The Survival Benefit of Chemoradiotherapy following Induction Chemotherapy with Gemcitabine Plus Nab-Paclitaxel for Unresectable Locally Advanced Pancreatic Cancer

Clinical significance of germline breast cancer susceptibility gene (gBRCA) testing and olaparib as maintenance therapy for patients with pancreatic cancer

BACKGROUND

Germline breast cancer susceptibility gene (gBRCA) mutation in patients with pancreatic cancer (PC) is not common in clinical practice. Therefore, factors that efficiently show gBRCA mutations and the real-world outcomes of olaparib maintenance therapy have not been fully established. In the present study, we clarified the indicators for the effective detection of gBRCA mutation and the efficacy and safety of olaparib as maintenance therapy.

METHODS

We retrospectively analyzed 84 patients with PC who underwent gBRCA testing (BRACAnalysis, Myriad Genetics, Salt Lake City, UT, USA) at our institute between January 2021 and March 2022. For each patient, clinical data were extracted from medical records.

RESULTS

The median patient age was 64 y (29-85 y), and 41 patients (48.8%) were male. The gBRCA mutations were identified in 10 (11.9%) patients; two patients had BRCA1 mutation and eight had BRCA2 mutation. All patients with gBRCA mutation had a family history of any cancer, and eight of them had a family history of Hereditary Breast and Ovarian Cancer syndrome (HBOC)-related cancer. The gBRCA mutation rate was higher for patients with PC with a family history of HBOC-related cancer compared to that in patients with PC having a family history of other cancers and no family history of cancer (22.9% vs. 4.1%; P = 0.014). In our study, eight out of 10 patients with gBRCA-positive PC received olaparib after platinum-based chemotherapy. The best responses to platinum-based chemotherapy included a complete response in one patient (12.5%) and a partial response in seven patients (87.5%). The median duration of treatment with platinum-based chemotherapy plus olaparib was 17.5 months (8-87 months), and the duration of treatment with olaparib maintenance therapy was 11 months (1-30 months). During olaparib maintenance therapy, three patients showed no disease progression. One of these three patients underwent conversion surgery after receiving olaparib for 12 months.

CONCLUSIONS

The gBRCA testing should be considered proactively, especially in patients with PC with a family history of HBOC-related cancer.

Dosimetric characteristics of self-expandable metallic and plastic stents for transpapillary biliary decompression in external beam radiotherapy

There is little evidence regarding radiation dose perturbation caused by the self-expandable metallic stents (SEMSs) used for transpapillary biliary decompression. We aimed to compare SEMSs with plastic stents (PSs) and clarify their dosimetric characteristics. Fifteen SEMSs (10 braided and 5 lasercut type) and six PSs (diameter: 2.3-3.3 mm) were inserted into a water-equivalent solid phantom. In total, 13 SEMSs had radiopaque markers, whereas the other two did not. Using radiochromic films, the dose difference adjacent to the stents at locations proximal, distal, and arc delivery to the radiation source was evaluated based on comparison to measurement of the dose delivery in phantom without any stent in place. The median values of the dose difference for each stent were used to compare the SEMS and PS groups.Results: The dose difference (median (minimum/maximum)) was as follows: proximal, SEMSs + 2.1% (1.8 / 4.7) / PSs + 5.4% (4.1 / 6.3) (p < 0.001); distal, SEMSs -1.0% (-1.6 /-0.4) / PSs -8.9% (-11.7 / -7.4) (p < 0.001); arc delivery, SEMSs 1.2% (0.9 / 2.3) / PSs 2.2% (1.6 / 3.6) (p = 0.005). These results demonstrated that the dose differences of SEMSs were significantly smaller than those of PSs. On the other hand, the dose difference was large at surface of the radiopaque markers for SEMSs: proximal, 10.3% (7.2 / 20.9); distal, -8.4% (-16.3 / -4.2); arc delivery, 5.5% (4.2 / 9.2). SEMSs for biliary decompression can be safely used in patients undergoing radiotherapy, by focusing on the dose distribution around the stents and by paying attention to local changes in the dose distribution of radiopaque markers.

