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Augustinus S, van Laarhoven HWM, Cirkel GA, de Groot JWB, Groot Koerkamp B, Macarulla T, Melisi D, O’Reilly EM, van Santvoort HC, Mackay TM, Besselink MG, Wilmink JW. Timing of Initiation of Palliative Chemotherapy in Asymptomatic Patients with Metastatic Pancreatic Cancer: An International Expert Survey and Case-Vignette Study. Cancers (Basel) 2023; 15:5603. [PMID: 38067306 PMCID: PMC10705283 DOI: 10.3390/cancers15235603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/15/2024] Open
Abstract
Background: The use of imaging, in general, and during follow-up after resection of pancreatic cancer, is increasing. Consequently, the number of asymptomatic patients diagnosed with metastatic pancreatic cancer (mPDAC) is increasing. In these patients, palliative systemic therapy is the only tumor-directed treatment option; hence, it is often immediately initiated. However, delaying therapy in asymptomatic palliative patients may preserve quality of life and avoid therapy-related toxicity, but the impact on survival is unknown. This study aimed to gain insight into the current perspectives and clinical decision=making of experts regarding the timing of treatment initiation of patients with asymptomatic mPDAC. Methods: An online survey (13 questions, 9 case-vignettes) was sent to all first and last authors of published clinical trials on mPDAC over the past 10 years and medical oncologists of the Dutch Pancreatic Cancer Group. Inter-rater variability was determined using the Kappa Light test. Differences in the preferred timing of treatment initiation among countries, continents, and years of experience were analyzed using Fisher's exact test. Results: Overall, 78 of 291 (27%) medical oncologists from 15 countries responded (62% from Europe, 23% from North America, and 15% from Asia-Pacific). The majority of respondents (63%) preferred the immediate initiation of chemotherapy following diagnosis. In 3/9 case-vignettes, delayed treatment was favored in specific clinical contexts (i.e., patient with only one small lung metastasis, significant comorbidities, and higher age). A significant degree of inter-rater variability was present within 7/9 case-vignettes. The recommended timing of treatment initiation differed between continents for 2/9 case-vignettes (22%), in 7/9 (77.9%) comparing the Netherlands with other countries, and based on years of experience for 5/9 (56%). Conclusions: Although the response rate was limited, in asymptomatic patients with mPDAC, immediate treatment is most often preferred. Delaying treatment until symptoms occur is considered in patients with limited metastatic disease, more comorbidities, and higher age.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, 3584 Utrecht, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, 3015 Rotterdam, The Netherlands
| | - Teresa Macarulla
- Department of Medical Oncology, Vall d’Hebron Unveristy Hospital, Vall d’Hebron Institute of Oncology (VHIO), 08035 Barcelona, Spain
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Unit, Univeristy of Verona, 37134 Verona, Italy
| | - Eileen M. O’Reilly
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein, Utrecht University, 3584 Utrech, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands; (S.A.); (M.G.B.)
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
| | - Johanna W. Wilmink
- Cancer Center Amsterdam, 1105 Amsterdam, The Netherlands
- Department of Medical Oncology, Location University of Amsterdam, Amsterdam University Medical Center, 1105 Amsterdam, The Netherlands
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Alfano MS, Garnier J, Palen A, Ewald J, Piana G, Poizat F, Mitry E, Delpero JR, Turrini O. Peak Risk of Recurrence Occurs during the First Two Years after a Pancreatectomy in Patients Receiving Neoadjuvant FOLFIRINOX. Cancers (Basel) 2023; 15:5151. [PMID: 37958326 PMCID: PMC10649429 DOI: 10.3390/cancers15215151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
No codified/systematic surveillance program exists for borderline/locally advanced pancreatic ductal carcinoma treated with neoadjuvant FOLFIRINOX and a secondary resection. This study aimed to determine the trend of recurrence in patients who were managed using such a treatment strategy. From 2010, 101 patients received FOLFIRINOX and underwent a pancreatectomy, in a minimum follow-up of 5 years. Seventy-one patients (70%, R group) were diagnosed with recurrence after a median follow-up of 11 months postsurgery. In the multivariable analysis, patients in the R-group had a higher rate of weight loss (p = 0.018), higher carbohydrate antigen (CA 19-9) serum levels at diagnosis (p = 0.012), T3/T4 stage (p = 0.017), and positive lymph nodes (p < 0.01) compared to patients who did not experience recurrence. The risk of recurrence in patients with T1/T2 N0 R0 was the lowest (19%), and all recurrences occurred during the first two postoperative years. The peak risk of recurrence for the entire population was observed during the first two postoperative years. The probability of survival decreased until the second year and rebounded to 100% permanently, after the ninth postoperative year. Close monitoring is needed at reduced intervals during the first 2 years following a pancreatectomy and should be extended to later than 5 years for those with unfavorable pathological results.
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Affiliation(s)
- Marie-Sophie Alfano
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
| | - Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
| | - Anaïs Palen
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
| | - Gilles Piana
- Department of Radiology, Institut Paoli-Calmettes, 13009 Marseille, France
| | - Flora Poizat
- Department of Pathology, Institut Paoli-Calmettes, 13009 Marseille, France
| | - Emmanuel Mitry
- Department of Oncology, Institut Paoli-Calmettes, 13009 Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
- Faculté de Médecine, Aix-Marseille University, 13005 Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, 13009 Marseille, France; (M.-S.A.)
