Pancreatic Cancer Arising From the Remnant Pancreas: Is It a Local Recurrence or New Primary Lesion?

Prediction of Recurrence Pattern of Pancreatic Cancer Post-Pancreatic Surgery Using Histology-Based Supervised Machine Learning Algorithms: A Single-Center Retrospective Study

BACKGROUND

Patients with pancreatic cancer (PC) have poor prognosis and a high incidence of recurrence. Since further treatment is applicable for specific recurrent events, it is important to predict recurrence patterns after surgery. This study aimed to identify and predict early and late recurrence patterns of PC using a histology-based machine learning model.

PATIENTS AND METHODS

Patients who underwent upfront curative surgery for PC between 2001 and 2014 were included. The timing of recurrence and prognosis of each first recurrence site were examined. A histology-based supervised machine learning method, which combined convolutional neural networks and random forest, was used to predict the recurrence and respective sites of metastasis. Accuracy was evaluated using area under the receiver operating characteristic curve (AUC).

RESULTS

In total, 524 patients were included. Recurrence in the liver accounted for 47.8% of all recurrence events in the first year after surgery. Meanwhile, recurrence in the lung occurred later and could become apparent more than 5 years post-surgery, with indications for further surgery. In terms of substantial distant organ metastases, liver and lung metastases were identified as representative early and late recurrence events. The predictive AUCs of the machine learning model for training and test data were 1.000 and 0.861, respectively, and for predicting nonrecurrence were 1.000 for both.

CONCLUSIONS

We identified the liver and lung as early and late recurrence sites, which could be distinguished with high probability using a machine learning model. Prediction of recurrence sites using this model may be useful for further treatment of patients with PC.

Laparoscopic repeated pancreatectomy for isolated local recurrence in remnant pancreas following laparoscopic radical pancreatectomy for pancreatic ductal adenocarcinoma: Two cases report

Typical treatment for recurrent pancreatic cancer is potent chemotherapy or chemoradiotherapy. However, recent clinical investigations suggest a potential therapeutic role of local resection in recurrent pancreatic cancer. Based on accumulating surgical experience of minimally invasive pancreatectomy, we report cases of two patients who underwent successful laparoscopic re-resection of isolated local recurrence following laparoscopic radical pancreatectomy for pancreatic cancer.

Is Laparoscopic Pancreaticoduodenectomy Feasible for Pancreatic Ductal Adenocarcinoma?

Simple Summary

Pancreatic cancer is known to be one of the most lethal malignant diseases in gastrointestinal tract. Margin-negative pancreatectomy followed by postoperative adjuvant chemotherapy is essential treatment for long-term survival. Due to anatomical complexity and technical difficulty, laparoscopic pancreaticoduodenectomy is still controversial. However, with the advance of laparoscopic surgery, laparoscopic pancreatic resection of pancreatic head cancer has been carefully applied in well selected patients. The accumulating data are suggesting its technical feasibility, safety, and potential equivalent long-term oncologic outcome. In this review, the current status of laparoscopic pancreaticoduodenectomy for pancreatic head cancer is summarized. In addition, potential surgical indications and future perspectives of laparoscopic pancreaticoduodenectomy for pancreatic cancer are discussed for safe implementation in our clinical practice.

Abstract

Margin-negative radical pancreatectomy is the essential condition to obtain long-term survival of patients with pancreatic cancer. With the investigation for early diagnosis, introduction of potent chemotherapeutic agents, application of neoadjuvnat chemotherapy, advancement of open and laparoscopic surgical techniques, mature perioperative management, and patients’ improved general conditions, survival of the resected pancreatic cancer is expected to be further improved. According to the literatures, laparoscopic pancreaticoduodenectomy (LPD) is also thought to be good alternative strategy in managing well-selected resectable pancreatic cancer. LPD with combined vascular resection is also feasible, but only expert surgeons should handle these challenging cases. LPD for pancreatic cancer should be determined based on surgeons’ proficiency to fulfil the goals of the patient’s safety and oncologic principles.