Genetic Signature of Human Pancreatic Cancer and Personalized Targeting

Pancreatic cancer is a highly lethal disease with a 5-year survival rate of around 11-12%. Surgery, being the treatment of choice, is only possible in 20% of symptomatic patients. The main reason is that when it becomes symptomatic, IT IS the tumor is usually locally advanced and/or has metastasized to distant organs; thus, early diagnosis is infrequent. The lack of specific early symptoms is an important cause of late diagnosis. Unfortunately, diagnostic tumor markers become positive at a late stage, and there is a lack of early-stage markers. Surgical and non-surgical cases are treated with neoadjuvant and/or adjuvant chemotherapy, and the results are usually poor. However, personalized targeted therapy directed against tumor drivers may improve this situation. Until recently, many pancreatic tumor driver genes/proteins were considered untargetable. Chemical and physical characteristics of mutated KRAS are a formidable challenge to overcome. This situation is slowly changing. For the first time, there are candidate drugs that can target the main driver gene of pancreatic cancer: KRAS. Indeed, KRAS inhibition has been clinically achieved in lung cancer and, at the pre-clinical level, in pancreatic cancer as well. This will probably change the very poor outlook for this disease. This paper reviews the genetic characteristics of sporadic and hereditary predisposition to pancreatic cancer and the possibilities of a personalized treatment according to the genetic signature.

Comprehensive review of pancreatic acinar cell carcinoma: epidemiology, diagnosis, molecular features and treatment

Pancreatic acinar cell carcinoma is a rare form (0.2-4.3%) of pancreatic neoplasm with unique clinical and molecular characteristics, which largely differ from pancreatic ductal adenocarcinoma. Pancreatic acinar cell carcinoma occurs more frequently in males and can occur in children. Serum lipase is elevated in 24-58% of patients with pancreatic acinar cell carcinoma. Pancreatic acinar cell carcinomas tend to be large at diagnosis (median tumour size: ~5 cm) and are frequently located in the pancreas head. Radiologically, pancreatic acinar cell carcinoma generally exhibits a solid appearance; however, necrosis, cystic changes and intratumoral haemorrhage can occur in larger lesions. Immunostaining is essential for the definitive diagnosis of pancreatic acinar cell carcinoma. Compared with pancreatic ductal adenocarcinoma, pancreatic acinar cell carcinoma has a more favourable prognosis. Although radical surgery is recommended for patients with pancreatic acinar cell carcinoma who do not have distant metastases, the recurrence rate is high. The effectiveness of adjuvant therapy for pancreatic acinar cell carcinoma is unclear. The response to FOLFIRINOX is generally favourable, and some patients achieve a complete response. Pancreatic acinar cell carcinoma has a different genomic profile compared with pancreatic ductal adenocarcinoma. Although genomic analyses have shown that pancreatic acinar cell carcinoma rarely has KRAS, TP53 and CDKN2A mutations, it has a higher prevalence of homologous recombination-related genes, including BRCA1/2 and ATM, than pancreatic ductal adenocarcinoma, suggesting high sensitivity to platinum-containing regimens and PARP inhibitors. Targeted therapies for genomic alternations are beneficial. Therefore, genetic testing is important for patients with pancreatic acinar cell carcinoma to choose the optimal therapeutic strategy.

Survival Benefit of Induction Chemotherapy with Paclitaxel and Carboplatin Followed by Chemoradiation Versus Postoperative Treatment in Locally Advanced Gastric Cancer: A Retrospective Cohort Study

BACKGROUND

Gastric cancer remains a prevalent worldwide illness that lacks a definitive cure. Recently, induction chemotherapy followed by concurrent chemoradiation has shown promising results in achieving a significant pathological response in locally advanced gastric cancer and improving survival rates. However, the optimal regimen for this approach continues to be a subject of discussion.

