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Rosengart TK, Chen JH, Gantt NL, Angelos P, Warshaw AL, Rosen JE, Perrier ND, Kaups KL, Doherty GM, Zoumpou T, Ashley SW, Doscher W, Welsh D, Savarise M, Sutherland MJ, Sidawy AN, Kopelan AM. Sustaining Lifelong Competency of Surgeons: Multimodality Empowerment Personal and Institutional Strategy. J Am Coll Surg 2024:00019464-990000000-00939. [PMID: 38591782 DOI: 10.1097/xcs.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Todd K Rosengart
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Jennifer H Chen
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Nancy L Gantt
- Department of Surgery, Northeast Ohio Medical University, Youngstown, OH
| | - Peter Angelos
- Section of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Rosen
- Division of Endocrine Surgery, MedStar-Washington Hospital Center, Washington, DC
| | - Nancy D Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Krista L Kaups
- Department of Surgery, University of California San Francisco Fresno, Fresno, CA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Theofano Zoumpou
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Stanley W Ashley
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William Doscher
- Department of Surgery, Zucker School of Medicine at Hofstra, Northwell, NY
| | | | - Mark Savarise
- Section of Community General Surgery, University of Utah South Jordan Health Center, South Jordan, UT
| | | | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC
| | - Adam M Kopelan
- Department of Surgery, Newark Beth Israel Medical Center, RWJ Barnabas Health, Newark, NJ
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Leonhardt CS, Pils D, Qadan M, Jomrich G, Assawasirisin C, Klaiber U, Sahora K, Warshaw AL, Ferrone CR, Schindl M, Lillemoe KD, Strobel O, Fernández-del Castillo C, Hank T. The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment. Ann Surg 2024; 279:314-322. [PMID: 37042245 PMCID: PMC10782940 DOI: 10.1097/sla.0000000000005874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
OBJECTIVE To investigate the oncological outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) who had an R 0 or R 1 resection based on the revised R status (1 mm) after neoadjuvant therapy (NAT). BACKGROUND The revised R status is an independent prognostic factor in upfront-resected PDAC; however, the significance of 1 mm margin clearance after NAT remains controversial. METHODS Patients undergoing pancreatectomy after NAT for PDAC were identified from 2 prospectively maintained databases. Clinicopathological and survival data were analyzed. The primary outcomes were overall survival (OS), recurrence-free survival (RFS), and pattern of recurrence in association with R 0 >1 mm and R 1 ≤1 mm resections. RESULTS Three hundred fifty-seven patients with PDAC were included after NAT and subsequent pancreatic resection. Two hundred eight patients (58.3%) received FOLFIRINOX, 41 patients (11.5%) received gemcitabine-based regimens, and 299 individuals (83.8%) received additional radiotherapy. R 0 resections were achieved in 272 patients (76.2%) and 85 patients (23.8%) had R 1 resections. Median OS after R 0 was 41.0 months, compared with 20.6 months after R 1 resection ( P = 0.002), and even longer after additional adjuvant chemotherapy ( R 0 44.8 vs R1 20.1 months; P = 0.0032). Median RFS in the R 0 subgroup was 17.5 months versus 9.4 months in the R 1 subgroup ( P < 0.0001). R status was confirmed as an independent predictor for OS ( R 1 hazard ratio: 1.56, 95% CI: 1.07-2.26) and RFS ( R 1 hazard ratio: 1.52; 95% CI: 1.14-2.0). In addition, R 1 resections were significantly associated with local but not distant recurrence ( P < 0.0005). CONCLUSIONS The revised R status is an independent predictor of postresection survival and local recurrence in PDAC after NAT. Achieving R 0 resection with a margin of at least 1 mm should be a primary goal in the surgical treatment of PDAC after NAT.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Pils
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gerd Jomrich
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Charnwit Assawasirisin
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ulla Klaiber
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Martin Schindl
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oliver Strobel
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Hank
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Assawasirisin C, Qadan M, Aimprasittichai S, Kambadakone A, Servin-Rojas M, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. Pancreatic Serous Cystadenoma: A Continuing Diagnostic Challenge. Ann Surg 2024:00000658-990000000-00747. [PMID: 38230538 DOI: 10.1097/sla.0000000000006203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Objective:
To understand the natural history of serous cystadenoma.
To understand the diagnostic accuracy of serous cystadenoma and identify possible factors that lead to the correct diagnosis.
Summary Background data:
Serous cystadenoma (SCA) is a benign cystic pancreatic neoplasm of the pancreas, accounting for approximately 15% of resected pancreatic cysts. Current recommendations are to proceed with surgical resection in symptomatic patients or when there is uncertainty regarding diagnosis. The latter continues to be a challenge since intentional resection of a serous cystadenoma account for only a minority of resected of cases.
Methods:
Retrospective single-institution review of patients who on final pathology had a diagnosis of pancreatic serous cystadenoma and of patients who had this diagnosis and were managed non-operatively. Demographic data, cyst characteristics, and growth rate were collected for analysis.
Results:
A total of 250 patients were analyzed. Median age was 62 (range 22 – 89), 65% were female, and 34% had symptoms. Tumor size ranged from 0.6 to 20, with a median of 3.4 cm. The morphological appearance was microcystic in 58%, macrocystic in 16%, mixed-type in 23%, and solid in 3%. Pancreatic duct dilation and pancreatic atrophy were found in 22% and 14%, respectively. The average growth rate was 1.8 mm/year regardless of tumor size. Of the 172 patients who underwent surgery, serous cystadenoma was the preoperative diagnosis in only 33%. A correct diagnosis was independently associated with large tumors and cyst fluid CEA analysis. Pancreatic duct dilation was independently associated with an in-growing cyst and presence of calcification.
Conclusion:
SCA is a slow-growing pancreatic cystic neoplasm that is mostly asymptomatic but can lead to pancreatic duct dilation and atrophy in some patients. A surprisingly small number of correct preoperative diagnoses confirms that this entity continues to be a diagnostic challenge. A more thorough preoperative workup that includes EUS should improve the rate of mis-diagnosis.
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Affiliation(s)
- Charnwit Assawasirisin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Satita Aimprasittichai
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Fong ZV, Teinor J, Engineer L, Yeo TP, Rinaldi D, Greer JB, Lavu H, Qadan M, Johnston FM, Ferrone CR, Chang DC, Yeo CJ, Wolfgang CL, Warshaw AL, Lillemoe KD, Castillo CFD, Weiss MJ, Wu AW, Wolff JL. Caregiver-reported quality of communication in pancreatic and periampullary cancer. Cancer 2023. [PMID: 38146683 DOI: 10.1002/cncr.35154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 10/05/2023] [Accepted: 10/25/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Communication between caregivers and clinical team members is critical for transitional care, but its quality and potential impact on outcomes are not well understood. This study reports on caregiver-reported quality of communication with clinical team members in the postpancreatectomy period and examines associations of these reports with patient and caregiver outcomes. METHODS Caregivers of patients with pancreatic and periampullary malignancies who had undergone pancreatectomy were surveyed. Instrument measures assessed care experiences using the Caregiver Perceptions About Communication with Clinical Team Members (CAPACITY) instrument. The instrument has two main subscales: communication, assessing the extent to which providers helped caregivers comprehend details of clinical visits, and capacity, defined as the extent to which providers assessed whether caregivers were able to care for patients. RESULTS Of 265 caregivers who were approached, 240 (90.6%) enrolled in the study. The mean communication and capacity subscale scores were 2.7 ± 0.6 and 1.5 ± 0.6, respectively (range, 0-4 [higher = better]). Communication subscale scores were lower among caregivers of patients who experienced (vs. those who did not experience) a 30-day readmission (2.6 ± 0.5 vs. 2.8 ± 0.6, respectively; p = .047). Capacity subscale scores were inversely associated with restriction in patient daily activities (a 0.04 decrement in the capacity score for every 1 point in daily activity restriction; p = .008). CONCLUSIONS After pancreatectomy, patients with pancreatic and periampullary cancer whose caregivers reported worse communication with care providers were more likely to experience readmission. Caregivers of patients with greater daily activity restrictions were less likely to report being asked about the caregiver's skill and capacity by clinicians. PLAIN LANGUAGE SUMMARY This prospective study used a validated survey instrument and reports on the quality of communication between health care providers and caregivers as reported by caregivers of patients with pancreatic and periampullary cancer after pancreatectomy. In an analysis of 240 caregivers enrolled in the study, lower communication scores (the extent to which providers helped caregivers understand clinical details) were associated with higher odds of 30-day patient readmission to the hospital. In addition, lower capacity scores (the extent to which providers assessed caregivers' ability to care for patients) were associated with greater impairment in caregivers. The strikingly low communication quality and capacity assessment scores suggest substantial room for improvement, with the potential to improve both caregiver and patient outcomes.
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Affiliation(s)
- Zhi Ven Fong
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan Teinor
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Lilly Engineer
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theresa P Yeo
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dee Rinaldi
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jonathan B Greer
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harish Lavu
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Motaz Qadan
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fabian M Johnston
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - David C Chang
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Charles J Yeo
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Matthew J Weiss
- Northwell Health University Hospital, Manhasset, New York, USA
| | - Albert W Wu
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jennifer L Wolff
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Smart AC, Niemierko A, Wo JY, Ferrone CR, Tanabe KK, Lillemoe KD, Clark JW, Blaszkowsky LS, Allen JN, Weekes C, Ryan DP, Warshaw AL, Castillo CFD, Hong TS, Keane FK. Portal Vein or Superior Mesenteric Vein Thrombosis with Dose-Escalated Radiation for Borderline or Locally Advanced Pancreatic Cancer. J Gastrointest Surg 2023; 27:2464-2473. [PMID: 37578568 DOI: 10.1007/s11605-023-05796-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Portal vein and superior mesenteric vein thrombosis (PVT/SMVT) are potentially morbid complications of radiation dose-escalated local therapy for pancreatic cancer. We retrospectively reviewed records for patients treated with and without intraoperative radiation (IORT) to identify risk factors for PVT/SMVT. METHODS Ninety-six patients with locally advanced or borderline resectable pancreatic adenocarcinoma received neoadjuvant therapy followed by surgical exploration from 2009 to 2014. Patients at risk for close or positive surgical margins received IORT boost to a biologically effective dose (BED10) > 100. Prognostic factors for PVT/SMVT were evaluated using competing risks regression. RESULTS Median follow-up was 79 months for surviving patients. Fifty-six patients (58%) received IORT. Twenty-nine patients (30%) developed PVT/SMVT at a median time of 18 months. On univariate competing risks regression, operative blood loss and venous repair with a vascular interposition graft, but not IORT dose escalation or diabetes history, were significantly associated with PVT/SMVT. The development of thrombosis in the absence of recurrence was significantly associated with a longstanding diabetes history, post-neoadjuvant treatment CA19-9, and operative blood loss. All 4 patients who underwent both IORT and vascular repair with a graft developed PVT/SMVT. PVT/SMVT in the absence of recurrence is not associated with significantly worsened overall survival but led to frequent medical interventions. CONCLUSIONS Approximately 30% of patients who underwent neoadjuvant chemoradiation for PDAC developed PVT/SMVT a median of 18 months following surgery. This was significantly associated with venous reconstruction with vascular grafts, but not with escalating radiation dose. PVT/SMVT in the absence of recurrence was associated with significant morbidity.
