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Funo T, Hashimoto D, Yamaki S, Matsumura K, Miyazaki H, Matsui Y, Tsybulskyi D, Sang NT, Yaolin X, Satoi S. Conversion surgery for BRCA-mutated pancreatic ductal adenocarcinoma with liver metastasis treated with platinum-based chemotherapy followed by olaparib. Surg Case Rep 2024; 10:179. [PMID: 39078424 PMCID: PMC11289193 DOI: 10.1186/s40792-024-01975-x] [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: 05/20/2024] [Accepted: 07/13/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND With recent dramatic developments in chemotherapy, attempts to incorporate surgery into the multidisciplinary treatment of unresectable pancreatic ductal adenocarcinoma with metastasis (UR-M PDAC) have emerged. Maintenance therapy with olaparib after chemotherapy including a platinum-based regimen, which inhibits the poly ADP-ribose polymerase (PARP) involved in DNA repair, was approved for UR-M PDAC with positive BRCA mutations. CASE PRESENTATION A 47-year-old male patient with a high carbohydrate antigen 19-9 (CA19-9) level was diagnosed with PDAC in the pancreatic tail. Staging laparoscopy revealed occult liver metastasis. Because BRCA2 mutation was confirmed, triple combination chemotherapy with SOXIRI (S-1/oxaliplatin/irinotecan) was introduced and continued for 16 weeks, followed by 14 weeks of olaparib. After that, CA19-9 was normalized, and no obvious liver metastases of any size could be seen on imaging studies during chemotherapy. Since staging laparoscopy after chemotherapy proved that the liver metastasis had disappeared, laparoscopic distal pancreatectomy was performed, and curative resection was completed. After adjuvant chemotherapy with olaparib for 12 months, the patient is alive 36 months from his initial diagnosis and 27 months postoperatively without recurrence. CONCLUSION We report a case of PDAC with liver metastasis and BRCA mutation-positivity who underwent conversion surgery and achieved long-term survival after irinotecan-based chemotherapy followed by maintenance therapy with olaparib.
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Affiliation(s)
- Takumi Funo
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Daisuke Hashimoto
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Kazuki Matsumura
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Hidetaka Miyazaki
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Yuki Matsui
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Denys Tsybulskyi
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Nguyen Thanh Sang
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Xu Yaolin
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata City, Osaka, 573-1010, Japan.
- Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Koti S, Demyan L, Deutsch G, Weiss M. Surgery for Oligometastatic Pancreatic Cancer: Defining Biologic Resectability. Ann Surg Oncol 2024; 31:4031-4041. [PMID: 38502293 PMCID: PMC11076395 DOI: 10.1245/s10434-024-15129-8] [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: 12/14/2023] [Accepted: 02/17/2024] [Indexed: 03/21/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is most often metastatic at diagnosis. As systemic therapy continues to improve alongside advanced surgical techniques, the focus has shifted toward defining biologic, rather than technical, resectability. Several centers have reported metastasectomy for oligometastatic PDAC, yet the indications and potential benefits remain unclear. In this review, we attempt to define oligometastatic disease in PDAC and to explore the rationale for metastasectomy. We evaluate the existing evidence for metastasectomy in liver, peritoneum, and lung individually, assessing the safety and oncologic outcomes for each. Furthermore, we explore contemporary biomarkers of biological resectability in oligometastatic PDAC, including radiographic findings, biochemical markers (such as CA 19-9 and CEA), inflammatory markers (including neutrophil-to-lymphocyte ratio, C-reactive protein, and scoring indices), and liquid biopsy techniques. With careful consideration of existing data, we explore the concept of biologic resectability in guiding patient selection for metastasectomy in PDAC.
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Affiliation(s)
- Shruti Koti
- Department of General Surgery, Northwell Health, Queens, NY, USA.
- Northwell Health Cancer Institute, Northwell Health, New Hyde Park, NY, USA.
| | - Lyudmyla Demyan
- Department of General Surgery, Northwell Health, Queens, NY, USA
| | - Gary Deutsch
- Northwell Health Cancer Institute, Northwell Health, New Hyde Park, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Matthew Weiss
- Northwell Health Cancer Institute, Northwell Health, New Hyde Park, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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3
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Giuliante F, Panettieri E, Campisi A, Coppola A, Vellone M, De Rose AM, Ardito F. Treatment of oligo-metastatic pancreatic ductal adenocarcinoma to the liver: is there a role for surgery? A narrative review. Int J Surg 2024; 110:01279778-990000000-01599. [PMID: 38818688 DOI: 10.1097/js9.0000000000001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 05/09/2024] [Indexed: 06/01/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a prognostically unfavorable malignancy that presents with distant metastases at the time of diagnosis in half of patients. Even if patients with metastatic PDAC have not been traditionally considered candidates for surgery, an increasing number of researchers have been investigating the efficacy of surgical treatment for patients with liver-only oligometastases from PDAC, showing promising results in extremely selected patients, mainly with metachronous metastases after perioperative chemotherapy. Nevertheless, a standardized definition of oligometastatic disease should be adopted and additional investigations focusing on the role of perioperative chemotherapy and tumor biology are warranted to reliably assess the role of resection for PDAC metastatic to the liver.
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Affiliation(s)
- Felice Giuliante
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elena Panettieri
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Campisi
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Maria Vellone
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
| | - Agostino M De Rose
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli "IRCCS", Università Cattolica del Sacro Cuore, Rome, Italy
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4
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Irfan A, Feng W, McElroy K, Dudeja V, Reddy S, Rose JB. What would you do? A survey of HPB surgeons practice patterns. HPB (Oxford) 2024; 26:436-443. [PMID: 38143165 DOI: 10.1016/j.hpb.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND The surgical decision making for pancreatic adenocarcinoma is complex. Although practice guidelines exist for many scenarios, these do not cover many common eventualities that may be encountered during these cases. We sought to identify the practice pattern variations amongst pancreatic surgeons in response to commonly experienced clinical scenarios. METHODS A multiple-choice questionnaire was distributed to all full members of the IHPBA. Participant demographics, training history, and clinical practice information were obtained. The survey provided various operative scenarios and participants were asked how they would likely proceed. Responses were collected and stored anonymously in a secure database. Statistical analysis was performed using Stata 16.0. RESULTS 164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40-50 years old. When asked about staging laparoscopy, the majority performed it selectively. For most respondents a pathological aorto-caval nodes was a reason to abort the procedure but most would have continued in the setting of a positive hepatic artery node. When encountering a single Segment 2 liver metastasis, participants who practiced in Europe were significantly more likely to resect and proceed compared to those in Asia and North America. Participants who had undergone only a Surgical Oncology fellowship were most likely to abort. With respect to direct colonic invasion, most participants would resect the specimen en bloc. Respondents who participated in fewer that 20 PDAC operations/year were most likely to abort. CONCLUSIONS Surgical decision making in PDAC surgery is complex and there is significant disagreement on the correct management. While formal guidelines cannot exist for all situations, this survey highlights the need for consensus on commonly encountered operative scenarios.
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Affiliation(s)
- Ahmer Irfan
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Wendy Feng
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Katherine McElroy
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sushanth Reddy
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Bart Rose
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Wang LT, Yang J, Wu J, Lu WJ. Combined Therapy of Chemotherapy and Radiofrequency Ablation for Pancreatic Cancer Patients With Metachronous Hepatic Metastatic Lesions After Radical Pancreatic Resection. Cancer Control 2024; 31:10732748241274559. [PMID: 39150275 PMCID: PMC11329956 DOI: 10.1177/10732748241274559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/09/2024] [Accepted: 07/22/2024] [Indexed: 08/17/2024] Open
Abstract
PURPOSE Hepatic metastasis frequently occurs in patients who have undergone radical pancreatic resection for pancreatic cancer. Besides chemotherapy, various local treatment approaches targeting hepatic lesions have been explored. However, research on radiofrequency ablation (RFA) as a localized therapy for hepatic metastasis is limited. Therefore, we conducted this retrospective study to provide clinical evidence. METHODS This is a single-center, retrospective, cohort study. After radical pancreaticoduodenectomy, 32 patients developed metachronous hepatic metastasis with fewer than 3 lesions, the largest of which was less than 3 cm in diameter. These patients underwent combined treatment with chemotherapy and RFA. After 8 weeks of chemotherapy, patients received RFA for hepatic lesions. Additional chemotherapy was administered, and the patients' tumor status and survival were monitored. The primary endpoint of this study was overall survival (OS). Factors affecting OS were analyzed using the Cox risk model. RESULTS Among the 32 patients, the mean OS was 28.4 months. Univariate and multivariate Cox regression analysis revealed that the time (in months) of liver metastasis (HR = 0.04, 95% CI: 0.01 to 0.19; P < 0.001), the number of liver metastases (HR = 7.08, 95% CI: 1.85 to 27.08, P = 0.004), and PD (progressive disease) response to the second round of chemotherapy (HR = 29.50, 95% CI: 1.46 to 597.27; P = 0.027) were independent predictors of poorer survival. CONCLUSION Combined therapy with RFA and chemotherapy is safe in patients with hepatic metastasis after radical pancreaticoduodenectomy. Early recurrence (≤12 months), three liver metastatic lesions, and a poor response to the second round of chemotherapy were associated with poor survival.
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Affiliation(s)
- L. T. Wang
- Department of Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - J. Yang
- Department of Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - J. Wu
- Department of Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - W. J. Lu
- Department of Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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6
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Kong Q, Teng F, Li H, Chen Z. Radical resection benefits patients suffering pancreatic ductal adenocarcinoma with liver oligometastases. Ann Surg Treat Res 2024; 106:51-60. [PMID: 38205094 PMCID: PMC10774701 DOI: 10.4174/astr.2024.106.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/16/2023] [Accepted: 11/15/2023] [Indexed: 01/12/2024] Open
Abstract
Purpose Whether patients suffering liver oligometastases from pancreatic ductal adenocarcinoma (LOPDA) should undergo surgical treatment remains controversial. Methods PubMed and Embase databases were systematically reviewed until 2023 June. Survival data were collected from the Kaplan-Meier curves. Safety and survival were evaluated using primary outcomes such as 1-year, 3-year, and 5-year survival rates, and 30-day mortality and morbidity. A subgroup meta-analysis was conducted to compare survival rates post-synchronous resection and resection post-neoadjuvant chemotherapy in LOPDA. Results Our analysis of 15 studies involving 1,818 patients (surgical group, 648 and nonsurgical group, 1,170) indicates that radical hepatectomy for LOPDA notably improved 1-year (odds ratio [OR], 3.24; 95% confidence interval [CI], 2.45-4.28; P < 0.001), 3-year (OR, 5.74; 95% CI, 3.36-8.90; P < 0.001), and 5-year (OR, 4.89; 95% CI, 2.56-9.35; P < 0.001) overall survival (OS) rates. A separate analysis of 6 studies with 750 patients demonstrated the safety of LOPDA surgery, with no increase in postoperative complications (P = 0.26 for overall morbidity and P = 0.99 for mortality) compared to the patients with no metastatic disease from the pancreatic ductal adenocarcinoma (NMPDA) group. The NMPDA group showed superior 1-year and 3-year OS rates, but not 5-year OS rates compared to the LOPDA group. Conclusion Surgical treatment apparently offers a survival advantage to LOPDA by comparing with nonsurgical groups in 1-, 3-, and 5-year OS rates. Radical resection for LOPDA is a safe treatment without more postoperative complications than NMPDA.