- Faculté de Médecine, Aix-Marseille University, 13005 Marseille, France
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3
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Tjaden C, Hinz U, Klaiber U, Heger U, Springfeld C, Goeppert B, Schmidt T, Mehrabi A, Strobel O, Berchtold C, Schneider M, Diener M, Neoptolemos JP, Hackert T, Büchler MW. Distal Bile Duct Cancer: Radical (R0 > 1 mm) Resection Achieves Favorable Survival. Ann Surg 2023; 277:e112-e118. [PMID: 34171863 PMCID: PMC9762700 DOI: 10.1097/sla.0000000000005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluation of the outcome after resection for distal bile duct cancer (DBC) with focus on the impact of microscopic histopathological resection status R0 (>1 mm) versus R1 (≤1 mm) vs R1 (direct). SUMMARY BACKGROUND DATA DBC is a rare disease for which oncologic resection offers the only chance of cure. METHODS Prospectively collected data of consecutive patients undergoing pancreaticoduodenectomy for DBC were analyzed. Histopathological resection status was classified according to the Leeds protocol for pancreatic ductal adeno carcinoma (PDAC) (PDAC; R0 >1 mm margin clearance vs R1 ≤1 mm vs R1 direct margin involvement). RESULTS A total of 196 patients underwent pancreaticoduodenectomy for DBC. Microscopic complete tumor clearance (R0>1 mm) was achieved in 113 patients (58%). Median overall survival (OS) of the entire cohort was 37 months (5- and 10-year OS rate: 40% and 31%, respectively). After R0 resection, median OS increased to 78 months with a 5-year OS rate of 52%. Negative prognostic factors were age >70 years ( P < 0.0001, hazard ratio (HR) 2.48), intraoperative blood loss >1000 mL ( P = 0.0009, HR 1.99), pN1 and pN2 status ( P = 0.0052 and P = 0.0006, HR 2.14 and 2.62, respectively) and American Society of Anesthesiologists score >II ( P = 0.0259, HR 1.61). CONCLUSIONS This is the largest European single-center study of surgical treatment for DBC and the first to investigate the prognostic impact of the revised PDAC resection status definition in DBC. The results show that this definition is valid in DBC and that "true" R0 resection (>1 mm) is a key factor for excellent survival. In contrast to PDAC, there was no survival difference between R1 (≤1 mm) and R1 (direct).
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Affiliation(s)
- Christine Tjaden
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulla Klaiber
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulrike Heger
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Springfeld
- Department of Medical Oncology, Heidelberg University Hospital, Heidelberg, Germany; and
| | - Benjamin Goeppert
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Diener
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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4
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Gonzales BA, Diniz AL, Torres SM, Salvador de Castro Ribeiro H, Correia de Farias I, Luís de Godoy A, Coimbra FJF, Fonseca de Jesus VH. Patterns of disease relapse and posttreatment follow-up of patients with resected pancreatic adenocarcinoma: A single-center analysis. J Surg Oncol 2022; 126:708-717. [PMID: 35699399 DOI: 10.1002/jso.26985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/02/2022] [Accepted: 06/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES To describe the patterns of disease relapse and follow-up of patients with resected pancreatic adenocarcinoma. Additionally, we looked at patients' characteristics at relapse and survival. METHODS We included patients with potentially resectable pancreatic adenocarcinoma diagnosed from 2008 to 2018 who were submitted to resection with clear macroscopic margins and started posttreatment surveillance. RESULTS The study population consists of 73 patients. The median interval between imaging studies was 3.2 months during the first 2 years of follow-up and 5.1 months thereafter. Forty-eight patients (65.8%) experienced disease relapse. The most frequent single site of relapse was locoregional (N = 21; 43.8%). At relapse, 31 patients (64.6%) were symptomatic and forty-two patients (87.6%) had Eastern Cooperative Oncology Group performance status 0 or 1. Most patients were able to undergo additional anticancer therapy (N = 41; 85.4%). Patients with asymptomatic relapses experienced longer median postrelapse survival (25.4 vs. 11.3 months; p = 0.015). CONCLUSIONS A follow-up protocol that included imaging studies every 3 months in the first 2 years and every 6 months thereafter is able to diagnose disease relapse when patients have adequate performance status and are still able to undergo additional anticancer treatment.
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Affiliation(s)
- Beatriz A Gonzales
- Department of Medical Oncology, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Alessandro L Diniz
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Silvio M Torres
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | | | - Igor Correia de Farias
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - André Luís de Godoy
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
| | - Felipe J F Coimbra
- Department of Abdominal Surgery, A.C. Camargo Cancer, CenterSão Paulo, São Paulo, Brazil
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5
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Daamen LA, Groot VP, Besselink MG, Bosscha K, Busch OR, Cirkel GA, van Dam RM, Festen S, Groot Koerkamp B, Haj Mohammad N, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, Los M, Meijer GJ, de Meijer VE, Nieuwenhuijs VB, Pranger BK, Raicu MG, Schreinemakers JMJ, Stommel MWJ, Verdonk RC, Verkooijen HM, Molenaar IQ, van Santvoort HC. Detection, Treatment, and Survival of Pancreatic Cancer Recurrence in the Netherlands: A Nationwide Analysis. Ann Surg 2022; 275:769-775. [PMID: 32773631 DOI: 10.1097/sla.0000000000004093] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether detection of recurrent pancreatic ductal adenocarcinoma (PDAC) in an early, asymptomatic stage increases the number of patients receiving additional treatment, subsequently improving survival. SUMMARY OF BACKGROUND DATA International guidelines disagree on the value of standardized postoperative surveillance for early detection and treatment of PDAC recurrence. METHODS A nationwide, observational cohort study was performed including all patients who underwent PDAC resection (2014-2016). Prospective baseline and perioperative data were retrieved from the Dutch Pancreatic Cancer Audit. Data on follow-up, treatment, and survival were collected retrospectively. Overall survival (OS) was evaluated using multivariable Cox regression analysis, before and after propensity-score matching, stratified for patients with symptomatic and asymptomatic recurrence. RESULTS Eight hundred thirty-six patients with a median follow-up of 37 months (interquartile range 30-48) were analyzed. Of those, 670 patients (80%) developed PDAC recurrence after a median follow-up of 10 months (interquartile range 5-17). Additional treatment was performed in 159/511 patients (31%) with symptomatic recurrence versus 77/159 (48%) asymptomatic patients (P < 0.001). After propensity-score matching on lymph node ratio, adjuvant therapy, disease-free survival, and recurrence site, additional treatment was independently associated with improved OS for both symptomatic patients [hazard ratio 0.53 (95% confidence interval 0.42-0.67); P < 0.001] and asymptomatic patients [hazard ratio 0.45 (95% confidence interval 0.29-0.70); P < 0.001]. CONCLUSIONS Additional treatment of PDAC recurrence was independently associated with improved OS, with asymptomatic patients having a higher probability to receive recurrence treatment. Therefore, standardized postoperative surveillance aiming to detect PDAC recurrence before the onset of symptoms has the potential to improve survival. This provides a rationale for prospective studies on standardized surveillance after PDAC resection.