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Affiliation(s)
- Alicia C Smart
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N Allen
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin Weekes
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Leonhardt CS, Pils D, Qadan M, Gustorff C, Sahora K, Klaiber U, Warshaw AL, Prager G, Ferrone CR, Lillemoe KD, Schindl M, Strobel O, Castillo CFD, Hank T. Smoking impairs the effect of neoadjuvant FOLFIRINOX on postresection survival in pancreatic cancer. Eur J Cancer 2023; 193:113293. [PMID: 37713740 DOI: 10.1016/j.ejca.2023.113293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Smoking plays an important role in carcinogenesis, including pancreatic ductal adenocarcinoma (PDAC). However, little is known about the association between smoking status and prognosis in resected PDAC. METHODS All patients who underwent resection for PDAC were identified from two prospective institutional databases. Clinicopathologic data as well as demographics including smoking status were extracted. Survival analysis and multivariable Cox regression modelling was performed. Restricted cubic splines were used for linear data to define cut-off points. RESULTS Out of 848 patients, 357 (42.1%) received neoadjuvant treatment (NAT), 491 upfront resection (57.9%), and 475 (56%) adjuvant therapy. The median overall survival (OS) was 27.8 months, 36.1 months, and 23.0 months for the entire cohort, after NAT and upfront resection. 464 patients were never smokers (54.7%), 250 former smokers (29.5%), and 134 active smokers (15.8%). In the multivariable model, the interaction of neoadjuvant FOLFIRINOX and active smoking was associated with the highest risk for decreased OS (harzard ratio (HR) 2.35; 95% confidence interval 1.13-4.90) and strongly mitigated the benefit of FOLFIRNOX (HR 0.40; 95% CI 0.25-0.63). Adjusted median OS in NAT patients with FOLFIRINOX was not reached for never and former smokers, compared to 26.2 months in active smokers. Based on the model, a nomogram was generated to illustrate the probability of 5-year survival after PDAC resection. CONCLUSION The present study confirms that neoadjuvant FOLFIRINOX is associated with excellent survival and demonstrates that active smoking reduces its benefit. The nomogram can assist in daily clinical practice and emphasises the importance of smoking cessation in patients with PDAC, especially prior to NAT with FOLFIRINOX.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Pils
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Charlotte Gustorff
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulla Klaiber
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gerald Prager
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin Schindl
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Oliver Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Hank
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria; Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Fong ZV, Teinor J, Yeo TP, Rinaldi D, Greer JB, Lavu H, Qadan M, Johnston FM, Ferrone CR, Chang DC, Yeo CJ, Wolfgang CL, Warshaw AL, Lillemoe KD, Fernandez-del Castillo C, Wolff JL, Wu AW, Weiss MJ. Profile of the Postoperative Care Provided for Patients With Pancreatic and Periampullary Cancers by Family and Unpaid Caregivers. JCO Oncol Pract 2023; 19:551-559. [PMID: 37192429 PMCID: PMC10424914 DOI: 10.1200/op.22.00736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/10/2023] [Accepted: 03/22/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE Patients with pancreatic and periampullary cancers may experience significant reduction in their quality of life and often rely on family and unpaid caregivers for assistance after surgery. However, as caregivers are not systematically identified, little is known about the nature, difficulty, and personal demands of assistance they provide. We aim to assess the frequency and difficulty of specific assistance caregivers provide and identify potential interventions that could alleviate the caregiving demands. METHODS This was a prospective, multi-institutional study of caregivers accompanying patients with periampullary and pancreatic cancer at their 1-month postpancreatectomy office visit. An instrument that drew heavily on the National Study of Caregiving was administered to caregivers. RESULTS Of 240 caregivers, more than half (58.3%) of caregivers were the patients' spouse, a quarter (25.8%) were daughters or sons, 12.9% other relatives, and 2.9% nonrelatives. Caregivers least frequently provided assistance with transportation (14.6% every day) and most frequently provided assistance with housework (65.0% every day, P = .003) and diet (56.5% every day, P = .004). Caregivers reported the least difficulty helping patients with exercise (1.5% somewhat difficult). Caregivers reported significantly more difficulty with assisting with housework (14.5% somewhat difficult, P < .001) and diet (14.9% somewhat difficult, P < .001). Caregivers identified the immediate postpancreatectomy and early discharge periods as the most stressful phases. They also reported having received very little information about available services that could have supported their efforts. CONCLUSION Caregivers of patients with periampullary or pancreatic cancer provide considerable assistance in the postoperative period and many reported difficulty in assisting with housework and diet. Work is needed to better prepare and support caregivers to better enable them to adequately care for patients with pancreas and periampullary cancer.
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Affiliation(s)
| | - Jonathan Teinor
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Dee Rinaldi
- Thomas Jefferson University, Philadelphia, PA
| | | | - Harish Lavu
- Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | - Jennifer L. Wolff
- Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W. Wu
- Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Matthew J. Weiss
- Northwell Health Cancer Institute, Zucker School of Medicine, Manhasset, NY
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8
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Hernandez-Barco YG, Daye D, Fernandez-Del Castillo CF, Parker RF, Casey BW, Warshaw AL, Ferrone CR, Lillemoe KD, Qadan M. IPMN-LEARN: A linear support vector machine learning model for predicting low-grade intraductal papillary mucinous neoplasms. Ann Hepatobiliary Pancreat Surg 2023; 27:195-200. [PMID: 37006188 DOI: 10.14701/ahbps.22-107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/07/2023] [Accepted: 01/16/2023] [Indexed: 04/04/2023] Open
Abstract
Backgrounds/Aims We aimed to build a machine learning tool to help predict low-grade intraductal papillary mucinous neoplasms (IPMNs) in order to avoid unnecessary surgical resection. IPMNs are precursors to pancreatic cancer. Surgical resection remains the only recognized treatment for IPMNs yet carries some risks of morbidity and potential mortality. Existing clinical guidelines are imperfect in distinguishing low-risk cysts from high-risk cysts that warrant resection. Methods We built a linear support vector machine (SVM) learning model using a prospectively maintained surgical database of patients with resected IPMNs. Input variables included 18 demographic, clinical, and imaging characteristics. The outcome variable was the presence of low-grade or high-grade IPMN based on post-operative pathology results. Data were divided into a training/validation set and a testing set at a ratio of 4:1. Receiver operating characteristics analysis was used to assess classification performance. Results A total of 575 patients with resected IPMNs were identified. Of them, 53.4% had low-grade disease on final pathology. After classifier training and testing, a linear SVM-based model (IPMN-LEARN) was applied on the validation set. It achieved an accuracy of 77.4%, with a positive predictive value of 83%, a specificity of 72%, and a sensitivity of 83% in predicting low-grade disease in patients with IPMN. The model predicted low-grade lesions with an area under the curve of 0.82. Conclusions A linear SVM learning model can identify low-grade IPMNs with good sensitivity and specificity. It may be used as a complement to existing guidelines to identify patients who could avoid unnecessary surgical resection.
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Affiliation(s)
| | - Dania Daye
- Division of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | | | | | - Brenna W Casey
- Division of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Andrew L Warshaw
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Cristina R Ferrone
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Keith D Lillemoe
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Motaz Qadan
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, United States
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9
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Xiao Z, Xu H, Strosberg JR, Lu R, Zhu X, Deng S, Ding L, Ni Q, Warshaw AL, Yu X, Luo G. EGFR is a potential therapeutic target for highly glycosylated and aggressive pancreatic neuroendocrine neoplasms. Int J Cancer 2023; 153:164-172. [PMID: 36891979 DOI: 10.1002/ijc.34499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 03/10/2023]
Abstract
pNENs are relative indolent tumors with heterogeneous clinical presentation at diagnosis. It is important to establish aggressive subgroups of pNENs and identify potential therapeutic targets. Patients with pNEN (322 cases) were included to examine the association between glycosylation biomarkers and clinical/pathological traits. The molecular and metabolic features stratified by glycosylation status were assessed by RNA-seq/whole exome sequencing and immunohistochemistry. A considerable proportion of patients had elevated glycosylation biomarkers (carbohydrate antigen [CA] 19-9, 11.9%; CA125, 7.5%; carcinoembryonic antigen [CEA], 12.8%). CA19-9 (hazard ratio [HR] = 2.26, P = .019), CA125 (HR = 3.79, P = .004) and CEA (HR = 3.16, P = .002) were each independent prognostic variables for overall survival. High glycosylation group, defined as pNENs with elevated level of circulating CA19-9, CA125 or CEA, accounted for 23.4% of all pNENs. High glycosylation (HR = 3.14, P = .001) was an independent prognostic variable for overall survival and correlated with G3 grade (P < .001), poor differentiation (P = .001), perineural invasion (P = .004) and distant metastasis (P < .001). Epidermal growth factor receptor (EGFR) was enriched in high glycosylation pNENs using RNA-seq. EGFR was expressed in 21.2% of pNENs using immunohistochemistry and associated with poor overall survival (P = .020). A clinical trial focusing on EGFR expressed pNENs was initiated (NCT05316480). Thus, pNEN with aberrant glycosylation correlates with a dismal outcome and suggests potential therapeutic target of EGFR.
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Affiliation(s)
- Zhiwen Xiao
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Huaxiang Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | | | - Renquan Lu
- Department of Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xinzhe Zhu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Shengming Deng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Lei Ding
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Andrew L Warshaw
- Department of Surgery and the Warshaw Institute for Pancreatic Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Guopei Luo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
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10
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Servin-Rojas M, Fong ZV, Fernandez-Del Castillo C, Ferrone CR, Rocha-Castellanos DM, Roldan J, Zelga PJ, Warshaw AL, Lillemoe KD, Qadan M. Identification of high-risk features in mucinous cystic neoplasms of the pancreas. Surgery 2023; 173:1270-1274. [PMID: 36822873 DOI: 10.1016/j.surg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/25/2022] [Accepted: 01/17/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Mucinous cystic neoplasms of the pancreas are uncommon tumors that have the potential of becoming cancer. There is no consensus regarding the high-risk features of these tumors. Our study aimed to identify the preoperative demographic, clinical, or radiologic factors that can predict the presence of high-grade dysplasia or invasive carcinoma in mucinous cystic neoplasms of the pancreas. METHODS We identified 157 patients who underwent resection and fulfilled the pathologic criteria for mucinous cystic neoplasms of the pancreas in a prospectively maintained database spanning 3 decades (1990-2020). Multivariable logistic regression was used to identify predictors of high-grade dysplasia or invasive carcinoma in mucinous cystic neoplasms of the pancreas. RESULTS The rate of high-grade dysplasia or invasive carcinoma was 11%. Tumor size ≥4 cm (P < .001), mural nodularity (P = .04), and a serum CA 19-9 level >37 U/mL (P < .001) were associated with high-grade dysplasia or invasive carcinoma. In the multivariable analysis, tumor size ≥4 cm (odds ratio 16.9, 95% confidence interval 2.04-140, P = .009) and a CA 19-9 level >37 U/mL (odds ratio 5.68, 95% confidence interval 1.52-21.3, P = .010) were predictors of high-grade dysplasia or invasive carcinoma. There were no tumors with high-grade dysplasia or invasive carcinoma in patients with tumor size <4 cm in the absence of an elevated CA 19-9 or mural nodularity. CONCLUSION Tumors with a size ≥4 cm and/or a high CA 19-9 level should be considered for prompt surgical resection. Conversely, tumors <4 cm with no other high-risk features have a negligible risk for high-grade dysplasia or invasive carcinoma and may benefit from nonoperative surveillance. Mural nodularity is an additional suspicious feature. These findings may contribute to future guidelines.
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Affiliation(s)
- Maximiliano Servin-Rojas
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/servinrojasmd
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/ZhiVenFongMD
| | | | | | | | - Jorge Roldan
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/md_roldan
| | - Piotr J Zelga
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
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11
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Fong ZV, Teinor J, Yeo TP, Rinaldi D, Greer JB, Lavu H, Qadan M, Johnston FM, Ferrone CR, Chang DC, Yeo CJ, Wolfgang CL, Warshaw AL, Lillemoe KD, Fernandez-del Castillo C, Weiss MJ, Wolff JL, Wu AW. Assessment of Caregivers' Burden When Caring for Patients With Pancreatic and Periampullary Cancer. J Natl Cancer Inst 2022; 114:1468-1475. [PMID: 35984312 PMCID: PMC9664174 DOI: 10.1093/jnci/djac153] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/14/2022] [Accepted: 08/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Family and other unpaid caregivers play an active role in the recovery of individuals with pancreatic and periampullary cancer after pancreatectomy. However, little is known about caregivers' experiences and how to better support them. METHODS Caregivers accompanying patients to 1-month postpancreatectomy visits at 3 hospitals completed an electronic survey between November 2018 and February 2020. We examine measures of absenteeism and work productivity loss among the subset of caregivers who reported working for pay and comparatively assess caregiver experiences by employment status. All analyses were performed as 2-sided tests. RESULTS Of 265 caregivers approached for study participation, 240 (90.6%) enrolled. Caregivers were primarily female (70.8% female, 29.2% male) and spouses (58.3%) or adult children (25.8%) of patients, with a median age of 60 years. Of the 240 caregivers included in the study, 107 (44.6%) worked for pay. Nearly half (44.4%) of working caregivers reported being absent from work because of caregiving amounting to a 14% loss in work hours. While at work, 58.9% of working caregivers reported increased work difficulty as a result of caregiving. Taken together, an estimated 59.7% loss in work productivity was experienced because of caregiving in the month following pancreatectomy. After adjustment for sociodemographic factors, working (vs nonworking) caregivers reported increased financial (odds ratio [OR] = 2.32; P = .04) and emotional (OR = 1.93; P = .04) difficulties and daily activity restrictions (OR = 1.85; P = .048). CONCLUSIONS Working caregivers of patients with pancreatic and periampullary cancer experience negative impacts on work and productivity, and caregiving-related financial and emotional difficulties may be amplified. This study highlights the need for workplace policies to support unpaid cancer caregiving.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Teinor
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Theresa P Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dee Rinaldi
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Matthew J Weiss
- Department of Surgery, Northwell Health University Hospital, Manhasset, NY, USA
| | - Jennifer L Wolff
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Albert W Wu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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12
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Baba T, Finetti P, Lillemoe KD, Warshaw AL, Fernández-Del Castillo C, Liss AS. A Lesson in Transcriptional Plasticity: Classical Identity Is Silenced, but Not Lost, in Pancreatic Ductal Adenocarcinoma Cell Lines. Gastroenterology 2022; 163:1450-1453.e3. [PMID: 35850199 PMCID: PMC9613505 DOI: 10.1053/j.gastro.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Taisuke Baba
- Department of Surgery, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts
| | - Pascal Finetti
- Department of Predictive Oncology, Cancer Research Center of Marseille, U1068 INSERM, UMR 7258 CNRS, Institut Paoli Calmettes, Aix-Marseille University, Marseille, France
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts.
