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Fromer MW, Hawthorne J, Philips P, Egger ME, Scoggins CR, McMasters KM, Martin RCG. An Improved Staging System for Locally Advanced Pancreatic Cancer: A Critical Need in the Multidisciplinary Era. Ann Surg Oncol 2021; 28:6201-6210. [PMID: 34089107 DOI: 10.1245/s10434-021-10174-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Locally-advanced pancreatic cancer (LAPC) is traditionally considered stage III unresectable disease. Advances in induction systemic therapy regimens, surgical technique, and perioperative care have led to successful resection of an increasing number of these tumors with reasonable perioperative outcomes and disease-free intervals. Certain anatomic characteristics that meet criteria for locally-advanced disease, however, are more likely to result in a successful surgical outcome. METHODS A practical and consistent system is needed to communicate such nuance between surgical and nonsurgical oncologists for optimal treatment planning and to improve recording for cancer registries and research studies. RESULTS The present study proposes a novel subclassification system for stage III pancreatic cancers based on their pattern of vascular involvement and examines the current evidence for resection in each scenario. Introducing needed detail into the current catch-all stage III categorization will help to direct patient referrals and increase the body of knowledge about the variable presentations of this complex malignancy. CONCLUSION This proposed staging revision for LAPC is designed to convey more actionable tumor descriptions for treating oncologists, clinical trial eligibility, and surgical patient selection in the era of effective induction systemic therapy.
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Affiliation(s)
- Marc W Fromer
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jenci Hawthorne
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Prejesh Philips
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA.
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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: 80] [Impact Index Per Article: 20.0] [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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Jegatheeswaran S, Baltatzis M, Jamdar S, Siriwardena AK. Superior mesenteric artery (SMA) resection during pancreatectomy for malignant disease of the pancreas: a systematic review. HPB (Oxford) 2017; 19:483-490. [PMID: 28410913 DOI: 10.1016/j.hpb.2017.02.437] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection of the superior mesenteric artery (SMA) during pancreatectomy is performed infrequently and is undertaken with the aim of removing non-metastatic locally advanced pancreatic tumours. SMA resection reports also encompass resection of other visceral vessels. The consequences of resection of these different arteries are not necessarily equivalent. This is a focused systematic review of the outcome of SMA resection during pancreatectomy for cancer. METHODS A computerized search of the English language literature was undertaken for the period 1st January 2000 through 30th April 2016. The keywords "Pancreatic surgery" and "Vascular resections" were used. Thirteen studies reported 70 patients undergoing pancreatectomy with SMA resection from 10,726 undergoing pancreatectomy. Individual patient-level outcome data were available for 25. RESULTS Median (range) accrual period was 132 (48-372) months. Reported peri-operative morbidity ranged from 39% to 91%. There were 5 peri-operative deaths in the 25 patients with individual-outcome data. Median survival was 11 months (95% Confidence interval 9.5-12.5 months; standard error 0.8 months). CONCLUSIONS SMA resection during pancreatectomy is undertaken infrequently incurring high peri-operative morbidity and mortality. Median survival is 11 (95% CI 9.5-12.5) months. In contemporary practice there is no evidence to support SMA resection during pancreatectomy.
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Affiliation(s)
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK.
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Miyazaki M, Yoshitomi H, Takano S, Shimizu H, Kato A, Yoshidome H, Furukawa K, Takayashiki T, Kuboki S, Suzuki D, Sakai N, Ohtuka M. Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer. Langenbecks Arch Surg 2017; 402:447-456. [PMID: 28361216 DOI: 10.1007/s00423-017-1578-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. METHODS Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. RESULTS Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. CONCLUSIONS Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan.
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Hiroaki Shimizu
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Atsushi Kato
- International University of Health & Welfare Mita Hospital, Tokyo, Japan
| | - Hiroyuki Yoshidome
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Katunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Masayuki Ohtuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
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Kasumova GG, Conway WC, Tseng JF. The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery. Ann Surg Oncol 2016; 25:51-58. [DOI: 10.1245/s10434-016-5676-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Indexed: 12/19/2022]
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Current State of Vascular Resections in Pancreatic Cancer Surgery. Gastroenterol Res Pract 2015; 2015:120207. [PMID: 26609306 PMCID: PMC4644845 DOI: 10.1155/2015/120207] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/05/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer (PDAC) is the fourth leading cause of cancer-related mortality in the Western world and, even in 2014, a therapeutic challenge. The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis. As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies. In contrast to adjuvant treatment which has to be regarded as a cornerstone to achieve long-term survival after resection, neoadjuvant treatment strategies for locally advanced findings are currently under debate. This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.
