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Habib JR, Kinny-Köster B, Amini N, Shoucair S, Cameron JL, Thompson ED, Fishman EK, Hruban RH, Javed AA, He J, Wolfgang CL. Predictors, Patterns, and Timing of Recurrence Provide Insight into the Disease Biology of Invasive Carcinomas Arising in Association with Intraductal Papillary Mucinous Neoplasms. J Gastrointest Surg 2022; 26:2311-2320. [PMID: 35915375 DOI: 10.1007/s11605-022-05428-4] [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: 04/27/2022] [Accepted: 07/10/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify predictors, patterns, and timing of recurrence after resection of invasive carcinomas arising in association with an IPMN. BACKGROUND Postoperative management of an invasive carcinoma arising in association with an intraductal papillary mucinous neoplasm (IPMN), a biologically distinct entity from PanIN-derived pancreatic ductal adenocarcinoma (PDAC), remains largely based on guidelines for PanIN-derived PDAC. To minimize treatment failure and inform disease-specific management, cancer recurrence must be better characterized. METHODS Patients were identified from a prospectively maintained registry between 1996 and 2018. Predictors of recurrence were evaluated by employing Cox regression models to determine risk-adjusted hazard ratios (HR) with 95% confidence intervals (95%CI). The patterns and timing of recurrence were recognized and compared utilizing a log-rank test, respectively. RESULTS Of the 213 patients included, 92 (43.2%) recurred with a median RFS of 23.7 months (16.7-30.7). The predominant pattern of recurrence included any systemic (65.2%). The median time to local recurrence was longer than systemic (21.6 versus 11.4 months, p = 0.05). Poor differentiation [HR: 3.01, 95%CI (1.06-8.61)] and nodal disease [N1, HR: 2.23, 95%CI (1.12-4.60); and N2, HR: 5.67 95%CI (2.93-10.99)] emerged as independent predictors of systemic recurrence. For local-specific recurrences, poor differentiation [HR: 3.73, 95%CI (1.04-13.45)] and an R1 margin [high-grade dysplasia or invasive carcinoma; HR: 2.66, 95%CI (1.14-6.21)] emerged as independent predictors. CONCLUSIONS The predominant pattern of recurrence after resection of invasive carcinomas arising in association with IPMNs is systemic, and occurs earlier than local recurrence. Poor differentiation and nodal disease are associated with systemic recurrence while poor differentiation and an R1 margin are associated with local recurrence. Future studies should investigate the role of systemic (chemotherapy) versus local (radiation) therapies and surveillance strategies in a personalized manner.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benedict Kinny-Köster
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth D Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.
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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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Kameyama S, Motonari H, Ishimine T, Isa T. Successful treatment with conversion surgery following chemoradiotherapy for unresectable invasive intraductal papillary mucinous neoplasm. Clin J Gastroenterol 2020; 13:579-84. [PMID: 31919675 DOI: 10.1007/s12328-019-01086-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/17/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Recent advances in chemotherapy and chemoradiotherapy (CRT) have enabled the use of conversion surgery in selected patients with initially unresectable pancreatic duct adenocarcinoma after a favorable response to preoperative treatment. However, conversion surgery for invasive intraductal papillary mucinous neoplasm (IPMN) has not been reported. CASE REPORT A 63-year-old man was referred to our hospital for invasive IPMN treatment. Computed tomography revealed a multilocular tumor of 7.2 × 5.8 cm in diameter, which surrounded approximately 180° of the superior mesenteric artery and totally occluded the superior mesenteric vein (SMV). He was diagnosed with unresectable invasive IPMN. CRT was performed using four cycles of S-1 (100 mg/day) based on body surface area for 14 days every 3 weeks plus gemcitabine 1,000 mg/m2 on days 8 and 15 with concurrent radiotherapy (50.4 Gy in 28 fractions). Response to chemotherapy revealed partial response according to the Response Evaluation Criteria in Solid Tumors; subsequently, subtotal stomach-preserving pancreaticoduodenectomy with SMV resection was performed. The postoperative course was uneventful. Four courses of adjuvant chemotherapy with TS-1 100 mg / day were administered postoperatively. At 5 years and 9 months after initiating treatment, the patient was alive without recurrence.