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13
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Zelga P, Hernandez-Barco YG, Qadan M, Ferrone CR, Kambadakone A, Horick N, Jah A, Warshaw AL, Lillemoe KD, Balakrishnan A, Fernández-Del Castillo C. Number of Worrisome Features and Risk of Malignancy in Intraductal Papillary Mucinous Neoplasm. J Am Coll Surg 2022; 234:1021-1030. [PMID: 35703792 DOI: 10.1097/xcs.0000000000000176] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The 2017 revised International Association of Pancreatology guidelines for management of intraductal papillary mucinous neoplasm (IPMN) describe worrisome features (WF) and high-risk stigmata (HRS), recommending resection in the latter and further work-up and close surveillance for patients with WF. The effect of multiple WF on the likelihood of malignancy has not been evaluated. STUDY DESIGN Eight hundred ten patients who underwent pancreatic resection for IPMN in 2 tertiary referral centers were identified from prospective institutional databases. Patients were retrospectively categorized into subgroups according to the number of WF or HRS and presence of malignancy, defined as high-grade dysplasia (HGD) or invasive cancer on final pathology. RESULTS Three hundred seventy-nine (47%) patients had HRS, 370 (46%) had 1 or more WF, and 61 patients (7%) had neither. Malignancy was present in 70% (n = 267) of patients with HRS and in 30% (n = 127) of those with WF. Only 3 of 61 patients without WF/HRS had malignancy, and all only in the form of HGD. The risk of malignancy increased in a stepwise fashion with the number of WF, to 22%, 34%, and 59% with 1, 2, and 3 WF, respectively (p = 0.001), and reached 100% in patients with 4 or more WF. Although the relative risks differed for particular WF, the areas under the curve were not statistically different. CONCLUSION We confirm that presence of HRS in IPMN is associated with a very high likelihood of malignancy. The presence of a single WF has a malignancy risk of 22%, and additional WF increase this risk significantly. When 3 or more WF are present, the risk is similar to that of HRS.
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Affiliation(s)
- Piotr Zelga
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology (Hernandez-Barco), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Motaz Qadan
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Cristina R Ferrone
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Avinash Kambadakone
- Department of Radiology (Kambadakone), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Nora Horick
- Biostatistics Center, Division of Clinical Research (Horick), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Asif Jah
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Andrew L Warshaw
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anita Balakrishnan
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Carlos Fernández-Del Castillo
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
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14
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Zelga P, Hernández-Barco YG, Qadan M, Ferrone CR, Baba T, Bolm L, Jah A, Warshaw AL, Lillemoe KD, Balakrishnan A, Fernández-Del Castillo C. ABO blood group distribution and risk of malignancy in patients undergoing resection for intraductal papillary mucinous neoplasm (IPMN). Pancreatology 2022; 22:264-269. [PMID: 35000863 DOI: 10.1016/j.pan.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The ABO blood type has been associated with risk of development of several malignancies, including pancreatic cancer. Data regarding IPMN is equivocal. To investigate this further, we analyzed the association between the ABO blood group and the presence of malignancy in a large cohort of resected IPMN and its influence in survival. METHODS 819 patients who underwent pancreatic resection for IPMN in the Massachusetts General Hospital (MGH) and Cambridge University Hospitals NHS Foundation Trust (CUH) from January 1993 to December 2020 were identified from prospective institutional databases. Pathological characteristics and blood type were correlated. RESULTS The distribution of blood types A, B, AB and O was 384 (47%), 92 (11%), 44 (5%) and 299 (37%), respectively. This blood type distribution was different than the reference population of the MGH and the CUH, which is 55% non-O blood group, and 45% type O. There was a significant predominance of non-O blood types when compared with O-blood type in patients with malignant IPMN (i.e. patients with high-grade dysplasia and invasive cancer) (67% vs 33%, OR 1.31 95%CI: 0.98-1.75, p = 0.069). The association was stronger for IPMN with invasive cancer (OR 1.43 95%CI: 1.01-2.02, p = 0.039). Blood group did not influence survival. CONCLUSION Non-O blood type is associated with need for resection in IPMN and with presence of invasive carcinoma.
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Affiliation(s)
- Piotr Zelga
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, United Kingdom
| | - Yasmin G Hernández-Barco
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Taisuke Baba
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Louisa Bolm
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Asif Jah
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, United Kingdom
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Anita Balakrishnan
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, United Kingdom
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15
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Hank T, Sandini M, Ferrone CR, Ryan DP, Mino-Kenudson M, Qadan M, Wo JY, Klaiber U, Weekes CD, Weniger M, Hinz U, Harrison JM, Heckler M, Warshaw AL, Hong TS, Hackert T, Clark JW, Büchler MW, Lillemoe KD, Strobel O, Castillo CFD. A Combination of Biochemical and Pathological Parameters Improves Prediction of Postresection Survival After Preoperative Chemotherapy in Pancreatic Cancer: The PANAMA-score. Ann Surg 2022; 275:391-397. [PMID: 32649455 DOI: 10.1097/sla.0000000000004143] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To build a prognostic score for patients with primary chemotherapy undergoing surgery for pancreatic cancer based on pathological parameters and preoperative Carbohydrate antigen 19-9 (CA19-9) levels. BACKGROUND Prognostic stratification after primary chemotherapy for pancreatic cancer is challenging and prediction models, such as the AJCC staging system, lack validation in the setting of preoperative chemotherapy. METHODS Patients with primary chemotherapy resected at the Massachusetts General Hospital between 2007 and 2017 were analyzed. Tumor characteristics independently associated with overall survival were identified and weighted by Cox-proportional regression. The pancreatic neoadjuvant Massachusetts-score (PANAMA-score) was computed from these variables and its performance assessed by Harrel concordance index and area under the receiving characteristics curves analysis. Comparisons were made with the AJCC staging system and external validation was performed in an independent cohort with primary chemotherapy from Heidelberg, Germany. RESULTS A total of 216 patients constituted the training cohort. The multivariate analysis demonstrated tumor size, number of positive lymph-nodes, R-status, and high CA19-9 to be independently associated with overall survival. Kaplan-Meier analysis according to low, intermediate, and high PANAMA-score showed good discriminatory power of the new metrics (P < 0.001). The median overall survival for the three risk-groups was 45, 27, and 12 months, respectively. External validation in 258 patients confirmed the prognostic ability of the score and demonstrated better accuracy compared with the AJCC staging system. CONCLUSION The proposed PANAMA-score, based on independent predictors of postresection survival, including pathologic variables and CA19-9, not only provides better discrimination compared to the AJCC staging system, but also identifies patients at high-risk for early death.
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Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jon M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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16
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Anteby R, Sinyard RD, Healy MG, Warshaw AL, Hodin R, Ellison EC, Phitayakorn R. Passing the Scalpel: Lessons on retirement planning from retired academic surgeons. Am J Surg 2021; 224:166-171. [PMID: 34865735 DOI: 10.1016/j.amjsurg.2021.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/05/2021] [Accepted: 11/28/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Almost half of practicing surgeons in the United States are currently older than 55, but guidelines on how to prepare for retirement are limited. We sought to identify possible facilitators for, and obstacles to, surgeons' preparations for retirement. METHODS A qualitative study was conducted using semi-structured interviews with clinically inactive academic surgeons. Emergent themes were identified via a grounded theory approach. RESULTS We interviewed 12 surgeons (83% male; median age 75 years). Major barriers to retirement from surgery included uncertainty about when to retire, limited identity outside of surgery, and perception of retirement as strictly individual/private. Facilitators of a successful retirement identified by the participants included early career financial planning, awareness of career trajectory, development of post-surgery goals, and utilization of collective knowledge. CONCLUSION There are numerous barriers encountered by surgeons seeking to transition from clinical practice to retirement that could be overcome by dedicated departmental and institutional efforts.
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Affiliation(s)
- Roi Anteby
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA; School of Public Health, Harvard University, Boston, MA, USA.
| | - Robert D Sinyard
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael G Healy
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Hodin
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - E Christopher Ellison
- Department of Surgery, The Wexner Medical Center at Ohio State University, Columbus, OH, USA
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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17
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Michelakos T, Sekigami Y, Kontos F, Fernández-Del Castillo C, Qadan M, Deshpande V, Ting DT, Clark JW, Weekes CD, Parikh A, Ryan DP, Wo JY, Hong TS, Allen JN, Catalano O, Warshaw AL, Lillemoe KD, Ferrone CR. Conditional Survival in Resected Pancreatic Ductal Adenocarcinoma Patients Treated with Total Neoadjuvant Therapy. J Gastrointest Surg 2021; 25:2859-2870. [PMID: 33501584 DOI: 10.1007/s11605-020-04897-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Dynamic survival data based on time already survived are lacking for resected borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC) patients who received total neoadjuvant therapy (TNT) with FOLFIRINOX followed by chemoradiation. Conditional survival, i.e., the probability of surviving an additional length of time after having already survived an amount of time, offers such information. We aimed to determine actuarial and conditional overall (OS, COS) and disease-free survival (DFS, CDFS) among this cohort. METHODS Clinicopathologic data were retrospectively collected for resected BR/LA PDAC patients who received TNT (2011-2019). COS and CDFS rates were calculated for patients being event (death/recurrence)-free at multiple intervals and by recurrence status. RESULTS After a median follow-up of 32.1 months, the 183 patients had a median OS and DFS of 39.1 months and 16.8 months, respectively. COS and CDFS increased as a function of time already survived. The probability of surviving an additional 24 months if a patient survived 2 years post-operatively was 70%, whereas the 4-year actuarial OS was 47%. Similarly, the probability of surviving disease-free an additional 24 months after 2 years was 66%, while actuarial 48-month DFS was 27%. COS for disease-free patients increased further over time. For patients remaining disease-free 12 months post-operatively, BR vs. LA status at diagnosis, tumor ≤ 4 cm at diagnosis, and R0 resection were independent predictors of favorable additional OS and DFS. CONCLUSIONS For resected TNT-treated BR/LA PDAC patients, the probability of surviving an additional length of time increases as a function of survival already accrued. Dynamic survival estimates may allow personalized follow-up and counseling.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Carlos Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aparna Parikh
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Onofrio Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA.
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Zhang B, Lee GC, Qadan M, Fong ZV, Mino-Kenudson M, Desphande V, Malleo G, Maggino L, Marchegiani G, Salvia R, Scarpa A, Luchini C, De Gregorio L, Ferrone CR, Warshaw AL, Lillemoe KD, Bassi C, Castillo CFD. Revision of Pancreatic Neck Margins Based on Intraoperative Frozen Section Analysis Is Associated With Improved Survival in Patients Undergoing Pancreatectomy for Ductal Adenocarcinoma. Ann Surg 2021; 274:e134-e142. [PMID: 31851002 DOI: 10.1097/sla.0000000000003503] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To test the hypothesis that complete, tumor-free resection at the pancreatic neck, achieved either en-bloc or non-en-bloc (ie, revision based on intraoperative frozen section [FS] analysis), is associated with improved survival as compared with incomplete resection (IR) in pancreatic ductal adenocarcinoma. SUMMARY BACKGROUND DATA Given the likely systemic nature of pancreatic ductal adenocarcinoma, the oncologic benefit of achieving a histologically complete local resection, particularly through revision of a positive intraoperative FS at the pancreatic neck, remains controversial. METHODS Clinicopathologic and treatment data were reviewed for 986 consecutive patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas who underwent open pancreatectomy as well as intraoperative FS analysis between 1998 and 2012 at Massachusetts General Hospital and between 1998 and 2013 at the University of Verona. Overall survival (OS) and perioperative morbidity and mortality were compared across 3 groups: complete resection achieved en-bloc (CR-EB), complete resection achieved non-en-bloc (CR-NEB), and IR. RESULTS The CR-EB cohort comprised 749 (76%) patients, CR-NEB 159 patients (16%), and IR 78 patients (8%). Other than a higher incidence of vascular resection among CR-NEB and IR patients, no demographic, pathologic (eg, tumor grade, lymph node positivity, superior mesenteric artery involvement), or treatment factors (eg, neoadjuvant and adjuvant therapy use) differed between the groups. Median OS was significantly higher in patients with CR-EB (28 mo, P = 0.01) and CR-NEB resections (24 mo, P = 0.02) as compared with patients with IR resections (19 mo). After adjusting for clinicopathologic and treatment characteristics, CR-EB and CR-NEB margin status were found to be independent predictors of improved OS (relative to IR, CR-EB hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.86; CR-NEB HR 0.69, 95% CI 0.50-0.96). There were no intergroup differences in perioperative morbidity and mortality, including rates of pancreatic fistula. CONCLUSIONS For patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas undergoing pancreatectomy, complete tumor extirpation via either en-bloc or non-en-bloc complete resection based on FS analysis is associated with improved OS, without an associated increased perioperative morbidity or mortality.