High-risk lesions in the remnant pancreas: fate of the remnant pancreas after pancreatic resection for pancreatic cancer and intraductal papillary mucinous neoplasms

Progress in diagnostic modalities, surgical procedures, and multidisciplinary treatment for pancreatic diseases has increased the number of long-term survivors after pancreatic resection. Several reports have focused on high-risk lesions (HRLs), including high-grade pancreatic intraepithelial neoplasia (PanIN), pancreatic ductal adenocarcinoma, high-grade intraductal papillary mucinous neoplasm (IPMN), and IPMN with an associated invasive carcinoma, in the remnant pancreas after partial pancreatic resection for pancreatic cancer or IPMN. The etiology of HRLs in the remnant pancreas is thought to be either isolated local recurrence of the initial lesion in the remnant pancreas or a newly developed primary lesion. Although it is difficult to distinguish between local recurrence and a new primary lesion, comparison of genetic alterations between two lesions may help with this distinction. Early detection of HRLs in the remnant pancreas may improve the prognosis of patients, and several investigators have proposed predictive factors for HRLs in the remnant pancreas after partial pancreatic resection for pancreatic cancer or IPMN. The reported short- and long-term outcomes of surgical resection of HRLs in the remnant pancreas are relatively favorable. Life-long surveillance of the remnant pancreas is recommended after partial pancreatic resection for pancreatic cancer or IPMN.

Pancreatic cancer arising from the remnant pancreas after pancreatectomy: a multicenter retrospective study by the Kyushu Study Group of Clinical Cancer

BACKGROUND

After initial pancreatic resection, local recurrence of pancreatic cancer (PC) or new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this retrospective study was to clarify the clinical features and establish a treatment strategy for remnant PC.

METHODS

A multicenter retrospective study with the Kyushu Study Group of Clinical Cancer was carried out. Clinical data from 50 patients who developed remnant PC were analyzed. RAS mutation analysis of the initial tumor and of remnant PC was performed in 17 cases.

RESULTS

The initial pancreatic resections were performed for 37 invasive ductal carcinomas, and for 13 other tumors. Thirty-seven patients underwent a second pancreatectomy for remnant PC (resected group), while thirteen patients were not operated (unresected group). The median overall survival times were 42.2 months in the resected group and 12.3 months in the unresected group (HR 0.374; 95% CI 0.17-0.83). In RAS mutation analysis, 14 cases had at least 1 missense variant of KRAS, HRAS, or NRAS in the initial pancreatic tumor and/or remnant PC. The same missense variants between the initial tumor and remnant PC were discovered only in KRAS of one patient, and in HRAS of one patient. No case had completely consistent missense variants between the initial tumor and remnant PC.

CONCLUSIONS

This study found that repeated pancreatectomy for remnant PC can prolong patient survival, and RAS mutation analysis indicated that many remnant PCs are developed from metachronous multifocal origins.

Integration of Genomic and Transcriptional Features in Pancreatic Cancer Reveals Increased Cell Cycle Progression in Metastases

We integrated clinical, genomic, and transcriptomic data from 224 primaries and 95 metastases from 289 patients to characterize progression of pancreatic ductal adenocarcinoma (PDAC). Driver gene alterations and mutational and expression-based signatures were preserved, with truncations, inversions, and translocations most conserved. Cell cycle progression (CCP) increased with sequential inactivation of tumor suppressors, yet remained higher in metastases, perhaps driven by cell cycle regulatory gene variants. Half of the cases were hypoxic by expression markers, overlapping with molecular subtypes. Paired tumor heterogeneity showed cancer cell migration by Halstedian progression. Multiple PDACs arising synchronously and metachronously in the same pancreas were actually intra-parenchymal metastases, not independent primary tumors. Established clinical co-variates dominated survival analyses, although CCP and hypoxia may inform clinical practice.