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Karimian F. A commentary on the article: "Intraductal papillary mucinous carcinoma versus pancreatic ductal adenocarcinoma: A systematic review and meta-analysis", Int J Surg 2019;71:91-99. Int J Surg 2019; 71:170-171. [PMID: 31605757 DOI: 10.1016/j.ijsu.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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Duconseil P, Périnel J, Autret A, Adham M, Sauvanet A, Chiche L, Mabrut JY, Tuech JJ, Mariette C, Régenet N, Fabre JM, Bachellier P, Delpéro JR, Paye F, Turrini O. Resectable invasive IPMN versus sporadic pancreatic adenocarcinoma of the head of the pancreas: Should these two different diseases receive the same treatment? A matched comparison study of the French Surgical Association (AFC). Eur J Surg Oncol 2017; 43:1704-1710. [PMID: 28687431 DOI: 10.1016/j.ejso.2017.06.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 03/28/2017] [Revised: 05/25/2017] [Accepted: 06/08/2017] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To compare survival and impact of adjuvant chemotherapy in patients who underwent pancreaticoduodenectomy (PD) for invasive intraductal papillary mucinous neoplasm (IIPMN) and sporadic pancreatic ductal adenocarcinoma (PDAC). METHODS From 2005 to 2012, 240 patients underwent pancreatectomy for IIPMN and 1327 for PDAC. Exclusion criteria included neoadjuvant treatment, pancreatic resection other than PD, vascular resection, carcinoma in situ, or <11 examined lymph nodes. Thus, 82 IIPMN and 506 PDAC were eligible for the present study. Finally, The IIPMN group was matched 1:2 to compose the PDAC group according to TNM disease stage, perineural invasion, lymph node ratio, and margin status. RESULTS There was no difference in patient's characteristics, intraoperative parameters, postoperative outcomes, and histologic parameters. Overall survival and disease-free survival times were comparable between the 2 groups. In each group, overall survival time was significantly poorer in patients who did not achieve adjuvant chemotherapy (p = 0.03 for the IIPMN group; p = 0.03 for the PDAC group). In lymph-node negative patients of the IIPMN group, adjuvant chemotherapy did not have any significant impact on overall survival time (OR = 0.57; 95% CI [0.24-1.33]). Considering the whole population (i.e. patients with IIPMN and PDAC; n = 246), patients who did not achieve adjuvant chemotherapy had poorer survival (p < 0.01). CONCLUSIONS The courses of IIPMN and PDAC were similar after an optimized stage-to-stage comparison. Adjuvant chemotherapy was efficient in both groups. However, in lymph node negative patients, adjuvant chemotherapy seemed not to have a significant impact.
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Affiliation(s)
- P Duconseil
- Department of Surgery, Hôpital Nord, Marseille, France.
| | - J Périnel
- Department of Surgery, Hôpital Edouard-Herriot, HCL, UCBL1, Lyon, France
| | - A Autret
- Department of Biostatistics, Institut Paoli-Calmettes, Marseille, France
| | - M Adham
- Department of Surgery, Hôpital Edouard-Herriot, HCL, UCBL1, Lyon, France
| | - A Sauvanet
- Department of Surgery, Hôpital Beaujon, Paris, France
| | - L Chiche
- Department of Surgery, Maison du Haut-Lévêque, Bordeaux, France
| | - J-Y Mabrut
- Department of Surgery, Hôpital de la Croix Rousse, Lyon, France
| | - J-J Tuech
- Department of Surgery, Hôpital Charles Nicolle, Rouen, France
| | - C Mariette
- Department of Surgery, Hôpital Claude-Huriez, Lille, France
| | - N Régenet
- Department of Surgery, Hôpital Hôtel Dieu, Nantes, France
| | - J-M Fabre
- Department of Surgery, Hôpital Saint Eloi, Montpellier, France
| | - P Bachellier
- Department of Surgery, Hôpital de Hautepierre, Strasbourg, France
| | - J-R Delpéro
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - F Paye
- Department of Surgery, Hôpital Saint Antoine, Paris, France
| | - O Turrini
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
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Marsoner K, Haybaeck J, Csengeri D, Waha JE, Schagerl J, Langeder R, Mischinger HJ, Kornprat P. Pancreatic resection for intraductal papillary mucinous neoplasm- a thirteen-year single center experience. BMC Cancer 2016; 16:844. [PMID: 27809876 PMCID: PMC5096332 DOI: 10.1186/s12885-016-2887-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/25/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this study is to review our results for pancreatic resection in patients with intraductal papillary mucinous neoplasm (IPMN) with and without associated carcinoma. METHODS A total of 54 patients undergoing pancreatic resection for IPMN in a single university surgical center (Medical University of Graz) were reviewed retrospectively. Their survival rates were compared to those of patients