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Shyr BS, Wang SE, Chen SC, Shyr YM, Shyr BU. Mesopancreas dissection level 3 for pancreatic head cancer in combined robotic/open pancreatoduodenectomy: a propensity score-matched study. Surg Endosc 2025; 39:1191-1199. [PMID: 39739104 PMCID: PMC11794409 DOI: 10.1007/s00464-024-11475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 12/04/2024] [Indexed: 01/02/2025]
Abstract
BACKGROUND Mesopancreas dissection (MPD) level 3 in combined robotic/open pancreatoduodenectomy (CR/OPD) is technique-demanding. This study aims to clarify the feasibility and justification of MPD level 3. METHODS Propensity score matching (PSM) analysis was conducted for 208 patients with pancreatic head cancer undergoing CR/OPD with or without MPD level 3. The comparison focused on surgical and oncological outcomes. RESULTS After PSM, each group comprised 86 patients. Surgical outcomes were comparable between these two groups, except longer operation time for MPD level 3 (+), median: 10.5 vs. 9.5 h, p = 0.002. MPD level 3 (+) group exhibited higher lymph node yield, median: 20 vs. 17, p < 0.001, and curative (R0) resection rate, 89.5% vs. 69.8%, p = 0.001, compared to MPD level 3 (-) group. Among the entire cohort, no significant survival difference was observed between the MPD Level 3 (+) and (-) groups. Survival outcome for R0 resection after CR/OPD was notably better than those for R2 resection, 5-year survival: 34.0% vs. 0, p = 0.038. However, within the curative (R0) resection cohort, no survival difference was observed between the MPD level 3 (+) and MPD level 3 (-) groups. CONCLUSION MPD level 3 in CR/OPD is technically feasible without increasing the surgical risks but takes one hour extra operating time. Incorporation of MPD level 3 does not confer a survival advantage within the curative (R0) resection cohort. The primary focus should continue to be on achieving curative (R0) resection to maximize the survival benefits for pancreatic head cancer.
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Affiliation(s)
- Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery and Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei Veterans General Hospital, National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery and Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei Veterans General Hospital, National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery and Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei Veterans General Hospital, National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery and Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei Veterans General Hospital, National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Bor-Uei Shyr
- Division of General Surgery, Department of Surgery and Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei Veterans General Hospital, National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC.
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
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Gundavda K, Chopde A, Pujari A, Reddy B, Pawar A, Ramaswamy A, Ostwal V, Patkar S, Bhandare M, Shrikhande SV, Chaudhari VA. Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers. Ann Surg Oncol 2024; 31:7052-7063. [PMID: 39031265 PMCID: PMC11413064 DOI: 10.1245/s10434-024-15847-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/02/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC. METHODS A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared. RESULTS Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections. CONCLUSION In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.
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Affiliation(s)
- Kaival Gundavda
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Amit Chopde
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Avinash Pujari
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Bhaskar Reddy
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Akash Pawar
- Department of Biostatistics, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Shraddha Patkar
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Manish Bhandare
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Shailesh V Shrikhande
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vikram A Chaudhari
- Division of Gastrointestinal and HPB Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.
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Rompen IF, Habib JR, Sereni E, Stoop TF, Musa J, Cohen SM, Berman RS, Kaplan B, Hewitt DB, Sacks GD, Wolfgang CL, Javed AA. What is the optimal surgical approach for ductal adenocarcinoma of the pancreatic neck? - a retrospective cohort study. Langenbecks Arch Surg 2024; 409:224. [PMID: 39028426 DOI: 10.1007/s00423-024-03417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The appropriate surgical approach for pancreatic ductal adenocarcinoma (PDAC) is determined by the tumor's relation to the porto-mesenteric axis. Although the extent and location of lymphadenectomy is dependent on the type of resection, a pancreatoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) are considered equivalent oncologic operations for pancreatic neck tumors. Therefore, we aimed to assess differences in histopathological and oncological outcomes for surgical approaches in the treatment of pancreatic neck tumors. METHODS Patients with resected PDAC located in the pancreatic neck were identified from the National Cancer Database (2004-2020). Patients with metastatic disease were excluded. Furthermore, patients with 90-day mortality and R2-resections were excluded from the multivariable Cox-regression analysis. RESULTS Among 846 patients, 58% underwent PD, 25% DP, and 17% TP with similar R0-resection rates (p = 0.722). Significant differences were observed in nodal positivity (PD:44%, DP:34%, TP:57%, p < 0.001) and mean-number of examined lymph nodes (PD:17.2 ± 10.4, DP:14.7 ± 10.5, TP:21.2 ± 11.0, p < 0.001). Furthermore, inadequate lymphadenectomy (< 12 nodes) was observed in 30%, 44%, and 19% of patients undergoing PD, DP, and TP, respectively (p < 0.001). Multivariable analysis yielded similar overall survival after DP (HR:0.83, 95%CI:0.63-1.11), while TP was associated with worse survival (HR:1.43, 95%CI:1.08-1.89) compared to PD. CONCLUSION While R0-rates are similar amongst all approaches, DP is associated with inadequate lymphadenectomy which may result in understaging disease. However, this had no negative influence on survival. In the premise that an oncological resection of the pancreatic neck tumor is feasible with a partial pancreatectomy, no benefit is observed by performing a TP.
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Affiliation(s)
- Ingmar F Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Joseph R Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisabetta Sereni
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Thomas F Stoop
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Julian Musa
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Steven M Cohen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Russell S Berman
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Brian Kaplan
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - D Brock Hewitt
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Greg D Sacks
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Christopher L Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Ammar A Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA.
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Goess R, Jäger C, Perinel J, Pergolini I, Demir E, Safak O, Scheufele F, Schorn S, Muckenhuber A, Adham M, Novotny A, Ceyhan GO, Friess H, Demir IE. Lymph node examination and survival in resected pancreatic ductal adenocarcinoma: retrospective study. BJS Open 2024; 8:zrad125. [PMID: 38271272 PMCID: PMC10810280 DOI: 10.1093/bjsopen/zrad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 09/12/2023] [Accepted: 10/01/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND The minimum number of examined lymph nodes (ELN) required for adequate staging and best prediction of survival has not been established in pancreatic ductal adenocarcinoma (PDAC). The aim of the study was to investigate the influence of ELN on staging and survival in PDAC. METHODS Patients undergoing partial or total pancreatectomy for PDAC at two European university hospitals between 2007 and 2018 were retrospectively reviewed. Multivariate Cox regression model and survival analyses were performed to verify adequate staging. RESULTS Overall 341 (73 per cent) patients showed lymph node metastasis (N1/N2), whereas 125 (27 per cent) patients had no lymph node involvement (N0). With increasing number of ELN, the proportion of positive lymph nodes increased. The minimum number of ELN needed to detect lymph node involvement was 21. In multivariate analysis, examination of <21 lymph nodes was a significant negative predictor for survival. Examination of ≥21 ELN reversed this effect and ruled out possible misclassification. CONCLUSION The number of ELN affects survival in PDAC. Possible misclassification was identified when <21 lymph nodes were examined. Therefore, at least 21 lymph nodes must be examined to avoid false lymph node classification in all types of resection.