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Affiliation(s)
- Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
- Department of Medical Oncology, Meander Medical Center, Amersfoort, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | | | | | - Martijn P W Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Bobby K Pranger
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Mihaela G Raicu
- Department of Pathology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Centre Utrecht; Utrecht University, Utrecht, the Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
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6
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Halle-Smith JM, Hall L, Daamen LA, Hodson J, Pande R, Young A, Jamieson NB, Lamarca A, van Santvoort HC, Molenaar IQ, Valle JW, Roberts KJ. Clinical benefit of surveillance after resection of pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:2248-2255. [PMID: 34034941 DOI: 10.1016/j.ejso.2021.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/03/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The value of routine surveillance after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear, and expert guidelines offer conflicting recommendations. This study is a systematic review of evidence for surveillance programs. METHODS A systematic review of studies evaluating different surveillance methods was undertaken. A meta-analysis was performed for those studies reporting rates of asymptomatic recurrence, treatment of recurrence and overall survival, according to different surveillance methods. RESULTS Ten studies were included in the literature review, with five studies appropriate for meta-analysis (1596 patients). Patients within active surveillance programs were more likely to have recurrence detected at an asymptomatic stage (Pooled Rate: 49.3% vs. 19.1%, p = 0.043). Within studies reporting these outcomes, patients with asymptomatic recurrence were more likely to receive treatment for recurrence (Odds Ratio 3.49; 95% CI: 1.73-7.07; p < 0.001) and had longer overall survival (Mean Difference: 9.5 months; 95% CI: 4.1-14.8; p < 0.001) than those with symptoms at time of recurrence. DISCUSSION Routine surveillance after surgery for PDAC appears to detect more patients at an asymptomatic stage. Data from these non-randomised trials also suggest that treatment rates and survival may be superior in patients were recurrence is detected when asymptomatic. As such, these data suggest that routine surveillance may improve patient outcomes, although an appropriately conducted trial would be required to address concerns that various sources of bias may be affecting these results.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Lewis Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - James Hodson
- Medical Statistics, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alastair Young
- Department of Pancreaticobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust / University of Manchester, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust / University of Manchester, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
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7
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Wong SK, Gondara L, Renouf DJ, Lim HJ, Loree JM, Davies JM, Gill S. Impact of surveillance among patients with resected pancreatic cancer following adjuvant chemotherapy. J Gastrointest Oncol 2021; 12:446-454. [PMID: 34012638 DOI: 10.21037/jgo-20-422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Pancreatic adenocarcinoma carries a high risk of recurrence even after surgery and adjuvant chemotherapy. Current guidelines do not endorse routine surveillance imaging due to lack of evidence supporting a survival benefit. With current first-line palliative chemotherapy options, it is unclear whether surveillance allows for early detection of asymptomatic disease and therefore an improved opportunity to offer chemotherapy to fit patients. We sought to describe patterns of surveillance of resected pancreatic cancer at British Columbia (BC) Cancer and determine whether utilization of computerized tomography (CT) scans affected likelihood of receiving palliative chemotherapy at the time of recurrence. Methods A retrospective review was completed to identify patients treated at BC Cancer centres between 2010-2016 who had undergone curative intent resection and received at least one cycle of adjuvant chemotherapy. Information was collected on baseline characteristics, imaging scans done between adjuvant chemotherapy and recurrence, and receipt of palliative chemotherapy. Two cohorts were defined based on number of scans done between completion of adjuvant chemotherapy and recurrence: those with only 1 scan were defined as "symptomatic" recurrences and patients who had undergone more than 1 scan were considered "surveillance" recurrences. Results In total, 142 patients were included of which 115 (81%) patients developed recurrence. There were 22 patients (19%) in the "symptomatic" cohort and 93 patients (81%) in the "surveillance" cohort. Median time to recurrence 274 days (9.1 months) in the symptomatic cohort compared to 471 days (15.7 months) in the surveillance group. Patients who underwent surveillance scans were more likely to receive palliative chemotherapy at the time of recurrence, though statistical significance was not reached: 51% in surveillance group versus 27% in symptomatic group [odds ratio (OR) 2.11, 95% confidence interval (CI): 0.75-6.58, P=0.17]. Conclusions Despite the absence of surveillance recommendations, the majority of patients underwent surveillance imaging. We demonstrated a non-significant increase in the likelihood of receiving palliative chemotherapy among patients who underwent surveillance scans. With more efficacious palliative chemotherapy options available, studies to determine whether receipt of chemotherapy in asymptomatic recurrences translates into improved survival and/or quality of life are warranted.