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Affiliation(s)
- Biqi Zhang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vikram Desphande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Applied Research on Cancer Centre (ARC-Net), University and Hospital Trust of Verona, Verona, Italy
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Lucia De Gregorio
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
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19
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Fong ZV, Hashimoto DA, Jin G, Haynes AB, Perez N, Qadan M, Ferrone CR, Castillo CFD, Warshaw AL, Lillemoe KD, Traeger LN, Chang DC. Simulated Volume-Based Regionalization of Complex Procedures: Impact on Spatial Access to Care. Ann Surg 2021; 274:312-318. [PMID: 31449139 PMCID: PMC7032992 DOI: 10.1097/sla.0000000000003574] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study simulates the regionalization of pancreatectomies to assess its impact on spatial access in terms of patient driving times. BACKGROUND Although policies to regionalize complex procedures to high-volume centers may improve outcomes, the impact on patient access is unknown. METHODS Patients who underwent pancreatectomies from 2005 to 2014 were identified from California's statewide database. Round-trip driving times between patients' home ZIP code and hospital addresses were calculated via Google Maps. Regionalization was simulated by eliminating hospitals performing <20 pancreatectomies/yr, and reassigning patients to the next closest hospital that satisfied the volume threshold. Sensitivity analyses were performed for New York and Medicare patients to assess for influence of geography and insurance coverage, respectively. RESULTS Of 13,317 pancreatectomies, 6335 (47.6%) were performed by hospitals with <20 cases/yr. Patients traveled a median of 49.8 minutes [interquartile range (IQR) 30.8-96.2] per round-trip. A volume-restriction policy would increase median round-trip driving time by 24.1 minutes (IQR 4.5-53.5). Population in-hospital mortality rates were estimated to decrease from 6.7% to 2.8% (P < 0.001). Affected patients were more likely to be racial minorities (44.6% vs 36.5% of unaffected group, P < 0.001) and covered by Medicaid or uninsured (16.3% vs 9.8% of unaffected group, P < 0.001). Sensitivity analyses revealed a 17.8 minutes increment for patients in NY (IQR 0.8-47.4), and 27.0 minutes increment for Medicare patients (IQR 6.2-57.1). CONCLUSIONS A policy that limits access to low-volume pancreatectomy hospitals will increase round-trip driving time by 24 minutes, but up to 54 minutes for 25% of patients. Population mortality rates may improve by 1.5%.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Ginger Jin
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Numa Perez
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Lara N Traeger
- Behavioral Medicine Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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20
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Weniger M, Hank T, Qadan M, Ciprani D, Michelakos T, Niess H, Heiliger C, Ilmer M, D'Haese JG, Ferrone CR, Warshaw AL, Lillemoe KD, Werner J, Liss A, Fernández-Del Castillo C. Influence of Klebsiella pneumoniae and quinolone treatment on prognosis in patients with pancreatic cancer. Br J Surg 2021; 108:709-716. [PMID: 34157083 DOI: 10.1002/bjs.12003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/03/2020] [Accepted: 07/23/2020] [Indexed: 06/13/2023]
Abstract
BACKGROUND An increasing body of evidence suggests that microbiota may promote progression of pancreatic ductal adenocarcinoma (PDAC). It was hypothesized that gammaproteobacteria (such as Klebsiella pneumoniae) influence survival in PDAC, and that quinolone treatment may attenuate this effect. METHODS This was a retrospective study of patients from the Massachusetts General Hospital (USA) and Ludwig-Maximilians-University (Germany) who underwent preoperative treatment and pancreatoduodenectomy for locally advanced or borderline resectable PDAC between January 2007 and December 2017, and for whom a bile culture was available. Associations between tumour characteristics, survival data, antibiotic use and results of intraoperative bile cultures were investigated. Survival was analysed using Kaplan-Meier curves and Cox regression analysis. RESULTS Analysis of a total of 211 patients revealed that an increasing number of pathogen species found in intraoperative bile cultures was associated with a decrease in progression-free survival (PFS) (-1·9 (95 per cent c.i. -3·3 to -0·5) months per species; P = 0·009). Adjuvant treatment with gemcitabine improved PFS in patients who were negative for K. pneumoniae (26·2 versus 15·3 months; P = 0·039), but not in those who tested positive (19·5 versus 13·2 months; P = 0·137). Quinolone treatment was associated with improved median overall survival (OS) independent of K. pneumoniae status (48·8 versus 26·2 months; P = 0·006) and among those who tested positive for K. pneumoniae (median not reached versus 18·8 months; P = 0·028). Patients with quinolone-resistant K. pneumoniae had shorter PFS than those with quinolone-sensitive K. pneumoniae (9·1 versus 18·8 months; P = 0·001). CONCLUSION K. pneumoniae may promote chemoresistance to adjuvant gemcitabine, and quinolone treatment is associated with improved survival.
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Affiliation(s)
- M Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - T Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - D Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - T Michelakos
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - H Niess
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - C Heiliger
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - M Ilmer
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - J G D'Haese
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - J Werner
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - A Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - C Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Michelakos T, Cai L, Villani V, Sabbatino F, Kontos F, Fernández-Del Castillo C, Yamada T, Neyaz A, Taylor MS, Deshpande V, Kurokawa T, Ting DT, Qadan M, Weekes CD, Allen JN, Clark JW, Hong TS, Ryan DP, Wo JY, Warshaw AL, Lillemoe KD, Ferrone S, Ferrone CR. Tumor Microenvironment Immune Response in Pancreatic Ductal Adenocarcinoma Patients Treated With Neoadjuvant Therapy. J Natl Cancer Inst 2021; 113:182-191. [PMID: 32497200 DOI: 10.1093/jnci/djaa073] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/08/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neoadjuvant folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) and chemoradiation have been used to downstage borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Whether neoadjuvant therapy-induced tumor immune response contributes to the improved survival is unknown. Therefore, we evaluated whether neoadjuvant therapy induces an immune response towards PDAC. METHODS Clinicopathological variables were collected for surgically resected PDACs at the Massachusetts General Hospital (1998-2016). Neoadjuvant regimens included FOLFIRINOX with or without chemoradiation, proton chemoradiation (25 Gy), photon chemoradiation (50.4 Gy), or no neoadjuvant therapy. Human leukocyte antigen (HLA) class I and II expression and immune cell infiltration (CD4+, FoxP3+, CD8+, granzyme B+ cells, and M2 macrophages) were analyzed immunohistochemically and correlated with clinicopathologic variables. The antitumor immune response was compared among neoadjuvant therapy regimens. All statistical tests were 2-sided. RESULTS Two hundred forty-eight PDAC patients were included. The median age was 64 years and 50.0% were female. HLA-A defects were less frequent in the FOLFIRINOX cohort (P = .006). HLA class II expression was lowest in photon and highest in proton patients (P = .02). The FOLFIRINOX cohort exhibited the densest CD8+ cell infiltration (P < .001). FOLFIRINOX and proton patients had the highest CD4+ and lowest T regulatory (FoxP3+) cell density, respectively. M2 macrophage density was statistically significantly higher in the treatment-naïve group (P < .001) in which dense M2 macrophage infiltration was an independent predictor of poor overall survival. CONCLUSIONS Neoadjuvant FOLFIRINOX with or without chemoradiation may induce immunologically relevant changes in the tumor microenvironment. It may reduce HLA-A defects, increase CD8+ cell density, and decrease T regulatory cell and M2 macrophage density. Therefore, neoadjuvant FOLFIRINOX therapy may benefit from combinations with checkpoint inhibitors, which can enhance patients' antitumor immune response.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Vincenzo Villani
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Francesco Sabbatino
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Teppei Yamada
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Azfar Neyaz
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin S Taylor
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tomohiro Kurokawa
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Soldano Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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22
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Sridharan V, Mino-Kenudson M, Cleary JM, Rahma OE, Perez K, Clark JW, Clancy TE, Rubinson DA, Goyal L, Bazerbachi F, Visrodia KH, Qadan M, Parikh A, Ferrone CR, Casey BW, Fernandez-Del Castillo C, Ryan DP, Lillemoe KD, Warshaw AL, Krishnan K, Hernandez-Barco YG. Pancreatic acinar cell carcinoma: A multi-center series on clinical characteristics and treatment outcomes. Pancreatology 2021; 21:S1424-3903(21)00162-9. [PMID: 34023183 DOI: 10.1016/j.pan.2021.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acinar cell carcinoma (ACC) is a very rare tumor of the exocrine pancreas, representing less than 1% of all pancreatic malignancies. The majority of data regarding ACC are limited to small case series. METHODS This is a retrospective study conducted at a large healthcare system from 1996 to 2019. Patients with pathologically confirmed ACC were included, and demographic data, tumor characteristics, and treatment outcomes were abstracted by chart review. Survival curves were obtained by using the Kaplan-Meier method and compared using the log-rank test. RESULTS Sixty-six patients with ACC were identified. The median patient age at diagnosis was 64, and 42% presented with metastatic disease. The majority presented with abdominal pain or pancreatitis (69%), and laboratory parameters did not correlate with tumor size, metastatic disease, or survival. Several somatic abnormalities were noted in tumors (BRCA2, TP53, and mismatch-repair genes). In patients with localized disease that underwent resection, the median time to develop metastatic lesions was 13 months. The median overall survival (OS) was 24.7 months from diagnosis, with a survival difference based on metastatic disease at diagnosis (median 15 vs 38 mos). Surgery was associated with improved survival in non-metastatic cases (p = 0.006) but not metastatic cases (p = 0.22), and chemotherapy showed OS benefit in metastatic disease (p < 0.01). Patients with metastatic ACC treated after 2010 utilized more platinum-based agents, and there was a OS benefit to FOLFOX or FOLFIRINOX chemotherapy compared to gemcitabine or capecitabine-based regimens (p = 0.006). CONCLUSION Pancreatic ACC patients often present with advanced disease. Surgery was associated with survival benefit among patients presenting with localized disease. The use of FOLFOX or FOLFIRINOX chemotherapy regimens was associated with improved OS in metastatic patients. These data add to our knowledge in this rare malignancy, and improves understanding about the genomic underpinnings, prognosis and treatment for acinar cancers.
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Affiliation(s)
- Vishwajith Sridharan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Mari Mino-Kenudson
- Division of Pathology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - James M Cleary
- Dana Farber Cancer Institute and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Osama E Rahma
- Dana Farber Cancer Institute and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Kimberly Perez
- Dana Farber Cancer Institute and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Jeffrey W Clark
- Division of Medical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Thomas E Clancy
- Dana Farber Cancer Institute and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Douglas A Rubinson
- Dana Farber Cancer Institute and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Lipika Goyal
- Division of Medical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Kavel H Visrodia
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Motaz Qadan
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Aparna Parikh
- Division of Medical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Cristina R Ferrone
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Brenna W Casey
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | | | - David Patrick Ryan
- Division of Medical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Keith D Lillemoe
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Andrew L Warshaw
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology, Massachusetts General Hospital, Harvard School of Medicine, Boston, MA, USA.