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Affiliation(s)
- Ruediger Goess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices civils de Lyon, Lyon, France
| | - Ilaria Pergolini
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Elke Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Okan Safak
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Alexander Muckenhuber
- Institute of Pathology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices civils de Lyon, Lyon, France
| | - Alexander Novotny
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Else Kröner Clinician Scientist Professorship for Translational Pancreatic Surgery, Munich, Germany
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Comparison of neoadjuvant chemohormonal therapy vs. extended pelvic lymph-node dissection in high-risk prostate cancer treated with robot-assisted radical prostatectomy. Sci Rep 2023; 13:3436. [PMID: 36859718 PMCID: PMC9978020 DOI: 10.1038/s41598-023-30627-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
We compared the impact of treatment strategies on postoperative complications and prognosis between robot-assisted radical prostatectomy (RARP) plus extended pelvic lymph-node dissection (ePLND) and RARP plus neoadjuvant chemohormonal therapy (NCHT) without ePLND. We retrospectively evaluated 452 patients with high-risk prostate cancer (defined as any one of prostate-specific antigen ≥ 20 ng/mL, Gleason score 8-10, or cT2c-3) who were treated with RARP between January 2012 and February 2021. The patients were divided into two groups: RARP with ePLND (ePLND group) and NCHT plus RARP without ePLND (NCHT group). We compared the complication rate (Clavien-Dindo classification), biochemical recurrence-free survival, and castration-resistant prostate cancer (CRPC)-free survival between the groups. We performed multivariable Cox regression analysis using inverse probability weighting (IPTW) methods to assess the impact of the different treatments on prognosis. There were 150 and 302 patients in the ePLND and NCHT groups, respectively. The postoperative complication rate was significantly higher in the ePLND group than in the NCHT group (P < 0.001). IPTW-adjusted biochemical recurrence-free survival and CRPC-free survival were significantly higher in the NCHT group than in the ePLND group (hazard ratio [HR] 0.29, P < 0.001, and HR 0.29, P = 0.010, respectively). NCHT plus RARP without ePLND may reduce the risk of postoperative complications compared with ePLND during RARP. The impact of treatment strategies on oncological outcomes needs further studies.
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Lin Q, Zheng S, Yu X, Chen M, Zhou Y, Zhou Q, Hu C, Gu J, Xu Z, Wang L, Liu Y, Liu Q, Wang M, Li G, Cheng H, Zhou D, Liu G, Fu Z, Long Y, Li Y, Wang W, Qin R, Li Z, Chen R. Standard pancreatoduodenectomy versus extended pancreatoduodenectomy with modified retroperitoneal nerve resection in patients with pancreatic head cancer: a multicenter randomized controlled trial. Cancer Commun (Lond) 2023; 43:257-275. [PMID: 36579790 PMCID: PMC9926959 DOI: 10.1002/cac2.12399] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The extent of pancreatoduodenectomy for pancreatic head cancer remains controversial, and more high-level clinical evidence is needed. This study aimed to evaluate the outcome of extended pancreatoduodenectomy (EPD) with retroperitoneal nerve resection in pancreatic head cancer. METHODS This multicenter randomized trial was performed at 6 Chinese high-volume hospitals that enrolled patients between October 3, 2012, and September 21, 2017. Four hundred patients with stage I or II pancreatic head cancer and without specific pancreatic cancer treatments (preoperative chemotherapy or chemoradiation) within three months were randomly assigned to undergo standard pancreatoduodenectomy (SPD) or EPD, with the latter followed by dissection of additional lymph nodes (LNs), nerves and soft tissues 270° on the right side surrounding the superior mesenteric artery and celiac axis. The primary endpoint was overall survival (OS) by intention-to-treat (ITT). The secondary endpoints were disease-free survival (DFS), mortality, morbidity, and postoperative pain intensity. RESULTS The R1 rate was slightly lower with EPD (8.46%) than with SPD (12.56%). The morbidity and mortality rates were similar between the two groups. The median OS was similar in the EPD and SPD groups by ITT in the whole study cohort (23.0 vs. 20.2 months, P = 0.100), while the median DFS was superior in the EPD group (16.1 vs. 13.2 months, P = 0.031). Patients with preoperative CA19-9 < 200.0 U/mL had significantly improved OS and DFS with EPD (EPD vs. SPD, 30.8 vs. 20.9 months, P = 0.009; 23.4 vs. 13.5 months, P < 0.001). The EPD group exhibited significantly lower locoregional (16.48% vs. 35.20%, P < 0.001) and mesenteric LN recurrence rates (3.98% vs. 10.06%, P = 0.022). The EPD group exhibited less back pain 6 months postoperation than the SPD group. CONCLUSIONS EPD for pancreatic head cancer did not significantly improve OS, but patients with EPD treatment had significantly improved DFS. In the subgroup analysis, improvements in both OS and DFS in the EPD arm were observed in patients with preoperative CA19-9 < 200.0 U/mL. EPD could be used as an effective surgical procedure for patients with pancreatic head cancer, especially those with preoperative CA19-9 < 200.0 U/mL.
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Hori T, Yasukawa D. Technical aspects in pancreaticoduodenectomy and therapeutic strategies for pancreatic cancer: History, current status, and future perspectives. Hepatobiliary Pancreat Dis Int 2022; 21:600-602. [PMID: 34497034 DOI: 10.1016/j.hbpd.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/16/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Tomohide Hori
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan.
| | - Daiki Yasukawa
- Department of Surgery, Shiga University of Medical Science, Otsu 520-2192, Japan
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Surgical treatment of pancreatic cancer: Currently debated topics on morbidity, mortality, and lymphadenectomy. Surg Oncol 2022; 45:101858. [DOI: 10.1016/j.suronc.2022.101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
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9
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James NE, Chidambaram S, Gall TM, Sodergren MH. Quality of life after pancreatic surgery - A systematic review. HPB (Oxford) 2022; 24:1223-1237. [PMID: 35304039 DOI: 10.1016/j.hpb.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery for patients with pancreatic cancer carries a high risk of major post-operative complications and only marginally improves overall survival. This review aims to assess the impact of surgical resection on health-related quality of life (HRQOL) of pancreatic cancer patients. METHODS A systematic review of the literature was performed according to the PRISMA guidelines. All studies assessing QOL using validated questionnaires in pancreatic cancer patients undergoing surgical resection were included. RESULTS Twenty-two studies were assessed. Patients reported a decrease in physical, social and global scales within the first 3 months after surgery. These values showed improvement and were comparable to baseline values by 6 months. Recovery in emotional functioning towards baseline figures was demonstrated in the first 3 months post-operatively. Symptom scales including pain, fatigue and diarrhoea deteriorated after surgery, but reverted to baseline after 3-6 months. CONCLUSIONS Surgical resection for pancreatic cancer has short-term negative impact on QOL. In the longer term, this will improve and eventually recover to baseline values after 6 months. Knowledge on the impact of surgery on QOL of pancreatic cancer patients is necessary to facilitate decision-making and tailoring of surgical techniques to the individual patient.