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8
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Luu AM, Belyaev O, Höhn P, Praktiknjo M, Janot M, Uhl W, Braumann C. Late recurrences of pancreatic cancer in patients with long-term survival after pancreaticoduodenectomy. J Gastrointest Oncol 2021; 12:474-483. [PMID: 34012641 PMCID: PMC8107632 DOI: 10.21037/jgo-20-433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/17/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Philipp Höhn
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | | | - Monika Janot
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr - University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
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9
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Hwang HK, Wada K, Kim HY, Nagakawa Y, Hijikata Y, Kawasaki Y, Nakamura Y, Lee LS, Yoon DS, Lee WJ, Kang CM. A nomogram to preoperatively predict 1-year disease-specific survival in resected pancreatic cancer following neoadjuvant chemoradiation therapy. Chin J Cancer Res 2020; 32:105-114. [PMID: 32194310 PMCID: PMC7072019 DOI: 10.21147/j.issn.1000-9604.2020.01.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective This study aimed to develop a nomogram to predict the 1-year survival of patients with pancreatic cancer who underwent pancreatectomy following neoadjuvant treatment with preoperatively detectable clinical parameters. Extended pancreatectomy is necessary to achieve complete tumor removal in borderline resectable and locally advanced pancreatic cancer. However, it increases postoperative morbidity and mortality rates, and should be balanced with potential benefit of long-term survival. Methods The medical records of patients who underwent pancreatectomy following neoadjuvant treatment from January 2005 to December 2016 at Severance Hospital were retrospectively reviewed. Medical records were collected from five international institutions from Japan and Singapore for external validation. Results A total of 113 patients were enrolled. The nomogram for predicting 1-year disease-specific survival was created based on 5 clinically detectable preoperative parameters as follows: age (year), symptom (no/yes), tumor size at initial diagnostic stage (cm), preoperative serum carbohydrate antigen (CA) 19-9 level after neoadjuvant treatment (<34/≥34 U/mL), and planned surgery [pancreaticoduodenectomy (PD) (pylorus-preserving PD)/distal pancreatectomy (DP)/total pancreatectomy]. Model performance was assessed for discrimination and calibration. The calibration plot showed good agreement between actual and predicted survival probabilities; the the Greenwood-Nam-D'Agostino (GND) goodness-of-fit test showed that the model was well calibrated (χ2=8.24, P=0.5099). A total of 84 patients were used for external validation. When correlating actual disease-specific survival and calculated 1-year disease-specific survival, there were significance differences according to the calculated probability of 1-year survival among the three groups (P=0.044). Conclusions The developed nomogram had quite acceptable accuracy and clinical feasibility in the decision-making process for the management of pancreatic cancer.
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Affiliation(s)
- Ho Kyoung Hwang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo 173-8605, Japan
| | - Ha Yan Kim
- Biostatistician, Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 160-8402, Japan
| | - Yosuke Hijikata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo 160-8402, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, Breast, and Thyroid Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima 890-0065, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo 890-0065, Japan
| | - Lip Seng Lee
- Department of General Surgery, Changi General Hospital, Singapore 529889, Singapore
| | - Dong Sup Yoon
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Woo Jung Lee
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Chang Moo Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
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10
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Schneider M, Strobel O, Hackert T, Büchler MW. Pancreatic resection for cancer—the Heidelberg technique. Langenbecks Arch Surg 2019; 404:1017-1022. [DOI: 10.1007/s00423-019-01839-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/04/2019] [Indexed: 01/11/2023]
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11
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Postoperative Imaging and Tumor Marker Surveillance in Resected Pancreatic Cancer. J Clin Med 2019; 8:jcm8081115. [PMID: 31357636 PMCID: PMC6722558 DOI: 10.3390/jcm8081115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/05/2019] [Accepted: 07/25/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Pancreatic cancer is a catastrophic disease with high recurrence and death rates, even in early stages. Early detection and early treatment improve survival in many cancer types but have not yet been clearly documented to do so in pancreatic cancer. In this study, we assessed the benefit on survival resulting from different patterns of surveillance in daily practice after curative surgery of early pancreatic cancer. Methods: Patients with pancreatic ductal adenocarcinoma who had received curative surgery between January 2000 and December 2013 at our institute were retrospectively reviewed. Patients were classified into one of four groups, based on surveillance strategy: the symptom group, the imaging group, the marker group (carbohydrate antigen 19-9 and/or carcinoembryonic antigen), and the intense group (both imaging and tumor marker assessment). Overall survival (OS), relapse-free survival (RFS), and post-recurrence overall survival (PROS) were evaluated. Results: One hundred and eighty-one patients with documented recurrence or metastasis were included in our analysis. The median OS for patients in the symptom group, imaging group, marker group, and intense group were 21.4 months, 13.9 months, 20.5 months, and 16.5 months, respectively (p = 0.670). Surveillance with imaging, tumor markers, or both was not an independent risk factor for OS in univariate and multivariate analyses. There was no significant difference in median RFS (symptom group, 11.7 months; imaging group, 6.3 months; marker group, 9.3 months; intense group, 6.9 months; p = 0.259) or median PROS (symptom group, 6.9 months; imaging group, 7.5 months; marker group, 5.0 months; intense group, 7.8 months; p = 0.953) between the four groups. Multivariate analyses identified poor Eastern Cooperative Oncology Group Performance Status (ECOG PS) (≥1), primary tumor site (tail), and tumor grade (poor differentiation) were poor prognostic factors for OS. Conclusions: Surveillance with regular imaging, tumor marker, or both was not an independent risk factor for OS of pancreatic cancer patients who undergo curative tumor resection.