METHODS

This retrospective cohort study was conducted on treatment-naïve patients with locally advanced gastric cancer who were referred to Imam Hossain General Hospital in Tehran, Iran, between April 2016 and March 2019. Eligible patients met the criteria of clinical T3-4 or nodal-positive stage, or both, and had non-metastatic resectable tumors. The patients were categorized into two groups: (a) the neoadjuvant group, which received induction chemotherapy (carboplatin AUC 2 and paclitaxel 50 mg/m2 weekly for 12 cycles) followed by concurrent neoadjuvant chemoradiation (radiotherapy 45-50 Gy/1.8 Gy per fraction concurrent with capecitabine 500 mg/m2 BID and oxaliplatin 40 mg/m2 weekly), and (b) the adjuvant group, which was treated with standard chemoradiation or chemotherapy regimens. The two groups were compared regarding the 3-year recurrence rate and 3-year overall survival.

RESULTS

A total of 102 patients were included in the study (63.7% male, mean age ± standard deviation 56 ± 13 years). Among these, 45 patients received neoadjuvant treatment, and 57 received adjuvant treatment. The neoadjuvant group had a higher proportion of patients with advanced disease (stage III: 91.1% vs. 57.9%, P = 0.001). In the neoadjuvant group, 20 patients (44.4%) achieved a complete pathologic response, and all underwent curative surgery. The neoadjuvant group exhibited a lower 3-year recurrence rate (13 [28.9%] vs. 33 [57.9%], P = 0.003) and a higher 3-year overall survival rate (36 [80%] vs. 32 [56.1%], P = 0.003).

CONCLUSIONS

Patients receiving induction chemotherapy with paclitaxel and carboplatin followed by chemoradiation demonstrated enhanced disease control and survival compared to standard adjuvant regimens. In addition, patients treated with the applied preoperative regimen in this study showed higher pathologic response and overall survival rates than in previous studies.

Clinical impact of multimodal treatment including chemoradiotherapy, conversion surgery and postoperative chemotherapy for borderline resectable and unresectable locally advanced pancreatic cancer without disease progression after gemcitabine plus nab-paclitaxel

BACKGROUND

The purpose of this study was to investigate treatment outcomes of chemoradiotherapy (CRT) using S-1 with or without conversion surgery after gemcitabine plus nab-paclitaxel (GnP) for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer.

METHODS

From 2016 to 2020, patients without disease progression after GnP for BR or UR-LA pancreatic cancer underwent CRT with S-1. If distant metastasis was not detected after CRT, conversion surgery and oral administration of S-1 as postoperative adjuvant chemotherapy for at least 6 months was performed.

RESULTS

Forty patients were included in the present study. The median number of cycles of GnP was 6. Surgery was performed after CRT in 25 patients. The median progression-free survival (PFS) and overall survival (OS) periods from the start of radiotherapy were 24.6 and 27.4 months, respectively. The OS periods from the start of radiotherapy in patients who underwent conversion surgery and those who did not undergo conversion surgery were 41.3 and 16.8 months, respectively. The PFS periods from the start of radiotherapy in patients who underwent surgery and those who did not undergo surgery were 28.3 and 8.6 months, respectively. Patients who were able to receive S-1 after conversion surgery for more than 6 months had better OS than those who were not (p = 0.039), although there was no significant difference of PFS (p = 0.365).

CONCLUSIONS

In BR/UR-LA pancreatic cancer without disease progression after GnP, multimodal treatment including CRT, conversion surgery and the scheduled postoperative chemotherapy may be effective.

Significance of multiple tumor markers measurements in conversion surgery for unresectable locally advanced pancreatic cancer

BACKGROUND

This study aimed to evaluate the significance of multiple tumor markers (TMs) measurements in determining the indications for conversion surgery (CS) in the management of unresectable locally advanced pancreatic cancer (UR-LAPC).

METHODS

A total of 103 patients with UR-LAPC, treated between 2008 and June 2021, were enrolled in this study. Three TMs, including carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and Duke pancreatic monoclonal antigen type 2 (DUPAN-2), were measured.

