjuvant therapy and pancreatoduodenectomy at 3 tertiary referral centers between 2010 and 2017. Positive resection margin was defined as 1 or more cancer cells at any margin. Overall survival was measured from the date of surgery until death or last follow-up.

RESULTS

One hundred and seventy-eight patients received neoadjuvant chemotherapy and 127 received neoadjuvant chemoradiotherapy. The median overall survival was 29.8 months. The 1-, 3-, and 5-year overall survival rates were 79.2%, 44.0%, and 23.5%, respectively. Negative margin was achieved in 275 (90.2%) patients. Negative margin resection patients had a significantly longer overall survival than positive resection margin patients (31.3 vs 16.3 months, P < .001). In univariate analyses, overall survival was associated with age, margin status, histologic grade, ypT, number of positive lymph nodes, perineural invasion, treatment effect, postoperative carbohydrate antigen 19-9, and adjuvant therapy. Positive margin resection, poorly differentiated carcinoma, treatment effect score of 3, postoperative carbohydrate antigen 19-9 of 37 U/mL or higher, and lack of adjuvant therapy were predictive of poor overall survival in multivariate Cox regression analysis.

CONCLUSION

Margin status was an independent predictor of overall survival in patients treated with neoadjuvant therapy and pancreatoduodenectomy, supporting the use of a negative margin resection as a surrogate of adequate oncological resection in this setting. Our findings may also have significant implications for patient stratification in future randomized trials.

Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study

Background

To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy.

Methods

We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index.

Results

We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores.

Conclusions

Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.

Positive Resection Margins Detected by Standardized Study of a Pancreaticoduodenectomy Sample: Is There Any Real Impact on Long-term Survival?

INTRODUCTION

The pathological evaluation of pancreaticoduodenectomy (PD) samples and the impact of R1 resections on survival has recently been questioned. This study evaluates the introduction of a standardized pathology study protocol (PSP) and the prognosis of R1 resections after long-term follow-up.

METHODS

We reviewed data from a prospectively maintained database regarding 109 periampullary tumors treated by PD from 2005 to 2013. The results of the introduction of a PSP were analysed, and the recurrence rate (RR), disease-free survival (DFS) and overall survival (OS) of the R1 resections were evaluated for each positive margin.

RESULTS

The PD specimens of periampullary tumors analyzed by PSP showed a higher rate of isolated lymph nodes (17 vs. 8; P=.003), N+ (60% vs. 31%; P<.001), microvascular invasion (67% vs. 34%; P=.001) and R1 resections (42% vs. 18%; P=.010). Pancreatic adenocarcinomas with R1 resection in the PSP group were compared with R0, presenting higher percentages of vascular resections (P=.033), N+ (P=.029), lymphatic and perineural invasion (P=.047; P=.029), higher RR (P=.026), lower DFS (P=.016) and lower OS (P=.025). Invasion of the medial margin correlated with a worse prognosis.

CONCLUSIONS

Our series shows an increase in R1 resection after the introduction of a PSP. Infiltration of the medial margin seems to be associated with a higher RR and a decrease in DFS and OS.

Readmissions after Pancreatic Surgery in Patients with Pancreatic Cancer: Does Hospital Variation Exist for Quality Measurement?

Background

The appropriateness of using readmission rate after pancreatic surgery among pancreatic cancer patients as a quality metric to evaluate hospital performance has been widely discussed in the literature.

Objectives

The present study reported readmission rate using Nationwide Readmissions Database (NRD), examined the reasons and risk factors for readmissions, and evaluated the appropriateness of using it as a quality metric.

Method

We analyzed 3,619 patient discharge records in 2014. The outcome of interest was all-cause 30-day readmission. Reasons for readmission were grouped into clinical associated categories. Hierarchical regression model was used for examining the relationship between risk factors and readmission.

