Time trends in the treatment and prognosis of resectable pancreatic cancer in a large tertiary referral centre

CA19-9 Level to Serum γ-Glutamyltransferase as a Potential Prognostic Biomarker in Patients with Pancreatic Head Carcinoma

Background

The aim of this study was to reduce the influence of biliary obstruction on carbohydrate antigen 19-9 level (CA19-9) by introducing the CA19-9 level to serum γ-glutamyltransferase (GGT) ratio as an indicator, and ultimately to reveal the correlation between CA19-9/GGT and the prognosis of patients with pancreatic head carcinoma (PHC).

Methods

A total of 339 enrolled patients who underwent pancreatoduodenectomy for PHC in Beijing ChaoYang Hospital from January 2010 to December 2019 were analyzed retrospectively. The optimal cut-off value, according to which patients were divided into a low-ratio group (Group 1, n=179) and a high-ratio group (Group 2, n=160), was determined by the ROC curve obtained from preoperative CA19-9/GGT and 1-year survival. Through univariate and multivariate analyses, risk factors for postoperative tumor recurrence and long-term survival were screened out among PHC patients.

Results

The best cut-off value of CA19-9/GGT was 2.07 (area under the curve=0.567, 95% CI 0.498-0.636). Compared with Group 2, Group 1 had lower CA19-9, and higher GGT, total bilirubin (TB) and lymph-node metastasis rate (P<0.05). The 1-, 2- and 3-year disease-free survival rates of patients in Groups 1 and 2 were 68.2%, 42.5% and 28.2%, and 42.2%, 19.3% and 18.3%, respectively (P=0.000), and the 1-, 2- and 3-year overall survival rates were 79.1%, 50.7% and 29.1%, and 56.7%, 22.2% and 17.2%, respectively (P=0.000). Multivariate analysis showed that CA19-9/GGT, portal system invasion and lymph-node metastasis were independent risk factors for postoperative tumor recurrence and long-term survival among patients with PHC.

Conclusion

Compared with CA19-9 level alone, CA19-9/GGT plays a more precise role in the evaluation of postoperative tumor recurrence and the long-term prognosis of PHC patients. The lower the ratio, the better the long-term prognosis. The CA19-9/GGT ratio may prove to be a useful biomarker for identifying PHC patients at high risk of early recurrence and unfavorable prognosis.

Ratio of CA19-9 level to total bilirubin as a novel prognostic indicator in patients with pancreatic head carcinoma following curative resection

Background

Ratio of carbohydrate antigen 19-9 level to total bilirubin (CA19-9/TB) is used to reduce the influence of obstructive jaundice on the concentration of CA19-9, thereby determining the correlation between CA19-9/TB and tumor recurrence or long-term prognosis of patients with pancreatic head cancer (PHC).

Methods

In this study, a total of 339 patients were enrolled. The optimal cut-off value of CA19-9/TB was determined by ROC curve based on preoperative CA19-9/TB and 1-year survival, and the patients were divided into low-ratio group (Group 1) and high-ratio group (Group 2) accordingly. Univariate and multivariate analyses were performed to screen out the risk factors affecting postoperative recurrence and long-term prognosis of PHC.

Results

The best cut-off value of CA19-9/TB was 7.7. [area under curve (AUC), 0.599, 95% CI: 0.533-0.666] Compared with Group 1, Group 2 had lower CA19-9, higher TB and lymph node metastasis rate (P<0.05). The 1-, 2- and 3-year disease-free survival (DFS) rates of patients in Group 1 and Group 2 were 70.1%, 44.3% and 30.8%, 39.9%, 17.1% and 13.6%, respectively (P=0.000), and the 1-, 2- and 3-year overall survival (OS) rates were 81.5%, 52.1% and 31.5%, 53.7%, 20.5% and 14.2%, respectively (P=0.000). Multivariate analysis showed that CA19-9/TB, portal vein invasion and lymph node metastasis were independent risk factors for postoperative tumor recurrence and long-term survival of PHC.

