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Addeo P, de Marini P, Averous G, Trog A, de Mathelin P, Gussago S, Fiore L, Geyer L, Noblet V, Bachellier P. Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score. HPB (Oxford) 2024; 26:717-725. [PMID: 38378305 DOI: 10.1016/j.hpb.2024.02.004] [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: 02/23/2023] [Revised: 10/27/2023] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications. METHODS A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents. RESULTS Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01). CONCLUSION A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France.
| | - Pierre de Marini
- Department of Radiology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Arnaud Trog
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France
| | - Pierre de Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Stefano Gussago
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Laura Fiore
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Lucas Geyer
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Vincent Noblet
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, 67400, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Ross SB, Popover J, Sucandy I, Christodoulou M, Pattilachan TM, Rosemurgy AS. The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma. Am Surg 2024:31348241248703. [PMID: 38635295 DOI: 10.1177/00031348241248703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.
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Affiliation(s)
- Sharona B Ross
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Jesse Popover
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
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AlMasri S, Zenati M, Hammad A, Nassour I, Liu H, Hogg ME, Zeh HJ, Boone B, Bahary N, Singhi AD, Lee KK, Paniccia A, Zureikat AH. Adaptive Dynamic Therapy and Survivorship for Operable Pancreatic Cancer. JAMA Netw Open 2022; 5:e2218355. [PMID: 35737385 PMCID: PMC9227002 DOI: 10.1001/jamanetworkopen.2022.18355] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/05/2022] [Indexed: 12/17/2022] Open
Abstract
Importance Neoadjuvant therapy is increasingly used in localized pancreatic carcinoma, and survival is correlated with carbohydrate antigen 19-9 (CA19-9) levels and histopathologic response following neoadjuvant therapy. With several regimens now available, the choice of chemotherapy could be best dictated by response to neoadjuvant therapy (as measured by CA19-9 levels and/or pathologic response), a strategy defined herein as adaptive dynamic therapy. Objective To evaluate the association of adaptive dynamic therapy with oncologic outcomes in patients with surgically resected pancreatic cancer. Design, Setting, and Participants This retrospective cohort study included patients with localized pancreatic cancer who were treated with either gemcitabine/nab-paclitaxel or fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) preoperatively between 2010 and 2019 at a high-volume tertiary care academic center. Participants were identified from a prospectively maintained database and had a median follow-up of 49 months. Data were analyzed from October 17 to November 24, 2020. Exposures The adaptive dynamic therapy group included 219 patients who remained on or switched to an alternative regimen as dictated by CA19-9 response and for whom the adjuvant regimen was selected based on CA19-9 and/or pathologic response. The nonadaptive dynamic therapy group included 103 patients who had their chemotherapeutic regimen selected independent of CA19-9 and/or tumoral response. Main Outcomes and Measures Prognostic implications of dynamic perioperative therapy assessed through Kaplan-Meier analysis, Cox regression, and inverse probability weighted estimators. Results A total of 322 consecutive patients (mean [SD] age, 65.1 [9] years; 162 [50%] women) were identified. The adaptive dynamic therapy group, compared with the nonadaptive dynamic therapy group, had a more pronounced median (IQR) decrease in CA19-9 levels (-80% [-92% to -56%] vs -45% [-81% to -13%]; P < .001), higher incidence of complete or near-complete tumoral response (25 [12%] vs 2 [2%]; P = .007), and lower median (IQR) number of lymph node metastasis (1 [0 to 4] vs 2 [0 to 4]; P = .046). Overall survival was significantly improved in the dynamic group compared with the nondynamic group (38.7 months [95% CI, 34.0 to 46.7 months] vs 26.5 months [95% CI, 23.5 to 32.9 months]; P = .03), and on adjusted analysis, dynamic therapy was independently associated with improved survival (hazard ratio, 0.73; 95% CI, 0.53 to 0.99; P = .04). On inverse probability weighted analysis of 320 matched patients, the average treatment effect of dynamic therapy was to increase overall survival by 11.1 months (95% CI, 1.5 to 20.7 months; P = .02). Conclusions and Relevance In this cohort study that sought to evaluate the role of adaptive dynamic therapy in localized pancreatic cancer, selecting a chemotherapeutic regimen based on response to preoperative therapy was associated with improved survival. These findings support an individualized and in vivo assessment of response to perioperative therapy in pancreatic cancer.