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Affiliation(s)
- Qingyan Kong
- Division of Hepatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Teng
- Division of Hepatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hang Li
- Division of Hepatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zheyu Chen
- Division of Hepatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
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7
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Leonhardt CS, Stamm T, Hank T, Prager G, Strobel O. Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus. ESMO Open 2023; 8:102067. [PMID: 37988953 PMCID: PMC10774968 DOI: 10.1016/j.esmoop.2023.102067] [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: 08/05/2023] [Accepted: 10/14/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Small retrospective series suggest that local consolidative treatment (LCT) may improve survival in oligometastatic pancreatic ductal adenocarcinoma (PDAC). However, no uniform definition of oligometastatic disease (OMD) in PDAC exists; this impedes meaningful conclusions. PATIENTS AND METHODS A systematic literature search using PubMed, Web of Science, and Cochrane CENTRAL registries for studies and protocols reporting on definitions and/or LCT of OMD in PDAC was performed. The primary endpoint was the definition of OMD. Levels of agreement were categorized as consensus (≥75% agreement between studies), fair agreement (50%-74%), and absent/poor agreement (<50%). RESULTS After screening of 5374 abstracts, the full text of 218 studies was assessed, of which 76 were included in the qualitative synthesis. The majority of studies were retrospective (n = 66, 87%), two were prospective studies and eight were study protocols. Studies investigated mostly liver (n = 38, 51%) and lung metastases (n = 15, 20%). Across studies, less than one-half (n = 32, 42%) reported a definition of OMD, while 44 (58%) did not. Involvement was limited to a single organ (consensus). Additional criteria for defining OMD were the number of lesions (consensus), metastatic site (poor agreement), metastatic size (poor agreement), treatment possibilities (poor agreement), and biomarker response (poor agreement). Liver OMD could involve three or fewer lesions (consensus) and synchronous disease (fair agreement), while lung metastases could involve two or fewer lesions and metachronous disease (consensus). The large majority of studies were at a high risk of bias or did not include any control groups. CONCLUSION Definitions of OMD were not used or varied widely between studies hampering across-study comparability and highlighting an unmet need for a consensus. The present study is part of a multistep process that aims to develop an interdisciplinary consensus on OMD in pancreatic cancer.
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Affiliation(s)
- C-S Leonhardt
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna
| | - T Stamm
- Institute of Outcomes Research, Center for Medical Data Science, Medical University of Vienna; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna
| | - T Hank
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna
| | - G Prager
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - O Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna.
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8
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Hashimoto D, Satoi S, Fujii T, Sho M, He J, Hackert T, Del Chiaro M, Jang JY, Gulla A, Yoon YS, Shan YS, Lou W, Valente R, Furuse J, Oba A, Nagai M, Terai T, Tanaka H, Sakai A, Yamamoto T, Yamaki S, Matsumoto I, Murakami Y, Takaori K, Takeyama Y. Is surgical resection justified for pancreatic ductal adenocarcinoma with distant abdominal organ metastasis? A position paper by experts in pancreatic surgery at the Joint Meeting of the International Association of Pancreatology (IAP) & the Japan Pancreas Society (JPS) 2022 in Kyoto. Pancreatology 2023; 23:682-688. [PMID: 37507301 DOI: 10.1016/j.pan.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/09/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a typical refractory malignancy, and many patients have distant organ metastases at diagnosis, such as liver metastasis and peritoneal dissemination. The standard treatment for unresectable PDAC with distant organ metastasis (UR-M) is chemotherapy, but the prognosis remained poor. However, with recent dramatic developments in chemotherapy, the prognosis has gradually improved, and some patients have experienced marked shrinkage or disappearance of their metastatic lesions. With this trend, attempts have been made to resect a small number of metastases (so-called oligometastases) in combination with the primary tumor or to resect the primary and metastatic tumor in patients with a favorable response to anti-cancer treatment after a certain period of time (so-called conversion surgery). An international consensus meeting on surgical treatment for UR-M PDAC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of the Japan Pancreas Society (JPS) in Kyoto in July 2022. The presenters showed their indications for and results of surgical treatment for UR-M PDAC and discussed their advantages and disadvantages with the experts. Although these reports were limited to a small number of patients, findings suggest that these surgical treatments for patients with UR-M PDAC who have had a significant response to chemotherapy may contribute to a prognosis of prolonged survival. We hope that this article summarizing the discussion and agreements at the meeting will serve as the basis for future trials and guidelines.
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Affiliation(s)
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Aiste Gulla
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yan-Shen Shan
- Department of Surgery, National Cheng Kung University Hospital, Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wenhui Lou
- Department of General Surgery, Fudan University Zhongshan Hospital, Shanghai, China
| | - Roberto Valente
- Department of Surgical and Perioperative Sciences, Umea University, Umea, Sweden
| | - Junji Furuse
- Department of Gastroenterology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Haruyoshi Tanaka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Ayano Sakai
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | | | - So Yamaki
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Surgery, Nagahama City Hospital, Shiga, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
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9
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Nagai M, Wright MJ, Ding D, Thompson ED, Javed AA, Weiss MJ, Hruban RH, Yu J, Burkhart RA, He J, Cameron JL, Wolfgang CL, Burns WR. Oncologic resection of pancreatic cancer with isolated liver metastasis: Favorable outcomes in select patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1025-1035. [PMID: 36652559 PMCID: PMC10548446 DOI: 10.1002/jhbp.1303] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/23/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with pancreatic ductal adenocarcinoma (PDAC) and liver metastasis are treated with palliative chemotherapy, whereas similar patients with metastatic colorectal cancer are considered for aggressive surgery. METHODS Using an institutional database, PDAC patients undergoing liver resection for isolated metastasis were identified. Their overall survival (OS), treatment factors, and clinicopathological variables associated with survival were also evaluated. RESULTS Forty-seven patients underwent curative-intent surgery for metastatic PDAC to the liver between 2000 and 2019. Median OS was 21.9 months from diagnosis. Fourteen patients underwent unplanned resection of radiographically occult liver metastasis during pancreatectomy with median OS of 8.7 months. On the other hand, 29 patients received systemic chemotherapy followed by planned resection; this cohort had the most favorable prognosis following aggressive surgery with median OS being 38.1 months from diagnosis and 24.1 months from surgery. Preoperative chemotherapy (HR = 7.1; p = .002) and moderate to well differentiation of the primary tumor (HR = 3.7; p = .003) were associated with prolonged survival in multivariate analysis, whereas lymph node metastases, response to preoperative therapy, number of liver metastasis, and extent of liver surgery were not. CONCLUSIONS In select patients with PDAC and isolated liver metastasis, curative-intent surgery can result in meaningful survival. This aggressive approach seems most beneficial in patients following induction chemotherapy.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Michael J. Wright
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth D. Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ammar A. Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew J. Weiss
- Department of Hepatobiliary Surgery, Pancreas, Oncology, Northwell Health Cancer Institute, New Hyde Park, New York, USA
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard A. Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John L. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher L. Wolfgang
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Medical Center, New York, New York, USA
| | - William R. Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Halle-Smith JM, Powell-Brett S, Roberts K, Chatzizacharias NA. Resection of isolated liver oligometastatic disease in pancreatic ductal adenocarcinoma: Is there a survival benefit? A systematic review. World J Gastrointest Surg 2023; 15:1512-1521. [PMID: 37555114 PMCID: PMC10405113 DOI: 10.4240/wjgs.v15.i7.1512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/22/2023] [Accepted: 05/05/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Presence of liver metastatic disease in pancreatic ductal adenocarcinoma (PDAC), either synchronous or metachronous after pancreatic resection, is a terminal diagnosis that warrants management with palliative intent as per all international practice guidelines. However, there is an increasing interest on any potential value of surgical treatment of isolated oligometastatic disease in selected cases. AIM To present the published evidence on surgical management of PDAC liver metastases, synchronous and metachronous, and compare the outcomes of these treatments to the current standard of care. METHODS A systematic review was performed in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to compare the outcomes of both synchronous and metachronous liver metastases resection to standard care. RESULTS 356 studies were identified, 31 studies underwent full-text review and of these 10 were suitable for inclusion. When synchronous resection of liver metastases was compared to standard care, most studies did not demonstrate a survival benefit with the exception of one study that utilised neoadjuvant treatment. However, resection of metachronous disease appeared to confer a survival advantage when compared to treatment with chemotherapy alone. CONCLUSION A survival benefit may exist in resection of selected cases of metachronous liver oligometastatic PDAC disease, after disease biology has been tested with time and systemic treatment. Any survival benefit is less clear in synchronous cases; however an approach with neoadjuvant treatment and consideration of resection in some selected cases may confer some benefit. Future studies should focus on pathways for selection of cases that may benefit from an aggressive approach.
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Affiliation(s)
- James M Halle-Smith
- Department of HPB and Liver Transplant, Queen Elizabeth Hospital, University of Birmingham, Birmingham B15 2GW, United Kingdom
| | - Sarah Powell-Brett
- Department of HPB and Liver Transplant, Queen Elizabeth Hospital, University of Birmingham, Birmingham B15 2GW, United Kingdom
| | - Keith Roberts
- Department of HPB and Liver Transplant, Queen Elizabeth Hospital, University of Birmingham, Birmingham B15 2GW, United Kingdom
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplant, Queen Elizabeth Hospital, University of Birmingham, Birmingham B15 2GW, United Kingdom
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11
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Lu W, Wang L, Lou J, Tang K. Sequential therapy for pancreatic cancer patients with synchronous oligo-hepatic metastatic lesions. TUMORI JOURNAL 2023; 109:307-313. [PMID: 35815545 DOI: 10.1177/03008916221110265] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatments for patients suffering from pancreatic cancer with oligo-hepatic metastasis have always been a cause of certain controversy. Herein, we reported 15 pancreatic cancer patients with oligo-hepatic metastasis who accepted sequential therapy of chemotherapy, radiofrequency ablation (RFA), and radical resection of the primary tumor. METHODS A total of 87 pancreatic cancer patients with synchronous oligo-metastatic hepatic lesions who received treatments in the 2nd Affiliated Hospital of Zhejiang University between January 2017 and July 2020 were enrolled. The chemotherapy regimens included modified folfirinox (54/87) and gemcitabine plus nab-paclitaxel (33/87). Test of blood tumor markers and contrast-enhanced computed tomography (CT) or magnetic resonance (MR) scan was performed at diagnosis and after eight weeks of chemotherapy. RESULTS Thirty-five patients received just chemotherapy because of poor reaction to the first round of chemotherapy(Overall survival (OS), 6.47±1.80 months); 15 patients reassessed as stable disease (SD)/partial response (PR) continued chemotherapy (OS, 10.35±3.15); nine patients reassessed as progressive disease (PD) after RFA and continued chemotherapy (OS, 10.90±2.60). The primary tumors in 13 patients were unresectable after chemotherapy and RFA (OS, 12.92±2.47), while 15 patients completed the sequential therapy of chemotherapy, radio-frequency ablation, and radical resection (OS, 16.76±6.55). CONCLUSIONS Sequential chemotherapy and RFA is a good treatment strategy to select the best candidates for surgical treatment among patients with pancreatic cancer with oligo-hepatic metastasis.
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Affiliation(s)
- Wenjie Lu
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lantian Wang
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianyao Lou
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kezhong Tang
- Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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12
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Yasuda S, Nagai M, Terai T, Kohara Y, Sho M. Essential updates 2021/2022: Surgical outcomes of oligometastasis in pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2023; 7:358-366. [PMID: 37152775 PMCID: PMC10154895 DOI: 10.1002/ags3.12655] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/25/2022] [Accepted: 01/01/2023] [Indexed: 01/20/2023] Open
Abstract
Oligometastatic disease has been proposed as an intermediate state between localized and polymetastatic disease that can benefit from multimodal treatment, including surgery. There is a growing concern about performing surgery for oligometastatic pancreatic ductal adenocarcinoma, although there is still little evidence. We reviewed articles published between 2021 and 2022, focusing mainly on surgical outcomes. Furthermore, we summarized the current status of surgery in the multidisciplinary treatment of oligometastatic pancreatic cancer and discuss future perspectives. In liver oligometastasis, multimodal treatment including surgery achieved favorable long-term survival, especially in patients with good responses to preoperative chemotherapy, with a median survival time from 25.5 to 54.6 months. In addition, the data from the National Cancer Database in the United States showed that patients who underwent surgery for oligometastatic liver metastases had a significantly longer overall survival than those who received chemotherapy alone. Prognostic biomarkers were identified, including carbohydrate antigen 19-9 (CA19-9) levels at diagnosis and preoperative chemotherapy with normalization of CA19-9 levels or favorable radiological response. Patients with lung oligometastasis had a more favorable long-term prognosis than those with other recurrence sites, and the updated literature further confirmed the previous studies. Overall survival was favorable, with 84 months after initial surgery and 29.2 months after metastasectomy, and a 5-year survival rate of 60.6% was also reported. In peritoneal oligometastasis, the results of conversion surgery after good responses to preoperative treatment with intraperitoneal therapy or systematic chemotherapy were reported, and the conversion rate and long-term prognosis were favorable. There is a growing concern about performing surgery for oligometastatic pancreatic ductal adenocarcinoma. We reviewed articles published between 2021 and 2022, focusing mainly on surgical outcomes. Furthermore, we summarize the current status of surgery in multidisciplinary treatment of oligometastatic pancreatic cancer and discuss future perspectives.