Conclusions

Compared with CA19-9 alone, CA19-9/TB is more valuable in judging postoperative tumor recurrence and long-term survival of PHC. The lower the ratio, the better the long-term prognosis.

Chemopreventive Agents After Pancreatic Resection for Ductal Adenocarcinoma: Legend or Scientific Evidence?

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is currently the fourth leading cause of cancer-related death in the USA. A wealth of evidence has demonstrated the chemopreventive activity of aspirin, statins, and metformin against PDAC. The aim of this study is to investigate the effect of aspirin, statins, and metformin on disease-free survival (DFS) and disease-specific survival (DSS) in a large population of PDAC patients undergoing pancreatic resection.

PATIENTS AND METHODS

All patients who underwent pancreatic resections between January 2015 and September 2018 were retrospectively reviewed. The potentially "chemopreventive agents" considered for the analysis were aspirin, statins, and metformin. Drug use was defined in case of regular assumption at least 6 months before diagnosis and regularly after surgery along the follow-up period.

RESULTS

A total of 430 patients were enrolled in this study, with median DFS and DSS of 21 months (IQR 13-30) months and 34 (IQR 26-52) months, respectively. On multivariable analysis, use of aspirin was associated with better DFS (HR: 0.62; p = 0.038). Metformin was associated with better DFS, without reaching statistical significance (p = 0.083). Use of statins did not influence DFS in the studied population. Aspirin, metformin, and statins were not associated with better DSS on multivariable analysis. Factors influencing DSS were pT3/pT4, N1, N2, no adjuvant treatment, G3, and ASA score > 3.

CONCLUSIONS

The results suggest that chronic use of aspirin is associated with increased DFS but not with better DSS after surgical resection in patients with PDAC.

Preoperative Clinical and Computed Tomography (CT)-Based Nomogram to Predict Oncologic Outcomes in Patients with Pancreatic Head Cancer Resected with Curative Intent: A Retrospective Study

Background: Currently, proposed nomograms are mainly based on post-operative histopathology. The purpose of this study was to identify preoperative computed tomography (CT) and clinical information that allow prediction of disease-free (DFS) and overall survival (OS) of patients surgically treated for pancreatic head cancer. Methods: A total of 136 patients who underwent curative-intent surgery were retrospectively reviewed. Based on results from multivariate Cox regression analysis, a prediction model was constructed with preoperative CT features and clinical information. Overall performance of the nomogram was calculated by Harrell’s C-index. Results: Symptoms at diagnosis, preoperative serum CA 19-9 ≥ 34 U/mL, and four imaging features (necrosis (DFS, P = 0.066; OS, P = 0.002), possible venous invasion (DFS, P = 0.150, OS, P = 0.055), suspected metastatic regional lymph node (DFS, P = 0.001; OS, P = 0.099), and associated pancreatitis or pseudocyst (DFS, P = 0.013; OS, P = 0.041)) were included to build the nomogram. The c-statistics for the discrimination power of the proposed nomogram was 0.6496 for DFS and 0.6746 for OS. Conclusion: A nomogram derived from preoperative CT and clinical information could estimate the risk of recurrence and all-cause death after curative-intent surgery for radiologically resectable pancreatic head cancer.

R0 Versus R1 Resection Matters after Pancreaticoduodenectomy, and Less after Distal or Total Pancreatectomy for Pancreatic Cancer

OBJECTIVE

The aim of this study was to decipher the true importance of R0 versus R1 resection for survival in pancreatic ductal adenocarcinoma (PDAC).

SUMMARY OF BACKGROUND DATA

PDAC is characterized by poor survival, even after curative resection. In many studies, R0 versus R1 does not result in different prognosis and does not affect the postoperative management.

METHODS

Pubmed, Embase, and Cochrane databases were screened for prognostic studies on the association between resection status and survival. Hazard ratios (HRs) were pooled in a meta-analysis. Furthermore, our prospective database was retrospectively screened for curative PDAC resections according to inclusion criteria (n = 254 patients) between July 2007 and October 2014.