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Affiliation(s)
- Samer AlMasri
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen Zenati
- Department of Surgery, Epidemiology, Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Abdulrahman Hammad
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Hao Liu
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E. Hogg
- Department of Surgery, NorthShore Hospital System, Chicago, Illinois
| | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Brian Boone
- Department of Surgery, West Virginia University, Morgantown
| | - Nathan Bahary
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Aatur D. Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth K. Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Amer H. Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Systematic review and meta-analysis of diagnostic performance of CT imaging for assessing resectability of pancreatic ductal adenocarcinoma after neoadjuvant therapy: importance of CT criteria. Abdom Radiol (NY) 2021; 46:5201-5217. [PMID: 34331549 DOI: 10.1007/s00261-021-03198-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess the CT diagnostic performance for evaluating resectability of pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant therapy and identify the factor(s) that affect(s) diagnostic performance. METHODS Databases were searched to identify studies published from January 1, 2000, to November 5, 2019 that evaluated the CT diagnostic performance for assessing resectability of post-neoadjuvant PDAC. Two reviewers independently extracted data and assessed the study quality. A meta-analysis was performed to obtain summary sensitivity and specificity values using a bivariate random-effects model, and heterogeneity across studies was assessed. Univariable meta-regression analysis was performed with eight variables, including the different CT criteria for resectability, conventional National Comprehensive Cancer Network (NCCN) criteria for upfront surgery, and modified criteria for post-neoadjuvant surgery. RESULTS Ten studies were included and analyzed. The summary sensitivity and specificity for resectability were 78% (95% CI 68-86%) and 60% (95% CI 44-74%), respectively. No significant heterogeneity was identified (bivariate correlation coefficient ρ = - 1, p-value for hierarchical summary receiver operating characteristics model β = 0.667). The two different CT criteria showed different diagnostic performance (p < 0.01), with higher sensitivity (81% [95% CI 73-90%] vs. 28% [95% CI 15-42%], p < 0.01) and lower specificity (57% [95% CI 41-73%] vs. 90% [95% CI 80-100%], p < 0.01) for the modified criteria. No other variables affected the diagnostic performance. CONCLUSION CT criteria were the factors that affected the diagnostic performance. Modification of the conventional criteria improved sensitivity but lowered specificity. Further modifications are required to improve specificity and uniformity.
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Prognostic significance of residual lymphovascular invasion after resection of locally advanced and borderline resectable pancreatic adenocarcinomas treated by neoadjuvant chemotherapy. HPB (Oxford) 2021; 23:1285-1295. [PMID: 33546897 DOI: 10.1016/j.hpb.2021.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/21/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The current study aimed to identify histological prognostic factors after resection of locally advanced (LA) and borderline (BL) pancreatic adenocarcinomas treated by neoadjuvant chemotherapy (NC). METHODS A retrospective review was performed of patients with LA and BL adenocarcinomas operated after NC between January 2010 and April 2018. Prognostic factors for survival were assessed by multivariate Cox analysis. RESULTS Of the 84 patients, 29 had BL and 55 had LA pancreatic adenocarcinomas. Seventy-five patients underwent synchronous venous resection and 57 underwent arterial resection. The median overall survival from surgery was 21.10 months (BL 23-LA 21) (95% CI: 14.8-30.3) with 1-, 3-, and 5-year overall survival rates of 73%, 32%, and 20%, respectively. Multivariate analysis identified lymphovascular invasion (LVI) as an independent prognostic factor for overall survival (HR: 2.32, 95% CI: 1.28-4.22; p = 0.004). Patients without LVI (n = 37) had superior median overall and 5-year survival rates (31.0 months [40 from diagnosis]; 39%) compared to patients with LVI (n = 47; 14.4 months [22 from diagnosis]; 7%). The absence of residual LVI was associated with major pathologic response rates (p < 0.05). CONCLUSION The persistence of LVI at pathology after resection of LA and BL treated by neoadjuvant chemotherapy predicts poor response and limited long-term survival.
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Addeo P, Bachellier P. Pancreaticoduodenectomy with Segmental Venous Resection: a Standardized Technique Avoiding Graft Interposition. J Gastrointest Surg 2021; 25:1925-1931. [PMID: 33904058 DOI: 10.1007/s11605-021-05012-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- 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, 1, Avenue Molière, 67098, Strasbourg, France. .,ICube, Université de Strasbourg, CNRS UMR 7357, 67400, Illkirch, France.
| | - 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, 1, Avenue Molière, 67098, Strasbourg, France
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Addeo P, Guerra M, Bachellier P. Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and arterial reconstruction: Techniques and outcomes. J Surg Oncol 2021; 123:1592-1598. [PMID: 33684225 DOI: 10.1002/jso.26424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/30/2021] [Accepted: 01/30/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ischemic complications are still prevalent after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) despite the use of preoperative arterial embolization. We described our institutional experience with arterial reconstruction during DP-CAR. METHODS We retrospectively reviewed short- and long-term outcomes of all DP-CAR performed for pancreatic adenocarcinoma between January 1, 1995 and March 30, 2020. Outcomes were compared according to the presence of arterial reconstruction. RESULTS Sixty consecutive DP-CARs were reviewed. Most patients underwent induction chemotherapy (85%) based on FOLFIRINOX protocol (80.3%). The hepatic artery was reconstructed in 50 patients (83.3%). The left gastric artery was reconstructed in 4 and preserved in 14 patients. A venous resection was associated during 44 DP-CARs (36 segmental venous resections/8 lateral venous resections). Ninety days mortality was 5.0% with 48.3% (n = 29) overall rate of morbidity. Postoperative outcomes in term of mortality, morbidity, and ischemic events between patients with and without arterial reconstruction were similar despite a higher rate of venous resection (81% vs. 40%; p = 0.005) and more complex cases (Mayo clinic DP-CARs class 1B, 2A, and 3A) in the reconstructed group. CONCLUSION Arterial reconstruction represents a safe surgical option during DP-CAR to lessen postoperative ischemic events. This technique, reserved to high volume centers expert in vascular resection during pancreatectomy, deserves further comparison with standard technique in a larger setting.