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Affiliation(s)
| | - Minako Nagai
- Department of SurgeryNara Medical UniversityNaraJapan
| | - Taichi Terai
- Department of SurgeryNara Medical UniversityNaraJapan
| | | | - Masayuki Sho
- Department of SurgeryNara Medical UniversityNaraJapan
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13
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Grotz TE, Yonkus JA, Thiels CA, Warner SG, McWilliams RR, Mahipal A, Bekaii-Saab TS, Cleary SP, Kendrick ML, Truty MJ. Cytoreduction with Hyperthermic Intraperitoneal Chemoperfusion for Pancreatic Cancer with Low-Volume Peritoneal Metastasis: Results from a Prospective Pilot Study. Ann Surg Oncol 2023; 30:395-403. [PMID: 35972667 DOI: 10.1245/s10434-022-12328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/12/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Resection of oligometastatic pancreatic ductal adenocarcinoma (PDAC) has historically been ineffective, however modern systemic chemotherapy has improved survival. Thus, re-evaluating safety and outcomes of surgical resection in selected patients with limited peritoneal metastasis (PM) warrants consideration. METHODS From 2018 to 2021, patients with PDAC and positive cytology or limited PM without extraperitoneal metastasis and who had an objective response to ≥ 6 months of systemic chemotherapy were enrolled. Patients underwent laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin/mitomycin C. If amenable to a complete cytoreduction, patients went on to cytoreduction and HIPEC. RESULTS Overall, 18 patients were enrolled and received a median of 14 (interquartile range [IQR] 12-17) cycles of chemotherapy; 16 (89%) patients received chemoradiation. Laparoscopic HIPEC was completed in 17 patients, with a median length of stay of 1 day, and no grade III complications or hematological toxicities were observed. All 18 patients subsequently underwent a complete cytoreduction (CC-0) along with definitive treatment of the primary tumor, with formal resection (7/18), irreversible electroporation (IRE; 10/18), or intraoperative radiation therapy (IORT; 1/18). Median PCI was 2 (IQR 0-4), median LOS was 7 days (IQR 6-8), and 7 (39%) patients were readmitted. Eight (44%) patients experienced grade 3 or higher complications, including one 30-day mortality. At a median follow-up of 16 months, the median progression-free survival was 20 months and the median overall survival was 26 months. CONCLUSION Cytoreduction and HIPEC for selected patients with low-volume PM from PDAC is safe and feasible with favorable short-term outcomes. A phase II trial (NCT04858009) is now enrolling to further assess this multimodality approach in select patients.
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Affiliation(s)
- Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Susanne G Warner
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
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14
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Bachellier P, Addeo P, Averous G, Dufour P. Resection of pancreatic adenocarcinomas with synchronous liver metastases: A retrospective study of prognostic factors for survival. Surgery 2022; 172:1245-1250. [PMID: 35422325 DOI: 10.1016/j.surg.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/16/2022] [Accepted: 03/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to evaluate the results of synchronous liver resection for metastatic pancreatic ductal adenocarcinomas and to identify prognostic factors for overall survival. METHODS We retrospectively reviewed clinical data from patients who underwent the synchronous resection of pancreatic adenocarcinoma with liver metastases. Cox analyses were used to identify factors prognostic of overall survival. RESULTS Of the 92 patients included in this study, preoperative chemotherapy was administered to 52 patients. The median overall survival was 18.26 months (95% confidence interval: 14.7-22.7) (from diagnosis) and 12.68 months (95% confidence interval: 9.5-15.57) from surgery; overall survival at 1, 3, and 5 years was 70%, 10%, and 0%, respectively. Twenty-eight patients (30.4%) had median overall survival >18 months after surgery. The median overall survival from diagnosis was longer in patients undergoing preoperative treatment (22.7 vs 13.8 months; P = .01) but similar after surgery (12.6 vs 13.8 months; P = .86). Multivariate Cox analysis found CA19-9 levels <500 kU/L (hazard ratio: 0.35; 95% confidence interval: 0.17-0.70; P = .003), R0 resection (hazard ratio: 0.46; 95% confidence interval: 0.24-0.88; P = .020), and adjuvant chemotherapy (hazard ratio: 0.39; 95% confidence interval: 0.17-0.88; P = .024) as independent prognostic factors for overall survival. CONCLUSION Survival after resection of oligometastatic liver disease remains limited, reflecting the dismal prognosis of metastatic disease even after aggressive treatment. Preresection CA19-9 serum levels represent a useful tool for patient selection, and administration of adjuvant chemotherapy has a major impact on overall survival. Large comparative studies with exclusive chemotherapy are needed to validate this approach and to identify optimal candidates.
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Affiliation(s)
- Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France.
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Patrick Dufour
- Department of Oncology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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15
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Hamad A, Underhill J, Ansari A, Thayaparan V, Cloyd JM, Li Y, Pawlik TM, Tsung A, Abushahin L, Ejaz A. Surgical treatment of hepatic oligometastatic pancreatic ductal adenocarcinoma: An analysis of the National Cancer Database. Surgery 2022; 171:1464-1470. [PMID: 35115154 DOI: 10.1016/j.surg.2021.12.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/11/2021] [Accepted: 12/29/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with liver-only metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone. Recent studies have explored the role of surgical resection among patients with limited metastatic disease. National practice patterns and the impact of surgery among these patients remains unknown. METHODS The National Cancer Database was queried for all patients with pancreatic adenocarcinoma between 2010 and 2015. The primary outcome was overall survival from the time of diagnosis. Patients with liver-only metastatic disease were included. Univariable and multivariable logistic regression models were constructed to determine the association of patient, hospital, and regional factors with receipt of surgical resection. A propensity score-matched cohort (1:1) was generated by matching patient- and tumor-related factors (age, sex, race, comorbidity burden, primary tumor site, primary tumor size) among patients with liver-only stage IV pancreatic adenocarcinoma who received chemotherapy alone compared to those who received chemotherapy and underwent pancreatectomy and liver metastatectomy. RESULTS Among 312,426 patients who met the study criteria, one half (n = 140,043, 50.4%) had stage IV disease; metastatic sites included bone (n = 5493, 3.1%), brain (n = 620, 0.4%), lung (n = 16,580, 9.5%), and liver (n = 62,444, 35.7%). Patients with stage IV disease were more likely to be younger (odds ratio: 1.10, 95% confidence interval: 1.0-1.2; P = .03) and have poorly (odds ratio: 2.1, 95% confidence interval: 1.8-2.5; P < .001) or undifferentiated (odds ratio: 3.1, 95% confidence interval: 2.3-4.1; P < .001) tumors. Among stage IV patients with liver-only disease (n = 47,785, 14.9%), 891 patients (1.9%) underwent pancreatic resection. Patients who underwent resection were more likely to be younger (odds ratio 1.4, 95% confidence interval: 1.0-1.8; P = .03) and treated at an academic/research center (odds ratio 2.1, 95% confidence interval: 1.2-3.5; P = .006). Median overall survival among patients who underwent resection was 10.74 months versus 3.4 months among patients who did not undergo resection. After controlling for patient and disease-related factors, patients who underwent surgical resection had a lower risk of death versus patients who did not undergo surgery (hazard ratio: 0.5, 95% confidence interval: 0.4-0.6; P < .001). After propensity score matching, patients who received multimodality treatment for liver-only metastatic pancreatic adenocarcinoma (surgery, chemotherapy) had a longer median overall survival (15.6 months vs 8.1 months) compared to those who received chemotherapy alone (P < .001). CONCLUSION This study suggests that pancreatic resection in patients with liver metastases, in combination with chemotherapy and/or chemoradiation, may be associated with improved survival in well-selected patients. However, attempts at an aggressive surgical approach for patients with liver-only stage IV pancreatic adenocarcinoma patients should only be performed only under a well-designed prospective clinical trial.
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Affiliation(s)
- Ahmad Hamad
- Division of Surgical Oncology, The Ohio State University, Columbus, OH. http://www.twitter.com/ahmadhamad4
| | - Jennifer Underhill
- Division of Surgical Oncology, The Ohio State University, Columbus, OH. http://www.twitter.com/Jenn_Underhill
| | - Aliya Ansari
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Varna Thayaparan
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University, Columbus, OH. http://www.twitter.com/jcloydmd
| | - Yaming Li
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University, Columbus, OH. http://www.twitter.com/timpawlik
| | - Allan Tsung
- Division of Surgical Oncology, The Ohio State University, Columbus, OH. http://www.twitter.com/allantsung
| | - Laith Abushahin
- Division of Medical Oncology, The Ohio State University, Columbus, OH
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University, Columbus, OH.
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16
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Hadjittofi C, Feretis M, Martin J, Harper S, Huguet E. Liver regeneration biology: Implications for liver tumour therapies. World J Clin Oncol 2021; 12:1101-1156. [PMID: 35070734 PMCID: PMC8716989 DOI: 10.5306/wjco.v12.i12.1101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/22/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
The liver has remarkable regenerative potential, with the capacity to regenerate after 75% hepatectomy in humans and up to 90% hepatectomy in some rodent models, enabling it to meet the challenge of diverse injury types, including physical trauma, infection, inflammatory processes, direct toxicity, and immunological insults. Current understanding of liver regeneration is based largely on animal research, historically in large animals, and more recently in rodents and zebrafish, which provide powerful genetic manipulation experimental tools. Whilst immensely valuable, these models have limitations in extrapolation to the human situation. In vitro models have evolved from 2-dimensional culture to complex 3 dimensional organoids, but also have shortcomings in replicating the complex hepatic micro-anatomical and physiological milieu. The process of liver regeneration is only partially understood and characterized by layers of complexity. Liver regeneration is triggered and controlled by a multitude of mitogens acting in autocrine, paracrine, and endocrine ways, with much redundancy and cross-talk between biochemical pathways. The regenerative response is variable, involving both hypertrophy and true proliferative hyperplasia, which is itself variable, including both cellular phenotypic fidelity and cellular trans-differentiation, according to the type of injury. Complex interactions occur between parenchymal and non-parenchymal cells, and regeneration is affected by the status of the liver parenchyma, with differences between healthy and diseased liver. Finally, the process of termination of liver regeneration is even less well understood than its triggers. The complexity of liver regeneration biology combined with limited understanding has restricted specific clinical interventions to enhance liver regeneration. Moreover, manipulating the fundamental biochemical pathways involved would require cautious assessment, for fear of unintended consequences. Nevertheless, current knowledge provides guiding principles for strategies to optimise liver regeneration potential.
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Affiliation(s)
- Christopher Hadjittofi
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Michael Feretis
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Jack Martin
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Simon Harper
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Emmanuel Huguet
- University Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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17
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Sutton TL, Grossberg A, Ey F, O’Reilly EM, Sheppard BC. Multimodality therapy in metastatic pancreas cancer with a BRCA mutation and durable long-term outcome: biology, intervention, or both? Cancer Biol Ther 2021; 22:532-536. [PMID: 34696697 PMCID: PMC8726708 DOI: 10.1080/15384047.2021.1991739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/09/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022] Open
Abstract
Metastatic pancreatic adenocarcinoma (PDAC) is a rapidly lethal disease, with less than half of patients surviving 12 months, and 5-year survival approximately 3%. These outcomes are in large part due to a lack of effective medical and surgical therapies for metastatic PDAC. Herein, we present the case of a patient with oligometastatic liver recurrence of BRCA2-mutated PDAC following a curative-intent resection. Through a combination of systemic chemotherapy, metastasectomy, radiotherapy, and subsequent targeted therapy with olaparib, the patient is asymptomatic four years following metastatic diagnosis with stable low-volume disease. This patient's excellent outcome is attributable to the multi-disciplinary care received, all aspects of which were informed by new evidence surrounding metastasectomy for metastatic PDAC, the unique biology and medical treatment of BRCA-mutated PDAC, and the role of radiotherapy in controlling locoregional recurrence. We provide a review of this evidence, while highlighting the importance of evaluating disease biology through somatic and germline genetic testing as well as monitoring response to systemic chemotherapy.