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Affiliation(s)
- Nicole E James
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK
| | - Swathikan Chidambaram
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK
| | - Tamara Mh Gall
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK
| | - Mikael H Sodergren
- Imperial College London, Exhibition Road, South Kensington, London SWC2AZ, UK; Department of Surgery and Cancer, Hammersmith Hospital Campus, Imperial College, London W12 0HS, UK.
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Xu D, Wu P, Zhang K, Cai B, Yin J, Shi G, Yuan H, Miao Y, Lu Z, Jiang K. The short-term outcomes of distal pancreatectomy with portal vein/superior mesenteric vein resection. Langenbecks Arch Surg 2022; 407:2161-2168. [PMID: 35606575 DOI: 10.1007/s00423-021-02382-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/10/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Portal vein/superior mesenteric vein (PV/SMV) resection during distal pancreatectomy (DP) is often associated with technical difficulties due to the close anatomic relationship between pancreatic head and PV/SMV. In this paper, we present our operative technique and short-term outcomes of DP combined with venous resection (DP-VR) for left-sided pancreatic cancer (PC). METHODS We reviewed 368 consecutive cases of DP for PC from January 2013 to December 2018 in our institution, and identified 41 patients (11.1%) who had undergone DP-VR. The remaining 327 DP patients (88.9%) were matched to DP-VR using propensity scores in the proportion of 1:2. Demographics, intraoperative details, postoperative complications and the pathological results were compared between the two groups. RESULTS Out of the 41 DP-VR cases, in 14 (34.1%) venous resection with primary closure was performed, while the remaining 27 (65.9%) underwent end-to-end anastomosis without graft. A propensity-score-matched analysis revealed that DP-VR caused an increased risk of postoperative bleeding (17.1% vs. 3.7%, P = 0.016) and delayed gastric emptying (9.8% vs. 1.2%, P = 0.042) compared to standard DP. Overall morbidity (46.3% vs. 36.6%, P = 0.332), postoperative pancreatic fistula (31.7% vs. 26.8%, P = 0.672), R0 resection (58.5% vs. 67.1%, P = 0.223), 30-day reoperation (2.4% vs. 3.7%, P = 0.719), and 90-day mortality (0% vs. 2.5%, P = 0.550) were comparable between the two groups. In postoperative computed tomographic scans of 34 patients (82.9%) at a 90-day follow-up, PV/SMV stenosis was suggested in two patients (5.9%). CONCLUSION Despite the higher rates of postoperative bleeding, DP-VR was found to be a feasible and safe surgery with acceptable postoperative morbidity and mortality compared to standard DP for left-sided pancreatic cancer.
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Affiliation(s)
- Dong Xu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Pengfei Wu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Kai Zhang
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Baobao Cai
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jie Yin
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Guodong Shi
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hao Yuan
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yi Miao
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zipeng Lu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Kuirong Jiang
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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11
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Minagawa T, Sugiura T, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Sasaki K, Uesaka K. Clinical implications of lymphadenectomy for invasive ductal carcinoma of the body or tail of the pancreas. Ann Gastroenterol Surg 2022; 6:531-542. [PMID: 35847444 PMCID: PMC9271019 DOI: 10.1002/ags3.12551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 01/05/2022] [Indexed: 01/23/2023] Open
Abstract
Aim The appropriate extent of lymphadenectomy for pancreatic cancer of the body/tail has not been standardized worldwide. The present study evaluated the optimal extent of harvesting lymph nodes. Methods Patients who underwent distal pancreatectomy for invasive ductal carcinoma of the pancreas between 2007 and 2018 were retrospectively reviewed. Patients were subclassified into three groups depending on the tumor location: pancreatic body (Pb), proximal pancreatic tail (Ptp), and distal pancreatic tail (Ptd). The pancreatic tail was further divided into even sections of Ptp and Ptd. Patterns of lymph node metastasis and the impact of lymph node metastasis on the prognosis were examined. Results A total of 120 patients were evaluated. Fifty-eight patients had a tumor in the Pb, 38 in the Ptp, and 24 in the Ptd. No patients with a Ptd tumor had metastasis beyond the peripancreatic and splenic hilar lymph nodes (LN-PSH). All patients with metastasis to the lymph nodes along the common hepatic artery (LN-CHA) or along the left lateral superior mesenteric artery (LN-SMA) also had metastasis to the LN-PSH. Recurrence after surgery occurred significantly earlier in this population. In a multivariate analysis, metastasis to the LN-CHA or LN-SMA (hazard ratio [HR] 3.3; P = .04) was an independent risk factor for overall survival. Furthermore, high levels of preoperative serum CA19-9 (HR 10.9; P = .013) were a predictive factor for metastasis to the LN-CHA or LN-SMA. Conclusions Metastasis to the LN-CHA or LN-SMA was rare but a significant prognostic factor in patients with pancreatic body/tail cancer.
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Affiliation(s)
- Takuya Minagawa
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Teiichi Sugiura
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Yukiyasu Okamura
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Takaaki Ito
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Yusuke Yamamoto
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Ryo Ashida
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Katsuhisa Ohgi
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
| | - Keiko Sasaki
- Division of PathologyShizuoka Cancer CenterShizuokaJapan
| | - Katsuhiko Uesaka
- Division of Hepato‐Biliary‐Pancreatic SurgeryShizuoka Cancer CenterShizuokaJapan
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12
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Iwamura H, Hatakeyama S, Narita T, Ozaki Y, Konishi S, Horiguchi H, Kodama H, Kojima Y, Fujita N, Okamoto T, Tobisawa Y, Yoneyama T, Yamamoto H, Yoneyama T, Hashimoto Y, Ohyama C. Significance of pelvic lymph node dissection during radical prostatectomy in high-risk prostate cancer patients receiving neoadjuvant chemohormonal therapy. Sci Rep 2022; 12:9675. [PMID: 35690635 PMCID: PMC9188590 DOI: 10.1038/s41598-022-13651-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
We aimed to determine the survival and staging benefit of limited pelvic lymph node dissection (PLND) during radical prostatectomy (RP) in high-risk prostate cancer (PC) patients treated with neoadjuvant chemohormonal therapy. We retrospectively analyzed 516 patients with high-risk localized PC (< cT4N0M0) who received neoadjuvant androgen-deprivation therapy plus estramustine phosphate followed by RP between January 2010 and March 2020. Since we stopped limited PLND for such patients in October 2015, we compared the surgical outcomes and biochemical recurrence-free survival (BCR-FS) between the limited-PLND group (before October 2015, n = 283) and the non-PLND group (after November 2015, n = 233). The rate of node metastases in the limited-PLND group were 0.8% (2/283). Operation time was significantly longer (176 vs. 162 min) and the rate of surgical complications were much higher (all grades; 19 vs. 6%, grade ≥ 3; 3 vs. 0%) in the limited-PLND group. The inverse probability of treatment weighting-Cox analysis revealed limited PLND had no significant impact on BCR-FS (hazard ratio, 1.44; P = 0.469). Limited PLND during RP after neoadjuvant chemohormonal therapy showed quite low rate of positive nodes, higher rate of complications, and no significant impact on BCR-FS.