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Affiliation(s)
- 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, Strasbourg, France
| | - Martina Guerra
- 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, Strasbourg, France
| | - 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, Strasbourg, France
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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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Systematic review and meta-analysis of contemporary pancreas surgery with arterial resection. Langenbecks Arch Surg 2020; 405:903-919. [PMID: 32894339 PMCID: PMC7541389 DOI: 10.1007/s00423-020-01972-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 12/19/2022]
Abstract
Objective Advances in multimodality treatment paralleled increasing numbers of complex pancreatic procedures with major vascular resections. The aim of this meta-analysis was to evaluate the current outcomes of arterial resection (AR) in pancreatic surgery. Methods A systematic literature search was carried out from January 2011 until January 2020. MOOSE guidelines were followed. Predefined outcomes were morbidity, pancreatic fistula, postoperative bleeding and delayed gastric emptying, reoperation rate, mortality, hospital stay, R0 resection rate, and lymph node positivity. Duration of surgery, blood loss, and survival were also analyzed. Results Eight hundred and forty-one AR patients were identified in a cohort of 7111 patients. Morbidity and mortality rates in these patients were 66.8% and 5.3%, respectively. Seven studies (579 AR patients) were included in the meta-analysis. Overall morbidity (48% vs 39%, p = 0.1) and mortality (3.2% vs 1.5%, p = 0.27) were not significantly different in the groups with or without AR. R0 was less frequent in the AR group, both in patients without (69% vs 89%, p < 0.001) and with neoadjuvant treatment (50% vs 86%, p < 0.001). Weighted median survival was shorter in the AR group (18.6 vs 32 months, range 14.8–43.1 months, p = 0.037). Conclusions Arterial resections increase the complexity of pancreatic surgery, as demonstrated by relevant morbidity and mortality rates. Careful patient selection and multidisciplinary planning remain important. Electronic supplementary material The online version of this article (10.1007/s00423-020-01972-2) contains supplementary material, which is available to authorized users.
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Is Surgery-first Still a Reasonable Option in the Era of Neoadjuvant Chemotherapy for Resectable Pancreatic Cancer? Am J Clin Oncol 2020; 43:298-304. [PMID: 31895096 DOI: 10.1097/coc.0000000000000661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The incidence of pancreatic ductal adenocarcinoma has risen rapidly. By 2030, it is likely to be the second most prevalent cause of death by cancer, following cancer of the lung. Unfortunately, most patients present with advanced disease. In fact, only 20% of patients are candidates for surgery. More research is needed to find dependable treatment options for this disease. Although we wait for more effective treatments to be developed, we continue using chemotherapy, radiation, and surgery-all with less than optimal outcomes. There is a debate about using chemotherapy in the neoadjuvant setting and counter-debate about better outcomes in the adjuvant settings. In the neoadjuvant setting, not everyone is able to make it to surgery; conversely, in the adjuvant setting, not everyone is able to make it to chemotherapy. Drop-out data after surgery are widely available, but similar drop-out rates after neoadjuvant treatment are not widely published. Here, we will analyze the literature to better understand the treatment strategies and outcomes of pancreatic ductal adenocarcinoma. We argue in favor of an upfront surgery and adjuvant therapy strategy for better outcomes and patient quality of life.
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Pancreatectomy With Arterial Resection for Pancreatic Adenocarcinoma: How Can It Be Done Safely and With Which Outcomes?: A Single Institution's Experience With 118 Patients. Ann Surg 2020; 271:932-940. [PMID: 30188399 DOI: 10.1097/sla.0000000000003010] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study assesses the safety and outcomes of the largest cohort of pancreatectomy with arterial resection (P-AR). BACKGROUND A high postoperative mortality rate and uncertain oncologic benefits have limited the use of P-AR for locally advanced pancreatic adenocarcinoma. METHODS We retrospectively reviewed a prospectively maintained database of patients who underwent P-AR between January 1990 and November 2017. Univariate and multivariate Cox analyses were used to assess prognostic factors for survival. RESULTS There were 118 consecutive resections (51 pancreaticoduodenectomies, 18 total pancreatectomies, and 49 distal splenopancreatectomies). Resected arterial segments included the coeliac trunk (50), hepatic artery (29), superior mesenteric artery (35), and other segments (4). The overall mortality and morbidity were 5.1% and 41.5%, respectively. There were 84 (75.4%) patients who received neoadjuvant chemotherapy, 105 (89%) simultaneous venous resections, and 101 (85.5%) arterial reconstructions. The rates of R0 resection and pathologic invasion of venous and arterial walls were 52.4%, 74.2%, and 58%, respectively. The overall survival was 59%, 13%, and 11.8% at 1, 3, and 5 years, respectively. The median overall survival after resection was 13.70 months (CI 95%:11-18.5 mo). In multivariate analysis, R0 resection (HR: 0.60; 95% CI: 0.38-0.96; P = 0.01) and venous invasion (HR: 1.67; 95% CI: 1.01-2.63; P = 0.04) were independent prognostic factors. CONCLUSION In a specialized setting, P-AR for locally advanced pancreatic adenocarcinoma can be performed safely with limited mortality and morbidity. Negative resection margin and the absence of associated venous invasion might predict favorable long-term outcomes.