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Affiliation(s)
- Thomas L. Sutton
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
| | - Aaron Grossberg
- Department of Radiation Medicine, OHSU, Portland, Oregon, USA
| | - Frederick Ey
- Department of Hematology/Oncology, OHSU, Portland, Oregon, USA
| | - Eileen M. O’Reilly
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Brett C. Sheppard
- Department of Surgery, Oregon Heath & Science University (OHSU), Portland, Oregon, USA
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18
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Breton C, Meyer A, Malka D, Matias M, De Baere T, Hammel P, Sa Cunha A, Lucchese A, Fuks D, Coriat R, Gallois C, Touchefeu Y, Maillet M, Trouilloud I, Rompteaux P, Carbonnel F, Soularue E. Local treatment of pancreatic cancer metastases: A multicenter French study of the AGEO group. Clin Res Hepatol Gastroenterol 2021; 45:101607. [PMID: 33662776 DOI: 10.1016/j.clinre.2020.101607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/14/2020] [Accepted: 12/06/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study reports the efficacy and safety of local treatment of metastases of pancreatic ductal adenocarcinoma (PDAC), with a curative intent. METHODS We retrospectively included patients with histologically proven PDAC, who underwent a local treatment for metastases between January 1, 2000 and December 31, 2017, from 11 French hospitals. Complications of local treatment were reported. Univariate Cox models were performed to identify prognosis factors associated with overall survival (OS) and disease-free survival (DFS). RESULTS We included 52 patients treated for 68 metastases; 33 (64%) of whom had metachronous metastases. Metastatic sites treated were: 39 (57%) hepatic, 18 (27%) pulmonary and 11 (16%) others. Metastases treatments were: 45 (66%) surgery, 9 (13%) radiofrequency and 14 (21%) other procedures. The rates of severe complications and mortality were respectively 10% and 4%. The median OS and DFS after local treatment were 36.5 months and 12.7 months, respectively. Prognosis factors associated with a shorter OS were: liver metastases when compared with lung metastases (HR 4.04; 95%CI: 1.18-13.81), N2 status of primary pancreatic tumor when compared to N0-N1 (HR 9.43; 95%CI: 2.44-36.36) and synchronous metastases when compared to metachronous metastases (HR 2.34; 95%CI: 1.05-5.23). N2 status of primary pancreatic tumor was associated with a shorter DFS when compared to N0-N1 (HR 2.82; 95%CI: 1.05-7.58). CONCLUSION In this series of highly selected patients, local treatment of metastases from PDAC is associated with prolonged survival. The rate of severe complications was low. Factors associated with shorter OS were liver metastases, N2 status and synchronous metastases.
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Affiliation(s)
- Clémence Breton
- Department of Gastroenterology, Bicêtre Hospital AP-HP, Paris-Saclay University, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.
| | - Antoine Meyer
- Department of Gastroenterology, Bicêtre Hospital AP-HP, Paris-Saclay University, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - David Malka
- Department of Medical Oncology, Gustave Roussy, Paris-Saclay University, 114 Rue Edouard Vaillant, 94800 Villejuif, France
| | - Margarida Matias
- Department of Medical Oncology, Gustave Roussy, Paris-Saclay University, 114 Rue Edouard Vaillant, 94800 Villejuif, France
| | - Thierry De Baere
- Department of Radiology, Gustave Roussy, Paris-Saclay University, 114 Rue Edouard Vaillant, 94800 Villejuif, France
| | - Pascal Hammel
- Department of Oncology, Beaujon Hospital AP-HP, Paris University, 100 Boulevard du Général Leclerc, 92110 Clichy, France
| | - Antonio Sa Cunha
- Department of Digestive Surgery, Hepatobiliary Center of Paul Brousse APHP, Paris-Saclay University, 12 Avenue Paul Vaillant Couturier, 94800 Villejuif, France
| | - Angelica Lucchese
- Department of Digestive Surgery, Hepatobiliary Center of Paul Brousse APHP, Paris-Saclay University, 12 Avenue Paul Vaillant Couturier, 94800 Villejuif, France
| | - David Fuks
- Department of Digestive Surgery, Institute Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France
| | - Romain Coriat
- Department of Gastro-enterology, Cochin Hospital AP-HP, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Claire Gallois
- Department of Hepato-Gastroenterology and Gastrointestinal Oncology, European Georges Pompidou Hospital AP-HP, Paris University, 20 Rue Leblanc, 75015 Paris, France
| | - Yann Touchefeu
- Department of Gastroenterology, Nantes University Hospital, 5 Allée de L'île Gloriette, 44000 Nantes, France
| | - Marianne Maillet
- Department of Gastroenterology, Saint-Louis Hospital AP-HP, Paris University,1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Isabelle Trouilloud
- Department of Medical Oncology, Saint-Antoine Hospital AP-HP, Sorbonne University, 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Pierre Rompteaux
- Department of Gastroenterology, Avicenne Hospital AP-HP, Sorbonne University, 125 Rue de Stalingrad, 93000 Bobigny, Paris, France
| | - Franck Carbonnel
- Department of Gastroenterology, Bicêtre Hospital AP-HP, Paris-Saclay University, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Emilie Soularue
- Department of Oncology, Institute Mutualiste Montsouris, 42 Boulevard Jourdan, 75014 Paris, France
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19
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Zhou W, Wang D, Lou W. Current Role of Surgery in Pancreatic Cancer With Synchronous Liver Metastasis. Cancer Control 2021; 27:1073274820976593. [PMID: 33238715 PMCID: PMC7791445 DOI: 10.1177/1073274820976593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer with synchronous liver metastasis has an extremely poor
prognosis, and surgery is not recommended for such patients by the current
guidelines. However, an increasing body of studies have shown that concurrent
resection of pancreatic cancer and liver metastasis is not only technically
feasible but also beneficial to the survival in the selected patients. In this
review, we aim to summarize the short- and long-term outcomes following
synchronous liver metastasectomy for pancreatic cancer patients, and discuss the
potential criteria in selecting appropriate surgical candidates, which might be
helpful in clinical decision-making.
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Affiliation(s)
- Wentao Zhou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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20
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Zhou W, Han X, Fang Y, Han S, Cai Y, Kuang T, Lou W, Wang D. Clinical Analysis of Acinar Cell Carcinoma of the Pancreas: A Single-Center Experience of 45 Consecutive Cases. Cancer Control 2021; 27:1073274820969447. [PMID: 33121259 PMCID: PMC7791459 DOI: 10.1177/1073274820969447] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Backgrounds: Acinar cell carcinoma of the pancreas is a rare malignancy, and its features
remain unclear. We aimed to analyze the clinical characteristics, treatment
and prognosis of acinar cell carcinoma with our institutional case
series. Methods: Patients diagnosed with acinar cell carcinoma in our hospital between 2005
and 2019 were reviewed. Investigations on clinicopathological features,
treatment details and long-term survival were performed. Results: A total of 45 pathologically confirmed acinar cell carcinomas were
identified. The median age at diagnosis was 58 years with a male-to-female
ratio of 3.1:1. There were 24 (53.3%) localized, 5 (11.1%) locally advanced
and 16 (35.6%) metastatic cases, with a pancreatic head-to-body/tail ratio
of 1:1.4 for all the primary lesions. In the localized group, there were 10
pancreatoduodenectomy, 12 distal pancreatectomy, 1 total pancreatectomy, and
1 distal pancreatectomy combined with proximal gastrectomy. Among the
locally advanced and metastatic cases, 13 patients received chemotherapy, 1
received concurrent radiochemotherapy, 1 underwent synchronous resection of
primary tumor and liver metastasis, 1 underwent palliative operation, 1
underwent exploratory laparotomy, and 4 required no treatment. The median
overall survival of this series was 18.9 months with a 5-year survival rate
of 19.6%. Moreover, the resected acinar cell carcinoma patients were
associated with prolonged survival compared with the unresected cases (36.6
vs. 8.5 months, P < 0.001). Conclusions: Surgical resection could improve the long-term survival of acinar cell
carcinoma patients, which might also improve the prognosis of selected
metastatic cases. Large-scale studies are needed to further clarify the
biological behavior and clinical features, and to seek the optimal
treatments.
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Affiliation(s)
- Wentao Zhou
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu Han
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Siyang Han
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yumeng Cai
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiantao Kuang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- The Research Institution of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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21
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Timmer FEF, Geboers B, Nieuwenhuizen S, Schouten EAC, Dijkstra M, de Vries JJJ, van den Tol MP, Meijerink MR, Scheffer HJ. Locoregional Treatment of Metastatic Pancreatic Cancer Utilizing Resection, Ablation and Embolization: A Systematic Review. Cancers (Basel) 2021; 13:cancers13071608. [PMID: 33807220 PMCID: PMC8036519 DOI: 10.3390/cancers13071608] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Metastatic pancreatic ductal adenocarcinoma (mPDAC) has a dismal prognosis. In selected patients with limited metastatic disease, locoregional therapy, in addition to systemic chemotherapy, may improve survival. This systematic review sought to examine current evidence on the value of additional locoregional treatment, including resection, ablation and embolization, in patients with hepatic or pulmonary mPDAC. The results, although liable to substantial bias, demonstrated superior survival from metastatic diagnosis or treatment in a subset of patients after radical-intent local primary and metastatic treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). However, as a consequence of the bias, definitive conclusions regarding the seemingly beneficial effect of locoregional treatment cannot be endorsed. Randomized controlled trials with strictly selected oligometastatic PDAC patients are required to deduce final recommendations on this notion. Abstract The prognosis of metastatic pancreatic ductal adenocarcinoma (mPDAC) remains universally poor, requiring new and innovative treatment approaches. In a subset of oligometastatic PDAC patients, locoregional therapy, in addition to systemic chemotherapy, may improve survival. The aim of this systematic review was to explore and evaluate the current evidence on locoregional treatments for mPDAC. A systematic literature search was conducted on locoregional techniques, including resection, ablation and embolization, for mPDAC with a focus on hepatic and pulmonary metastases. A total of 59 studies were identified, including 63,453 patients. Although subject to significant bias, radical-intent local therapy for both the primary and metastatic sites was associated with a superior median overall survival from metastatic diagnosis or treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to control groups receiving chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). To recruit patients that may benefit from these local treatments, selection appears essential. Most significant is the upfront possibility of local radical pancreatic and metastatic treatment. In addition, a patient’s response to neoadjuvant systemic chemotherapy, performance status, metastatic disease load and, to a lesser degree, histological differentiation grade and tumor marker CA19-9 serum levels, are powerful prognostic factors that help identify eligible subjects. Although the exact additive value of locoregional treatments for mPDAC patients cannot be distillated from the results, locoregional primary pancreatic and metastatic treatment seems beneficial for a highly selected group of oligometastatic PDAC patients. For definite recommendations, well-designed prospective randomized controlled trials with strict in- and exclusion criteria are needed to validate these results.
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Affiliation(s)
- Florentine E. F. Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
- Correspondence: ; Tel.: +31-20-444-4571
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Evelien A. C. Schouten
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Jan J. J. de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - M. Petrousjka van den Tol
- Department of Surgery, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
| | - Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (Location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (B.G.); (S.N.); (E.A.C.S.); (M.D.); (J.J.J.d.V.); (M.R.M.); (H.J.S.)
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22
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Su BB, Bai DS, Yu JQ, Zhang C, Jin SJ, Zhou BH, Jiang GQ. Can Patients with Pancreatic Cancer and Liver Metastases Obtain Survival Benefit from Surgery? A Population-Based Study. J Cancer 2021; 12:539-552. [PMID: 33391450 PMCID: PMC7739005 DOI: 10.7150/jca.51218] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Surgery for pancreatic cancer with liver metastases (PCL) is not recommended in the international guidelines, and investigation of its clinical significance in patients with PCL is very limited. This study explored whether surgery, especially synchronous resection of the primary tumor and liver metastases (SPL), could improve survival in PCL. Methods: Data of 14,248 patients with PCL from Surveillance, Epidemiology, and End Results database was analyzed. Patients were divided into following groups: SPL, synchronous primary site, and other resection (SPO), single resection of the primary site (SPS), and no resection (NR). Results: In this study, only 93 (0.7%) underwent SPL, 88 (0.6%) for SPO, and 232 (1.6%) for SPS. Multivariate Cox analysis showed surgical procedures of both the primary site and other sites were independent protective prognostic factors for pancreatic cancer cause-specific survival (PCSS) (all P < 0.001). Patients in the SPL group showed the most survival benefit, with a significant and gradually increased difference as compared with the SPO, SPS, and NR groups (median survival: 54, 34, 15, and 3 months, respectively, all P < 0.001). Compared with the NR group, mortalities were significant and gradually declining in the SPS, SPO, and SPL groups, with hazard ratio 0.329 (95% confidence interval [CI], 0.281 to 0.386), 0.220 (95% CI, 0.164 to 0.294), and 0.162 (95% CI, 0.118 to 0.222), respectively (all P < 0.001). Conclusions: Surgical procedures for both primary site and other sites improved survival. SPL, particularly, showed a considerable survival benefit in well-selected patients with PCL.