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Affiliation(s)
- Hiromichi Iwamura
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Hatakeyama
- Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Takuma Narita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yusuke Ozaki
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Sakae Konishi
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirotaka Horiguchi
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirotake Kodama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuta Kojima
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoki Fujita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Teppei Okamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Tobisawa
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tohru Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hayato Yamamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takahiro Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuhiro Hashimoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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13
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Brunner M, Krautz C, Weber GF, Grützmann R. [Better Therapy for Pancreatic Cancer through More Radical Surgery?]. Zentralbl Chir 2022; 147:173-187. [PMID: 35378558 DOI: 10.1055/a-1766-7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.Even if even more radical surgical approaches such as an "extended" lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an "existing limited prognosis". On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.
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Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Christian Krautz
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Georg F Weber
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
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14
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Chen Z, Yu B, Bai J, Li Q, Xu B, Dong Z, Zhi X, Li T. The Impact of Intraoperative Frozen Section on Resection Margin Status and Survival of Patients Underwent Pancreatoduodenectomy for Distal Cholangiocarcinoma. Front Oncol 2021; 11:650585. [PMID: 34012916 PMCID: PMC8127005 DOI: 10.3389/fonc.2021.650585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023] Open
Abstract
Background Intraoperative frozen section (FS) is broadly used during pancreaticoduodenectomy (PD) to ensure a negative margin status, but its survival benefits on obtaining a secondary R0 resection for distal cholangiocarcinoma (dCCA) is controversial and unclear. Methods Clinical data of 107 patients who underwent PD for dCCA was retrospectively collected and divided into different groups based on use of FS (FS and non-FS groups) and status of resection margin (pR0, sR0 and R1 groups), and clinical parameters and survival of patients were compared and analyzed accordingly. Results There were 50 patients in FS group with a median survival of 28 months, 57 patients in non-FS group with a median survival of 27 months. There was no statistical difference between the two groups with Kaplan-Meier survival analysis (P = 0.347). There were 98 patients in R0 group (88 in pR0 and 10 in sR0) and nine patients in R1 group, with a median survival of 29 months and 22 months respectively, which showed a better survival in R0 group than in R1 group (P = 0.006). Survival analyses between subgroups revealed difference between pR0 and R1 group (P = 0.005), while no statistical difference concerning pR0 vs. sR0 (P = 0.211) and sR0 vs. R1 groups (P = 0.262). Multivariate Cox regression analysis revealed resection margin status, pre-operative biliary drainage and lymph node invasion to be independent prognostic factors for dCCA patients. Conclusions Intraoperative FS should be recommended as it significantly increased the rate of R0 resection, which was positively related to a better survival. A primary R0 resection should also be encouraged and if not, a secondary R0 could be considered at the discretion of surgeons as it showed similar survival with primary R0 resection.
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Affiliation(s)
- Zhiqiang Chen
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bingran Yu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jiaping Bai
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiong Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bowen Xu
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhaoru Dong
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xuting Zhi
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tao Li
- Department of Hepatobiliary Surgery, General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Touijer KA, Sjoberg DD, Benfante N, Laudone VP, Ehdaie B, Eastham JA, Scardino PT, Vickers A. Limited versus Extended Pelvic Lymph Node Dissection for Prostate Cancer: A Randomized Clinical Trial. Eur Urol Oncol 2021; 4:532-539. [PMID: 33865797 DOI: 10.1016/j.euo.2021.03.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Pelvic lymph node dissection (PLND) is the most reliable procedure for lymph node staging. However, the therapeutic benefit remains unproven; although most radical prostatectomies at academic centers are accompanied by PLND, there is no consensus regarding the optimal anatomical extent of PLND. OBJECTIVE To evaluate whether extended PLND results in a lower biochemical recurrence rate. DESIGN, SETTING, AND PARTICIPANTS We conducted a single-center randomized trial. Patients, enrolled between October 2011 and March 2017, were scheduled to undergo radical prostatectomy and PLND. Patients were assigned to limited or extended PLND by cluster randomization. Specifically, surgeons were randomized to perform limited or extended PLND for 3-mo periods. INTERVENTION Randomization to limited (external iliac nodes) or extended (external iliac, obturator fossa and hypogastric nodes) PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the rate of biochemical recurrence. RESULTS AND LIMITATIONS Of 1440 patients included in the final analysis, 700 were randomized to limited PLND and 740 to extended PLND. The median number of nodes retrieved was 12 (interquartile range [IQR] 8-17) for limited PLND and 14 (IQR 10-20) extended PLND; the corresponding rate of positive nodes was 12% and 14% (difference -1.9%, 95% confidence interval [CI] -5.4% to 1.5%; p = 0.3). With median follow-up of 3.1 yr, there was no significant difference in the rate of biochemical recurrence between the groups (hazard ratio 1.04, 95% CI 0.93-1.15; p = 0.5). Rates for grade 2 and 3 complications were similar at 7.3% for limited versus 6.4% for extended PLND; there were no grade 4 or 5 complications. CONCLUSIONS Extended PLND did not improve freedom from biochemical recurrence over limited PLND for men with clinically localized prostate cancer. However, there were smaller than expected differences in nodal count and the rate of positive nodes between the two templates. A randomized trial comparing PLND to no node dissection is warranted. PATIENT SUMMARY In this clinical trial we did not find a difference in the rate of biochemical recurrence of prostate cancer between limited and extended dissection of lymph nodes in the pelvis. This study is registered on ClinicalTrials.gov as NCT01407263.
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Affiliation(s)
- Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Staerkle RF, Vuille-Dit-Bille RN, Soll C, Troller R, Samra J, Puhan MA, Breitenstein S. Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma. Cochrane Database Syst Rev 2021; 1:CD011490. [PMID: 33471373 PMCID: PMC8094380 DOI: 10.1002/14651858.cd011490.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins. OBJECTIVES To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma. DATA COLLECTION AND ANALYSIS Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes. MAIN RESULTS We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence). AUTHORS' CONCLUSIONS There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.