Results

The 30-day readmission rate was 20.95%. The most common reason for readmission was surgery-related complication. In descriptive analyses, age, certain comorbidities, number of chronic conditions, mortality risk, severity of illness, living at large metropolitan area, resident of the state where patients received initial care, postoperative complication, length of stay, discharge location, and receiving care at the hospitals in large metropolitan area were predictive of readmission. In multivariable analysis, age, depression, peripheral vascular disorder, mortality risk, and discharge location were independently associated with readmission. The intraclass correlation coefficient was 0.41 for hierarchical regression model.

Conclusions

Readmission after pancreatic surgery remains an important issue. Our study found the majority of variation in readmissions is accounted for by patient factors whereas there was little between hospital variation. This finding does not support the use of readmission rate after pancreatic surgery as a quality metric.

Environmental Risk Factors of Pancreatic Cancer

Despite the advancement in medical knowledge that has improved the survival rate of many cancers, the survival rate of pancreatic cancer has remained dismal with a five-year survival rate of only 9%. The poor survival of pancreatic cancer emphasizes the urgent need to identify the causes or the risk factors of pancreatic cancer in order to establish effective preventive strategies. This review summarizes the current evidence regarding the environmental (non-genetic, including lifestyle, and clinical factors) risk factors of pancreatic cancer. Based on the current evidence, the established risk factors of pancreatic cancer are cigarette smoking, chronic diabetes, and obesity. Other strong risk factors include low consumption of fruits and vegetables, excess consumption of alcohol, poor oral hygiene, and the lack of allergy history. In the future, more studies are needed to identify additional risk factors of pancreatic cancer, especially the modifiable risk factors that could be included in a public health campaign to educate the public in order to reduce the incidence of pancreatic cancer.

A Qualitative Review of Neoadjuvant Chemotherapy in Resectable Pancreatic Adenocarcinoma

The aim of this study was to evaluate outcomes of patients with resectable pancreatic adenocarcinoma (PDAC) who underwent neoadjuvant chemotherapy. The MEDLINE and PubMed databases were searched to identify relevant original articles investigating neoadjuvant therapy in resectable PDAC. Qualitative analyses were performed to investigate patient selection, disease stage, impact on perioperative outcomes, and cost-effectiveness. Forty-three studies met inclusion criteria for this review. Neoadjuvant chemotherapy for upfront resectable PDAC is cost-effective, safe, may result in lower stage disease and has potential survival advantages. With proper patient selection, neoadjuvant chemotherapy is an appropriate approach for upfront resectable PDAC. Nevertheless, the risk for disease progression and losing a curative surgical window highlights the need for appropriate patient identification, further discovery of superior biomarkers or molecular profiles representative of positive treatment response, and additional prospective comparative study.

Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients

Introduction

Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy.

Patients and Methods

We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant.

Results

Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%.

Conclusion

Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.

Surgery for Recurrent Pancreatic Cancer: Is It Effective?

Despite improvements to surgical procedures and novel combinations of drugs for adjuvant and neoadjuvant therapies for pancreatic adenocarcinoma, the recurrence rate after radical surgery is still high. Little is known about the role of surgery in the treatment of isolated recurrences of pancreatic cancer. The aim of this study was to review the current literature dealing with surgery for recurrent pancreatic cancer in order to examine its feasibility and effectiveness. An extensive literature review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and 14 articles dealing with re-resections for recurrent pancreatic adenocarcinoma were analyzed, focusing on the characteristics of the primary neoplasm and its recurrence, the surgical procedures used, and patient outcomes. Data were retrieved on a total of 301 patients. The interval between surgery for primary pancreatic cancer and the detection of a recurrence ranged from 2 to 120 months. The recurrence was local or regional in 230 patients, and distant in 71. The median overall survival was 68.9 months (range 3–152) after resection of the primary tumor, and 26.0 months (range 0–112) after surgery for recurrent disease. The disease-free interval after the resection of recurrences was 14.2 months (range 4–29). Although data analysis was performed on a heterogeneous and limited number of patients, some of these may benefit from surgery for isolated recurrence of pancreatic adenocarcinoma. Further studies are needed to identify these cases.