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Affiliation(s)
- Bing-Bing Su
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Dou-Sheng Bai
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Jiang-Quan Yu
- Department of Intensive Care Unit, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Chi Zhang
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Sheng-Jie Jin
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Bao-Huan Zhou
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
| | - Guo-Qing Jiang
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, Yangzhou 225001, China
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23
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Yamamoto M, Yoshida M, Furuse J, Sano K, Ohtsuka M, Yamashita S, Beppu T, Iwashita Y, Wada K, Nakajima TE, Sakamoto K, Hayano K, Mori Y, Asai K, Matsuyama R, Hirashita T, Hibi T, Sakai N, Tabata T, Kawakami H, Takeda H, Mizukami T, Ozaka M, Ueno M, Naito Y, Okano N, Ueno T, Hijioka S, Shikata S, Ukai T, Strasberg S, Sarr MG, Jagannath P, Hwang TL, Han HS, Yoon YS, Wang HJ, Luo SC, Adam R, Gimenez M, Scatton O, Oh DY, Takada T. Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:1-25. [PMID: 33200538 DOI: 10.1002/jhbp.868] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/30/2020] [Accepted: 11/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors. METHODS Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy. CONCLUSIONS These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.
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Affiliation(s)
- Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare, School of Medicine, Ichikawa, Japan
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Mitaka, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shingo Yamashita
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toru Beppu
- Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan
| | - Yukio Iwashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takako Eguchi Nakajima
- Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan.,Kyoto Innovation Center for Next Generation Clinical Trials and iPS Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokoama, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisato Kawakami
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Hiroyuki Takeda
- Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takuro Mizukami
- Department of Clinical Oncology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masato Ozaka
- Department of Gastroenterology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makoto Ueno
- Division of Hepatobiliary and Pancreatic Medical Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoichi Naito
- Department of Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Naohiro Okano
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Mitaka, Japan
| | - Takayuki Ueno
- Breast Surgical Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | | | - Tomohiko Ukai
- Division of Public Health, Osaka Institute of Public Health, Higashinari, Japan
| | - Steven Strasberg
- Section of HPB Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | | | | | - Tsann-Long Hwang
- Division of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Ho-Seong Han
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | - Shao-Ciao Luo
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - René Adam
- AP HP Paul Brousse Hospital, University Paris Sud, Villejuif, France
| | - Mariano Gimenez
- Docencia Asistencia Investigación en Cirugía Invasiva Mínima Foundation, General and Minimally Invasive Surgery, University of Buenos Aires, Viamonte, Argentina.,Institute of Image-Guided Surgery, Strasbourg, France
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, APHP Pitié-Salpêtrière Hospital, Sorbonne Université, CRSA, Paris, France
| | - Do-Youn Oh
- Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
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24
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Mitsuka Y, Yamazaki S, Yoshida N, Yan M, Higaki T, Takayama T. Time interval-based indication for liver resection of metastasis from pancreatic cancer. World J Surg Oncol 2020; 18:294. [PMID: 33172482 PMCID: PMC7656747 DOI: 10.1186/s12957-020-02058-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022] Open
Abstract
Background Surgical indications for liver metastases from pancreatic ductal adenocarcinoma (PDAC) are lacking because outcomes are usually poor. However, liver resection and the recent progress in perioperative chemotherapy have been observed to improve survival. Methods We performed liver resection for liver metastases from PDAC only under the following criteria: (1) liver-only metastasis, (2) up to three tumors, and (3) no increase in the number of metastases during the 3-month observation period. No limitations were placed on the location or size of liver metastasis. In this study, we aimed to validate our surgical criteria and analyze factors affecting survival in patients with PDAC. Results Seventy-nine patients underwent curative resection for PDAC between 2005 and 2015. Seventy-one patients experienced recurrence, with liver-only recurrence in 17 patients. Among these, nine patients underwent liver resection and eight did not. The median survival time was significantly better for patients who underwent liver resection (55 months) than for those with other recurrences (17.5 months, p = 0.016). The median survival after liver recurrence was significantly better in the liver resection group (31 months) than in the non-liver resection group (7 months, p = 0.0008). The median disease-free interval (DFI) after pancreatectomy was significantly longer in the liver resection group (21 months; range, 3–44 months) than in the non-liver resection group (3 months; range, 2–7 months; p = 0.02). Conclusion Good indications for liver metastases from PDAC include solitary metachronous tumors and longer DFIs.
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Affiliation(s)
- Yusuke Mitsuka
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shintaro Yamazaki
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Nao Yoshida
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masahiro Yan
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tokio Higaki
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tadatoshi Takayama
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Ohyaguchikami-machi, Itabashi-ku, Tokyo, 173-8610, Japan
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25
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Schwarz C, Fitschek F, Primavesi F, Stättner S, Margonis GA, Weiss MA, Stavrou GA, Oldhafer KJ, Kornprat P, Wundsam H, Fischer I, Längle F, Függer R, Hauer A, Klug R, Kieler M, Prager G, Schindl M, Stremitzer S, Bodingbauer M, Sahora K, Kaczirek K. Metachronous hepatic resection for liver only pancreatic metastases. Surg Oncol 2020; 35:169-173. [PMID: 32889249 DOI: 10.1016/j.suronc.2020.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The value of liver resection (LR) for metachronous pancreatic ductal adenocarcinoma (PDAC) metastases remains controversial. However, in light of increasing safety of liver resections, surgery might be a valuable option for metastasized PDAC in selected patients. METHODS We performed a retrospective, multicenter study including patients undergoing hepatectomy for metachronous PDAC liver metastases between 2004 and 2015 to analyze postoperative outcome and overall survival. All patients were operated with curative intent. Patients with oligometastatic metachronous liver metastasis with definitive chemotherapy (n = 8) served as controls. RESULTS Overall 25 patients in seven centers were included in this study. The median age at the time of LR was 63.8 years (56.9-69.9) and the median number of metastases in the liver was 1 (IQR 1-2). There were eight non-anatomical resections (32%), 15 anatomical minor (60%) and 2 major LR (8%). Postoperative complications occurred in eleven patients (eight Clavien-Dindo grade I complications (32%) and three grade IIIa complications (12%), respectively). The 30-day mortality was 0%. The median length of stay was 8.6 days (IQR 5-11). Median overall survival following LR was 36.8 months compared to 9.2 months in patients with metachronous liver metastasis with chemotherapy (p = 0007). DISCUSSION Liver resection for metachronous PDAC metastasis is safe and feasible in selected patients. To address general applicability and to find factors for patient selection, larger trials are urgently warranted.
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Affiliation(s)
- C Schwarz
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
| | - F Fitschek
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
| | - F Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Austria
| | - S Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Austria
| | - G A Margonis
- Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - M A Weiss
- Department of Surgery, Northwell Health Cancer Institute, New York, USA
| | - G A Stavrou
- Department of Surgery, Division of HPB Surgery, Asklepios Campus Barmbek, Hamburg, Germany; Semmelweis University Budapest, Asklepios Campus Hamburg, Germany
| | - K J Oldhafer
- Department of Surgery, Division of HPB Surgery, Asklepios Campus Barmbek, Hamburg, Germany; Semmelweis University Budapest, Asklepios Campus Hamburg, Germany
| | - P Kornprat
- Department of Surgery, Medical University Graz, Graz, Austria
| | - H Wundsam
- Department of Surgery, Hospital Sisters of Mercy Linz, Linz, Austria
| | - I Fischer
- Department of Surgery, Hospital Sisters of Mercy Linz, Linz, Austria
| | - F Längle
- Department of Surgery, LK Wiener Neustadt, Wiener Neustadt, Austria
| | - R Függer
- Department of Surgery, Hospital Sisters of Mercy Linz, Linz, Austria
| | - A Hauer
- Department of Surgery, KH Horn, Austria
| | - R Klug
- Department of Surgery, KH Horn, Austria
| | - M Kieler
- Department of Internal Medicine/Division of Oncology, Medical University Vienna, Austria
| | - G Prager
- Department of Internal Medicine/Division of Oncology, Medical University Vienna, Austria
| | - M Schindl
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
| | - S Stremitzer
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
| | - M Bodingbauer
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
| | - K Sahora
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria.
| | - K Kaczirek
- Department of Surgery/Division of General Surgery, Medical University Vienna, Austria
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26
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Jin T, Dai C, Xu F. Surgical and local treatment of hepatic metastasis in pancreatic ductal adenocarcinoma: recent advances and future prospects. Ther Adv Med Oncol 2020; 12:1758835920933034. [PMID: 32636941 PMCID: PMC7313332 DOI: 10.1177/1758835920933034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/07/2020] [Indexed: 12/19/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with increasing incidence and mortality. More than half of PDAC patients develop metastases, with the liver being the most common site. Patients with pancreatic ductal adenocarcinoma with liver metastases (PCLM) have a very limited scope for surgery due to aggressive tumor behavior and poor prognosis. However, with the improvements in preoperative systemic therapy and perioperative outcomes, an increasing number of patients are being considered for surgical management. However, the best choice of surgical treatment and criteria for selecting suitable PCLM patients who may benefit from surgical treatment remains controversial. Palliative local treatments, such as ablation, locoregional chemotherapy, and brachytherapy, which are less invasive and have fewer contraindications and complications, are the preferred alternatives to surgery. The present study reviews the advances in the management of PCLM, with focus on resection and local therapies.
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Affiliation(s)
- Tianqiang Jin
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chaoliu Dai
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Feng Xu
- Department of General Surgery, Shengjing Hospital of China Medical University, 36 Sanhao Street, Heping District, Shenyang, Liaoning Province 110004, China
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Leigh N, Solomon D, Pletcher E, Labow DM, Magge DR, Sarpel U, Golas BJ. Is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy indicated in hepatobiliary malignancies? World J Surg Oncol 2020; 18:124. [PMID: 32527272 PMCID: PMC7291534 DOI: 10.1186/s12957-020-01898-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Background Hepatopancreaticobiliary malignancies with peritoneal carcinomatosis exhibit poor survival with current therapies: hepatocellular carcinoma 11 months with sorafenib, and pancreaticobiliary 9–14 months with systemic chemotherapy. However, limited data exist on the utility of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in these patients. Methods We retrospectively reviewed our institutional hepatopancreaticobiliary malignancies with peritoneal carcinomatosis which underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy from 2007 to 2017 and analyzed perioperative and oncologic outcomes. Results Seventeen patients were included: 9 hepatocellular carcinoma, 8 pancreaticobiliary (4 cholangiocarcinoma, 3 gallbladder, 1 pancreatic). Peritoneal cancer index, number of organs resected, completeness of cytoreduction, and 30-day morbidity were equivalent. Hepatocellular carcinoma received significantly less neoadjuvant therapy (11%, p = 0.008), though adjuvant therapy rates were similar. At a median follow-up of 15 months, progression-free survival was similar amongst all cohorts. However, overall survival was longer in hepatocellular carcinoma (42 months vs. cholangiocarcinoma 19 months, gallbladder 8 months, pancreatic 15 months, p = 0.206) with 59% 3-year overall survival (vs. 0% cholangiocarcinoma, 0% gallbladder, 0% pancreatic). Conclusions Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy may offer a survival benefit in select hepatocellular carcinoma patients with peritoneal carcinomatosis, though has dubious utility in pancreaticobiliary malignancies.