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12
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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Rosso E, Zimmitti G, Iannelli A, Garatti M. The ‘TRIANGLE Operation’ by Laparoscopy: Radical Pancreaticoduodenectomy with Major Vascular Resection for Borderline Resectable Pancreatic Head Cancer. Ann Surg Oncol 2019; 27:1613-1614. [DOI: 10.1245/s10434-019-08101-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Indexed: 02/06/2023]
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14
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Janssen QP, Buettner S, Suker M, Beumer BR, Addeo P, Bachellier P, Bahary N, Bekaii-Saab T, Bali MA, Besselink MG, Boone BA, Chau I, Clarke S, Dillhoff M, El-Rayes BF, Frakes JM, Grose D, Hosein PJ, Jamieson NB, Javed AA, Khan K, Kim KP, Kim SC, Kim SS, Ko AH, Lacy J, Margonis GA, McCarter MD, McKay CJ, Mellon EA, Moorcraft SY, Okada KI, Paniccia A, Parikh PJ, Peters NA, Rabl H, Samra J, Tinchon C, van Tienhoven G, van Veldhuisen E, Wang-Gillam A, Weiss MJ, Wilmink JW, Yamaue H, Homs MYV, van Eijck CHJ, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in Patients With Borderline Resectable Pancreatic Cancer: A Systematic Review and Patient-Level Meta-Analysis. J Natl Cancer Inst 2019; 111:782-794. [PMID: 31086963 PMCID: PMC6695305 DOI: 10.1093/jnci/djz073] [Citation(s) in RCA: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/19/2018] [Accepted: 04/22/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. METHODS We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. RESULTS We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n = 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] = 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI = 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patient-level survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI = 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI = 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI = 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI = 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI = 8.1 to 14.2). No deaths were attributed to FOLFIRINOX. CONCLUSIONS This patient-level meta-analysis of BRPC patients treated with neoadjuvant FOLFIRINOX showed a favorable median OS, resection rate, and R0-resection rate. These results need to be assessed in a randomized trial.
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Affiliation(s)
| | - Stefan Buettner
- See the Notes section for the full list of authors’ affiliations
| | - Mustafa Suker
- See the Notes section for the full list of authors’ affiliations
| | - Berend R Beumer
- See the Notes section for the full list of authors’ affiliations
| | - Pietro Addeo
- See the Notes section for the full list of authors’ affiliations
| | | | - Nathan Bahary
- See the Notes section for the full list of authors’ affiliations
| | | | - Maria A Bali
- See the Notes section for the full list of authors’ affiliations
| | - Marc G Besselink
- See the Notes section for the full list of authors’ affiliations
| | - Brian A Boone
- See the Notes section for the full list of authors’ affiliations
| | - Ian Chau
- See the Notes section for the full list of authors’ affiliations
| | - Stephen Clarke
- See the Notes section for the full list of authors’ affiliations
| | - Mary Dillhoff
- See the Notes section for the full list of authors’ affiliations
| | | | - Jessica M Frakes
- See the Notes section for the full list of authors’ affiliations
| | - Derek Grose
- See the Notes section for the full list of authors’ affiliations
| | - Peter J Hosein
- See the Notes section for the full list of authors’ affiliations
| | - Nigel B Jamieson
- See the Notes section for the full list of authors’ affiliations
| | - Ammar A Javed
- See the Notes section for the full list of authors’ affiliations
| | - Khurum Khan
- See the Notes section for the full list of authors’ affiliations
| | - Kyu-Pyo Kim
- See the Notes section for the full list of authors’ affiliations
| | - Song Cheol Kim
- See the Notes section for the full list of authors’ affiliations
| | - Sunhee S Kim
- See the Notes section for the full list of authors’ affiliations
| | - Andrew H Ko
- See the Notes section for the full list of authors’ affiliations
| | - Jill Lacy
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Colin J McKay
- See the Notes section for the full list of authors’ affiliations
| | - Eric A Mellon
- See the Notes section for the full list of authors’ affiliations
| | | | - Ken-Ichi Okada
- See the Notes section for the full list of authors’ affiliations
| | | | - Parag J Parikh
- See the Notes section for the full list of authors’ affiliations
| | - Niek A Peters
- See the Notes section for the full list of authors’ affiliations
| | - Hans Rabl
- See the Notes section for the full list of authors’ affiliations
| | - Jaswinder Samra
- See the Notes section for the full list of authors’ affiliations
| | | | | | | | | | - Matthew J Weiss
- See the Notes section for the full list of authors’ affiliations
| | | | - Hiroki Yamaue
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Matthew H G Katz
- See the Notes section for the full list of authors’ affiliations
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15
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Pathologic tumor response to neoadjuvant therapy in borderline resectable pancreatic cancer. Hepatobiliary Pancreat Dis Int 2019; 18:373-378. [PMID: 31176601 DOI: 10.1016/j.hbpd.2019.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy (NAT). The aim of this study was to determine the incidence of significant pathologic response to NAT in borderline resectable pancreatic cancer (BRPC), and association of NAT regimen and other clinico-pathologic characteristics with pathologic response. METHODS Patients with BRPC who underwent NAT and pancreatic resection between January 2012 and June 2017 were included. Pathologic response was assessed on a qualitative scale based on the College of American Pathologists grading system. Demographics and baseline characteristics, oncologic treatment, pathology, and survival outcomes were compared. RESULTS Seventy-one patients were included for analysis. Four patients had complete pathologic responses (tumor regression score 0), 12 patients had marked responses (score 1), 42 had moderate responses (score 2), and 13 had minimal responses (score 3). Patients with complete or marked responses were more likely to have received neoadjuvant gemcitabine chemoradiation (62.5%, 38.1%, and 23.1% of the complete/marked, moderate, and minimal response groups, respectively; P = 0.04). Of the complete/marked, moderate, and minimal response groups, margins were negative in 75.0%, 78.6%, and 46.2% (P = 0.16); node negative disease was observed in 87.5%, 54.8%, and 15.4% (P < 0.01); and median overall survival was 50.0 months, 31.7 months, and 23.2 months (P = 0.563). Of the four patients with pathologic complete responses, three were disease-free at 66.1, 41.7 and 31.4 months, and one was deceased with metastatic liver disease at 16.9 months. CONCLUSIONS A more pronounced pathologic tumor response to NAT in BRPC is correlated with node negative disease, but was not associated with a statistically significant survival benefit in this study.