Neoadjuvant therapy versus upfront surgery for borderline-resectable pancreatic cancer

BACKGROUND

Neoadjuvant therapy is recommended for patients with borderline-resectable pancreatic cancer (BRPC). In this study, we compare survival outcomes of neoadjuvant therapy with upfront surgery.

METHODS

From January 2011 to June 2016, 1415 patients underwent treatments for pancreatic cancer in Samsung Medical Center. Among them, 112 (7.9%) patients were categorized as BRPC by the NCCN 2016 guideline. They were classified by type of initial treatments into neoadjuvant group (NA, N.=26) and upfront surgery group (US, N.=86).

RESULTS

The median survival duration of all patients was 18.3 months. Patients in the NA group had more T4 disease than those in the US group (38.5% in NA versus 15.1% in the US group; P=0.010). Arterial involvement was more frequent in the NA group (42.3% versus 15.1%; P=0.003). In the NA group, ten (38.5%) patients underwent surgery, and seven of them had complete R0 resection. In the US group, 83 (96.5%) patients received radical surgery, and 42 (48.8%) had R0 resection. In survival analysis according to intent to treat, the overall two-year survival rate was 51.1% in the US group and 36.7% in the NA group (P=0.001). However, among patients who underwent surgery (N.=96), the two-year overall survival rate was not significantly different between the two groups (P=0.089). According to involved vessels, the survival rate was not different between patients with arterial or both arterial and venous involvement and in patients with only venous involvement (P=0.649).

CONCLUSIONS

It is necessary to demonstrate the efficacy of neoadjuvant therapy and to standardize the regimens through large-scale, multicenter, randomized controlled studies.

Diagnostic Ability of Convex-Arrayed Endoscopic Ultrasonography for Major Vascular Invasion in Pancreatic Cancer

Background/Aims

This study aimed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for major vascular invasion in pancreatic cancer and to evaluate the relationship between EUS findings and pathological distance.

Methods

In total, 57 consecutive patients who underwent EUS for pancreatic cancer before surgery were retrospectively reviewed. EUS image findings were divided into four types according to the relationship between the tumor and major vessel (types 1 and 2: invasion, types 3 and 4: non-invasion). We also compared the EUS findings and pathologically measured distances between the tumors and evaluated vessels.

Results

The sensitivity, specificity, and accuracy of EUS diagnosis for vascular invasion were 89%, 92%, and 91%, respectively, in the veins and 83%, 94%, and 93%, respectively, in the arteries. The pathologically evaluated distances of cases with type 2 EUS findings were significantly shorter than those of cases with type 3 EUS findings in both the major veins (median [interquartile range], 96 [0–742] µm vs. 2,833 [1,076–5,694] µm, p=0.012) and arteries (623 [0–854] µm vs. 3,097 [1,396–6,000] µm, p=0.0061). All cases with a distance of ≥1,000 µm between the tumors and main vessels were correctly diagnosed.

Conclusions

Tumors at a distance ≥1,000 µm from the main vessels were correctly diagnosed by EUS.

The emerging links between chromosomal instability (CIN), metastasis, inflammation and tumour immunity

Many cancers possess an incorrect number of chromosomes, a state described as aneuploidy. Aneuploidy is often caused by Chromosomal Instability (CIN), a process of continuous chromosome mis-segregation. CIN is believed to endow tumours with enhanced evolutionary capabilities due to increased intratumour heterogeneity, and facilitating adaptive resistance to therapies. Recently, however, additional consequences and associations with CIN have been revealed, prompting the need to understand this universal hallmark of cancer in a multifaceted context. This review is focused on the investigation of possible links between CIN, metastasis and the host immune system in cancer development and treatment. We specifically focus on these links since most cancer deaths are due to the consequences of metastasis, and immunotherapy is a rapidly expanding novel avenue of cancer therapy.