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Affiliation(s)
- Natasha Leigh
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA.
| | - Daniel Solomon
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
| | - Eric Pletcher
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
| | - Daniel M Labow
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
| | - Deepa R Magge
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
| | - Benjamin J Golas
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai St. Luke's West Hospital, 425 West 59th Street, Suite 7B, New York, NY, 10019, USA
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Liver metastases from pancreatic ductal adenocarcinoma: is there a place for surgery in the modern era? JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Crippa S, Cirocchi R, Weiss MJ, Partelli S, Reni M, Wolfgang CL, Hackert T, Falconi M. A systematic review of surgical resection of liver-only synchronous metastases from pancreatic cancer in the era of multiagent chemotherapy. Updates Surg 2020; 72:39-45. [PMID: 31997233 DOI: 10.1007/s13304-020-00710-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
Recent studies considered surgery as a treatment option for patients with pancreatic ductal adenocarcinoma (PDAC) and synchronous liver metastases. The aim of this study was to evaluate systematically the literature on the role of surgical resection in this setting as an upfront procedure or following primary chemotherapy. A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines. Only studies that included patients with synchronous liver metastases published in the era of multiagent chemotherapy (after 2011) were considered, excluding those with lung/peritoneal metastases or metachronous liver metastases. Median overall survival (OS) was the primary outcome. Six studies with 204 patients were analyzed. 63% of patients underwent upfront pancreatic and liver resection, 35% had surgery after primary chemotherapy with strict selection criteria and 2% had an inverse approach (liver surgery first). 38 patients (18.5%) did not undergo any liver resection since metastases disappeared after chemotherapy. Postoperative mortality was low (< 2%). Median OS ranged from 7.6 to 14.5 months after upfront pancreatic/liver resection and from 34 to 56 months in those undergoing preoperative treatment. This systematic review suggests that surgical resection of pancreatic cancer with synchronous liver oligometastases is safe, and it can be associated with improved survival, providing a careful selection of patients after primary chemotherapy.
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Affiliation(s)
- Stefano Crippa
- Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Division of Pancreatic Surgery, Vita-Salute University, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, St. Maria Hospital, Terni, Italy
| | - Matthew J Weiss
- Department of Surgery, Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefano Partelli
- Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Christopher L Wolfgang
- Department of Surgery, Division of Surgical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Massimo Falconi
- Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy. .,Division of Pancreatic Surgery, Vita-Salute University, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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Treatment of hepatic pancreatic ductal adenocarcinoma metastases with high-dose-rate image-guided interstitial brachytherapy: a single center experience. J Contemp Brachytherapy 2019; 11:329-336. [PMID: 31523233 PMCID: PMC6737574 DOI: 10.5114/jcb.2019.87269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/23/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose To evaluate the efficacy and safety of image-guided (computed tomography/magnetic resonance imaging – CT/MRI) high-dose-rate (HDR) interstitial brachytherapy (iBT) as a salvage maneuver for the treatment of hepatic metastases originating from hepatic pancreatic ductal adenocarcinoma (PDAC). PDAC metastases present a major and unresolved problem, and any surgical approach or local therapeutic intervention remains extremely controversial. Material and methods A cumulative number of 45 hepatic PDAC metastases in 16 patients were treated and retrospectively analyzed. Synchronous metastatic spread was observed in five patients, metachronous in eleven. 14 patients had resection of the pancreatic primary prior to iBT: eight Whipple/PPPD and six distal pancreatectomy procedures. The hepatic metastases were progressing under chemotherapy, thus iBT was applied as a salvage maneuver with the intention of local tumor control and prolonged survival. iBT is applied interstitially, with temporarily introduced 192Ir source in a single fraction HDR irradiation regime to eradicate vital tumor cells. Response to treatment was assessed clinically with CT/MRI every three months. Results Local tumor control was achieved in 87% of all treated metastases. The median diameter of the irradiated lesions was 2.2 cm (range, 1-11.2 cm), the median irradiation dose was 21 Gy (range, 5-29.1 Gy). Median progression-free survival (PFS) after iBT was 3.4 months (range, 1.5-19.6 months), the median overall survival (OS) after iBT was 8.9 months (range, 3.1-29.3 months). Three major complications (CTCAE grade 3) occurred following iBT: three cases of liver abscess, which were successfully resolved with drainage and antibiotics. Conclusions Overall, iBT is a safe procedure, which enables excellent rates of local tumor control and presents a viable anti-neoplastic treatment option as a salvage therapy for metastatic PDAC patients.
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Bailey RE, Surapaneni PK, Core J, Vidal LLC, LeGout J, Ritchie C, Frey G, McKinney JM, Sella D, Paz-Fumagalli R, Toskich B, Mody K. Safety and efficacy of locoregional therapy for metastatic pancreatic ductal adenocarcinoma to the liver: a single-center experience. J Gastrointest Oncol 2019; 10:688-694. [PMID: 31392049 DOI: 10.21037/jgo.2019.03.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Many patients with pancreatic ductal adenocarcinoma (PDAC) are diagnosed with liver metastatic disease (mPDAC), and few are surgical candidates. Interventional oncology (IO) locoregional therapies (LRT) have proven beneficial in other primary and metastatic hepatic malignancies. Systemic chemotherapy is the standard of care for patients with mPDAC. This study assessed the safety and efficacy of LRT including thermal ablation, chemoembolization, and radioembolization for mPDAC. Methods A retrospective analysis was performed of 28 patients with mPDAC referred to IR clinic for consideration of LRT from 01/2006 to 08/2017, of whom 20 underwent treatment. Laboratory values were analyzed at 0, 3, and 6 months post-treatment. Imaging response was evaluated at 1, 3, and 6 months post-intervention by modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Adverse events (AE) were classified by CTCAE v5.0. Overall survival (OS) from the diagnosis of PDAC, survival from the time of mPDAC diagnosis, and survival from the time of LRT were calculated. Results Median OS (mOS) was 25 months. Median survival from time of mPDAC diagnosis and post LRT were 16.25 and 9.7 months, respectively. At one month post-intervention, 12 of 17 patients demonstrated disease response (CR or PR per mRECIST). Survival among responders was 9 months vs. 6 months for patients with stable or progressive disease (P=0.08). There were two grade 3 AE which included post-embolization syndrome and transient renal failure. Chemotherapy was briefly delayed in one of these patients, but ultimately resumed. Conclusions The use of LRT in patients with mPDAC is safe. Additionally, no significant chemotherapy limiting toxicities were observed. Responders to therapy demonstrated a survival benefit trend in this small and heterogeneous cohort. Further investigations with randomized trials are warranted.
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Affiliation(s)
| | | | - Jacob Core
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Jordan LeGout
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Gregory Frey
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - David Sella
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Beau Toskich
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Kabir Mody
- Division of Hematology/Oncology, Mayo Clinic Cancer Center, Mayo Clinic, Jacksonville, FL, USA
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Surgery or Locoregional Approaches for Hepatic Oligometastatic Pancreatic Cancer: Myth, Hope, or Reality? Cancers (Basel) 2019; 11:cancers11081095. [PMID: 31374916 PMCID: PMC6721290 DOI: 10.3390/cancers11081095] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/27/2019] [Accepted: 07/28/2019] [Indexed: 12/15/2022] Open
Abstract
Despite extensive research, pancreatic ductal adenocarcinoma (PDAC) remains a difficult-to-treat cancer associated with poor survival. Due to the known aggressive disease biology, palliative chemotherapy is the only routinely recommended treatment in the metastatic setting in patients with adequate performance status. However, in a subset of patients with oligometastatic disease, multimodality treatment with surgery and/or locoregional approaches may provide long-term disease control and prolong survival. In fact, in highly selected cases, median overall survival has been reported to extend to 56 months in patients treated with surgery. In particular, liver and extraregional nodal resections may provide long-term tumor control with acceptable morbidity. Current guidelines do not recommend surgery for patients with metastatic PDAC and, in the case of PDAC with oligometastases, there are no published randomized controlled trials regarding locoregional or surgical approaches. Here we review the literature on surgical and locoregional approaches including radiofrequency ablation, irreversible electroporation, and stereotactic body radiation, and focus on patients with hepatic oligometastatic pancreatic cancer. We provide a summary regarding survival outcomes, morbidity and mortality and discuss selection criteria that may be useful to predict the best outcomes for such strategies.
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Voss N, Izbicki JR, Nentwich MF. Oligometastases in pancreatic cancer (Synchronous resections of hepatic oligometastatic pancreatic cancer: Disputing a principle in a time of safe pancreatic operations in a retrospective multicenter analysis). Ann Gastroenterol Surg 2019; 3:373-377. [PMID: 31346576 PMCID: PMC6635688 DOI: 10.1002/ags3.12255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/25/2022] Open
Abstract
The aim of the present review was to analyze the current data on surgery of synchronous liver metastases in pancreatic ductal adenocarcinoma (PDAC) in curative intent. A review of the literature was carried out to identify the current international concepts regarding surgery of liver metastases of PDAC and, furthermore, we addressed the current challenges of resection of liver metastases of PDAC. Resection of liver metastases in PDAC may provide survival benefit without compromising safety and quality of life in a highly selected group of patients.
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Affiliation(s)
- Nina Voss
- Department of General, Visceral and Thoracic SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Michael F. Nentwich
- Department of General, Visceral and Thoracic SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Sakaguchi T, Valente R, Tanaka K, Satoi S, Del Chiaro M. Surgical treatment of metastatic pancreatic ductal adenocarcinoma: A review of current literature. Pancreatology 2019; 19:672-680. [PMID: 31285145 DOI: 10.1016/j.pan.2019.05.466] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/05/2019] [Accepted: 05/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is no international consensus concerning the role of surgical treatment of metastatic pancreatic ductal adenocarcinoma (mPDAC), but favorable prognoses can be expected for highly selected patients. METHODS A comprehensive literature search of the PubMed and Cochrane databases was conducted using combinations of keywords to 4 July 2018. Eligible studies were those reporting on patients with histologically confirmed mPDAC undergoing surgery with curative intent. We excluded case reports with fewer than five patients, insufficient descriptions of survival data, and palliative or cytoreductive surgery as well as studies that assessed para-aortic lymph node metastasis or peritoneal washing cytology. RESULTS Thirteen studies were deemed eligible, and six studies were identified from their references. The studies involved 428 patients who underwent surgical resection for liver metastases (n = 343), lung metastases (n = 57), and peritoneal dissemination (n = 28). Median overall survival (OS) in patients with synchronous liver metastases who underwent conversion surgery following favorable response to initial chemotherapy was 27 or 34 months, and peritoneum metastases was 28 months. Median OS after the initial treatment was varied from 51 to 121 months in metachronous lung metastasis and from 24 to 40 months in metachronous liver metastasis, respectively. CONCLUSION Encouraging OS was indicated in patients with synchronous mPDAC of liver and peritoneum who underwent conversion surgery. Metastasectomy for metachronous lung and liver oligometastases could be considered a practical treatment option.
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Affiliation(s)
| | - Roberto Valente
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital, Stockholm, Sweden.
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University, Faculty of Medicine, Sapporo, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, USA
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[Oligometastasis in pancreatic cancer : Current state of knowledge and spectrum of local therapy]. Chirurg 2019; 89:510-515. [PMID: 29557488 DOI: 10.1007/s00104-018-0626-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several case series reported results of surgical resection in patients with pancreatic ductal adenocarcinoma in a metastasized stage. AIM A summarized overview of the current state of knowledge and a summary of the results of currently available studies. MATERIAL AND METHODS A systematic search was carried out in MEDLINE and PubMed with respect to metastasized pancreatic cancer and surgical resection. RESULTS The evidence level for surgical resection in the metastasized stage is weak and so far no prospective trials are available. The largest single-arm trial included 85 patients with hepatic metastasis. In cases of hepatic oligometastasis an overall survival of 11-14 months was observed. In the presence of pulmonary metastasis, overall survival seems to be prolonged compared to intra-abdominal metastasis, although the evidence level is relatively weak. CONCLUSION According to the available results, a general recommendation for surgical resection in a metastasized stage cannot be given; however, the results show a possible benefit for some well-selected patient subgroups. Prospective trials must validate these data and investigate the use of combined surgical and systemic treatments in the case of resectable metastatic pancreatic cancer.