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23
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Fong ZV, Sekigami Y, Qadan M, Fernandez-Del Castillo C, Warshaw AL, Lillemoe KD, Ferrone CR. Assessment of the Long-Term Impact of Pancreatoduodenectomy on Health-Related Quality of Life Using the EORTC QLQ-PAN26 Module. Ann Surg Oncol 2021; 28:4216-4224. [PMID: 33774773 DOI: 10.1245/s10434-021-09853-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Long-term pancreatoduodenectomy (PD) survivors have previously reported favorable quality of life (QoL). However, there has been a paucity of studies utilizing pancreas-specific modules for QoL assessment, which may uncover disability that general modules cannot detect. METHODS The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-PAN26 questionnaires were administered to PD survivors who were at least 5 years out of their operations for neoplasms (1998-2011, study cohort) and compared their scores with published preoperative scores of patients with pancreatic cancer (control cohort). The clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (> 20) based on validated interpretation of clinically important differences. RESULTS Of 1266 patients who underwent PD, there were 305 survivors with valid contact information, of whom 248 responded to the questionnaire (response rate 81.3%) and made up the study cohort. The median follow-up was 9.1 years (range 5.1-21.2 years). When compared with the control cohort, patients in the study cohort reported higher pancreatic pain (41.7 ± 17.6 vs. 18.1 ± 20.5, p < 0.001, CR large), sexuality dissatisfaction (63.0 ± 37.5 vs. 35.1 ± 34.3, p < 0.001, CR large), altered bowel habits (37.6 ± 30.6 vs. 20.0 ± 24.5, p < 0.001, CR moderate), and digestive symptoms (26.3 ± 29.5 vs. 18.7 ± 27.8, p = 0.002, CR small) scores. There was a higher prevalence of bloating, indigestion, and flatulence, but lower prevalence of future health worry (71.7% vs. 89.6%, p < 0.001) and limitation in planning activities (30.1% vs. 48.3%, p < 0.001) at 5 years. CONCLUSION While post-PD patients had better long-term global QoL than healthy controls, a more granular, pancreas-specific questionnaire uncovered digestive abnormalities and sexuality dissatisfaction. These data can better inform clinical decision making and provide potential areas for improvement and patient support.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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24
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Birnbaum DJ, Begg SKS, Finetti P, Vanderburg C, Kulkarni AS, Neyaz A, Hank T, Tai E, Deshpande V, Bertucci F, Birnbaum D, Lillemoe KD, Warshaw AL, Mino-Kenudson M, Fernandez-Del Castillo C, Ting DT, Liss AS. Transcriptomic Analysis of Laser Capture Microdissected Tumors Reveals Cancer- and Stromal-Specific Molecular Subtypes of Pancreatic Ductal Adenocarcinoma. Clin Cancer Res 2021; 27:2314-2325. [PMID: 33547202 DOI: 10.1158/1078-0432.ccr-20-1039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) lethality is multifactorial; although studies have identified transcriptional and genetic subsets of tumors with different prognostic significance, there is limited understanding of features associated with the minority of patients who have durable remission after surgical resection. In this study, we performed laser capture microdissection (LCM) of PDAC samples to define their cancer- and stroma-specific molecular subtypes and identify a prognostic gene expression signature for short-term and long-term survival. EXPERIMENTAL DESIGN LCM and RNA sequencing (RNA-seq) analysis of cancer and adjacent stroma of 19 treatment-naïve PDAC tumors was performed. Gene expression signatures were tested for their robustness in a large independent validation set. An RNA-ISH assay with pooled probes for genes associated with disease-free survival (DFS) was developed to probe 111 PDAC tumor samples. RESULTS Gene expression profiling identified four subtypes of cancer cells (C1-C4) and three subtypes of cancer-adjacent stroma (S1-S3). These stroma-specific subtypes were associated with DFS (P = 5.55E-07), with S1 associated with better prognoses when paired with C1 and C2. Thirteen genes were found to be predominantly expressed in cancer cells and corresponded with DFS in a validation using existing RNA-seq datasets. A second validation on an independent cohort of patients using RNA-ISH probes to six of these prognostic genes demonstrated significant association with overall survival (median 17 vs. 25 months; P < 0.02). CONCLUSIONS Our results identified specific signatures from the epithelial and the stroma components of PDAC, which add clarity to the nature of PDAC molecular subtypes and may help predict survival.
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Affiliation(s)
- David J Birnbaum
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Digestive Surgery, Aix-Marseille University, Marseille, France.,Department of Predictive Oncology, Cancer Research Center of Marseille, U1068 Inserm, UMR 7258 CNRS, Institut Paoli Calmettes, Aix-Marseille University, Marseille, France
| | - Sebastian K S Begg
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pascal Finetti
- Department of Predictive Oncology, Cancer Research Center of Marseille, U1068 Inserm, UMR 7258 CNRS, Institut Paoli Calmettes, Aix-Marseille University, Marseille, France
| | - Charles Vanderburg
- Harvard NeuroDiscovery Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Anupriya S Kulkarni
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Azfar Neyaz
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eric Tai
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - François Bertucci
- Department of Predictive Oncology, Cancer Research Center of Marseille, U1068 Inserm, UMR 7258 CNRS, Institut Paoli Calmettes, Aix-Marseille University, Marseille, France.,Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Daniel Birnbaum
- Department of Predictive Oncology, Cancer Research Center of Marseille, U1068 Inserm, UMR 7258 CNRS, Institut Paoli Calmettes, Aix-Marseille University, Marseille, France
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - David T Ting
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts.
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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25
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Fong ZV, Lim PW, Hendrix R, Castillo CFD, Nipp RD, Lindberg JM, Whalen GF, Kastrinakis W, Qadan M, Ferrone CR, Warshaw AL, Lillemoe KD, Chang DC, Traeger LN. Patient and Caregiver Considerations and Priorities When Selecting Hospitals for Complex Cancer Care. Ann Surg Oncol 2021; 28:4183-4192. [PMID: 33415563 DOI: 10.1245/s10434-020-09506-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Healthcare policies have focused on centralizing care to high-volume centers in an effort to optimize patient outcomes; however, little is known about patients' and caregivers' considerations and selection process when selecting hospitals for care. We aim to explore how patients and caregivers select hospitals for complex cancer care and to develop a taxonomy for their selection considerations. METHODS This was a qualitative study in which data were gathered from in-depth interviews conducted from March to November 2019 among patients with hepatopancreatobiliary cancers who were scheduled to undergo a pancreatectomy (n = 20) at a metropolitan, urban regional, or suburban medical center and their caregivers (n = 10). RESULTS The interviews revealed six broad domains that characterized hospital selection considerations: hospital factors, team characteristics, travel distance to hospital, referral or recommendation, continuity of care, and insurance considerations. The identified domains were similar between participants seen at the metropolitan center and urban/suburban medical centers, with the following exceptions: participants receiving care specifically at the metropolitan center noted operative volume and access to specific services such as clinical trials in their hospital selection; participants receiving care at urban/suburban centers noted health insurance considerations and having access to existing medical records in their hospital selection. CONCLUSIONS This study delineates the many considerations of patients and caregivers when selecting hospitals for complex cancer care. These identified domains should be incorporated into the development and implementation of centralization policies to help increase patient access to high-quality cancer care that is consistent with their priorities and needs.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Pei-Wen Lim
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Ryan Hendrix
- Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | | | - Ryan D Nipp
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James M Lindberg
- Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Giles F Whalen
- Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | | | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lara N Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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26
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Michelakos T, Taylor MS, Sekigami Y, Kontos F, Warshaw AL, Lillemoe KD, Ferrone S, Deshpande V, Ferrone CR. Mutation Profile of Borderline/Locally Advanced Pancreatic Ductal Adenocarcinoma Responding to Total Neoadjuvant Therapy with FOLFIRINOX. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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27
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Warshaw AL. Commentary on: Prevalence and extent of industry support for program directors of surgical fellowships in the United States. Surgery 2020; 168:1108. [PMID: 32912780 DOI: 10.1016/j.surg.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew L Warshaw
- Andrew L. Warshaw Institute for Pancreatic Cancer Research, Boston, MA; Massachusetts General Hospital, Boston, MA.
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28
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Ciprani D, Weniger M, Qadan M, Hank T, Horick NK, Harrison JM, Marchegiani G, Andrianello S, Pandharipande PV, Ferrone CR, Lillemoe KD, Warshaw AL, Bassi C, Salvia R, Fernández-Del Castillo C. Risk of malignancy in small pancreatic cysts decreases over time. Pancreatology 2020; 20:1213-1217. [PMID: 32819844 PMCID: PMC8168401 DOI: 10.1016/j.pan.2020.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cysts <15 mm without worrisome features have practically no risk of malignancy at the time of diagnosis but this can change over time. Optimal duration of follow-up is a matter of debate. We evaluated predictors of malignancy and attempted to identify a time to safely discontinue surveillance. METHODS Bi-centric study utilizing prospectively collected databases of patients with pancreatic cysts measuring <15 mm and without worrisome features who underwent surveillance at the Massachusetts General Hospital (1988-2017) and at the University of Verona Hospital Trust (2000-2016). The risk of malignant transformation was assessed using the Kaplan-Meier method and parametric survival models, and predictors of malignancy were evaluated using Cox regression. RESULTS 806 patients were identified. Median follow-up was 58 months (6-347). Over time, 58 (7.2%) cysts were resected and of those, 11 had high grade dysplasia (HGD) or invasive cancer. Three additional patients had unresectable cancer for a total rate of malignancy of 1.7%. Predictors of development of malignancy included an increase in size ≥2.5 mm/year (HR = 29.54, 95% CI: 9.39-92.91, P < 0.001) and the development of worrisome features (HR = 9.17, 95% CI: 2.99-28.10, P = 0.001). Comparison of parametric survival models suggested that the risk of malignancy decreased after three years of surveillance and was lower than 0.2% after five years. CONCLUSIONS Pancreatic cysts <15 mm at the time of diagnosis have a very low risk of malignant transformation. Our findings indicate the risk decreases over time. Size increase of ≥2.5 mm/year is the strongest predictor of malignancy.
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Affiliation(s)
- D Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - N K Horick
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - J M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - G Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - P V Pandharipande
- Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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29
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Honselmann KC, Finetti P, Birnbaum DJ, Monsalve CS, Wellner UF, Begg SKS, Nakagawa A, Hank T, Li A, Goldsworthy MA, Sharma H, Bertucci F, Birnbaum D, Tai E, Ligorio M, Ting DT, Schilling O, Biniossek ML, Bronsert P, Ferrone CR, Keck T, Mino-Kenudson M, Lillemoe KD, Warshaw AL, Fernández-Del Castillo C, Liss AS. Neoplastic-Stromal Cell Cross-talk Regulates Matrisome Expression in Pancreatic Cancer. Mol Cancer Res 2020; 18:1889-1902. [PMID: 32873625 DOI: 10.1158/1541-7786.mcr-20-0439] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/28/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is characterized by a highly desmoplastic reaction, warranting intense cancer-stroma communication. In this study, we interrogated the contribution of the BET family of chromatin adaptors to the cross-talk between PDAC cells and the tumor stroma. Short-term treatment of orthotopic xenograft tumors with CPI203, a small-molecule inhibitor of BET proteins, resulted in broad changes in the expression of genes encoding components of the extracellular matrix (matrisome) in both cancer and stromal cells. Remarkably, more than half of matrisome genes were expressed by cancer cells. In vitro cocultures of PDAC cells and cancer-associated fibroblasts (CAF) demonstrated that matrisome expression was regulated by BET-dependent cancer-CAF cross-talk. Disrupting this cross-talk in vivo resulted in diminished growth of orthotopic patient-derived xenograft tumors, reduced proliferation of cancer cells, and changes in collagen structure consistent with that of patients who experienced better survival. Examination of matrisome gene expression in publicly available data sets of 573 PDAC tumors identified a 65-gene signature that was able to distinguish long- and short-term PDAC survivors. Importantly, the expression of genes predictive of short-term survival was diminished in the cancer cells of orthotopic xenograft tumors of mice treated with CPI203. Taken together, these results demonstrate that inhibiting the activity BET proteins results in transcriptional and structural differences in the matrisome are associated with better patient survival. IMPLICATIONS: These studies highlight the biological relevance of the matrisome program in PDAC and suggest targeting of epigenetically driven tumor-stroma cross-talk as a potential therapeutic avenue.
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Affiliation(s)
- Kim C Honselmann
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pascal Finetti
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France
| | - David J Birnbaum
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France.,Département de Chirurgie Générale et Viscérale, AP-HM, Marseille, France
| | - Christian S Monsalve
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Sebastian K S Begg
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Akifumi Nakagawa
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annie Li
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mathew A Goldsworthy
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Himanshu Sharma
- Partners Healthcare Personalized Medicine Center, Cambridge, Massachusetts
| | - François Bertucci
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France.,Département d'Oncologie Médicale, Institut Paoli-Calmettes, Marseille, France
| | - Daniel Birnbaum
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France
| | - Eric Tai
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - Matteo Ligorio
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - David T Ting
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - Oliver Schilling
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin L Biniossek
- Institute of Molecular Medicine and Cell Research, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Freiburg, Germany
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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30
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Honselmann KC, Pergolini I, Castillo CFD, Deshpande V, Ting D, Taylor MS, Bolm L, Qadan M, Wellner U, Sandini M, Bausch D, Warshaw AL, Lillemoe KD, Keck T, Ferrone CR. Timing But Not Patterns of Recurrence Is Different Between Node-negative and Node-positive Resected Pancreatic Cancer. Ann Surg 2020; 272:357-365. [PMID: 32675550 PMCID: PMC6639153 DOI: 10.1097/sla.0000000000003123] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Our aim was to evaluate recurrence patterns of surgically resected PDAC patients with negative (pN0) or positive (pN1) lymph nodes. SUMMARY BACKGROUND DATA Pancreatic ductal adenocarcinoma (PDAC) is predicted to become the second leading cause of cancer death by 2030. This is mostly due to early local and distant metastasis, even after surgical resection. Knowledge about patterns of recurrence in different patient populations could offer new therapeutic avenues. METHODS Clinicopathologic data were collected for 546 patients who underwent resection of their PDAC between 2005 and 2016 from 2 tertiary university centers. Patients were divided into an upfront resection group (n = 394) and a neoadjuvant group (n = 152). RESULTS Tumor recurrence was significantly less common in pN0 patients as compared with pN1 patients, (upfront surgery: 55% vs. 77%, P < 0.001 and 64% vs. 78%, P = 0.040 in the neoadjuvant group). In addition, time to recurrence was significantly longer in pN0 versus pN1 patients in the upfront resected patients (median 16 mo pN0 vs. 10 mo pN1 P < 0.001), and the neoadjuvant group (pN0 21 mo vs. 11 mo pN1, P < 0.001). Of the patients who recurred, 62% presented with distant metastases (63% of pN0 and 62% of pN1, P = 0.553), 24% with local disease (27% of pN0 and 23% of pN1, P = 0.672) and 14% with synchronous local and distant disease (10% of pN0 and 15% of pN1, P = 0.292). Similarly, there was no difference in recurrence patterns between pN0 and pN1 in the neoadjuvant group, in which 68% recurred with distant metastases (76% of pN0 and 64% of pN1, P = 0.326) and 18% recurred with local disease (pN0: 22% and pN1: 15%, P = 0.435). CONCLUSION Time to recurrence was significantly longer for pN0 patients. However, patterns of recurrence for pN0 vs. pN1 patients were identical. Lymph node status was predictive of time to recurrence, but not location of recurrence.