RESULTS

Twenty-five patients (24%) underwent CS. The median preoperative treatment period was 9.5 months. The median survival time (MST) from the initial treatment for patients with CS was significantly longer than that for patients without surgery (34.6 vs. 18.9 months, P < 0.001). The number of elevated TMs before CS was one in five patients and two in five patients, while 15 patients had normal levels of all three TMs. Notably, the MST from the initial treatment for patients with all three preoperative normal TMs levels was favorable for 70.5 months. In contrast, patients with one or two preoperatively elevated TMs levels had a significantly worse prognosis (25.4 and 21.0 months, respectively, P < 0.001). Furthermore, the relapse-free survival of patients with three preoperative normal TMs levels was significantly longer than those with one or two elevated TMs levels (21.9 vs. 11.3 or 3.0 months, respectively, P < 0.001). Non-normal values of all TMs before CS were identified as independent poor prognostic factors.

CONCLUSIONS

Simultaneous measurement and assessment of the three TMs levels may help determine the surgical indications for UR-LAPC after systemic anticancer treatment.

Proton radiotherapy as a treatment strategy to increase survival in locally advanced pancreatic cancer in the body and tail: a retrospective study

BACKGROUND

Long-term outcomes and prognostic factors of proton radiotherapy for locally advanced pancreatic cancer (LAPC) in the body and tail are still unknown. The aim of this study was to determine the prognostic factors after proton radiotherapy in a large group of patients with LAPC in the body and tail.

METHODS

The medical records of 200 patients with LAPC in the body and tail who underwent proton radiotherapy between February 2009 and January 2021 at the Hyogo Ion Beam Medical Center were retrospectively reviewed to identify prognostic factors that contribute to long-term survival.

RESULTS

The overall survival rate at 1- and 2-year after PT was 69.6% and 35.4% with a median overall survival of 18.4 months. The 1- and 2-year local progression-free, and progression-free survival rates were 84.3% and 68.0%, and 44.3% and 19.4%, respectively. In multivariate analysis, superior mesenteric artery (SMA) invasion (SMA only invasion vs. celiac artery only invasion; P = 0.049: SMA and celiac artery invasion vs. celiac artery only invasion; P = 0.017), carbohydrate antigen 19-9 (CA 19-9) level ≥ 231.9 U/mL (P = 0.001), anterior peripancreatic invasion (P = 0.006), and incomplete scheduled concurrent chemotherapy (P = 0.009) were statistically significant prognostic factors for overall survival. There was no significant difference in local progression-free survival; however, distant metastasis-free survival was statistically worse in patients with prognostic factors than in those without.

CONCLUSIONS

Proton radiotherapy for LAPC in the body and tail may be a valuable multidisciplinary treatment option. Patients with SMA invasion, higher pre-proton radiotherapy serum CA 19-9 level, anterior peripancreatic invasion, or incomplete scheduled concurrent chemotherapy had worse overall survival because of worse distant metastasis-free survival, suggesting that distant metastases have a significant impact on overall survival in such patients.

TRIAL REGISTRATION

Retrospectively registered.

Parallel administration of nanoliposomal irinotecan and levo-leucovorin for pancreatic cancer

BACKGROUND

Nanoliposomal irinotecan (nal-IRI) plus 5-fluorouracil (5-FU)/levo-leucovorin (Levo-LV) was approved for unresectable pancreatic cancer (UR-PC) in March 2020 in Japan. Levo-LV is administered by intravenous infusion over 120 min following 90 min intravenous infusion of nal-IRI (conventional method), causing a significant burden on both patients and the outpatient chemotherapy room owing to the prolonged administration time. Thus, from July 2021, we introduced the simultaneous intravenous administration of nal-IRI and Levo-LV (parallel method) with the approval of the institutional regimen committee.

METHODS

We retrospectively reviewed the data of 69 patients with UR-PC who received nal-IRI plus 5-FU/Levo-LV at our hospital between June 2020 and October 2021. We examined the safety of the parallel method and compared the treatment outcomes and administration times between the two methods.

RESULTS

The median age was 66 years (54%, male). Disease statuses were locally advanced, metastatic, and postoperative recurrence after pancreatectomy in 7, 50, and 12 patients, respectively. Nal-IRI plus 5-FU/Levo-LV treatment was second and third-line or later in 35 and 34 patients, respectively. No intravenous line problems were observed during the parallel administration of nal-IRI and Levo-LV. Although there were no significant differences in response rates and adverse events between the two methods, the administration time was significantly shorter in the parallel method than in the conventional method.