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Lopez-Lopez V, Robles-Campos R, López-Conesa A, Brusadin R, Carbonel G, Gomez-Ruiz A, Ruiz JJ, Parrilla P. Surgical resection of liver metastasis in pancreatic and periampullary carcinoma. MINERVA CHIR 2019; 74. [DOI: 10.23736/s0026-4733.18.07972-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Improving preoperative detection of synchronous liver metastases in pancreatic cancer with combined contrast-enhanced and diffusion-weighted MRI. Abdom Radiol (NY) 2019; 44:1756-1765. [PMID: 30659309 DOI: 10.1007/s00261-018-1867-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To explore the value of gadolinium-enhanced MRI combined with diffusion-weighted MRI (Gd-enhanced MRI with DWI) in addition to contrast-enhanced CT (CECT) for detection of synchronous liver metastases for potentially resectable pancreatic cancer. METHODS By means of a retrospective cohort study we included patients with potentially resectable pancreatic cancer on CECT, who underwent Gd-enhanced MRI with DWI between January 2012 and December 2016. A single observer evaluated MRI and CT and was blinded to imaging, pathology, and surgery reports. Liver lesions were scored in both modalities, using a 3-point scale: 1-benign, 2-indeterminate, 3- malignant (i.e., metastasis). The primary outcome parameters were the presence of liver metastases on Gd-enhanced MRI with DWI and the sensitivity of Gd-enhanced MRI with DWI for synchronous liver metastases. RESULTS We included 66 patients (42 men, 24 women; median age 65 years, range 36-82 years). In 19 patients, liver metastases were present, which were confirmed by histopathology (n = 12), 18FDG-PET (n = 6), or surgical inspection (n = 1). Gd-enhanced MRI with DWI showed metastases in 16/19 patients (24%), which resulted in a sensitivity of 84% (95% CI 60-97%). Contrast-enhanced MRI showed 156 and DWI 397 metastases (p = 0.051), and 339 were particularly small (< 5 mm). CONCLUSIONS In this study, Gd-enhanced MRI with DWI detected synchronous liver metastases in 24% of patients with potentially resectable pancreatic cancer on CECT with a sensitivity of 84%. Diffusion-weighted MRI showed a greater number of metastases than any other sequence, particularly small metastases (< 5 mm).
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Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma with synchronous liver metastasis after treatment with FOLFIRINOX. Clin J Gastroenterol 2019; 12:603-608. [PMID: 30993652 DOI: 10.1007/s12328-019-00965-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/09/2019] [Indexed: 01/05/2023]
Abstract
FOLFIRINOX is a highly effective anticancer treatment, even in advanced pancreatic cancer, which provides a potential cure in patients initially treated with a palliative strategy. A 47-year-old man was found to have an unresectable pancreatic cancer (4 cm in size) surrounding both the superior mesenteric artery and superior mesenteric vein. A simultaneous liver metastasis in Segment 8, with a diameter of 17 mm, was also detected. The pancreatic tumor markers CEA, CA19-9, and DUPAN-2 were significantly elevated to 21.7 ng/mL, 6224 ng/mL, and 1200U/mL, respectively. After 21 courses of FOLFIRINOX, the primary pancreatic tumor diminished in size (partial response) from 42 to 17 mm, and the liver mass almost disappeared. The tumor markers significantly decreased to almost normal levels. Fourteen months after the initial chemotherapy, conversion surgery was performed. Upon surgical resection, the pancreatic tumor was found to be Grade 1b, and a pathologically complete response was observed for the liver metastasis. The patient is still alive 32 months after initial treatment with no recurrence. This is an informative case of a locally advanced pancreatic cancer with a synchronous liver metastasis that had a significant response to FOLFIRINOX, allowing for subsequent curative resection.
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Tanaka M, Heckler M, Mihaljevic AL, Sun H, Klaiber U, Heger U, Büchler MW, Hackert T. CT response of primary tumor and CA19-9 predict resectability of metastasized pancreatic cancer after FOLFIRINOX. Eur J Surg Oncol 2019; 45:1453-1459. [PMID: 30981446 DOI: 10.1016/j.ejso.2019.03.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/01/2019] [Accepted: 03/27/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Effective chemotherapy protocols are currently changing the treatment options for metastasized pancreatic cancer. Survival benefits after synchronous metastasectomy have been reported for selected patients. We set out to assess predictive factors of resectability for synchronous metastases after FOLFIRINOX. METHODS Consecutive patients with metastatic pancreatic cancer undergoing surgery after FOLFIRINOX between 2011 and 2017 were identified from a prospectively collected database. Surgery following chemotherapy was indicated in patients with no more than six metastatic lesions, no progression detected on CT, and technically resectable disease. Patients who received synchronous metastasectomy were compared with patients who received explorative laparotomy or palliative surgery in terms of predictors of resectability and overall survival. In patients undergoing resection, prognostic factors were examined. RESULTS Of 101 patients scheduled for surgery after FOLFIRINOX, synchronous metastasectomy was performed in 43 cases (43%) and non-resection surgery in 58 cases (57%). The shrinkage rate of the primary tumor on CT (P = 0.04) and the postchemotherapy serum CA19-9 concentration (P = 0.02) were associated with resectability. The median overall survival of the patients undergoing metastasectomy was longer than that of the patients without resection (21.9 months vs 16.4 months, P = 0.006). Postchemotherapy serum CA19-9 value (P = 0.04) and lymph node ratio (P = 0.01) were prognostic factors in the patients undergoing metastasectomy. CONCLUSIONS In selected patients who satisfied our surgical criteria, shrinkage rate of primary tumor and postchemotherapy serum CA19-9 level, which predict resectability of metastasized pancreatic cancer, should be considered in decision making to avoid unnecessary surgery.
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Affiliation(s)
- Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Huihui Sun
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
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Dolay K, Malya FU, Akbulut S. Management of pancreatic head adenocarcinoma: From where to where? World J Gastrointest Surg 2019; 11:143-154. [PMID: 31057699 PMCID: PMC6478601 DOI: 10.4240/wjgs.v11.i3.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.
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Affiliation(s)
- Kemal Dolay
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery, Istinye University, Liv Hospital, Istanbul 34340, Turkey
| | - Fatma Umit Malya
- Department of Surgery, Bezmialem Vakif University Faculty of Medicine, Istanbul 34093, Turkey
| | - Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
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Piątek M, Kuśnierz K, Bieńkowski M, Pęksa R, Kowalczyk M, Nawrocki S. Primarily resectable pancreatic adenocarcinoma - to operate or to refer the patient to an oncologist? Crit Rev Oncol Hematol 2019; 135:95-102. [PMID: 30819452 DOI: 10.1016/j.critrevonc.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/12/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of this work is to investigate the optimal therapeutic sequence of resectable pancreatic cancer - primary surgery with adjuvant therapy or neoadjuvant followed by resection. Application of the neoadjuvant approach in routine treatment of pancreatic cancer is rapidly growing every year, despite the lack of final results from randomized trials. Recent advancements in the adjuvant therapy, due to the more effective chemotherapy regimens, favor the upfront surgery strategy. On the other hand, theoretical background and metaanalyses favor the neoadjuvant strategy. Currently, primary resection with adjuvant chemotherapy remains the standard approach in resectable pancreatic cancer, but the first recommendations considering the neoadjuvant approach as an option seem to arise among the scientific societies with a global impact. Preliminary results of Prodige 24 study and PREOPANC-1 trial demonstrates that both options are worth further evaluation in clinical trials. Their results should soon provide more answers to this important clinical questions.
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Affiliation(s)
- Michał Piątek
- Department of Oncology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Rafał Pęksa
- Department of Patomorphology, Medical University of Gdańsk, Poland
| | - Marek Kowalczyk
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sergiusz Nawrocki
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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Ouyang H, Ma W, Zhang T, Liu F, Zhao L, Fang M, Quan M, Pan Z. Systemic chemotherapy in combination with liver-directed therapy improves survival in patients with pancreatic adenocarcinoma and synchronous liver metastases. Pancreatology 2018; 18:983-989. [PMID: 30287168 DOI: 10.1016/j.pan.2018.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We investigated whether the combination of systemic chemotherapy (SCT) and liver-directed therapy (LDT) was superior to chemotherapy alone for patients with pancreatic adenocarcinoma and synchronous liver metastases (PACLM). METHODS We reviewed the medical records of 184 patients treated with SCT ± LDT at Tianjin Medical University Cancer Hospital from 2001 to 2015. Overall survival (OS) was the primary end-point. The role of treatment modality and other clinical factors was evaluated by univariate and Cox regression analyses. RESULTS Sixty-four (34.8%) patients in the SCT-LDT group and 120 (65.2%) patients in the SCT group were included in the analysis. Baseline clinical characteristics were similar between the groups (all P > 0.05). The median survival was 8.7 months in the SCT-LDT group and was 6.3 months in the SCT group. The 0.5-, 1-, 2- and 3-year survival rates were 67.2%, 33.4%, 13.3% and 8.9%, respectively, after SCT-LDT, and were 54.9%, 19.0%, 4.5% and 2.0%, respectively, after SCT (P = 0.01). Primary tumor size, ascites, and treatment modality (SCT + LDT vs. SCT) independently predicted survival (P < 0.05). The clinical efficacy congruously favored the SCT-LDT group across the majority of subgroups. CONCLUSIONS SCT combined with LDT was well tolerated and may be effective to improve survival of patients with PACLM. Ascites and large primary tumor size were poor prognostic factors associated with survival.
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Affiliation(s)
- Huaqiang Ouyang
- Department of Integrative Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China; National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Weidong Ma
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China; Department of Pancreatic Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Ti Zhang
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China; Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Fang Liu
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China; Department of Interventional Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Lujun Zhao
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China; Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Minghui Fang
- Department of Integrative Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China; National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Manman Quan
- Department of Integrative Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China; National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Zhanyu Pan
- Department of Integrative Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China; National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Tianjin, China.
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Lee RC, Kanhere H, Trochsler M, Broadbridge V, Maddern G, Price TJ. Pancreatic, periampullary and biliary cancer with liver metastases: Should we consider resection in selected cases? World J Gastrointest Oncol 2018; 10:211-220. [PMID: 30147847 PMCID: PMC6107475 DOI: 10.4251/wjgo.v10.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/14/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To analyse the safety and efficacy of curative intent surgery in biliary and pancreatic cancer.
METHODS An extensive literature review was performed using MEDLINE, Google Scholar and EMBASE to identify articles regarding hepato-pancreatoduodenectomy or resection of liver metastasis in patients with pancreatic, biliary tract, periampullary and gallbladder cancers.
RESULTS A total of 19 studies were identified and reviewed. Major hepatectomy was undertaken in 391 patients. The median overall survival for pancreatic cancer ranged from 5-36 mo and for biliary tract/gallbladder cancer, it was 8-38 mo. The 30 d mortality rate was only 1%-9%. Overall Survival was significantly better for patients, who had good response to neoadjuvant chemotherapy, underwent metachronous liver resection and who had intestinal type tumours.
CONCLUSION Resection of liver metastases in pancreatic and biliary cancers may provide survival benefit without compromising safety and quality of life in a very select group of patients. These data may be utilised to formulate selection criteria that may allow future investigation of resection in the era of more effective systemic therapy.
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Affiliation(s)
- Rachael Chang Lee
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
| | - Harsh Kanhere
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Markus Trochsler
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Vy Broadbridge
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
| | - Guy Maddern
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Timothy J Price
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
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Hong Y, Rice J, Sharma D, Martin RCG. The use of IRE in multi-modality treatment for oligometastatic pancreatic cancer. Am J Surg 2018; 216:106-110. [PMID: 29506753 DOI: 10.1016/j.amjsurg.2018.01.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma (PDAC) often presents late with only 20% of patients being candidates for resection while majority already have advanced metastases with median overall survival of 3-6 months. Currently, the role of oligometastasectomy and local therapy options in PDAC is unknown in patients who have favorable response to systemic chemotherapy. The aim of this study is to analyze the survival outcome of oligometastasectomy and local IRE therapy in select patients who are treated with systemic chemotherapy for PDAC metastases. METHODS We utilized a prospective database from 2010 to 2016 to identify patients with local surgical therapy after induction systemic chemotherapy for oligometastatic PDAC (Stage 4). The initial local therapy treatment of distant metastatic lesions was followed by adjuvant chemotherapy. Subsequently, resection of the primary PDAC in conjunction with irreversible electroporation (IRE) was performed after favorable response by RECIST criteria. RESULTS Seven patients were identified with metastatic PDAC treated with oligometastasectomy and/or local therapy. There was single metastatic lesion in 43% (3/7) of which 57% (4/7) were localized in the liver. The treatment of the primary pancreatic cancer was performed utilizing IRE in situ in 6/7 (86%) of patients in our study with resection or radiation of oligometastasis. The median survival in our study group was 16 months with 28% (2/7) patients who remain NED (range 16-41 months). CONCLUSION Combination of systemic chemotherapy and oligometastasectomy with adjunctive local IRE therapy is a feasible treatment strategy in highly select patients with oligometastatic PDAC that demonstrate favorable tumor biology with objective response to systemic therapy.