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Affiliation(s)
- Ralph F Staerkle
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
- University Basel, Basel, Switzerland
| | - Raphael Nicolas Vuille-Dit-Bille
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
- Department of Pediatric Surgery, Children's University Hospital, Basel, Switzerland
| | - Christopher Soll
- Visceral Surgery, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Rebekka Troller
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Jaswinder Samra
- Gastrointestinal Surgery, Royal North Shore Hospital, St. Leonards, Australia
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Stefan Breitenstein
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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17
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Dillhoff M, Pawlik TM. Role of Node Dissection in Pancreatic Tumor Resection. Ann Surg Oncol 2021; 28:2374-2381. [PMID: 33393035 DOI: 10.1245/s10434-020-09394-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pancreatic cancer is a lethal disease, and, even with modern therapies, the mortality has not decreased significantly in decades. The prognostic importance of lymph node status is well defined; however, the role of extended lymphadenectomy to improve local recurrence and overall survival remains debated. Six randomized controlled trials have evaluated the extent of lymph node dissection in pancreaticoduodenectomy for pancreatic cancer. OBJECTIVE We sought to review the current literature to evaluate the role of lymphadenectomy in pancreatic cancer. The impact of each trial and its contribution to the literature is discussed. CONCLUSIONS Multiple randomized trials have failed to note an improvement in overall survival with extended lymphadenectomy for pancreatic cancer. Rather, extended lymphadenectomy was associated with increased morbidity, operating room time, and length of stay.
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Affiliation(s)
- Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Division of Surgical Oncology, James Cancer Center, Ohio State University, Columbus, OH, USA.
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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18
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Gkika E, Hawkins MA, Grosu AL, Brunner TB. The Evolving Role of Radiation Therapy in the Treatment of Biliary Tract Cancer. Front Oncol 2021; 10:604387. [PMID: 33381458 PMCID: PMC7768034 DOI: 10.3389/fonc.2020.604387] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTC) are a disease entity comprising diverse epithelial tumors, which are categorized according to their anatomical location as intrahepatic (iCCA), perihilar (pCCA), distal (dCCA) cholangiocarcinomas, and gallbladder carcinomas (GBC), with distinct epidemiology, biology, and prognosis. Complete surgical resection is the mainstay in operable BTC as it is the only potentially curative treatment option. Nevertheless, even after curative (R0) resection, the 5-year survival rate ranges between 20 and 40% and the disease free survival rates (DFS) is approximately 48–65% after one year and 23–35% after three years without adjuvant treatment. Improvements in adjuvant chemotherapy have improved the DFS, but the role of adjuvant radiotherapy is unclear. On the other hand, more than 50% of the patients present with unresectable disease at the time of diagnosis, which limits the prognosis to a few months without treatment. Herein, we review the role of radiotherapy in the treatment of cholangiocarcinoma in the curative and palliative setting.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Magdeburg, Magdeburg, Germany
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19
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Para-aortic lymph node metastasis detected intraoperatively by systematic frozen section examination in pancreatic head adenocarcinoma: is resection improving the prognosis? HPB (Oxford) 2020; 22:1604-1612. [PMID: 32179009 DOI: 10.1016/j.hpb.2020.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/16/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate the controversial benefit of a pancreaticoduodenectomy (PD) in patients with PALN metastasis intraoperatively detected by systematic frozen section examination in pancreatic adenocarcinoma. METHODS PALN intraoperative examination by frozen section was systematically performed from January 2006 to February 2018 prior to performing PD for pancreatic adenocarcinoma. Until June 2012, PALN + patients still underwent PD (PALN+/PD group) in the framework of a prospective study. Since July 2012, PALN+ was considered as contraindicating the planned PD (PALN+/No-PD group). Post-operative morbidity and survival were compared between these two groups. RESULTS Of the 32 PALN + patients intraoperatively detected, the first 13 underwent a PD, while the last 19 did not undergo resection. Seven patients (54%) among 13 PALN+/PD patients developed a post-operative complication against 3 (16%) among 19 PALN+/No-PD patients (p = 0.049). The median length of stay was 5 days longer for PALN+/PD patients (p = 0.001). The median survival did not differ between PALN+/No-PD and PALN+/PD groups (respectively 13.4 months (95%CI:7.6-19.3) and 11.5 months (95%CI:5.9-17.1), p = 0.471). No patient was alive 4 years after surgery in both the PALN+/No-PD or PALN+/PD groups. CONCLUSION In case of PALN detected intraoperatively in pancreatic adenocarcinoma, PD does not improve survival compared to current palliative treatment.
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20
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Kotb A, Hajibandeh S, Hajibandeh S, Satyadas T. Meta-analysis and trial sequential analysis of randomised controlled trials comparing standard versus extended lymphadenectomy in pancreatoduodenectomy for adenocarcinoma of the head of pancreas. Langenbecks Arch Surg 2020; 406:547-561. [PMID: 32978673 DOI: 10.1007/s00423-020-01999-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare baseline demographics, operative, and survival outcomes of randomised controlled trials (RCTs) comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer METHODS: In compliance with PRISMA standards we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors. RESULTS Overall, 724 patients from 5 RCTs were included. The included populations were comparable in terms of baseline characteristics. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR 0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. The results remained consistent through subgroup analyses based on lymph node positive or negative status and studies from the West and East. CONCLUSIONS Robust evidence from randomised controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.
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Affiliation(s)
- Ahmed Kotb
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK.
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Thomas Satyadas
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
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Li YF, Xiang YC, Zhang QQ, Wang WL. Impact of examined lymph node count on prognosis in patients with lymph node-negative pancreatic body/tail ductal adenocarcinoma. J Gastrointest Oncol 2020; 11:644-653. [PMID: 32953148 DOI: 10.21037/jgo-20-158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Because the overall prognosis remains dismal for patients with resected pancreatic cancer (PC), we aimed to explore the prognostic impact of examined lymph node (ELN) count on lymph node (LN)-negative pancreatic body/tail ductal adenocarcinoma. Methods Patients' data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (National Cancer Institute, USA) to investigate the relationship between ELN count and survival outcomes of LN-negative pancreatic body/tail ductal adenocarcinoma. Results A total of 700 patients were included, and the median number of ELNs was 11. The respective 1-, 3-, 5-year overall survival (OS) rates were 75.3%, 37.7%, 30.3%, and the 1-, 3-, 5-year cancer-specific survival (CSS) were 78.3%, 41.7%, 34.5%. The X-tile analysis showed that 14 was the most optimal cutoff for both OS and CSS. Kaplan-Meier survival analysis indicated that patients with ELNs >14 had better OS and CSS than ELNs ≤14. Multivariate Cox analysis showed ELNs ≤14 was an independent risk factor for both OS [hazard ratio (HR), 1.357; 95% confidence interval (CI), 1.080-1.704; P=0.009] and CSS (HR, 1.394; 95% CI, 1.092-1.778; P=0.008). Conclusions ELN count is associated with the survival rate in patients with LN-negative pancreatic body/tail ductal adenocarcinoma. Accurate nodal staging for these patients requires more than 14 ELNs.