with pancreatic ductal adenocarcinoma. RESULTS Twenty-four patients exhibit non-invasive IPMN and thirty patients invasive IPMN with associated carcinoma. The mean age is 67 (+/-11) years, 43 % female. Surgical strategies include classical or pylorus-preserving Whipple procedure (n = 30), distal (n = 13) or total pancreatectomy (n = 11), and additional portal venous resection in three patients (n = 3). Median intensive care stay is three days (range 1 - 87), median in hospital stay is 23 days (range 7 - 87). Thirty-day mortality is 3.7 %. Median follow up is 42 months (range 0 - 127). One-, five- and ten-year overall actuarial survival is 87 %; 84 % and 51 % respectively. Median overall survival is 120 months. Patients with non-invasive IPMN have significantly better survival than patients with invasive IPMN and IPMN-associated carcinoma (p < 0.008). In the subgroup of invasive IPMN with associated carcinoma, a positive nodal state, perineural invasion as well as lymphovascular infiltration are associated with poor outcome (p < 0.0001; <0.0001 and =0.001, respectively). Elevated CA 19-9(>37 U/l) as well as elevated lipase (>60 U/l) serum levels are associated with unfavorable outcome (p = 0.009 and 0.018; respectively). Patients operated for pancreatic ductal adenocarcinoma show significantly shorter long-term survival than patients with IPMN associated carcinoma (p = 0.001). CONCLUSIONS Long-term outcome after pancreatic resection for non-invasive IPMN is excellent. Outcome after resection for invasive IPMN with invasive carcinoma is significantly better than for pancreatic ductal adenocarcinoma. In low- and intermediate risk IPMN with no clear indication for immediate surgical resection, a watchful waiting strategy should be evaluated carefully against surgical treatment individually for each patient.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/mortality
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Papillary/diagnosis
- Adenocarcinoma, Papillary/mortality
- Adenocarcinoma, Papillary/surgery
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/surgery
- Female
- Follow-Up Studies
- Humans
- Length of Stay
- Male
- Middle Aged
- Morbidity
- Multimodal Imaging
- Neoplasm Staging
- Pancreatectomy/adverse effects
- Pancreatectomy/methods
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/surgery
- Survival Analysis
- Treatment Outcome
- Pancreatic Neoplasms
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Affiliation(s)
- Katharina Marsoner
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | | | - Dora Csengeri
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | - James Elvis Waha
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | - Jakob Schagerl
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | - Rainer Langeder
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | - Hans Joerg Mischinger
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
| | - Peter Kornprat
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria
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Bhardwaj N, Dennison AR, Maddern GJ, Garcea G. Management implications of resection margin histology in patients undergoing resection for IPMN: A meta-analysis. Pancreatology 2016; 16:309-17. [PMID: 26987800 DOI: 10.1016/j.pan.2016.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 01/15/2016] [Accepted: 02/12/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION IPMN is a relatively new clinical entity and surgeons are continuing to develop their understanding of this complex pathology. Little is known of the natural disease process post-resection of an IPMN, particularly the impact of gland histology and margin status on the chance of recurrence and survival in benign and invasive IPMN. METHODS An online search was conducted to evaluate and include those studies which reported on gland histology, margin status and disease recurrence in resected benign and malignant IPMN. A Meta analysis was then performed using a random effects model. RESULTS The chance of recurrence in non-invasive margin positive IPMN is similar to margin negative IPMN. The chance of recurrence is higher in invasive gland IPMN compared to non-invasive gland. The vast majority of recurrences occurred in patients with positive margins demonstrating invasion. CONCLUSION All patients with intra- or post-operative evidence of invasive carcinoma at the resection margin should undergo further resection to achieve a negative margin. Patients with evidence of IPMN at the transaction margin (even with changes of high grade dysplasia/CIS) may not achieve any benefit from further resection. Patients with recurrence in benign/non-invasive IPMN should undergo re-resection, whereas patients with recurrence in invasive IPMN should not.
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