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12
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Daamen LA, Groot VP, Intven MPW, Besselink MG, Busch OR, Koerkamp BG, Mohammad NH, Hermans JJ, van Laarhoven HWM, Nuyttens JJ, Wilmink JW, van Santvoort HC, Molenaar IQ, Stommel MWJ. Postoperative surveillance of pancreatic cancer patients. Eur J Surg Oncol 2019; 45:1770-1777. [PMID: 31204168 DOI: 10.1016/j.ejso.2019.05.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/21/2019] [Accepted: 05/31/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study is to collect the best available evidence for diagnostic modalities, frequency, and duration of surveillance after resection for pancreatic ductal adenocarcinoma (PDAC). METHODS PDAC guidelines published after 2015 were collected. Furthermore, a systematic search of the literature on postoperative surveillance was performed in PubMed and Embase from 2000 to 2019. Articles comparing different diagnostic modalities and frequencies of postoperative surveillance in PDAC patients with regard to survival, quality of life, morbidity and cost-effectiveness were selected. RESULTS The literature search resulted in 570 articles. A total of seven guidelines and twelve original clinical studies were eventually evaluated. PDAC guidelines increasingly recommend a combination of tumor marker testing and computed tomography (CT) imaging every three to six months during the first two years after resection. These guidelines are, however, based on expert opinion and other low-level evidence. Prospective studies comparing different surveillance strategies are lacking. According to recent studies, surveillance with tumor markers and imaging at regular intervals results in the detection of PDAC recurrence before the onset of symptoms and more frequent administration of further therapy, such as chemotherapy or radiotherapy. CONCLUSION Current evidence for recurrence-focused surveillance after PDAC resection is limited and contradictory. Consequently, recommendations on surveillance are conflicting. To define the clinical merit of recurrence-focused surveillance, patients who are most likely to benefit from early detection and treatment of PDAC recurrence need to be identified. To this purpose, well-designed prospective studies are needed, accounting for both economical and psychosocial implications of surveillance.
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Affiliation(s)
- L A Daamen
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands.
| | - V P Groot
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - M P W Intven
- Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - M G Besselink
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - O R Busch
- Dept. of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - N Haj Mohammad
- Dept. of Medical Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - J J Hermans
- Dept. of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H W M van Laarhoven
- Dept. of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - J J Nuyttens
- Dept. of Radiation Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J W Wilmink
- Dept. of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - H C van Santvoort
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - I Q Molenaar
- Dept. of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - M W J Stommel
- Dept. of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
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Kim SH, Lee MJ, Hwang HK, Lee SH, Kim H, Paik YK, Kang CM. Prognostic potential of the preoperative plasma complement factor B in resected pancreatic cancer: A pilot study. Cancer Biomark 2019; 24:335-342. [DOI: 10.3233/cbm-181847] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Sung Hyun Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Min Jung Lee
- Yonsei Proteome Research Center, Yonsei University, Seoul, Korea
- Department of Integrated OMICS for Biomedical Science, Yonsei University, Seoul, Korea
- Department of Biochemistry, College of Life Science and Biotechnology, Yonsei University, Seoul, Korea
| | - Ho Kyung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Sung Hwan Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
- Department of Systems Biology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hoguen Kim
- Department of Pathology, College of Medicine, Yonsei University, Seoul, Korea
| | - Young-Ki Paik
- Yonsei Proteome Research Center, Yonsei University, Seoul, Korea
- Department of Integrated OMICS for Biomedical Science, Yonsei University, Seoul, Korea
- Department of Biochemistry, College of Life Science and Biotechnology, Yonsei University, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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14
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Detection of recurrent pancreatic cancer: value of second-opinion interpretations of cross-sectional images by subspecialized radiologists. Abdom Radiol (NY) 2019; 44:586-592. [PMID: 30251132 DOI: 10.1007/s00261-018-1765-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To investigate the value of second-opinion interpretation of cross-sectional images by subspecialized radiologists to diagnose recurrent pancreatic cancer after surgery. METHODS The IRB approved and issued a waiver of informed consent for this retrospective study. Initial and second-opinion interpretations of 69 consecutive submitted MRI or CT follow-up after pancreatic cancer resection between January 1, 2009 and December 31, 2013 were evaluated by one oncologic imaging radiologist, who was blinded to patient's clinical details and histopathologic data. The reviewer was asked to classify each interpretation in reference of the diagnosis of PDAC recurrence. It was also recorded if the radiologic interpretation recommended additional imaging studies to confirm recurrence. The diagnosis of recurrence was determined by pathology when available, otherwise by imaging follow-up, clinical, or laboratory assessments. Cohen's kappa statistic was used to assess agreement between initial and second-opinion interpretations. The differences between the initial and second-opinion interpretations were examined using McNemar test or Bowker's test of symmetry. RESULTS Disagreement on recurrence between the initial report and the second-opinion interpretation was observed in 32% of cases (22/69; k = 0.44). Second-opinion interpretations had a higher sensitivity and a higher specificity on recurrence compared to the initial interpretations (0.93 vs. 0.75 and 0.90 vs. 0.68, respectively), and the difference in specificity was significant (p = 0.016). Additional imaging studies were recommended more frequently in the initial interpretation (22% vs. 6%, p = 0.006). CONCLUSIONS Our study shows the second-opinion interpretation by subspecialized radiologists improves the detection of pancreatic cancer recurrence after surgical resection.