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Affiliation(s)
- Young Hong
- Department of Surgery, University of Louisville, USA
| | - Jonathan Rice
- Department of Surgery, University of Louisville, USA
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Shimura M, Mizuma M, Hayashi H, Mori A, Tachibana T, Hata T, Iseki M, Takadate T, Ariake K, Maeda S, Ohtsuka H, Sakata N, Morikawa T, Nakagawa K, Naitoh T, Kamei T, Motoi F, Unno M. A long-term survival case treated with conversion surgery following chemotherapy after diagnostic metastasectomy for pancreatic cancer with synchronous liver metastasis. Surg Case Rep 2017; 3:132. [PMID: 29285651 PMCID: PMC5746493 DOI: 10.1186/s40792-017-0409-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/18/2017] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatic cancer with distant metastases is classified as “unresectable,” for which the standard treatment is systemic chemotherapy. The effectiveness of radical resection for pancreatic cancer with distant metastases is unknown. Here, we report a case of long term survival treated with conversion surgery following chemotherapy after diagnostic metastasectomy for pancreatic cancer with synchronous liver metastasis. Case presentation A 73-year-old man was referred to our hospital to examine and treat for cancer of the pancreatic body. Computed tomography (CT) scan revealed a 26-mm hypovascular tumor in contact with the common hepatic artery (CHA) (> 180°), the celiac artery (< 180°), and portal vein at the pancreatic body. Resectability was determined as “borderline resectable.” Two courses of gemcitabine plus S-1 combination therapy (GS) were administered as neoadjuvant chemotherapy (NAC). CT scan showed tumor shrinkage (21 mm), determined as stable disease (SD) according to Response Evaluation Criteria in Solid Tumors (RECIST). Although the abdomen was opened for radical resection, a small nodule on the liver was detected and removed. Since the nodule was diagnosed as adenocarcinoma by intraoperative frozen section, resection of the primary tumor was not performed. After three subsequent courses of GS therapy, no distant metastases were detected under radiological findings. Distal pancreatectomy with celiac artery resection (DP-CAR) was performed as radical surgery 6 months after the initial diagnosis. Histological diagnosis was well-differentiated tubular adenocarcinoma, showing ypT1 ypN1 M1 stage IV, negative surgical margin (R0), and grade III in the Evans classification. S-1 was administered every other day from 6 months after resection up to the present. The patient has been alive with no recurrence for 5 years after the initial diagnosis and 4.5 years after the resection. Conclusion There is a case that received survival benefits from conversion surgery following chemotherapy after diagnostic metastasectomy in pancreatic cancer with synchronous liver metastasis.
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Affiliation(s)
- Mitsuhiro Shimura
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Masamichi Mizuma
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan.
| | - Hiroki Hayashi
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Akiko Mori
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Tomoyoshi Tachibana
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Tatsuo Hata
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Masahiro Iseki
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Tatsuyuki Takadate
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Kyohei Ariake
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Shimpei Maeda
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Naoaki Sakata
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Takanori Morikawa
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Kei Nakagawa
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Takeshi Naitoh
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Takashi Kamei
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryomachi, Aobaku, Sendai, 980-8574, Japan
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Yu X, Gu J, Fu D, Jin C. Dose surgical resection of hepatic metastases bring benefits to pancreatic ductal adenocarcinoma? A systematic review and meta-analysis. Int J Surg 2017; 48:149-154. [DOI: 10.1016/j.ijsu.2017.10.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/07/2017] [Accepted: 10/21/2017] [Indexed: 01/11/2023]
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Renz BW, Boeck S, Roeder F, Trumm C, Heinemann V, Werner J. Oligometastatic Disease in Pancreatic Cancer - How to Proceed? Visc Med 2017; 33:36-41. [PMID: 28612015 DOI: 10.1159/000455027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pancreatic cancer is a highly aggressive malignancy and will become the second leading cause of cancer-related death in the USA and also in Germany by 2030. Furthermore, the majority of patients with pancreatic ductal adenocarcinoma (PDAC) will present with distant metastases, limiting surgical management in this population as there is little evidence available to support surgical or ablative treatment options for advanced-stage disease. However, highly selected patients suffering from synchronous and metachronous oligometastatic PDAC may potentially benefit from a surgical resection with an acceptable morbidity. METHODS This review summarizes and discusses the current literature on the management of oligometastatic disease regarding PDAC, focusing on para-aortic lymph nodes as well as isolated hepatic and pulmonary metastases. RESULTS AND CONCLUSION In order to further investigate the feasibility and efficacy of such an approach, a prospective multicenter trial, in which survival and quality of life after metastatic resection and systemic chemotherapy is evaluated, has to be initiated. Additionally, local and locoregional ablation techniques or stereotactic body radiation therapy as therapeutic options for isolated metastases in PDAC need further research in order to determine their significance and benefit.
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Affiliation(s)
- Bernhard W Renz
- Department of General, Visceral and Transplantation Surgery, Hospital of the University of Munich, Munich, Germany, Munich, Germany.,Pancreatic Cancer Center Munich, Comprehensive Cancer Center-LMU, University of Munich, Munich, Germany, Munich, Germany
| | - Stefan Boeck
- Pancreatic Cancer Center Munich, Comprehensive Cancer Center-LMU, University of Munich, Munich, Germany, Munich, Germany.,Department of Internal Medicine III, Hospital of the University of Munich, Munich, Germany, Munich, Germany
| | - Falk Roeder
- Pancreatic Cancer Center Munich, Comprehensive Cancer Center-LMU, University of Munich, Munich, Germany, Munich, Germany.,Department of Radiation Oncology, Hospital of the University of Munich, Munich, Germany, Munich, Germany.,Department of Molecular Radiation Oncology, German Cancer Research Center, Heidelberg, Germany, Munich, Germany
| | - Christoph Trumm
- Department of Clinical Radiology, Hospital of the University of Munich, Munich, Germany
| | - Volker Heinemann
- Pancreatic Cancer Center Munich, Comprehensive Cancer Center-LMU, University of Munich, Munich, Germany, Munich, Germany.,Department of Internal Medicine III, Hospital of the University of Munich, Munich, Germany, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, Hospital of the University of Munich, Munich, Germany, Munich, Germany.,Pancreatic Cancer Center Munich, Comprehensive Cancer Center-LMU, University of Munich, Munich, Germany, Munich, Germany
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Shi HJ, Jin C, Fu DL. Preoperative evaluation of pancreatic ductal adenocarcinoma with synchronous liver metastasis: Diagnosis and assessment of unresectability. World J Gastroenterol 2016; 22:10024-10037. [PMID: 28018110 PMCID: PMC5143749 DOI: 10.3748/wjg.v22.i45.10024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/09/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To identify predictors for synchronous liver metastasis from resectable pancreatic ductal adenocarcinoma (PDAC) and assess unresectability of synchronous liver metastasis.
METHODS Retrospective records of PDAC patients with synchronous liver metastasis who underwent simultaneous resections of primary PDAC and synchronous liver metastasis, or palliative surgical bypass, were collected from 2007 to 2015. A series of pre-operative clinical parameters, including tumor markers and inflammation-based indices, were analyzed by logistic regression to figure out predictive factors and assess unresectability of synchronous liver metastasis. Cox regression was used to identify prognostic factors in liver-metastasized PDAC patients after surgery, with intention to validate their conformance to the indications of simultaneous resections and palliative surgical bypass. Survival of patients from different groups were analyzed by the Kaplan-Meier method. Intra- and post-operative courses were compared, including complications. PDAC patients with no distant metastases who underwent curative resection served as the control group.
RESULTS CA125 > 38 U/mL (OR = 12.397, 95%CI: 5.468-28.105, P < 0.001) and diabetes mellitus (OR = 3.343, 95%CI: 1.539-7.262, P = 0.002) independently predicted synchronous liver metastasis from resectable PDAC. CA125 > 62 U/mL (OR = 5.181, 95%CI: 1.612-16.665, P = 0.006) and age > 62 years (OR = 3.921, 95%CI: 1.217-12.632, P = 0.022) correlated with unresectability of synchronous liver metastasis, both of which also indicated a worse long-term outcome of liver-metastasized PDAC patients after surgery. After the simultaneous resections, patients with post-operatively elevated serum CA125 levels had shorter survival than those with post-operatively reduced serum CA125 levels (7.7 mo vs 16.3 mo, P = 0.013). The survival of liver-metastasized PDAC patients who underwent the simultaneous resections was similar to that of non-metastasized PDAC patients who underwent curative pancreatectomy alone (7.0 mo vs 16.9 mo, P < 0.001), with no higher rates of either pancreatic fistula (P = 0.072) or other complications (P = 0.230) and no greater impacts on length of hospital stay (P = 0.602) or post-operative diabetic control (P = 0.479).
CONCLUSION The criterion set up by CA125 levels could facilitate careful diagnosis of synchronous liver metastases from PDAC, and prudent selection of appropriate patients for the simultaneous resections.
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Pancreatic cancer and liver metastases: state of the art. Updates Surg 2016; 68:247-251. [PMID: 27832445 DOI: 10.1007/s13304-016-0407-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/18/2016] [Indexed: 12/16/2022]
Abstract
Pancreatic cancer is still one of the most aggressive oncological diseases with a 5-year mortality rate below 10%. Surgery remains the only curative treatment; however, most patients present with late-stage disease deemed unresectable, either due to extensive local vascular involvement or the presence of distant metastasis. In the detection of hepatic metastases, the current standard is palliative chemotherapy with fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) or nab-paclitaxel with gemcitabine. Once hepatic metastases are diagnosed, the guidelines do not recommend resection of the primary tumor. Recent findings suggest that some patients with non-resectable diseases initially have survival rates as good as those with initially resectable disease when they are able to undergo surgical resection. Synchronous resection of both the primary tumour as well as the liver metastases may be beneficial and improves the outcome.
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50
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Wright GP, Poruk KE, Zenati MS, Steve J, Bahary N, Hogg ME, Zuriekat AH, Wolfgang CL, Zeh HJ, Weiss MJ. Primary Tumor Resection Following Favorable Response to Systemic Chemotherapy in Stage IV Pancreatic Adenocarcinoma with Synchronous Metastases: a Bi-institutional Analysis. J Gastrointest Surg 2016; 20:1830-1835. [PMID: 27604886 DOI: 10.1007/s11605-016-3256-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Patients with metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone, and the role of surgery in these patients remains unknown. METHODS A bi-institutional retrospective review was performed for patients with metastatic pancreatic adenocarcinoma who underwent resection of the primary tumor from 2008 to 2013. The primary outcome measured was postoperative overall survival. Secondary outcomes included postoperative disease-free survival and overall survival from the time of diagnosis. RESULTS Twenty-three patients were identified who met the study criteria with a median follow-up of 30 months. Metastatic sites included the liver (n = 16), the lung (n = 6), and the peritoneum (n = 2). Chemotherapy included FOLFIRINOX (n = 14) and gemcitabine-based regimens (n = 9), with a median of 9 cycles (range 2-31) prior to surgical treatment. Median time from diagnosis to surgery was 9.7 months (IQR 5.8-12.8). Median overall survival (OS) from surgery, disease-free survival, and OS from diagnosis were 18.2 months (95 % CI 11.8-35.5), 8.6 months (95 % CI 5.2-16.8), and 34.1 months (95 % CI 22.5-46.2), respectively. The 1- and 3-year OS from surgery were 72.7 % (95 % CI 49.1-86.7) and 21.5 % (95 % CI 4.3-47.2), respectively. CONCLUSION Resection of the primary tumor in patients with metastatic pancreatic adenocarcinoma may be considered in highly selected patients with favorable imaging and CA 19-9 response following chemotherapy at high-volume centers providing multidisciplinary care. These patients should be enrolled in prospective clinical trials or institutional registries to better quantify the potential benefits of such a strategy.
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Affiliation(s)
- G Paul Wright
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA.
| | - Katherine E Poruk
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA
| | - Jennifer Steve
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA
| | - Nathan Bahary
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA
| | - Amer H Zuriekat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA, 15232, USA
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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