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Affiliation(s)
- Kim C Honselmann
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Ilaria Pergolini
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Carlos Fernandez-Del Castillo
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Vikram Deshpande
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David Ting
- MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Martin S Taylor
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Motaz Qadan
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ulrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Marta Sandini
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Dirk Bausch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Andrew L Warshaw
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Cristina R Ferrone
- Department of Gastrointestinal Surgery and Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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31
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Behrns K, Warshaw AL. A TRIBUTE TO OUR LONG-TIME CO-EDITOR AND FRIEND, MICHAEL G. SARR, MD. Surgery 2020; 168:208. [PMID: 32718665 DOI: 10.1016/j.surg.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Fong ZV, Sell NM, Fernandez-Del Castillo C, Del Carmen G, Ferrone CR, Chang DC, Warshaw AL, Polk HC, Lillemoe KD, Qadan M. Does preoperative pharmacologic prophylaxis reduce the rate of venous thromboembolism in pancreatectomy patients? HPB (Oxford) 2020; 22:1020-1024. [PMID: 31732463 DOI: 10.1016/j.hpb.2019.10.2437] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/05/2019] [Accepted: 10/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whether the risk of venous thromboembolism (VTE) may be reduced by preoperative administration of prophylactic heparin is unknown. We hypothesized that timing of heparin administration does not significantly alter the incidence of VTE in pancreatic surgery. METHODS An analysis was conducted using data from Massachusetts General Hospital's National Surgical Quality Improvement Program from 2012 to 2017. All patients admitted for elective pancreatic resection were included. The primary outcome was development of VTE. Multivariable regression was performed, adjusting for patient demographics and various clinical factors. RESULTS In total, 1448 patients were analyzed, of whom 1062 received preoperative heparin (73.3%). Overall, 36 (2.5%) patients developed VTE. On unadjusted analysis, there was no statistically significant difference between patients who received preoperative heparin compared with those who did not (2.6% vs. 1.3%, respectively; p = 0.079). On adjusted analysis, there was an association with increased VTE rates among patients who received preoperative heparin (OR 2.93, 95% CI 1.10-7.81; p = 0.031). CONCLUSION There was an association between preoperative heparin administration and increased incidence of VTE on adjusted analysis, possibly reflecting appropriate surgical judgment in patient selection for prophylaxis. These data question the inclusion of preoperative VTE pharmacologic prophylaxis as a reliable quality indicator.
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Affiliation(s)
- Zhi V Fong
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Naomi M Sell
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | | | - Gabriel Del Carmen
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Hiram C Polk
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, 55, Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
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Begg SKS, Birnbaum DJ, Clark JW, Mino-Kenudson M, Wellner UF, Schilling O, Lillemoe KD, Warshaw AL, Castillo CFD, Liss AS. FOLFIRINOX Versus Gemcitabine-based Therapy for Pancreatic Ductal Adenocarcinoma: Lessons from Patient-derived Cell Lines. Anticancer Res 2020; 40:3659-3667. [PMID: 32620605 DOI: 10.21873/anticanres.14355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM FOLFIRINOX [fluorouracil (5-FU), irinotecan, oxaliplatin] and gemcitabine plus nab-paclitaxel are standard treatments for patients with pancreatic ductal adenocarcinoma (PDAC). Despite efficacy rates of less than 32%, evidence is lacking to guide the use of one drug over the other. Herein, we compared the sensitivity of patient-derived PDAC cell lines to each of these regimens. MATERIALS AND METHODS Changes in the growth of 19 low-passage patient-derived PDAC cell lines were evaluated in response to treatment with FOLFIRINOX and gemcitabine plus paclitaxel (Gem-Pac). RESULTS Six cell lines exhibited optimal sensitivity (high EMax and low GI50) to FOLFIRINOX and three cell lines exhibited optimal sensitivity to Gem-Pac. Several cell lines that were optimally sensitive to one drug regimen exhibited very poor response to the other. CONCLUSION Further characterization of cancer cells exhibiting preferential sensitivity to each of these regimens may allow the identification of biomarkers to guide the selection of appropriate chemotherapy for a given patient.
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Affiliation(s)
- Sebastian K S Begg
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - David J Birnbaum
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Oliver Schilling
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A.
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Rodrigues C, Hank T, Qadan M, Ciprani D, Mino-Kenudson M, Weekes CD, Ryan DP, Clark JW, Allen JN, Hong TS, Wo JY, Ferrone CR, Warshaw AL, Lillemoe KD, Fernandez-Del Castillo C. Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2020; 20:722-728. [PMID: 32222340 DOI: 10.1016/j.pan.2020.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is limited data on the efficacy of adjuvant therapy (AT) in patients with invasive intraductal papillary mucinous neoplasms of the pancreas (IPMN). This single center retrospective cohort study aims to assess the impact of AT on survival in these patients. METHODS Patients undergoing surgery for invasive IPMN between 1993 and 2018 were included in the study. We compared the clinicopathologic features and evaluated overall survival (OS) using multivariate Cox regression adjusting for adjuvant therapy, age, T and N stage, perineural and lymphovascular invasion. We also assessed survival differences between surgery alone and AT in node negative (N0) and node positive (N+) subgroups. RESULTS 103 patients were included in the study; 69 underwent surgery alone while 34 also received AT. Patients in the AT group were significantly younger, presented at higher T and N stages and had more perineural and lymphovascular invasion. Median OS in the surgery alone group was 134 months and 65 months in the AT group, p = 0.052. On multivariate analysis, AT was not associated with improved OS; hazard ratio (HR) = 1.03 (0.52-2.05). In N0 patients, compared to surgery alone, AT was associated with a worse median OS (65 vs 167 months, p = 0.03), whereas in N+ patients there was a non-significant improvement (50.5 vs 20.4 months, p = 0.315). CONCLUSION AT did not improve survival in the overall cohort even after multivariate analysis. N0 patients have excellent survival, and AT should probably be avoided in them, whereas it may be considered in patients with N+ disease.
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Affiliation(s)
- Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Debora Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Ciprani D, Morales-Oyarvide V, Qadan M, Hank T, Weniger M, Harrison JM, Rodrigues C, Horick NK, Mino-Kenudson M, Ferrone CR, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. An elevated CA 19-9 is associated with invasive cancer and worse survival in IPMN. Pancreatology 2020; 20:729-735. [PMID: 32332003 DOI: 10.1016/j.pan.2020.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines for IPMN include an elevated serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. Serum CEA is also currently used for preoperative management of IPMN, although its measurement is not evidence-based. Accordingly, we aimed to assess the role of these tumor markers as predictors of malignancy in IPMN. METHODS IPMN resected between 1998 and 2018 at Massachusetts General Hospital were analyzed. Clinical, pathological and survival data were collected and compared to preoperative levels of CA 19-9 and CEA. Receiver operating characteristic (ROC) and Cox regression analyses were performed considering cut-offs of 37 U/ml (CA 19-9) and 5 μg/l (CEA). RESULTS Analysis of 594 patients showed that preoperative CA 19-9 levels > 37 U/ml (n = 128) were associated with an increased likelihood of invasive carcinoma when compared to normal levels (45.3% vs. 18.0%, P < 0.001), while there was no difference with respect to high-grade dysplasia (32.9% vs 31.9%, P = 0.88). The proportion of concurrent pancreatic cancer was higher in patients with CA 19-9 > 37 U/ml (17.2% vs 4.9%, P < 0.001). An elevated CA 19-9 was also associated with worse overall and disease-free survival (HR = 1.943, P = 0.007 and HR = 2.484, P < 0.001 respectively). CEA levels did not correlate with malignancy. CONCLUSION In patients with IPMN, serum CA19-9 > 37 U/ml is associated with invasive IPMN and concurrent pancreatic cancer as well as worse survival, but not with high-grade dysplasia. Serum CEA appears to have minimal utility in the management of these patients.
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Affiliation(s)
- D Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - V Morales-Oyarvide
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - J M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - N K Horick
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Bausch D, Fritz S, Bolm L, Wellner UF, Fernandez-Del-Castillo C, Warshaw AL, Thayer SP, Liss AS. Hedgehog signaling promotes angiogenesis directly and indirectly in pancreatic cancer. Angiogenesis 2020; 23:479-492. [PMID: 32444947 DOI: 10.1007/s10456-020-09725-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The inhibition of Hedgehog (Hh) signaling in pancreatic ductal adenocarcinoma (PDAC) reduces desmoplasia and promotes increased vascularity. In contrast to these findings, the Hh ligand Sonic Hedgehog (SHH) is a potent proangiogenic factor in non-tumor models. The aim of this study was to determine the molecular mechanisms by which SHH affects the tumor stroma and angiogenesis. METHODS Mice bearing three different xenografted human PDAC (n = 5/group) were treated with neutralizing antibodies to SHH. After treatment for 7 days, tumors were evaluated and the expression of 38 pro- and antiangiogenic factors was assessed in the tumor cells and their stroma. The effect of SHH on the regulation of pro- and antiangiogenic factors in fibroblasts and its impact on endothelial cells was then further assessed in in vitro model systems. RESULTS Inhibition of SHH affected tumor growth, stromal content, and vascularity. Its effect on the Hh signaling pathway was restricted to the stromal compartment of the three cancers. SHH-stimulated angiogenesis indirectly through the reduction of antiangiogenic THBS2 and TIMP2 in stromal cells. An additional direct effect of SHH on endothelial cells depended on the presence of VEGF. CONCLUSION Inhibition of Hh signaling reduces tumor vascularity, suggesting that Hh plays a role in the maintenance or formation of the tumor vasculature. Whether the reduction in tumor growth and viability seen in the epithelium is a direct consequence of Hh pathway inhibition, or indirectly caused by its effect on the stroma and vasculature, remains to be evaluated.
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Affiliation(s)
- Dirk Bausch
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.,Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Stefan Fritz
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.,Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Louisa Bolm
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Carlos Fernandez-Del-Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Sarah P Thayer
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA. .,Division of Surgical Oncology and the Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, 68198-6895, USA.
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.