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15
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Progressive Resistance Training to Impact Physical Fitness and Body Weight in Pancreatic Cancer Patients: A Randomized Controlled Trial. Pancreas 2019; 48:257-266. [PMID: 30589829 DOI: 10.1097/mpa.0000000000001221] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Maintaining or improving muscle mass and muscle strength is an important treatment goal in pancreatic cancer (PC) patients because of high risk of cachexia. Therefore, we assessed feasibility and effectivity of a 6-month progressive resistance training (RT) in PC patients within a randomized controlled trial. METHODS Sixty-five PC patients were randomly assigned to either supervised progressive RT (RT1), home-based RT (RT2), or usual care control group (CON). Both exercise groups performed training 2 times per week for 6 months. Muscle strength for knee, elbow, and hip extensors and flexors and cardiorespiratory fitness and body weight were assessed before and after the intervention period. RESULTS Of 65 patients, 43 patients were analyzed. Adherence rates were 64.1% (RT1) and 78.4% (RT2) of the prescribed training sessions. RT1 showed significant improvements in elbow flexor/extensor muscle strength and in maximal work load versus CON and RT2 (P < 0.05). Further, knee extensors were significantly improved for RT1 versus CON (P < 0.05). Body weight revealed no significant group differences over time. CONCLUSIONS Progressive RT was feasible in PC patients and improved muscle strength with significant results for some muscle groups. Supervised RT seemed to be more effective than home-based RT.
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16
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Neuzillet C, Gaujoux S, Williet N, Bachet JB, Bauguion L, Colson Durand L, Conroy T, Dahan L, Gilabert M, Huguet F, Marthey L, Meilleroux J, de Mestier L, Napoléon B, Portales F, Sa Cunha A, Schwarz L, Taieb J, Chibaudel B, Bouché O, Hammel P. Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC). Dig Liver Dis 2018; 50:1257-1271. [PMID: 30219670 DOI: 10.1016/j.dld.2018.08.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND This document is a summary of the French intergroup guidelines regarding the management of pancreatic adenocarcinoma (PA), updated in July 2018. DESIGN This collaborative work was produced under the auspices of all French medical and surgical societies involved in the management of PA. It is based on the previous guidelines, recent literature review and expert opinions. Recommendations were graded in three categories, according to the level of evidence. RESULTS Over the last seven years, significant changes in PA management have been implemented in clinical practice. Imaging/staging: diffusion magnetic resonance imaging is useful before surgery to rule out small liver metastases. SURGERY centralization of pancreatic surgery in expert centers is associated with a decreased postoperative mortality. Adjuvant chemotherapy: modified FOLFIRINOX in fit patients, or gemcitabine, or 5-FU, or gemcitabine plus capecitabine, to be discussed on a case-by-case basis. Locally advanced PA: no survival benefit of chemoradiotherapy. Metastatic PA: FOLFIRINOX and gemcitabine plus nab-paclitaxel combination are first-line standards in fit patients; second-line with 5FU/nal-IRI or 5FU/oxaliplatin combination after first-line gemcitabine. CONCLUSION Guidelines for management of PA are continuously evolving and need to be regularly updated. This constant progress is made possible through clinical and translational research. However, as each individual case is particular, they cannot substitute to multidisciplinary tumor board discussion.
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Affiliation(s)
- Cindy Neuzillet
- Department of Medical Oncology, Curie Institute, Versailles Saint-Quentin University (UVSQ), Saint-Cloud, France.
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery, Cochin Hospital, AP-HP, Paris Descartes Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Nicolas Williet
- Hepato-Gastroenterology Department, University Hospital of Saint-Etienne, Saint Priest en Jarez, France
| | - Jean-Baptiste Bachet
- Hepato-Gastroenterology Department, Pitié Salpétrière University Hospital, AP-HP, Paris Cedex 13, France
| | - Lucile Bauguion
- Hepato-Gastroenterology Department, Departmental Hospital Center, La Roche sur Yon, France
| | - Laurianne Colson Durand
- Department of Radiotherapy, Henri Mondor Hospital, AP-HP, Université Paris Est Creteil, Créteil, France
| | - Thierry Conroy
- Department of Medical Oncology, Lorraine Institute of Oncology and Lorraine University, Vandoeuvre-lès-Nancy Cedex, France
| | - Laetitia Dahan
- Digestive Oncology Department, "DACCORD" (Digestif, Anatomie pathologique, Chirurgie, CISIH, Oncologie, Radiothérapie, Dermatologie) pole, CHU Timone, Marseille Cedex 05, France
| | - Marine Gilabert
- Paoli Calmettes Institute, Department of Medical Oncology and Cancer Research Center of Marseille (CRCM), INSERM U1068 Stress Cell, Aix-Marseille University, Marseille, France
| | - Florence Huguet
- Department of Oncology and Radiotherapy, Tenon Hospital, East Paris University Hospitals, AP-HP, Paris Sorbonne University, Paris, France
| | - Lysiane Marthey
- Gastroenterology Department, Béclère Hospital, AP-HP, Clamart, France
| | - Julie Meilleroux
- Pathology Department, Toulouse University Hospital, Toulouse, France
| | - Louis de Mestier
- Department of Gastroenterology-Pancreatology, Beaujon Hospital, APHP, Paris 7 University, Clichy, France
| | - Bertrand Napoléon
- Jean Mermoz Private Hospital, Ramsay Générale de Santé, Lyon, France
| | - Fabienne Portales
- Digestive Oncology Department, Regional Institute of Cancer, Montpellier, France
| | - Antonio Sa Cunha
- INSERM UMR 935, Paul Brousse Hospital, Hepatobiliary Center, AP-HP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen University Hospital, Rouen, France and Genomic and Personalized Medicine in Cancer and Neurological Disorders, UMR 1245 INSERM, Rouen University, France
| | - Julien Taieb
- Hepato-Gastroenterology and Digestive Oncology Department, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Benoist Chibaudel
- Department of Medical Oncology, Franco-British Institute, Levallois-Perret, France
| | - Olivier Bouché
- Hepato-Gastroenterology and Digestive Oncology Department, Robert Debré University Hospital, Avenue Général Koenig, 51092 Reims Cedex, France
| | - Pascal Hammel
- Department of Digestive Oncology, Beaujon University Hospital (AP-HP), Paris VII Diderot University, Clichy-la-Garenne, France.