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He M, Liu Z, Lin Y, Wan J, Li J, Xu K, Wang Y, Jin Z, Tian J, Xue H. Differentiation of atypical non-functional pancreatic neuroendocrine tumor and pancreatic ductal adenocarcinoma using CT based radiomics. Eur J Radiol 2019; 117:102-111. [PMID: 31307634 DOI: 10.1016/j.ejrad.2019.05.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/04/2019] [Accepted: 05/30/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To develop and validate an effective model to differentiate NF-pNET from PDAC. MATERIALS AND METHODS Between July 2014 and December 2017, 147 patients (80 patients with PDAC and 67 patients with atypical NF-pNET) with pathology results and enhanced CT were consecutively enrolled and chronologically divided into primary and validation cohorts. Three models were built to differentiate atypical NF-pNET from PDAC, including a model based on radiomic signature alone, one based on clinicoradiological features alone and one that integrated the two. The diagnostic performance of the three models was estimated and compared with the area under the receiver operating characteristic curve (AUC) in the validation cohort. A nomogram was used to represent the model with the best performance, and the associated calibration was also assessed. RESULTS In the validation cohort, the AUC for differential diagnosis was 0.884 with the integrated model, which was significantly improved over that of the model based on clinicoradiological features (AUC = 0.775, p value = 0.004) and was comparable to that of the model based on the radiomic signature (AUC = 0.873, p value = 0.512). The nomogram representing the integrated model achieved good discrimination performances in both the primary and validation cohorts, with C-indices of 0.960 and 0.884, respectively. CONCLUSION The integrated model outperformed the model based on clinicoradiological features alone and was comparable to the model based on the radiomic signature alone with respect to the differential diagnosis of atypical NF-pNET and PDAC. The nomogram achieved an optimal preoperative, noninvasive differential diagnosis between atypical pNET and PDAC, which can better inform therapeutic choice in clinical practice.
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Affiliation(s)
- Ming He
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China
| | - Zhenyu Liu
- From CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing and China and University of Chinese Academy of Sciences, Beijing, 100049, China; University of Chinese Academy of Sciences, Beijing, 100080, China
| | - Yusong Lin
- From the Software Technology School of Zhengzhou University, Zhengzhou, China
| | - Jianzhong Wan
- From the Software Technology School of Zhengzhou University, Zhengzhou, China
| | - Juan Li
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China
| | - Kai Xu
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China
| | - Yun Wang
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China
| | - Zhengyu Jin
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China
| | - Jie Tian
- From CAS Key Laboratory of Molecular Imaging, Beijing Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing and China and University of Chinese Academy of Sciences, Beijing, 100049, China; University of Chinese Academy of Sciences, Beijing, 100080, China; Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Medicine, Beihang University, Beijing, 100191, China; Engineering Research Center of Molecular and Neuro Imaging of Ministry of Education, School of Life Science and Technology, Xidian University, Xi'an, Shaanxi, 710126, China.
| | - Huadan Xue
- From the Department of Radiology, Peking Union Medical College Hospital Beijing, China.