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Fong ZV, Chang DC, Hur C, Jin G, Tramontano A, Sell NM, Warshaw AL, Fernandez-Del Castillo C, Ferrone CR, Lillemoe KD, Qadan M. Variation in long-term oncologic outcomes by type of cancer center accreditation: An analysis of a SEER-Medicare population with pancreatic cancer. Am J Surg 2020; 220:29-34. [PMID: 32265013 DOI: 10.1016/j.amjsurg.2020.03.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cancer center accreditation is designed to identify centers that provide high-quality cancer care. This also guides patients and referring physicians towards centers of excellence for specialized care. We sought to examine if cancer center accreditation was associated with improved long-term oncologic outcomes in patients with pancreatic adenocarcinoma. METHODS Using the SEER-Medicare database, we identified patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1996 to 2013. Hospitals were categorized into three groups: National Cancer Institute-designated (NCI-designated) centers, Commission on Cancer (CoC)-accredited centers, and "non-accredited" (NA) centers. Multilevel mixed-effects models were used to calculate adjusted examined lymph nodes, disease-specific survival (DSS), and overall survival (OS). RESULTS We identified 5,118 patients who underwent pancreatectomy at 632 hospitals (41.0% NA, 49.6% CoC, 9.4% NCI). NCI-designated centers had a greater median number of lymph nodes examined compared with CoC-accredited or NA centers (14 vs. 10 vs. 11.0 nodes, respectively; p < 0.001). Patients treated at NCI centers had a higher 5-year DSS compared to those treated at CoC or NA centers (31.2% vs. 23.6% vs. 23.0%, respectively; p < 0.001). Finally, patients treated at NCI centers had a higher 5-year OS compared to those treated at CoC or NA centers (23.5% vs. 18.9% vs. 17.9%, respectively; p < 0.001). The associations held true when adjusted analyses were performed. CONCLUSION Patients with resected pancreatic cancer treated at NCI-designated centers were associated with improved long-term oncologic outcomes. There was no difference between CoC-accredited centers compared with NA centers. Meticulous validation of accreditation is warranted globally prior to implementation.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Ginger Jin
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Angela Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Naomi M Sell
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Michelakos T, Pergolini I, Castillo CFD, Honselmann KC, Cai L, Deshpande V, Wo JY, Ryan DP, Allen JN, Blaszkowsky LS, Clark JW, Murphy JE, Nipp RD, Parikh A, Qadan M, Warshaw AL, Hong TS, Lillemoe KD, Ferrone CR. Predictors of Resectability and Survival in Patients With Borderline and Locally Advanced Pancreatic Cancer who Underwent Neoadjuvant Treatment With FOLFIRINOX. Ann Surg 2020; 269:733-740. [PMID: 29227344 DOI: 10.1097/sla.0000000000002600] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to determine (1) whether preoperative factors can predict resectability of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant FOLFIRINOX, (2) which patients might benefit from adjuvant therapy, and (3) survival differences between resected BR/LA patients who received neoadjuvant FOLFIRINOX and upfront resected patients. BACKGROUND Patients with BR/LA PDAC are often treated with FOLFIRINOX to obtain a margin-negative resection, yet selection of patients for resection remains challenging. METHODS Clinicopathologic data of PDAC patients surgically explored between 04/2011-11/2016 in a single institution were retrospectively collected. RESULTS Following neoadjuvant FOLFIRINOX, 141 patients were surgically explored (BR: 49%, LA: 51%) and 110 (78%) were resected. Resected patients had lower preoperative CA 19-9 levels (21 vs 40 U/mL, P = 0.03) and smaller tumors on preoperative computed tomography (CT) scan (2.3 vs 3.0 cm, P = 0.03), but no predictors of resectability were identified. Median overall survival (OS) was 34.2 months from diagnosis for all FOLFIRINOX patients and 37.7 months for resected patients. Among resected patients, preoperative CA 19-9 >100 U/mL and >8 months between diagnosis and surgery predicted a shorter postoperative disease-free survival (DFS); Charlson comorbidity index >1, preoperative CA 19-9 >100 U/mL and tumor size (>3.0 cm on CT or >2.5 cm on pathology) predicted decreased OS. DFS and OS were significantly better for BR/LA PDAC patients treated with neoadjuvant FOLFIRINOX compared with upfront resected patients (DFS: 29.1 vs 13.7, P < 0.001; OS: 37.7 vs 25.1 months from diagnosis, P = 0.01). CONCLUSION BR/LA PDAC patients with no progression on neoadjuvant FOLFIRINOX should be offered surgical exploration. Except size, traditional pathological parameters fail to predict survival among resected FOLFIRINOX patients. Resected FOLFIRINOX patients have survival that appears to be superior than that of resectable patients who go directly to surgery.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ilaria Pergolini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Kim C Honselmann
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aparna Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Hank T, Sandini M, Qadan M, Weniger M, Ciprani D, Li A, Ferrone CR, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. Diabetes mellitus is associated with unfavorable pathologic features, increased postoperative mortality, and worse long-term survival in resected pancreatic cancer. Pancreatology 2020; 20:125-131. [PMID: 31706821 DOI: 10.1016/j.pan.2019.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/07/2019] [Accepted: 10/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The risk of pancreatic ductal adenocarcinoma (PDAC) is increased in patients with diabetes mellitus (DM), particularly in those with new-onset DM. However, the impact of DM on outcomes following pancreatic surgery is not fully understood. We sought to explore the effects of DM on post-resection outcomes in patients undergoing either upfront resection or following neoadjuvant treatment (NAT). METHODS Resections for PDAC between 2007 and 2016 were identified from a prospectively-maintained database. Data on demographics, pathology, and perioperative outcomes were compared between patients with or without DM. Survival analysis was performed using Kaplan-Meier curves and adjusted for confounders by a Cox-proportional hazards model. RESULTS 662 patients were identified, of whom 277 (41.8%) had DM. Diabetics were more likely to be male, had higher BMI, and higher ASA-scores. At pathology, DM was associated with larger tumors (30 vs. 26 mm; p = 0.041), higher rates of lymph-node involvement (69% vs. 59%; p = 0.031) and perineural invasion (88% vs. 82%; p = 0.026). Despite having similar rates of complications, diabetics experienced higher 30-day mortality (3.2% vs. 0.8%; p = 0.019). Median overall survival was worse in diabetic patients (18 vs. 34 months; p < 0.001); this effect was more pronounced in patients with NAT (18 vs. 54 months; p < 0.001). At multivariate analysis, DM was confirmed as an independent predictor of post-resection survival. CONCLUSION DM is a common comorbidity in PDAC and is associated with unfavorable pathology, as well as worse postoperative and oncologic outcomes. The blunted effect on survival is more pronounced in patients who undergo resection following NAT.
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Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Debora Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Annie Li
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Sandini M, Negreros-Osuna AA, Qadan M, Hank T, Patino M, Ferrone CR, Warshaw AL, Lillemoe KD, Sahani D, Castillo CFD. Main Pancreatic Duct to Parenchymal Thickness Ratio at Preoperative Imaging is Associated with Overall Survival in Upfront Resected Pancreatic Cancer. Ann Surg Oncol 2019; 27:1606-1612. [PMID: 31722071 DOI: 10.1245/s10434-019-08040-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic cancer induces parenchymal atrophy and duct dilation. The aim of this study was to evaluate whether these radiologic modifications are associated with outcomes. METHODS Upfront pancreaticoduodenectomy patients with available preoperative contrast enhanced CT scan imaging were retrospectively analyzed. Thickness of the pancreas, size of the main pancreatic duct (MPD), and distance of the tumor from the ampulla were assessed. A training cohort was selected, including short- (3-12 months following surgery) and long-term (≥ 36 months) survivors. Identified survival determinants were validated in the overall cohort. RESULTS Two-hundred-sixteen patients were analyzed. In the training cohort (N = 118), 68 patients (57.6%) were in the short-term and 50 (42.4%) in the long-term survival group. The short-term survival group had significantly higher CA 19-9 levels (p = 0.027), larger tumors (32.6 ± 12.1 mm vs. 26.5 ± 11.6 mm, p = 0.007), poorer differentiation (p = 0.003), higher rate of R < 1 mm resections (54% vs. 32%, p = 0.008), and reduced receipt of adjuvant chemotherapy (p = 0.020). The MPD-to-pancreatic thickness ratio was significantly lower in the short-term survivors (3.6 ± 6.2 vs. 8.2 ± 12.0, p = 0.016). In the entire cohort, an MPD-to-pancreatic thickness ratio ≥ 3.5 was associated with improved OS [median 33.0 months IQR (19.7-48.1) versus 17 months IQR (14.8-19.2), p = 0.004], and confirmed by a Cox-proportional hazards model independently associated with OS (HR = 0.58; p = 0.009), together with tumor size (HR = 1.02; p =0.012), R1/R2 status (HR = 1.53; p = 0.029), and receipt of adjuvant treatment (HR = 0.61; p = 0.021). CONCLUSIONS High MPD-to-pancreatic thickness ratio was associated with improved long-term survival in pancreaticoduodenectomy for cancer. Whether these features are related to tumor chronicity, indolent biology, or local growth over metastasis remains to be determined.
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Affiliation(s)
- Marta Sandini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adrian A Negreros-Osuna
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Manuel Patino
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dushyant Sahani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Hank T, Sandini M, Ferrone CR, Rodrigues C, Weniger M, Qadan M, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy. JAMA Surg 2019; 154:943-951. [PMID: 31411659 PMCID: PMC6694396 DOI: 10.1001/jamasurg.2019.2272] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/17/2019] [Indexed: 01/05/2023]
Abstract
Importance In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited. Objective To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential associations with OS. Design, Setting, and Participants This retrospective cohort study was conducted on data from patients who underwent pancreatic resection for PDAC at the Massachusetts General Hospital from January 1, 2007, to December 31, 2017. Exposures Pancreatic cancer surgery with or without NAT. Main Outcomes and Measures Overall morbidity and CR-POPF rates were compared between NAT and upfront resection. Factors associated with CR-POPF were assessed with univariate and multivariate analysis. Survival data were analyzed by Kaplan-Meier curves and a Cox proportional hazards regression model. Results Of 753 patients, 364 were men (48.3%); median (interquartile range) age was 68 (61-75) years. A total of 346 patients (45.9%) received NAT and 407 patients (54.1%) underwent upfront resection. At pathologic examination, NAT was associated with smaller tumor size (mean [SD], 26.0 [15.3] mm vs 32.7 [14.4] mm; P < .001), reduced nodal involvement (102 [25.1%] vs 191 [55.2%]; P < .001), and higher R0 rates (257 [74.3%] vs 239 [58.7%]; P < .001). There were no significant differences in severe complication rate or 90-day mortality. The rate of CR-POPF was 3.6-fold lower in patients receiving NAT vs upfront resection (13 [3.8%] vs 56 [13.8%]; P < .001). In addition, factors associated with CR-POPF changed after NAT, and only soft pancreatic texture was associated with a higher risk of CR-POPF (38.5% vs 6.3%; P < .001). Survival analysis showed no differences between patients with or without CR-POPF after upfront resection (26 vs 25 months; P = .66), but after NAT, a worse overall survival rate was observed in patients with CR-POPF (17 vs 34 months; P = .002). This association was independent of other established predictors of overall survival by multivariate analysis (hazard ratio, 2.80; 95% CI, 1.44-5.45; P < .002). Conclusions and Relevance Neoadjuvant therapy may be associated with a significant reduction in the rate of CR-POPF. In addition, standard factors associated with CR-POPF appear to be no longer applicable following NAT. However, once CR-POPF occurs, it is associated with a significant reduction in long-term survival. Patients with CR-POPF may require closer follow-up and could benefit from additional therapy.
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Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Sandini M, Ruscic KJ, Ferrone CR, Qadan M, Eikermann M, Warshaw AL, Lillemoe KD, Castillo CFD. Major Complications Independently Increase Long-Term Mortality After Pancreatoduodenectomy for Cancer. J Gastrointest Surg 2019; 23:1984-1990. [PMID: 30225794 DOI: 10.1007/s11605-018-3939-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/17/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative major morbidity has been associated with worse survival gastrointestinal tumors. This association remains controversial in pancreatic cancer (PC). We analyzed whether major complications after surgical resection affect long-term survival. METHODS Records of all PC patients resected from 2007 to 2015 were reviewed. Major morbidity was defined as any grade-3 or higher 30-day complications, per the Clavien-Dindo Classification. Patients who died within 90 days after surgery were excluded from survival analysis. RESULTS Of 616 patients, 81.7% underwent pancreatoduodenectomy (PD) and 18.3% distal pancreatectomy (DP). Major complications occurred in 19.1% after PD and 15.9% after DP. In patients who survived > 90 days, the likelihood of receiving adjuvant treatment was 43.9% if major complications had occurred, vs. 68.5% if not (p < 0.001), and those who received it started the treatment median 10 days later compared with uncomplicated patients (median 60 days (50-72) vs. 50 days (41-61), p = 0.001). By univariate analysis, in addition to the conventional pathology-related prognostic determinants and the receipt of adjuvant treatment, major complications worsened long-term survival after PD (median OS 26 months vs. 15, p = 0.008). A difference was also seen after DP, but it did not reach statistical significance, likely related to the small sample size (median OS 33 months vs. 18, p = 0.189). At multivariate analysis for PD, major postoperative complications remained independently associated with worse survival [HR 1.37, 95%CI (1.01-1.86)]. CONCLUSIONS Major surgical complications after pancreaticoduodenectomy are associated with worse long-term survival in pancreatic cancer. This effect is independent of the receipt of adjuvant treatment.
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Affiliation(s)
- M Sandini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA
| | - K J Ruscic
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA
| | - Carlos Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman ST, Boston, MA, 02114-02115, USA.