CONCLUSION

The parallel administration of nal-IRI and Levo-LV is clinically safe and not inferior in efficacy. Moreover, parallel administration may offer convenience to patients and healthcare workers by reducing administration time.

Prognosis of Pancreatic Cancer Based on Resectability: A Single Center Experience

Although conversion surgery has increasingly been performed for initially unresectable advanced pancreatic ductal adenocarcinoma (PDAC), the rate of conversion, including that for patients who do not undergo resection, remains unclear. Patients with PDAC who were treated between January 2013 and December 2018 were classified into three groups: resectable (R), borderline resectable (BR), and unresectable (UR). We analyzed patient outcomes, including the rate of surgical resection and survival, in each of these groups. In total, 211 patients (R, 118; BR, 22; UR, 81) were selected. Among them, 117 (99%), 18 (82%), and 15 (19%) patients in the R, BR, and UR groups, respectively, underwent surgical resection. R0 resection rates were 88, 78, and 67%, whereas median overall survival (OS) from treatment initiation were 31, 18, and 11 months (p < 0.0001) in the R, BR, and UR groups, respectively. In patients who underwent surgical resection, relapse-free survival (RFS) and OS were similar among the three groups (R vs. BR vs. UR; median RFS (months), 17 vs. 13 vs. 11, p = 0.249; median OS (months), 31 vs. 26 vs. 32, p = 0.742). Lymph node metastases and incomplete adjuvant chemotherapy were identified as independent prognostic factors for OS. Although the surgical resection rate was low, particularly in the BR and UR groups, the prognosis of patients who underwent surgical resection was similar irrespective of the initial resectability status.

Main pancreatic duct dilatation and pancreatic cysts in relatives and spouses of patients with pancreatic cancer

Although main pancreatic duct dilatation and pancreatic cysts are risk factors for developing pancreatic cancer, limited data exist regarding these findings in relatives and spouses of pancreatic cancer patients. The frequency of these findings was examined using long-term follow-up data and transabdominal ultrasonography focusing on the pancreas. We prospectively enrolled 184 relatives and spouses of pancreatic cancer patients and performed special pancreatic ultrasonography to detect main pancreatic duct dilatation and pancreatic cysts. First-degree relatives (148 participants) of patients with pancreatic cancer were significantly younger than the spouses (36 participants; 41 vs. 65 years old). The frequency of ultrasonographic findings was significantly different between the relative (8.8%) and spouse (33.3%) groups. Main pancreatic duct dilatation and pancreatic cysts were observed in seven (4.7%) and seven (4.7%) participants in the relative group, and in nine (25.0%) and five (13.9%) participants in the spouse group, respectively. On multivariate analysis, age was an independent risk factor for the ultrasonographic findings. The frequency of ultrasonographic findings was significantly higher in spouses than in first-degree relatives of patients with pancreatic cancer and was strongly influenced by the age gap between the groups. Main pancreatic duct dilatation was frequently observed, especially in the spouse group.

Prognostic Impact of Positive Peritoneal Lavage Cytology on Resectable Pancreatic Body and Tail Cancer: A Retrospective Study

BACKGROUND

The prognostic impact of positive peritoneal lavage cytology on pancreatic cancer is unclear. Therefore, this study aimed to evaluate its impact in resectable pancreatic body and tail cancer.

METHODS

Between January 2006 and December 2019, 97 patients with pancreatic body and tail cancer underwent peritoneal lavage cytology and curative resection at our institution. We analyzed the impact of positive peritoneal lavage cytology on clinicopathological factors and on the prognosis of pancreatic body and tail cancer.

RESULTS

Malignant cells were detected in 14 patients (14.4%) using peritoneal lavage cytology. In these patients, the tumor diameter was significantly larger (p < 0.001) and anterior serosal invasion (p = 0.034), splenic artery invasion (p = 0.013), lympho-vessel invasion (p = 0.025), and perineural invasion (p = 0.008) were significantly more frequent. The R1 resection rate was also significantly higher in patients with positive peritoneal lavage cytology than in negative patients (p = 0.015). Positive peritoneal lavage cytology had a significantly poor impact on overall survival (p = 0.001) and recurrence-free survival (p < 0.001). This cytology was also an independent poor prognostic factor for recurrence (p = 0.022) and was associated with peritoneal dissemination and liver metastasis.