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Affiliation(s)
- Yu-Feng Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Yu-Cheng Xiang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Qiu-Qiang Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | - Wei-Lin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China.,Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou, China.,Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, China
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22
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. Surgery 2020; 169:362-368. [PMID: 32896373 DOI: 10.1016/j.surg.2020.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/28/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. METHODS Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared. RESULTS There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage. CONCLUSION Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan.
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Mathur A, Ross SB, Luberice K, Kurian T, Vice M, Toomey P, Rosemurgy AS. Margin Status Impacts Survival after Pancreaticoduodenectomy but Negative Margins Should Not be Pursued. Am Surg 2020. [DOI: 10.1177/000313481408000416] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Negative margins are the goal with pancreaticoduodenectomy for pancreatic adenocarcinoma. Thereby, margins are assessed intraoperatively with frozen section analysis and negative margins are pursued. This study was undertaken to determine the impact of margin status with pancreaticoduodenectomy for pancreatic adenocarcinoma and the value of extending resections to achieve negative margins. The intraoperative frozen section analysis and final margins for 448 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were assessed and their impact on survival was determined. Median data are presented. Two hundred ninety-eight (67%) patients had negative margins (R0), an additional 110 (25%) patients had microscopically positive and macroscopically negative margins (R1), and an additional 40 (9%) patients had initially positive microscopic margins, which became negative with further resection (R1 å R0). R0 resections were more likely to have smaller tumors, earlier T grade, earlier N grade, lower American Joint Committee on Cancer stage, and less frequent extrapancreatic extension ( P ≤ 0.03 for each). Survival was better with R0 resections than R1 resections (20 vs 12 months, P < 0.001); extending resections to achieve negative margins (i.e., R1 ! R0) did not improve survival beyond R1 resections (14 vs 12 months, P = 0.19). Survival after pancreaticoduodenectomy is disappointing. Patients with initial negative margins do best. Positive microscopic margins reflect more aggressive tumor-specific factors and lead to abbreviated survival even with extended resections to achieve negative margins (i.e., R1 ! R0). With an initial positive margin, pursuing negative margins does not improve survival and, thereby, negative margins should not be “chased.”
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Affiliation(s)
- Abhishek Mathur
- University of South Florida, Department of Surgery, Tampa, Florida
| | - Sharona B. Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Kenneth Luberice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Tony Kurian
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Michelle Vice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Paul Toomey
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
- University of South Florida, Department of Surgery, Tampa, Florida
| | - Alexander S. Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
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Lamarca A, Edeline J, McNamara MG, Hubner RA, Nagino M, Bridgewater J, Primrose J, Valle JW. Current standards and future perspectives in adjuvant treatment for biliary tract cancers. Cancer Treat Rev 2020; 84:101936. [PMID: 31986437 DOI: 10.1016/j.ctrv.2019.101936] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/23/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
Biliary tract cancer, including cholangiocarcinoma (CCA) and gallbladder cancer (GBC) are rare tumours with a rising incidence. Prognosis is poor, since most patients are diagnosed with advanced disease. Only ~20% of patients are diagnosed with early-stage disease, suitable for curative surgery. Despite surgery performed with potentially-curative intent, relapse rates are high, with around 60-70% of patients expected to have disease recurrence. Most relapses occur in the form of distant metastases, with a predominance of liver spread. In view of high tumour recurrence, adjuvant strategies have been explored for many years, in the form of radiotherapy, chemo-radiotherapy and chemotherapy. Historically, few randomised trials were available, which included a variety of additional tumours (e.g. pancreatic and ampullary tumours); most evidence relied on phase II and retrospective studies, with no high-quality evidence available to define the real benefit derived from adjuvant strategies. Since 2017, three randomised phase III clinical trials have been reported; all recruited patients with resected biliary tract cancer (CCA and GBC) who were randomised to observation alone, or chemotherapy in the form of gemcitabine (BCAT study; included patients diagnosed with extrahepatic CCA only), gemcitabine and oxaliplatin (PRODIGE-12/ACCORD-18; included patients diagnosed with CCA and GBC) or capecitabine (BILCAP; included patients diagnosed with CCA and GBC). While gemcitabine-based chemotherapy failed to show an impact on patient outcome (relapse-free survival (RFS) or overall survival (OS)), the BILCAP study showed a benefit from adjuvant capecitabine in terms of OS (pre-planned sensitivity analysis in the intention-to-treat population and in the per-protocol analysis), with confirmed benefit in terms of RFS. Based on the BILCAP trial, international guidelines recommend adjuvant capecitabine for a period of six months following potentially curative resection of CCA as the current standard of care for resected CCA and GBC. However, BILCAP failed to show OS benefit in the intention-to-treat (non-sensitivity analysis) population (primary end-point), and this finding, as well as some inconsistencies between studies has been criticised and has led to confusion in the biliary tract cancer medical community. This review summarises the adjuvant field in biliary tract cancer, with evidence before and after 2017, and comparison between the latest randomised phase III studies. Potential explanations are presented for differential findings, and future steps are explored.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Julien Edeline
- Department of Medical Oncology, Centre Eugene Marquis, Rennes, France
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Masato Nagino
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - John Bridgewater
- Department of Medical Oncology, UCL Cancer Institute, London, United Kingdom
| | - John Primrose
- Department of Surgery, University of Southampton, Southampton, United Kingdom
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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25
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Lamarca A, Frizziero M, McNamara MG, Valle JW. Clinical and Translational Research Challenges in Biliary Tract Cancers. Curr Med Chem 2020; 27:4756-4777. [PMID: 31971102 DOI: 10.2174/0929867327666200123090153] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 11/27/2019] [Accepted: 01/13/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biliary Tract Cancers (BTC) are rare malignancies with a poor prognosis. There are many challenges encountered in treating these patients in daily practice as well as in clinical, translational and basic research. OBJECTIVE This review summarises the most relevant challenges in clinical and translational research in BTCs and suggests potential solutions towards an improvement in quality of life and outcomes of patients diagnosed with such malignancies. FINDINGS The main challenge is the low number of patients with BTCs, complicated by the aggressive natural behaviour of cancer and the lack of funding sources for research. In addition, the clinical characteristics of these patients and the specific cancer-related complications challenge clinical research and clinical trial recruitment. It is worth highlighting that BTCs are a group of different malignancies (cholangiocarcinoma, gallbladder cancer and ampullary cancer) rather than a unique homogeneous disease. These subgroups differ not only in molecular aspects, but also in clinical and demographic characteristics. In addition, tailored imaging and quality of life assessment are required to tackle some of the issues specific to BTCs. Finally, difficulties in tissue acquisition both in terms of biopsy size and inclusion of sufficient tumour within the samples, may adversely impact translational and basic research. CONCLUSION Increasing awareness among patients and clinicians regarding BTC and the need for further research and treatment development may address some of the main challenges in BTC research. International collaboration is mandatory to progress the field.