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Garbarino GM, Fuks D, Cowan J, Ward M, Moisan F, Donatelli G, Beaussier M, Gayet B. Total Laparoscopic Pancreaticoduodenectomy with Venous Reconstruction for Pancreatic Head Cancer with Involvement of the Superior Mesenteric Vein–Portal Vein Confluence. Ann Surg Oncol 2018; 25:4035-4036. [DOI: 10.1245/s10434-018-6762-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Indexed: 01/15/2023]
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18
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Kim BR, Kim JH, Ahn SJ, Joo I, Choi SY, Park SJ, Han JK. CT prediction of resectability and prognosis in patients with pancreatic ductal adenocarcinoma after neoadjuvant treatment using image findings and texture analysis. Eur Radiol 2018; 29:362-372. [PMID: 29931561 DOI: 10.1007/s00330-018-5574-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess utility of CT findings and texture analysis for predicting the resectability and prognosis in patients after neoadjuvant therapy for pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS Among 308 patients, 45 with PDAC underwent neoadjuvant therapy (concurrent-chemoradiation-therapy, CCRT, n = 27 and chemotherapy, ChoT, n = 18) before surgery were included. All underwent baseline and preoperative CT. Two reviewers assessed CT findings and resectability. We analyzed relationship between CT resectability and residual tumor. CT texture values obtained by subtracting preoperative from baseline CT were analyzed using multivariate Cox/logistic regression analysis to identify significant parameters predicting resectability and prognosis. RESULTS There were 30 patients without residual tumor (CCRT, n = 20; ChoT, n = 10) and 15 with residual tumor (CCRT, n = 7; ChoT, n = 8). Considering borderline as resectable was more accurate for R0 resectability than considering borderline as unresectable (68.9% vs 55.6% and 51.1%, p < 0.001). Particularly, neoadjuvant CCRT provided better accuracy than that in (p < 0.001). In CT texture analysis, higher subtracted entropy (cut-off: 0.03, HR 0.159, p = 0.005) and lower subtracted GLCM entropy (cut-off: -0.35, HR 10.235, p = 0.036) are important parameters for prediction of longer overall survival. CONCLUSION CT findings with texture analysis can be useful for predicting a patient's outcome, including resectability and prognosis, after neoadjuvant therapy for PDAC. KEY POINTS • Considering borderline resectable tumor as resectable have better accuracy for resectability. • Considering borderline as resectable, CCRT-patients have better resectability accuracy than chemotherapy-patients. • Higher subtracted entropy and lower subtracted GLCM entropy are predictors of favorable outcome.
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Affiliation(s)
- Bo Ram Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea.
- Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Su Joa Ahn
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang Joon Park
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul, 110-744, Republic of Korea
- Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
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19
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Chen X, Liu G, Wang K, Chen G, Sun J. Neoadjuvant radiation followed by resection versus upfront resection for locally advanced pancreatic cancer patients: a propensity score matched analysis. Oncotarget 2018; 8:47831-47840. [PMID: 28599299 PMCID: PMC5564608 DOI: 10.18632/oncotarget.18091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/07/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM To compare cancer-specific survival (CSS) between patients who received neoadjuvant radiation followed by resection (NRR) and those who received upfront resection (UR) for locally advanced pancreatic cancer (LAPC). METHODS A total of 772 LAPC patients who underwent curative-intent surgical resection with or without neoadjuvant radiation from 2004 to 2013 were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Propensity score matching (PSM) was conducted to eliminate possible bias. Kaplan-Meier method was used to analyze long-term outcome. Independent risk factors of CSS were predicted by Cox proportional hazards model. Subgroup analyses were done according to 5 variables. RESULTS The propensity score model matched 196 patients from the whole cohort. Neoadjuvant radiation was an independent predictor of CSS no matter before or after PSM. After PSM, the 1-, 3-, 5-year CSS rates of NRR group were 82.7%, 39.2% and 17.1%, while 64.3%, 19.9% and 12.4% for UR group. The median CSS for NRR group was 25 months, while 17 months for UR group. In subgroup analyses, CSS rates or median CSS of NRR group were still superior to those of UR group in married, unmarried, pancreatic adenocarcinoma, G1+G2, G3+G4, N0 stage, N1 stage and M0 stage subgroups, but no differences were found in other histological types and M1 stage subgroups. Other predictors of CSS included histological type, tumor grade and marital status. CONCLUSIONS Neoadjuvant radiation followed by resection has a significant survival benefit compared with upfront resection in LAPC patients. Therapeutic strategy for LAPC patients should be further explored.
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Affiliation(s)
- Xing Chen
- Department of Hepatopancreatobiliary Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Geng Liu
- Department of Hepatopancreatobiliary Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Kaiqiang Wang
- Department of Hepatopancreatobiliary Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guodong Chen
- Department of Hepatopancreatobiliary Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Jinjin Sun
- Department of Hepatopancreatobiliary Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
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20
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Zhang Y, Qin L, Zhang C. Investigation of Association Between Borderline Pancreatic Head Cancer and Glucose Uptake by Using Positron-Emission Tomographic Studies. Med Sci Monit 2017; 23:4947-4953. [PMID: 29036034 PMCID: PMC5655162 DOI: 10.12659/msm.904746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In the background of the well-known importance of positron-emission tomographic studies (PET) in the prediction of pancreatic oncologic problems, we designed and performed this investigation to study the link between borderline pancreatic head cancer and glucose uptake by using PET. MATERIAL AND METHODS We retrospectively investigated patients during the period of almost 4 years (May 2013 to December 2016). Patients underwent potentially curative resection for borderline exocrine pancreatic head adenocarcinoma without undergoing neoadjuvant therapy. We divided our PET protocol into 2 sets of methods as per renal calyces: 1) U-RC type in which renal calyx (RC) has relatively higher value than that of 18F-fluoro-2-deoxyglucose (18F-FDG) uptake and 2) S-RC type in which renal calyx has similar value than that of 18F-FDG uptake. RESULTS A total of 67 patients were enrolled after reclassification on the basis of majority-agreement. Among these patients, U-RC type was found in 22 patients (32.8%) while S-RC type was found in 45 patients (67.2%). Significant statistical differences were observed for each of the 2 types of pancreatic head cancer (U-RC type and S-RC type) in terms of adjusted cancer antigen 19-9 (CA 19-9), size of the tumor, tumor volume (TV2.8), maximum standard uptake value (SUV↑), and lesion glycolysis (LG). A significantly longer disease-free survival time was shown by U-RC type (n=18) pancreatic cancer in comparison to S-RC type (n=42) (25.3 vs. 11.2 months). Additionally, U-RC type (n=4) had higher disease-free survival than did aS-RC type (n=3) (29.4 vs. 12.5 months). CONCLUSIONS Our PET protocol appears to be an indicator for estimation of recurrence of pancreatic head cancer and is as an indispensable asset to oncologists.