RESULTS

In the meta-analysis, R1 was associated with a decreased overall survival [HR 1.45 (95% confidence interval, 95% CI 1.37-1.52)] and disease-free survival [HR 1.44 (1.30-1.59)] in PDAC when compared with R0. Importantly, this effect held true only for pancreatic head resection both in the meta-analysis [R0 ≥0 mm: HR 1.21 (1.05-1.39) vs R0 ≥1 mm: HR 1.66 (1.46-1.89)] and in our cohort (R0 ≥0 mm: 31.8 vs 14.5 months, P < 0.001; R0 ≥1 mm, 41.2 vs 16.8 months; P < 0.001). Moreover, R1 resections were associated with advanced tumor disease, that is, larger tumor size, lymph node metastases, and extended resections. Multivariable Cox proportional hazard model suggested G3, pN1, tumor size, and R1 (0 mm/1 mm) as independent predictors of overall survival.

CONCLUSION

Resection margin is not a valid prognostic marker in publications before 2010 due to heterogeneity of cohorts and lack of standardized histopathological examination. Within standardized pathology protocols, R-status' prognostic validity may be primarily confined to pancreatic head cancers.

Pancreatectomy combined with multivisceral resection for pancreatic malignancies: is it justified? Results of a systematic review

BACKGROUND

Multivisceral resections combined with pancreatectomy have been proposed in selected patients with tumor invasion into adjacent organs, in order to allow complete tumor resection. Some authors have also reported multivisceral resection combined with metastasectomy in very selected cases. The utility of this practice is debated. The aim of the review is to compare the postoperative results and survival of pancreatectomies combined with multivisceral resections with those of standard pancreatectomies.

METHODS

A systematic literature search was performed to identify all studies published up to February 2017 that analyzed data of patients undergoing multivisceral and standard pancreatectomies. Clinical effectiveness was synthetized through a narrative review with full tabulation of results.

RESULTS

Three studies were retrieved, including 713 (80%) patients undergoing standard pancreatectomies and 176 (20%) undergoing multivisceral resections (MVR). Postoperative morbidity ranged from 37% to 50% after standard resections and from 56% to 69% after MVR. In-hospital mortality ranged from 4% after standard pancreatectomies to 10% after MVR. Median survival ranged from 20 to 23 months in standard resections and from 12 to 20 months after MVR, without significant differences.

DISCUSSION

The current literature suggests that multivisceral pancreatectomies are feasible and may increase the number of completely resected patients. Morbidity and mortality are higher than after standard pancreatectomies, and these procedures should be reserved to selected patients in referral centers. Further studies on the role of neoadjuvant therapy in this setting are advisable.

Multimodal treatment of resectable pancreatic ductal adenocarcinoma

After a timing preoperative staging, treatment of resectable pancreatic adenocarcinoma (PDAC) includes surgery and adjuvant therapies, the former representing the initial therapeutic option and the latter aiming to reduce the incidence of both distant metastases (chemotherapy) and locoregional failures (chemoradiotherapy). Herein, we provide a critical overview on the role of multimodal treatment in PDAC and on new opportunities related to current more active poli-chemotherapy regimens, targeted therapies, and the more recent immunotherapy approaches. Moreover, an analysis of pathological markers and clinical features able to help clinicians in the selection of the best therapeutic strategy will be discussed. Lastly, the role of neoadjuvant treatment of initially resectable disease will be considered mostly in patients whose malignancy shows morphological but not clinical or biological criteria of resectability. Depending on the results of these investigational studies, today a multidisciplinary approach can offer the best address therapy for these patients.

Clinical Impact of Structured Follow-up After Pancreatic Surgery

OBJECTIVES

Structured follow-up after surgery for pancreatic ductal adenocarcinoma (PDAC) remains controversial and is currently not recommended due to a supposed lack of therapeutic consequences. Furthermore, it is not clear whether noncancer patients after pancreas resection need to be seen in the clinic on a regular basis. The present study analyzed how follow-up after pancreatic surgery affected postoperative treatment and long-term outcomes.