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Daamen LA, Groot VP, Goense L, Wessels FJ, Borel Rinkes IH, Intven MPW, van Santvoort HC, Molenaar IQ. The diagnostic performance of CT versus FDG PET-CT for the detection of recurrent pancreatic cancer: a systematic review and meta-analysis. Eur J Radiol 2018; 106:128-136. [PMID: 30150034 DOI: 10.1016/j.ejrad.2018.07.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Radiologic surveillance after resection of pancreatic ductal adenocarcinoma (PDAC) can provide information on the extent and location of disease recurrence. This systematic review and meta-analysis aims to give an overview of the literature on the diagnostic performance of different imaging modalities for the detection of recurrent disease after surgery for PDAC. METHODS A systematic search was performed in PubMed, EMBASE and Cochrane Library up to 20 December 2017. All studies reporting on the diagnostic value of imaging modalities for the detection of local and/or distant disease recurrence during follow-up after resection of PDAC were eligible. Both histologic confirmation of recurrent PDAC and clinical confirmation by disease progression on follow-up imaging were considered as suitable reference standard. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used for critical appraisal of methodological quality. Diagnostic accuracy data were extracted or calculated and presented in forest plots. A bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity. RESULTS A total of seven retrospective studies with 333 relevant patients were ultimately eligible for data extraction. Overall, the methodological quality of the included studies was acceptable. All seven articles described test results of contrast-enhanced CT, whilst five and three articles reported outcomes on diagnostic accuracy of FDG PET-CT and FDG PET-CT combined with contrast-enhanced CT, respectively. For CT, pooled estimates for sensitivity were 0.70 (95% CI 0.61-0.78) and for specificity 0.80 (95% CI 0.69-0.88). For FDG PET-CT, pooled estimates for sensitivity and specificity were 0.88 (95% CI 0.81-0.93) and 0.89 (95% CI 0.80-0.94), respectively. For FDG PET-CT in combination with contrast-enhanced CT, pooled estimates for sensitivity were 0.95 (95% CI 0.88-0.98) and for specificity 0.81 (95% CI 0.63-0.92). CONCLUSIONS According to the current literature, post-operative CT has a moderate diagnostic accuracy in the detection of recurrent disease. FDG PET-CT imaging could be of additional value when disease recurrence is suspected despite negative or equivocal CT findings. Nevertheless, evidence supporting radiologic surveillance after resection of PDAC is limited. Future prospective studies are needed to optimize surveillance strategies after resection of pancreatic cancer.
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Affiliation(s)
- Lois A Daamen
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, The Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands.
| | - Vincent P Groot
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, The Netherlands; Dept. of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucas Goense
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, The Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Frank J Wessels
- Dept. of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Martijn P W Intven
- Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein
| | - I Quintus Molenaar
- Dept. of Surgery, UMC Utrecht Cancer Center, Utrecht, The Netherlands; Dept. of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein.
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Systematic review on the role of serum tumor markers in the detection of recurrent pancreatic cancer. HPB (Oxford) 2018; 20:297-304. [PMID: 29366815 DOI: 10.1016/j.hpb.2017.11.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biomarker testing can be helpful to monitor disease progression after resection of pancreatic cancer. This systematic review aims to give an overview of the literature on the diagnostic value of serum tumor markers for the detection of recurrent pancreatic cancer during follow-up. METHODS A systematic search was performed to 2 October 2017. All studies reporting on the diagnostic value of postoperatively measured serum biomarkers for the detection of pancreatic cancer recurrence were included. Data on diagnostic accuracy of tumor markers were extracted. Forest plots and pooled values of sensitivity and specificity were calculated. RESULTS Four articles described test results of CA 19-9. A pooled sensitivity and specificity of respectively 0.73 (95% CI 0.66-0.80) and 0.83 (95% CI 0.73-0.91) were calculated. One article reported on CEA, showing a sensitivity of 50% and specificity of 65%. No other serum tumor markers were discussed for surveillance purposes in the current literature. CONCLUSION Although testing of serum CA 19-9 has considerable limitations, CA 19-9 remains the most used serum tumor marker for surveillance after surgical resection of pancreatic cancer. Further studies are needed to assess the role of serum tumor marker testing in the detection of recurrent pancreatic cancer and to optimize surveillance strategies.