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Affiliation(s)
- Ying Zhang
- Department of Nuclear Medicine, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
| | - Lei Qin
- Department of Nuclear Medicine, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
| | - Changming Zhang
- Department of Nuclear Medicine, Liaocheng People's Hospital, Liaocheng, Shandong, China (mainland)
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21
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El Nakeeb A, Askar W, Atef E, Hanafy EE, Sultan AM, Salah T, shehta A, Sorogy ME, Hamdy E, Hemly ME, El-Geidi AA, Kandil T, Shobari ME, Allah TA, Fouad A, Zeid MA, Eneen AAE, El-Hak NG, Ebidy GE, Fathy O, Sultan A, Wahab MA. Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases. World J Gastroenterol 2017; 23:7025-7036. [PMID: 29097875 PMCID: PMC5658320 DOI: 10.3748/wjg.v23.i38.7025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/28/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors.
METHODS This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017).
RESULTS The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.
CONCLUSION Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Waleed Askar
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ehab Atef
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ehab El Hanafy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmad M Sultan
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Tarek Salah
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed shehta
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Sorogy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Emad Hamdy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Hemly
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed A El-Geidi
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Tharwat Kandil
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Shobari
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Talaat Abd Allah
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Amgad Fouad
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mostafa Abu Zeid
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Abu El Eneen
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Nabil Gad El-Hak
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Gamal El Ebidy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Omar Fathy
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Sultan
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed Abdel Wahab
- Gastroenterology surgical center, Mansoura University, Mansoura 35516, Egypt
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Addeo P, Velten M, Averous G, Faitot F, Nguimpi-Tambou M, Nappo G, Felli E, Fuchshuber P, Bachellier P. Prognostic value of venous invasion in resected T3 pancreatic adenocarcinoma: Depth of invasion matters. Surgery 2017; 162:264-274. [PMID: 28576385 DOI: 10.1016/j.surg.2017.03.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/20/2017] [Accepted: 03/02/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Incomplete evaluation of venous invasion has led to conflicting results regarding the prognosis of patients undergoing pancreatectomy with a synchronous venous resection. This study evaluates the prognostic value associated with the presence and the depth of venous invasion in T3 pancreatic adenocarcinoma. METHODS This study evaluated retrospectively 181 consecutive pancreatoduodenectomies performed for T3N0M0 and T3N1M0 pancreatic adenocarcinomas (stages IIA and IIB) from January 2006 to December 2014. Univariate and multivariate Cox analyses were performed to assess survival prognostic factors. RESULTS Pancreatoduodenectomies with a segmental venous resection was performed on 91 patients, while 90 other patients had a standard pancreatoduodenectomies without venous resection. Pathologic venous invasion was detected in 68 (74%) of the 91 venous resection patients. Depth of venous invasion was into the adventitia (n = 25), media (n = 28), and intima (n = 15). The overall survival rates at 1, 3, 5, and 10 years were 75%, 33%, 21%, and 6%, respectively. There were no differences in survival between patients undergoing standard pancreatoduodenectomies and pancreatoduodenectomies with venous resection (27 vs 22 months; P = .28) or between patients with and without venous invasion (20 vs 27 months; P = .08). In multivariate analysis, depth of venous invasion into the intima (hazard ratio, 2.25; 95% confidence interval, 1.16-4.34; P = .0001) and adjuvant chemotherapy (hazard ratio, 0.16; 95% confidence interval, 0.09-0.43; P ≤ .0001) were identified as independent prognostic factors of overall survival. CONCLUSION Depth of venous invasion into the intima indicates poor survival in pancreatic T3 adenocarcinoma. Preoperative identification of this factor could be helpful for better selection of patients for curative operation.
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Affiliation(s)
- 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, Strasbourg, France; Cancer Registry of Bas-Rhin, Faculty of medicine, University of Strasbourg, Strasbourg, France
| | - Michel Velten
- Cancer Registry of Bas-Rhin, Faculty of medicine, University of Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Strasbourg, France
| | - François Faitot
- 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, Strasbourg, France
| | - Marlene Nguimpi-Tambou
- Department of Hepatogastroenterology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gennaro Nappo
- 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, Strasbourg, France
| | - Emanuele Felli
- 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, Strasbourg, France
| | - Pascal Fuchshuber
- Department of Surgery, The Permanente Medical Group, Kaiser Medical Center Walnut Creek, Walnut Creek, CA
| | - 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, Strasbourg, France.