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Yang F, Jin C, Fu DL, Warshaw AL. Modified FOLFIRINOX for resected pancreatic cancer: Opportunities and challenges. World J Gastroenterol 2019; 25:2839-2845. [PMID: 31249443 PMCID: PMC6589737 DOI: 10.3748/wjg.v25.i23.2839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/17/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer death worldwide. Adjuvant chemotherapy has been developed based on the experiences made with palliative chemotherapy, and advocated to improve long-term survival of patients with this disease. However, the optimal chemotherapeutic regimen remains controversial. Recently, Conroy et al demonstrated the impressive benefits of modified FOLFIRINOX over gemcitabine alone in the multicenter Partenariat de Recherche en Oncologie Digestive 24 (PRODIGE-24) trial. The remarkable results mark a new milestone in treating resectable pancreatic cancer and have now changed the standard of care for this patient population. In this commentary, we discuss an issue of difference of tumor grade between the PRODIGE-24 trial and previous phase III trials. We also discuss potential biomarkers predicting therapeutic response to modified FOLFIRINOX. Finally, we summarize several ongoing clinical trials of replacing part of the FOLFIRINOX regimen with Xeloda/S-1/nanoliposomal irinotecan for pancreatic cancer.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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Yang F, Jin C, Warshaw AL, You L, Mao Y, Fu D. Cover Image, Volume 119, Number 6, May 1, 2019. J Surg Oncol 2019. [DOI: 10.1002/jso.25479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Feng Yang
- Department of Pancreatic SurgeryPancreatic Disease Institute, Huashan Hospital affiliated to Fudan UniversityShanghai China
| | - Chen Jin
- Department of Pancreatic SurgeryPancreatic Disease Institute, Huashan Hospital affiliated to Fudan UniversityShanghai China
| | - Andrew L. Warshaw
- Department of SurgeryMassachusetts General Hospital, Harvard Medical SchoolBoston MA
| | - Li You
- Department of Pancreatic SurgeryPancreatic Disease Institute, Huashan Hospital affiliated to Fudan UniversityShanghai China
| | - Yishen Mao
- Department of Pancreatic SurgeryPancreatic Disease Institute, Huashan Hospital affiliated to Fudan UniversityShanghai China
| | - Deliang Fu
- Department of Pancreatic SurgeryPancreatic Disease Institute, Huashan Hospital affiliated to Fudan UniversityShanghai China
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Cai L, Michelakos T, Deshpande V, Arora KS, Yamada T, Ting DT, Taylor MS, Castillo CFD, Warshaw AL, Lillemoe KD, Ferrone S, Ferrone CR. Role of Tumor-Associated Macrophages in the Clinical Course of Pancreatic Neuroendocrine Tumors (PanNETs). Clin Cancer Res 2019; 25:2644-2655. [PMID: 30670493 DOI: 10.1158/1078-0432.ccr-18-1401] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/28/2018] [Accepted: 01/10/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE This study evaluated the potential role of immune cells and molecules in the pathogenesis and clinical course of pancreatic neuroendocrine tumors (PanNET). EXPERIMENTAL DESIGN Surgically resected PanNETs (N = 104) were immunohistochemically analyzed for Ki67 index, mitotic rate, macrophage, CD4+ cells, and CD8+ T-cell infiltration, as well as HLA class I, PD-L1, and B7-H3 expression. Results were correlated with clinicopathologic characteristics as well as with disease-free (DFS) and disease-specific (DSS) survival. RESULTS The median age of the 57 WHO grade 1 and 47 WHO grade 2 patients was 55 years. High intratumoral CD8+ T-cell infiltration correlated with prolonged DFS (P = 0.05), especially when the number of tumor-associated macrophages (TAM) was low. In contrast, high peritumoral CD4+ cell and TAM infiltration was associated with a worse DFS and DSS. PD-L1 and B7-H3 were expressed in 53% and 78% PanNETs, respectively. HLA class I expression was defective in about 70% PanNETs. HLA-A expression correlated with favorable DSS in PD-L1-negative tumors (P = 0.02). TAM infiltration (P = 0.02), WHO grade (P = 0.04), T stage (P = 0.01), and lymph node positivity (P = 0.04) were independent predictors of DFS. TAM infiltration (P = 0.026) and T stage (P = 0.012) continued to be predictors of DFS in WHO grade 1 PanNET patients. TAM infiltration was the sole independent predictor of DSS for WHO grade 1 and 2 patients (P = 0.02). Therefore, this biomarker may contribute to identifying WHO grade 1 patients with poor prognosis. CONCLUSIONS TAM infiltration appears to be the most informative prognostic biomarker in PanNET. It may represent a useful immunotherapeutic target in patients with PanNET.
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Affiliation(s)
- Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kshitij S Arora
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Teppei Yamada
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David T Ting
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marty S Taylor
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Soldano Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Yang F, Jin C, Warshaw AL, You L, Mao Y, Fu D. Total pancreatectomy for pancreatic malignancy with preservation of the spleen. J Surg Oncol 2019; 119:784-793. [PMID: 30636049 DOI: 10.1002/jso.25377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Total pancreatectomy may be necessary to achieve margin-negative resection for pancreatic cancer. However, despite the desirability of saving the spleen, the feasibility, safety, and oncological outcomes of spleen-preserving total pancreatectomy have not been studied in patients with malignancy involving the pancreatic neck or proximal body. The aim of this study was to report the efficacy of spleen-preserving total pancreatectomy using the Warshaw technique for patients with pancreatic malignancies. METHODS A retrospective analysis of patients who underwent total pancreatectomy for malignant pancreatic diseases between December 2006 and January 2018 focused on comparing the clinical outcomes between conventional operations with splenectomy and spleen-preserving total pancreatectomy using the Warshaw technique. RESULTS Thirty-eight patients among a total of 59 total pancreatectomies had the spleen preservation by the Warshaw operation. In this series, the pancreatic ductal adenocarcinomas resected with the Warshaw technique were of smaller tumor size but had greater rates of vascular invasion, resulting in the more frequent vascular resection. No patients had splenic complications requiring splenectomy, but two patients intended to have the Warshaw operation were converted to splenectomy because of splenic malperfusion. Asymptomatic perigastric varices were noted in 4 patients. Postoperative morbidity and mortality were comparable between the Warshaw and conventional operation groups. Recurrence-free and overall survival was similar in both groups. CONCLUSION In patients with pancreatic malignancy, total pancreatectomy with preservation of the spleen using the Warshaw technique achieves outcomes comparable with conventional total pancreatectomy with splenectomy in selected patients.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Li You
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Yishen Mao
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, Shanghai, China
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Mehtsun WT, Chipidza FE, Fernández-del Castillo C, Hemingway K, Fong ZV, Chang DC, Pandharipande P, Clark JW, Allen J, Hong TS, Wo JY, Warshaw AL, Lillemoe KD, Ferrone CR. Are Staging Computed Tomography (CT) Scans of the Chest Necessary in Pancreatic Adenocarcinoma? Ann Surg Oncol 2018; 25:3936-3942. [DOI: 10.1245/s10434-018-6764-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Indexed: 08/30/2023]
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Luo G, Fan Z, Cheng H, Jin K, Guo M, Lu Y, Yang C, Fan K, Huang Q, Long J, Liu L, Xu J, Lu R, Ni Q, Warshaw AL, Liu C, Yu X. New observations on the utility of CA19-9 as a biomarker in Lewis negative patients with pancreatic cancer. Pancreatology 2018; 18:971-976. [PMID: 30131287 DOI: 10.1016/j.pan.2018.08.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carbohydrate antigen 19-9 (CA19-9) is the best-validated biomarker for pancreatic cancer. The National Comprehensive Cancer Network (NCCN) guideline asserts that "CA19-9 will be undetectable in Lewis antigen-negative individuals". However, reports of CA19-9 secretion and its significance in Lewis (-) patients with pancreatic cancer have been inconsistent. This study was to examine serum CA19-9 levels in patients with pancreatic cancer according to Lewis status. METHODS Patients with pancreatic cancer (1482 cases) were retrieved from a prospectively maintained database. Patients with benign pancreatic disease (210 cases) and normal subjects (315 cases) were used as controls. Lewis genotypes were examined by fucosyltransferase 3 (FUT3) sequencing. RESULTS In patients with pancreatic cancer, 8.4% of subjects were Lewis (-), but only 41.9% of Lewis (-) subjects had CA19-9 values ≤ 2 U/mL. CA19-9 was even elevated (>37 U/mL) in 27.4% of Lewis (-) patients. The area under the receiver operating characteristic (ROC) curve for CA19-9 as a diagnostic biomarker was 0.842 in Lewis (-) patients with pancreatic cancer, which is closing to that of CA19-9 applied in all of patients with pancreatic cancer (0.898). Lewis (-) status was an independent prognostic factor for shorter survival in a multivariable analysis (hazard ratio (HR), 1.30, 95% confidence interval (CI), 1.03-1.64; P = 0.028). CONCLUSIONS Not all Lewis (-) patients with pancreatic cancer are non-secretors of CA19-9. Contrary to general understanding, CA19-9 can retain its utility as a biomarker in these patients in spite of Lewis (-) genotype.
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Affiliation(s)
- Guopei Luo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Zhiyao Fan
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - He Cheng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Meng Guo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Yu Lu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Chao Yang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Kun Fan
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Qiuyi Huang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Jiang Long
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Liang Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Renquan Lu
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China
| | - Andrew L Warshaw
- Department of Surgery and the Warshaw Institute for Pancreatic Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chen Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China.
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai, China.
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Sandini M, Ruscic KJ, Ferrone CR, Warshaw AL, Qadan M, Eikermann M, Lillemoe KD, Fernández-del Castillo C. Intraoperative Dexamethasone Decreases Infectious Complications After Pancreaticoduodenectomy and is Associated with Long-Term Survival in Pancreatic Cancer. Ann Surg Oncol 2018; 25:4020-4026. [DOI: 10.1245/s10434-018-6827-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 01/08/2023]
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Ligorio M, Sil S, Malagon-Lopez J, Misale S, Karabacak M, Nieman L, Maheswaran S, Haber DA, Warshaw AL, Castillo CFD, Ferrone CR, Haas W, Aryee M, Ting DT. Abstract 210: Uncovering a novel layer of complexity in the architecture of pancreatic cancer. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Single cell technologies have described heterogeneity across tissues, but the spatial distribution and forces that drive single cell phenotypes has not been well defined. We integrated single cell RNA-seq (scRNA-Seq) and phospho mass cytometry (CyTOF) with high-content digital imaging to investigate tumor heterogeneity of human pancreatic cancer (PDAC) using a novel tumor-architecture approach.
Patient-derived PDAC cells co-cultured at different ratios with cancer associated fibroblasts (CAFs) were found to heterogeneously acquire proliferative (PRO) and invasive (EMT) phenotypes. scRNA-Seq enabled the identification of a novel cell phenotype with upregulation of both PRO and EMT programs, which we named the double positive (DP) phenotype. Functional studies confirmed the heterogeneous activation of PRO and EMT programs with different patterns of tumor growth and metastasis in mice orthotopically xenografted with distinct PDAC:CAF ratios.
In a time-course experiment of PDAC cells with CAF conditioned media (CM), mass spectrometry-based phosphoproteomics demonstrated selective enrichment of MAPK and STAT3 pathways. This was validated with mass cytometry (CyTOF) at the single cell level in our cell line model as well as from primary PDAC tumors, which identified the dual enrichment of MAPK and STAT3 signaling in the DP cell population. Functional validation of MAPK and STAT3 signaling was performed with small molecule inhibitors of MAPK (Trametinib) and STAT3 (pyrimethamine) in our cell line models.
To evaluate the generalizability of these cell subpopulations, we performed RNA-ISH for EMT (FN1) and PRO (MKI67) across 195 human PDAC primary tumors and scored 319,626 cancer cells revealing significant heterogeneity of PRO, EMT, and DP cells among patients. Single-cell analysis within the context of tissue architecture
revealed these cells were grouped together in discrete tumor glands. Using each of the 3 cell types (PRO, EMT, and DP), we classified 8 distinct types of tumor glands in these primary tumors. This provided the ability to define inter and intra-tumor heterogeneity at the tumor gland level, which provides an extra layer of tumor cell organization not appreciable with single cell analysis alone. We showed that tumor glands are independent functional units in human PDACs carrying distinct prognostic information. In fact, by comparing their prognostic power we noticed that some tumor glands are positively linked with worsened survival (Type I p=0.003, Type II p=0.04, Type II p=0.001 and Type VII p=0.02), while Type III glands are associated with a favorable patient prognosis (p=0.01, log-rank test).
In conclusion, our study showed for the first time at this scale level that integrating single-cell technologies with tissue architectural information provides a more comprehensive landscape of intra-tumoral cancer cell heterogeneity that has implications on PDAC cell behavior and patient outcomes.
Citation Format: Matteo Ligorio, Srinjoy Sil, Jose Malagon-Lopez, Sandra Misale, Murat Karabacak, Linda Nieman, Shyamala Maheswaran, Daniel A. Haber, Andrew L. Warshaw, Carlos Fernandez-Del Castillo, Cristina R. Ferrone, Wilhelm Haas, Martin Aryee, David T. Ting. Uncovering a novel layer of complexity in the architecture of pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 210.
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