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Ouaïssi M, Turrini O, Hubert C, Louis G, Gigot JF, Mabrut JY. Vascular resection during radical resection of pancreatic adenocarcinomas: evolution over the past 15 years. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:623-38. [PMID: 24890182 DOI: 10.1002/jhbp.122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This literature review aimed to critically analyze oncological results of vascular resection during pancreatectomy for adenocarcinoma in the light of the concept evolution of locally advanced tumors and microscopic complete resection. The literature search was conducted in PubMed and Medline for the period June 1994 to December 2012, retaining English as the language of publication. The review of 12 publications indicated that mortality and morbidity rates were not significantly different for pancreatectomy with or without venous resection (VR). Six comparative studies showed worse long-term survival in the VR group, though one meta-analysis, albeit with a significant population heterogeneity, demonstrated that the overall survival between VR and the control group was similar (12% vs. 17%). The compilation of 13 comparative studies showed a significantly lower rate of complete microscopic resection in the VR patient group compared to controls (63% vs. 77%; P = 0.001). Concerning pancreatectomy combined to arterial resection, the literature review indicated a significantly greater mortality and morbidity rate and a lower survival rate compared to pancreatic resection alone. Conflicting results concerning the long-term outcome of VR was due to the heterogeneity of the patient population. Since the only chance to cure patients of pancreatic adenocarcinoma is to obtain free resection margins, VR is a valid therapeutic option. But combined arterial resection to pancreatic resection does not appear to be recommended.
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Affiliation(s)
- Mehdi Ouaïssi
- Department of Digestive Surgery, Timone Hospital, Marseille, France
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Calvo F, Guillen Ponce C, Muñoz Beltran M, Sanjuanbenito Dehesa A. Multidisciplinary management of locally advanced–borderline resectable adenocarcinoma of the head of the pancreas. Clin Transl Oncol 2012. [DOI: 10.1007/s12094-012-0962-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 2012; 254:882-93. [PMID: 22064622 DOI: 10.1097/sla.0b013e31823ac299] [Citation(s) in RCA: 316] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of pancreatic cancers are diagnosed at an advanced stage. As surgical resection remains the only hope for cure, more aggressive surgical approaches have been advocated to increase resection rates. Institutions have begun to release data on their experience with pancreatectomy and simultaneous arterial resection (AR), which has traditionally been considered a general contraindication to resection. The aim of the present meta-analysis was to evaluate the perioperative and long-term outcomes of patients with AR during pancreatectomy for pancreatic cancer. METHODS The Medline, Embase, and Cochrane Library and J-East databases were systematically searched to identify studies reporting outcome of patients who underwent pancreatectomy with AR for pancreatic cancer. Studies that reported perioperative and/or long-term results after pancreatectomy with AR were eligible for inclusion. Meta-analyses included comparative studies providing data on patients with and without AR and were performed using a random effects model. RESULTS The literature search identified 26 studies including 366 and 2243 patients who underwent pancreatectomy with and without AR. All studies were retrospective cohort studies and the methodological quality was moderate to low. Meta-analyses revealed AR to be associated with a significantly increased risk for perioperative mortality [Odds ratio (OR) = 5.04; 95% confidence interval (CI), 2.69-9.45; P < 0.0001; I² = 24%], poor survival at 1 year (OR = 0.49; 95% CI, 0.31-0.78; P = 0.002; I² = 35%) and 3 years (OR = 0.39; 95% CI, 0.17-0.86; P = 0.02; I² = 49%) compared with patients without AR. The increased perioperative mortality (OR = 8.87; 95% CI, 3.40-23.13; P < 0.0001; I² = 5%) and lower survival rate at 1 year (OR = 0.50; 95% CI, 0.31-0.82; P = 0.006; I² = 40%) was confirmed in the comparison to patients undergoing venous resection. Despite substantial perioperative mortality, pancreatectomy with AR was associated with more favorable survival compared with patients who did not undergo resection for locally advanced disease. CONCLUSIONS AR in patients undergoing pancreatectomy for pancreatic cancer is associated with a poor short and long-term outcome. Pancreatectomy with AR may, however, be justified in highly selected patients owing to the potential survival benefit compared with patients without resection. These patients should be treated within the bounds of clinical trials to assess outcomes after AR in the era of modern pancreatic surgery and multimodal therapy.
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Abstract
The increase in surgery for pancreatic cancer during the last 3 decades can be correlated with a gradual decline in operative mortality and postoperative complications. Although not all surgeons (nor all hospitals) can have equal outcomes, the definition and tabulation of these outcomes have been difficult. This article asks several pertinent questions: (1) what is the scientific rationale for pancreatic resection? (2) what are the best available results at this time? (3) who should be performing pancreatic resections? The article analyzes results of resection for adenocarcinoma of the exocrine pancreas, and excludes duodenal and ampullary cancers, pancreatic endocrine tumors, and tumors of less malignant potential.
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