CONCLUSIONS

Positive peritoneal lavage cytology is considered to be indicative of more systemic disease in patients with resectable pancreatic body and tail cancer than in patients with negative peritoneal lavage cytology. Early detection of pancreatic cancer before it develops micrometastases is important to improve prognosis, and CY+ patients require more intensive multimodality treatment than standard treatment for resectable pancreatic cancer.

Prognostic factors in conversion surgery following nab-paclitaxel with gemcitabine and subsequent chemoradiotherapy for unresectable locally advanced pancreatic cancer: Results of a dual-center study

Background

In pancreatic ductal adenocarcinoma (PDAC), only radical surgery improves long-term survival. We focused on surgical outcome after induction gemcitabine along with nab-paclitaxel (GnP) and subsequent chemoradiotherapy (CRT) with S-1 administration for unresectable locally advanced (UR-LA) PDAC.

Methods

We retrospectively analyzed 144 patients with UR-LA PDAC between 2014 and 2020. The first-line regimen of induction chemotherapy was GnP for 125 of the 144 patients. Of the 125 patients who received GnP, 41 who underwent radical resection after additional preoperative CRT were enrolled. We evaluated the prognostic factors for this treatment strategy.

Results

The median length of preoperative GnP was 8.8 months, and 30 (73%) patients had normalized CA19-9 levels. R0 resection was achieved in 36 (88%) patients. Postoperative major complications of ≥Clavien-Dindo grade IIIa developed in 16 (39%) patients. With a median follow-up of 35.2 months, 14 (34%) patients developed distant metastasis postoperatively. Using the Kaplan-Meier method, prognostic analysis of the 41 cases revealed the 3-y overall survival rate (OS) was 77.4% and the 5-y OS was 58.6%. In univariate analysis, length of preoperative GnP (≥8 months), CA19-9 normalization, and good nutritional status at operation (prognostic nutritional index ≥41.7) were significantly associated with favorable prognosis. Multivariate analysis revealed CA19-9 normalization (hazard ratio [HR] 0.23; P = .032) and prognostic nutritional index ≥41.7 (HR 0.05; P = .021) were independent prognostic factors.

Conclusion

For surgical outcome after induction GnP and subsequent CRT for UR-LA PDAC, CA19-9 normalization and maintenance of good nutritional status during treatment until surgery were important for prolonged prognosis.

Chemotherapy effectiveness and age-group analysis of older adult patients with metastatic pancreatic cancer: A Japanese cancer registry cohort study

INTRODUCTION

Although older adults aged ≥75 years comprise a substantial proportion of patients diagnosed with pancreatic cancer (PC), the effectiveness of chemotherapy in older adults with PC remains to be established.

MATERIALS AND METHODS

This retrospective study examined the effectiveness of chemotherapy according to age in older adult patients with metastatic PC. We used a large database that combined three data sources (the hospital-based cancer registry database, Osaka Cancer Registry, and Japan's Diagnosis Procedure Combination) and extracted data from patients pathologically diagnosed with metastatic PC between 2013 and 2015 in 31 designated cancer care hospitals in Japan. Propensity score matching (PSM) was used to identify a cohort of patients with similar backgrounds. The effect of chemotherapy on overall survival (OS) was analyzed using the log-rank test.

RESULTS

Compared with 687 younger patients (<75 years old), 276 older adult patients had significant impairments in activities of daily living and poorer prognoses (6.8 vs. 4.1 months, p < 0.001), with a lower frequency of chemotherapy (81.5% vs. 55.1%; p < 0.001). PSM of older adult patients showed that chemotherapy significantly contributed to a better prognosis (best supportive care, 2.6 months vs. chemotherapy, 5.8 months, p < 0.001). Age group analysis with PSM of five-year age ranges revealed that the median OS was significantly longer in the chemotherapy group among older adult patients aged <85 years.

DISCUSSION

Chemotherapy provides a survival benefit in older adult patients with metastatic PC, and patients aged <85 years could be promising candidates for chemotherapy.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.