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Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Melissa Frizziero
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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26
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Castle J, Kotopoulis S, Forsberg F. Sonoporation for Augmenting Chemotherapy of Pancreatic Ductal Adenocarcinoma. Methods Mol Biol 2020; 2059:191-205. [PMID: 31435922 PMCID: PMC7418147 DOI: 10.1007/978-1-4939-9798-5_9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third most common cancer diagnosed in the United States, with more than 53,000 new cases in 2017. It is the fourth leading cause of cancer-related death in both men and women. Nonetheless, there has been no significant improvement in survival for pancreatic ductal adenocarcinoma (PDAC) patients over the past 30+ years. For this reason, there is a considerable and urgent clinical need to develop innovative strategies for effective drug delivery and treatment monitoring, resulting in improved outcomes for patients with PDAC.This chapter describes the development of contrast-enhanced ultrasound image-guided drug delivery (CEUS-IGDD or sonoporation) to be that method and to translate it from the lab to the clinic. The initial clinical focus has been on a Phase I clinical trial for enhancing the effectiveness of standard chemotherapeutics for treatment of inoperable PDAC, which demonstrated a median survival increase from 8.9 months to 17.6 months in ten subjects augmented with sonoporation compared to 63 historical controls (p = 0.011). Recent efforts to optimize this platform and move forward to a larger Phase II clinical trial will be described.
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Affiliation(s)
| | - Spiros Kotopoulis
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
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27
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Rodrigues V, Dopazo C, Pando E, Blanco L, Caralt M, Gómez-Gavara C, Bilbao I, Salcedo MT, Balsells J, Charco R. Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma? Cir Esp 2019; 98:204-211. [PMID: 31839175 DOI: 10.1016/j.ciresp.2019.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/18/2019] [Accepted: 09/29/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS A single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN- (peripancreatic lymph node)/HALN-, PPLN+/HALN- and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses. RESULTS Out of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12patients (PPLN-/HALN-, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN-, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN-/HALN- group (82%, 72%, 54%) than in the PPLN+/HALN- group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN-/HALN- group (18%, 46%, 55%) than in the PPLN+/HALN- group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. CONCLUSIONS In pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.
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Affiliation(s)
- Victor Rodrigues
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Cristina Dopazo
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España.
| | - Elizabeth Pando
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Laia Blanco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Mireia Caralt
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Concepción Gómez-Gavara
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Itxarone Bilbao
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - María Teresa Salcedo
- Servicio de Anatomía Patológica, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Joaquim Balsells
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
| | - Ramon Charco
- Departamento de Cirugía Hepatobiliopancreática y Trasplantes, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, España
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Significance of Examined Lymph Node Number in Accurate Staging and Long-term Survival in Resected Stage I–II Pancreatic Cancer—More is Better? A Large International Population-based Cohort Study. Ann Surg 2019; 274:e554-e563. [DOI: 10.1097/sla.0000000000003558] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Navarro JG, Kang CM. Pitfalls for laparoscopic pancreaticoduodenectomy: Need for a stepwise approach. Ann Gastroenterol Surg 2019; 3:254-268. [PMID: 31131354 PMCID: PMC6524087 DOI: 10.1002/ags3.12242] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/18/2019] [Accepted: 01/28/2019] [Indexed: 12/20/2022] Open
Abstract
Because of today's advancements in surgical techniques and perioperative management skills, surgeons are beginning to explore the usefulness of the laparoscopic approach in managing periampullary tumors. However, as a result of its innate complexity and associated high surgery-related complications, its applicability to the general surgical community remains controversial. To date, only retrospective data from high-volume centers support the safety and feasibility of laparoscopic pancreaticoduodenectomy (Lap PD) for the treatment of benign conditions and malignant periampullary tumors. In addition, various surgical techniques in terms of port placement, dissection, and reconstruction have evolved in different centers depending on the preferred method commonly used by the surgeon through accumulated experience. In our center, we used a stepwise approach and standardized our surgical technique to overcome this technically demanding procedure. A collaborative implementation of video review and analysis, practice training and simulation, operating room didactics, and strict adherence to our stepwise approach in Lap PD, might potentially improve the surgical skills of young hepatobiliary surgeons and possibly overcome the volume-based learning curve of Lap PD.
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Affiliation(s)
- Jonathan Geograpo Navarro
- Division of Surgical OncologyDepartment of SurgeryVicente Sotto Memorial Medical CenterCebu CityPhilippines
| | - Chang Moo Kang
- Division of HBP SurgeryDepartment of SurgeryYonsei University College of MedicineSeoulKorea
- Pancreatobiliary Cancer CenterYonsei Cancer CenterSeverance HospitalSeoulKorea
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Bruno MJ, Maluf-Filho F. Palliation of Malignant Pancreaticobiliary Obstruction. CLINICAL GASTROINTESTINAL ENDOSCOPY 2019:734-747.e4. [DOI: 10.1016/b978-0-323-41509-5.00063-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called "borderline resectable pancreatic cancers" have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.
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32
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Jang JY, Kang JS, Han Y, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Park JS, Yu HC, Kang KJ, Kim SG, Lee H, Kwon W, Yoon YS, Han HS, Kim SW. Long-term outcomes and recurrence patterns of standard versus extended pancreatectomy for pancreatic head cancer: a multicenter prospective randomized controlled study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 24:426-433. [PMID: 28514000 DOI: 10.1002/jhbp.465] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Our previous randomized controlled trial revealed no difference in 2-year overall survival (OS) between extended and standard resection for pancreatic adenocarcinoma. The present study evaluated the 5-year OS and recurrence patterns according to the extent of pancreatectomy. METHODS Between 2006 and 2009, 169 consecutive patients were prospectively enrolled and randomized to standard (n = 83) or extended resection (n = 86) groups to compare 5-year OS rate, long-term recurrence patterns and factors associated with long-term survival. RESULTS The surgical R0 rate was similar between the standard and extended groups (85.5 vs. 90.7%, P = 0.300). Five-year OS (18.4 vs. 14.4%, P = 0.388), 5-year disease-free survival (14.8 vs. 14.0%, P = 0.531), and overall recurrence rates (74.7 vs. 69.9%, P = 0.497) were not significantly different between the two groups, although the incidence of peritoneal seeding was higher in the extended group (25 vs. 8.1%, P = 0.014). CONCLUSIONS Extended pancreatectomy does not have better short-term and long-term survival outcomes, and shows similar R0 rates and overall recurrence rates compared with standard pancreatectomy. Extended pancreatectomy does not have to be performed routinely for all cases of resectable pancreatic adenocarcinoma, especially considering its associated increased morbidity shown in our previous study.