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Ganschow P, Werner J. [Distinctive features in the postoperative course of patients after abdominal surgeries]. MMW Fortschr Med 2018; 160:54-61. [PMID: 29556986 DOI: 10.1007/s15006-018-0009-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Petra Ganschow
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Campus Großhadern, Marchioninistraße 15, D-81377, München, Deutschland.
| | - Jens Werner
- München, Campus Großhadern, München, Deutschland
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20
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Groot VP, Daamen LA, Hagendoorn J, Borel Rinkes IHM, van Santvoort HC, Molenaar IQ. Use of imaging during symptomatic follow-up after resection of pancreatic ductal adenocarcinoma. J Surg Res 2017; 221:152-160. [PMID: 29229122 DOI: 10.1016/j.jss.2017.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/03/2017] [Accepted: 08/11/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Controversy exists whether follow-up after resection of pancreatic ductal adenocarcinoma (PDAC) should include standardized imaging for the detection of disease recurrence. The purpose of this study was to evaluate how often patients undergo imaging in a setting where routine imaging is not performed. Secondly, the pattern, timing, and treatment of recurrent PDAC were assessed. MATERIALS AND METHODS This was a post hoc analysis of a prospective database of all consecutive patients undergoing pancreatic resection of PDAC between January 2011 and January 2015. Data on imaging procedures during follow-up, recurrence location, and treatment for recurrence were extracted and analyzed. Associations between clinical characteristics and post-recurrence survival were assessed with the log-rank test and Cox univariable and multivariable proportional hazards models. RESULTS A total of 85 patients were included. Seventy-four patients (87%) underwent imaging procedures during follow-up at least once, with a mean amount of 3.1 ± 1.9 imaging procedures during the entire follow-up period. Sixty-eight patients (80%) were diagnosed with recurrence, 58 (85%) of whom after the manifestation of clinical symptoms. Additional tumor-specific treatment was administered in 17 of 68 patients (25%) with recurrence. Patients with isolated local recurrence, treatment after recurrence, and a recurrence-free survival >10 mo had longer post-recurrence survival. CONCLUSIONS Even though a symptomatic follow-up strategy does not include routine imaging, the majority of patients with resected PDAC underwent additional imaging procedures during their follow-up period. Further prospective studies are needed to determine the actual clinical value, psychosocial implications, and cost-effectiveness of different forms of follow-up after resection of PDAC.
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Affiliation(s)
- Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands; Department of Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center University Medical Center Utrecht, Utrecht, The Netherlands.
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21
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Labori KJ, Brudvik KW. Follow-up After Surgery for Pancreatic Ductal Adenocarcinoma: Steps Toward an International Consensus. Pancreas 2017; 46:e2-e3. [PMID: 27977631 DOI: 10.1097/mpa.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo, Norway
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22
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Kaiser J, Fritz S, Klauss M, Bergmann F, Hinz U, Strobel O, Schneider L, Büchler MW, Hackert T. Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms. Surgery 2016; 161:602-610. [PMID: 27884612 DOI: 10.1016/j.surg.2016.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/06/2016] [Accepted: 09/16/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Small, asymptomatic, branch-duct intraductal papillary mucinous neoplasms of the pancreas are often kept under surveillance despite their malignant potential. The management of branch-duct intraductal papillary mucinous neoplasm is controversial with regard to indications and extent of any operative intervention. The present study aimed to evaluate enucleation as an alternative operative approach for branch-duct intraductal papillary mucinous neoplasms to exclude and prevent malignancy. METHODS For branch-duct intraductal papillary mucinous neoplasms of <30 mm in diameter and an acceptable distance from the main pancreatic duct, enucleation was considered as the operative approach of choice. All patients scheduled for enucleation of branch-duct intraductal papillary mucinous neoplasm on the basis of these features between January 2004 and September 2014 were analyzed. Among these, patients with successful enucleation were compared with those who were scheduled for enucleation but converted intraoperatively to pancreatic resection (intention-to-treat analysis). End points were hospital morbidity and mortality as well as histopathology and functional outcome at a mean follow-up of 32 months. RESULTS In the study, 115 patients with presumed branch-duct intraductal papillary mucinous neoplasm and the intention to perform pancreatic enucleation were included; 87 enucleations were performed in 74 patients. In 41 patients, enucleation was converted to a pancreatic resection (procedure-specific success rate 64%); indications for conversion included location or size (46%), presence of multicystic lesions (39%), or involvement of the main pancreatic duct (15%). Of the 74 patients with enucleation, 64 branch-duct intraductal papillary mucinous neoplasms revealed low- (85%), 11% moderate dysplasia-, and 4% high-grade dysplasia on histology. Among converted resections, 6 intraductal papillary mucinous neoplasms revealed high-grade dysplasia or invasive carcinoma (15%). Intention-to-treat analysis with patients converted to pancreatic resection showed that enucleations resulted in less blood loss (100 vs 400 mL) and a shorter operation time (146 vs 255 minutes; P < .001 each). Postoperative morbidity including postoperative pancreatic fistula was similar in both groups. No mortality occurred after enucleation; after formal resection, 1 patient died due to multiorgan failure. Both hospital stay (10 vs 14 days) and rates of postoperative endocrine and exocrine dysfunction rates were less after enucleation (P < .02 each). Intraductal papillary mucinous neoplasm-specific recurrence rates (3% vs 6%) were similar in both groups. CONCLUSION Enucleation is a safe procedure that can be performed successfully in a high proportion of branch-duct intraductal papillary mucinous neoplasms and should be considered instead of standard resections as an important function-preserving alternative. Limitations may occur due to malignancy, size, localization, multilocularity, or main-duct involvement requiring conversion to a formal, anatomic resection. Beside the advantages in the short-term course, functional outcome seems to be superior after enucleation, and intraductal papillary mucinous neoplasm-specific recurrence rates are not increased compared with standard resections, at least at a mean follow-up of 32 months.
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Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Fritz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Department of General and Visceral Surgery, Katharinenhospital, Stuttgart, Germany
| | - Miriam Klauss
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lutz Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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