METHODS

Data of all postoperative visits in a specialized outpatient clinic for pancreatic diseases were analyzed for a 1-year period with regard to symptoms, diagnostic procedures, and therapeutic consequences.

RESULTS

Six hundred eighteen patients underwent 940 postoperative follow-ups. Nearly half of them needed a change of medication due to altered pancreatic function. In 74 (40%) of 184 resected PDAC patients, recurrence (local or systemic) was detected during follow-up, although only 19 of these had shown associated symptoms (26%). In all patients with recurrence, a cancer-directed treatment was induced. Eleven (69%) of 16 patients with isolated local recurrence were referred for reresection.

CONCLUSIONS

Follow-up examinations are a substantial part of the clinical management after pancreas resections. Follow-up is particularly important for PDAC because recurrence is often asymptomatic, but its detection allows for therapeutic interventions and potentially improved prognosis. This should be implemented in future guidelines.

Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is increasingly common and a leading cause of cancer-related mortality. Surgery remains the only possibility for cure. Upwards of 40% of patients present with locally advanced PDAC (LA-PDAC), where management strategies continue to evolve. In this review, we highlight current trends in neoadjuvant chemotherapy, surgical resection, and other multimodality approaches for patients with LA-PDAC. Despite promising early results, additional work is needed to more accurately and appropriately tailor treatment for patients with LA-PDAC.

The association of adjuvant therapy with survival at the population level following pancreatic adenocarcinoma resection

BACKGROUND

Using a retrospective observational cohort approach, the overall survival (OS) following curative-intent resection of pancreatic adenocarcinoma (PC) was defined at the population level according to adjuvant treatment, and predictors of OS were identified.

METHODS

Patients undergoing resection of PC in the province of Ontario between 2005 and 2010 were identified using the provincial cancer registry, and linked to databases that include all treatments received and outcomes experienced in the province. Pathology reports were abstracted for staging and margin status. Patients were identified as having received chemotherapy (CT), chemoradiation therapy (CRT), or no adjuvant treatment (NAT). Kaplan-Meier survival analysis of patients surviving ≥ 6 months was performed, and predictors of OS identified by log-rank test. Cox multivariable analysis was used to define independent predictors of OS.

RESULTS

Among the 473 patients undergoing PC resection, the median survival was 17.8 months; for the 397 who survived ≥ 6 months following surgery, the 5-year OS for the CT, CRT, and NAT groups was 21%, 16%, and 17%, respectively (p = 0.584). Lymph node-negative patients demonstrated improved OS associated with chemotherapy on multivariable analysis (HR = 2.20, 95% CI = 1.25-3.83 for NAT vs. CT).

CONCLUSIONS

Following PC resection, only patients with negative lymph nodes demonstrated improved OS associated with adjuvant chemotherapy.

Selection criteria in resectable pancreatic cancer: A biological and morphological approach

Pancreatic ductal adenocarcinoma (PDA) remains one of the most aggressive tumors with a low rate of survival. Surgery is the only curative treatment for PDA, although only 20% of patients are resectable at diagnosis. During the last decade there was an improvement in survival in patients affected by PDA, possibly explained by the advances in cancer therapy and by improve patient selection by pancreatic surgeons. It is necessary to select patients not only on the basis of surgical resectability, but also on the basis of the biological nature of the tumor. Specific preoperative criteria can be identified in order to select patients who will benefit from surgical resection. Duration of symptoms and level of carbohydrate antigen 19.9 in resectable disease should be considered to avoid R1 resection and early relapse. Radiological assessment can help surgeons to distinguish resectable disease from borderline resectable disease and locally advanced pancreatic cancer. Better patient selection can increase survival rate and neoadjuvant treatment can help surgeons select patients who will benefit from surgery.