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Surgical strategies and novel therapies for locally advanced pancreatic cancer. J Surg Oncol 2017; 116:16-24. [DOI: 10.1002/jso.24654] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/29/2017] [Indexed: 12/23/2022]
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Xia BT, Fu B, Wang J, Kim Y, Ahmad SA, Dhar VK, Levinsky NC, Hanseman DJ, Habib DA, Wilson GC, Smith M, Olowokure OO, Kharofa J, Al Humaidi AH, Choe KA, Abbott DE, Ahmad SA. Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? J Surg Oncol 2017; 115:376-383. [DOI: 10.1002/jso.24538] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 11/24/2016] [Accepted: 12/04/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Brent T. Xia
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Baojin Fu
- Department of Pathology; University of Cincinnati; Cincinnati Ohio
| | - Jiang Wang
- Department of Pathology; University of Cincinnati; Cincinnati Ohio
| | - Young Kim
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - S. Ameen Ahmad
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Vikrom K. Dhar
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Nick C. Levinsky
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Dennis J. Hanseman
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - David A. Habib
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Gregory C. Wilson
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Milton Smith
- Division of Gastroenterology, Department of Internal Medicine; University of Cincinnati; Cincinnati Ohio
| | - Olugbenga O. Olowokure
- Division of Medical Oncology, Department of Internal Medicine; University of Cincinnati; Cincinnati Ohio
| | - Jordan Kharofa
- Department of Radiation Oncology; University of Cincinnati; Cincinnati Ohio
| | - Ali H. Al Humaidi
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
| | - Kyuran A. Choe
- Department of Radiology; University of Cincinnati; Cincinnati Ohio
| | - Daniel E. Abbott
- Division of Surgical Oncology, Department of Surgery; Univesity of Wisconsin; Madison Wisconsin
| | - Syed A. Ahmad
- Division of Surgical Oncology, Department of Surgery; University of Cincinnati; Cincinnati Ohio
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25
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Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement. Langenbecks Arch Surg 2016; 401:1131-1142. [PMID: 27476146 DOI: 10.1007/s00423-016-1488-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/21/2016] [Indexed: 12/22/2022]
Abstract
Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.
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Liu L, Xiang J, Chen R, Fu D, Hong D, Hao J, Li Y, Li J, Li S, Mou Y, Mai G, Ni Q, Peng L, Qin R, Qian H, Shao C, Sun B, Sun Y, Tao M, Tian B, Wang H, Wang J, Wang L, Wang W, Wang W, Zhang J, Zhao G, Zhou J, Yu X. The clinical utility of CA125/MUC16 in pancreatic cancer: A consensus of diagnostic, prognostic and predictive updates by the Chinese Study Group for Pancreatic Cancer (CSPAC). Int J Oncol 2015; 48:900-7. [PMID: 26718269 DOI: 10.3892/ijo.2015.3316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 12/28/2015] [Indexed: 02/05/2023] Open
Abstract
The prognosis for pancreatic cancer (PC) is poor; however, the timely and accurate treatment of this disease will significantly improve prognosis. Serum biomarkers involve non-invasive tests that facilitate the early detection of tumors, predict outcomes and assess responses to therapy, so that the patient can be continuously monitored and receive the most appropriate therapy. Studies have reported that cancer antigen (CA)125 [also known as mucin 16 (MUC16)] has functional significance in the tumorigenic, metastatic and drug resistant properties of PC. Our aim was to use this biomarker in the diagnosis, detection of metastasis, prognosis and in the monitoring of the treatment effects of PC. Members of the Chinese Study Group for Pancreatic Cancer (CSPAC) reviewed the literature on CA125/MUC16 and developed an objective consensus on the clinical utility of CA125/MUC16 for PC. They confirmed the role of CA125/MUC16 in tumorigenesis and the progression of PC, and recommended monitoring CA125/MUC16 levels in all aspects of the diagnosis and treatment of PC, particularly those that involve the monitoring of treatments. In addition, they suggested that the combination of other biomarkers and imaging techniques, together with CA125/MUC16, would improve the accuracy of the clinical decision-making process, thereby facilitating the optimization of treatment strategies. Periodic clinical updates of the use of CA125/MUC16 have been established, which are important for further analyses and comparisons of clinical results from affiliates and countries, particularly as regards the in-depth biological function and clinical translational research of this biomarker.
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Affiliation(s)
- Liang Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Jinfeng Xiang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Rufu Chen
- Department of Pancreaticobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, P.R. China
| | - Defei Hong
- Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, P.R. China
| | - Jihui Hao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, P.R. China
| | - Yixiong Li
- Department of Pancreatic-Bililary Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Jiangtao Li
- Department of Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Shengping Li
- Department of Hepatobiliary Oncology, Cancer Center, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yiping Mou
- Department of Gastroenterological and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, P.R. China
| | - Gang Mai
- Department of Hepatobiliopancreatic Surgery, The People's Hospital of Deyang, Deyang, P.R. China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
| | - Li Peng
- Department of Hepato-Pancreato-Biliary Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Honggang Qian
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, P.R. China
| | - Chenghao Shao
- Department of Pancreatic-Biliary Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P.R. China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Min Tao
- Department of Medical Oncology, The First Hospital Affiliated to Soochow University, Suzhou, P.R. China
| | - Bole Tian
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Hongxia Wang
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P.R. China
| | - Liwei Wang
- Department of Medical Oncology, Shanghai First People's Hospital, Shanghai, P.R. China
| | - Wei Wang
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, P.R. China
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Hangzhou, Zhejiang, P.R. China
| | - Jun Zhang
- Department of Medical Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, P.R. China
| | - Gang Zhao
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Jun Zhou
- Department of Medical Oncology, Peking University School of Oncolocy, Beijing Institute for Cancer Research, Beijing, P.R. China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, P.R. China
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