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Affiliation(s)
- Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Dong Sup Yoon
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seong Park
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Koo Jeong Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Sang Geol Kim
- Department of Surgery, Kyungpook National University College of Medicine, Daegu, Korea
| | - Hongeun Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Abstract
OBJECTIVES The optimal number of lymph nodes that need to be analyzed to reliably assess nodal status in distal pancreatectomy for adenocarcinoma is still unknown. METHODS Two hundred seventy-eight patients who underwent distal pancreatectomy for adenocarcinoma were retrieved from a retrospective French nationwide database. The relations between the number of analyzed lymph nodes and the nodal status of the tumor were studied. The beta-binomial law was used to estimate the probability of being truly node negative depending on the number of analyzed lymph nodes. Cox proportional hazard model was used for the survival analysis. RESULTS The median number of analyzed lymph nodes was 15. There was a positive correlation between the number of positive lymph nodes and the number of lymph nodes analyzed. The curve reached a plateau at approximately 25 lymph nodes. The beta binomial model demonstrated that an analysis of 21 negative lymph nodes shows a probability to be truly N0 at 95%. N+ status was associated with survival, but the number of lymph node analyzed was not. CONCLUSION At least 21 lymph nodes should be analyzed to ensure a reliable assessment of the nodal status, but this number may be hard to reach in distal pancreatectomy.
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Schunke KJ, Rosati LM, Zahurak M, Herman JM, Narang AK, Usach I, Klein AP, Yeo CJ, Korman LT, Hruban RH, Cameron JL, Laheru DA, Abrams RA. Long-term analysis of 2 prospective studies that incorporate mitomycin C into an adjuvant chemoradiation regimen for pancreatic and periampullary cancers. Adv Radiat Oncol 2018; 3:42-51. [PMID: 29556579 PMCID: PMC5856978 DOI: 10.1016/j.adro.2017.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/20/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The purpose of this study was to report toxicity and long-term survival outcomes of 2 prospective trials evaluating mitomycin C (MMC) with 5-fluorouracil-based adjuvant chemoradiation in resected periampullary adenocarcinoma. METHODS AND MATERIALS From 1996 to 2002, 119 patients received an adjuvant 4-drug chemotherapy regimen of 5-fluorouracil, leucovorin, MMC, and dipyridamole with chemoradiation on 2 consecutive trials (trials A and B). Trial A patients received upfront chemoradiation (50 Gy split-course, 2.5 Gy/fraction) followed by 4 cycles of the 4-drug chemotherapy with bolus 5-fluorouracil. Trial B patients received 1 cycle of the 4-drug chemotherapy with continuous infusion 5-fluorouracil followed by continuous chemoradiation (45-54 Gy, 1.8 Gy/fraction) and 2 additional cycles of chemotherapy. Cox proportional hazards models were performed to identify prognostic factors for overall survival (OS). RESULTS Of the 62 trial A patients, 61% had pancreatic and 39% nonpancreatic periampullary carcinomas. Trial B (n = 57) consisted of 68% pancreatic and 32% nonpancreatic periampullary carcinomas. Resection margin and lymph node status were similar for both trials. Median follow-up was longer for trial A than trial B (197.5 vs 107.0 months), with median OS of 32.2 and 24.2 months, respectively. Rates of 3-, 5-, and 10-year OS were 48%, 31%, and 26% in trial A and 32%, 23%, and 9% in trial B. On multivariate analysis, lymph node-positive resection was the strongest prognostic factor for OS. A pancreatic primary and positive margin status were also associated with inferior survival (P < .05). Rates of grade ≥3 treatment-related toxicity in trials A and B were 2% and 7%, respectively. CONCLUSIONS This is the first study to report long-term outcomes of MMC with 5-fluorouracil-based adjuvant chemoradiation in periampullary cancers. Because MMC may be considered in DNA repair-deficient carcinomas, randomized trials are needed to determine the true benefit of adjuvant MMC.
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Affiliation(s)
- Kathryn J. Schunke
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lauren M. Rosati
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marianna Zahurak
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M. Herman
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amol K. Narang
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irina Usach
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles J. Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Larry T. Korman
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John L. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A. Laheru
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ross A. Abrams
- Department of Radiation Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
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Xiong J, Wei A, Ke N, He D, Chian SK, Wei Y, Hu W, Liu X. A case-matched comparison study of total pancreatectomy versus pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma. Int J Surg 2017; 48:134-141. [PMID: 29081373 DOI: 10.1016/j.ijsu.2017.10.065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/20/2017] [Accepted: 10/21/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Total pancreatectomy (TP) is considered a viable option in some selected patients with pancreatic ductaladenocarcinoma (PDAC). The aim of this study was to compare the clinical outcomes between TP and pancreaticoduodenectomy (PD) in patients with PDAC. MATERIALS AND METHODS A total of 375 patients were selected from our center's database in China and classified into two groups: the PD group (n = 325) and the TP group (n = 50). A matched-pair analysis of the patients was conducted with a ratio of 1:1. Univariate and multivariate survival analyses were performed for overall survival. RESULTS Overall morbidity was lower in the PD group than in the TP group (31.4% vs 52%, respectively, P = 0.004). However, no significant difference was observed in major morbidity between the two groups (24.9% vs 30%, P = 0.455). The rates of 5-year overall (P = 0.043) and disease-free (P = 0.037) survival were significantly higher in the PD group. Furthermore, the univariate and multivariate analyses revealed that adjuvant chemotherapy (HR = 0.684, 95%CI = 0.545-0.860, P = 0.001) and margin resection status (HR = 1.666, 95%CI = 1.196-2.321, P = 0.003) were significant prognostic factors. After the matched-pair analysis, there were no significant differences between the two groups regarding postoperative complications and overall survival. However, the matched PD group had greater estimated blood loss (P = 0.037) and blood transfusion (56% vs 36%, P = 0.045). CONCLUSION From our study, the postoperative outcomes and survival time of TP are similar to those of matched PD. It seems reasonable to suggest that TP can be considered as safe, feasible, and efficacious as PD for patients with PDAC.
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Affiliation(s)
- Junjie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ailin Wei
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Nengwen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Selina Kwong Chian
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi Wei
- Department of Transportation Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Weiming Hu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Sweet Sixteen: The Prospective Clinical Trials of John L. Cameron, MD-The Clinician-Scientist: From Alternate-allocation to Randomized Controlled Trials. Ann Surg 2017; 267:S29-S33. [PMID: 28922207 DOI: 10.1097/sla.0000000000002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: The era of randomized controlled trials was ushered in by the British epidemiologist-statistician Austin Bradford Hill, with his work on the use of streptomycin in patients with tuberculosis. John L. Cameron, can be linked to 16 prospective clinical trials over his career thus far, starting with alternate-allocation trials and transitioning to prospective, randomized, placebo-controlled trials. These trials studied various topics in surgery-from pancreatitis to surgical site infections, to drain trials, a trial in Crohn disease and multiple trials in pancreatic surgery and cancer. Herein are described the "sweet sixteen" prospective clinical trials of Dr Cameron.
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Contreras CM, Lin CP, Oster RA, Reddy S, Wang T, Vickers S, Heslin M. Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base. Am J Surg 2017; 214:442-449. [PMID: 28687101 DOI: 10.1016/j.amjsurg.2017.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/23/2017] [Accepted: 06/14/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated the role of lymph node (LN) retrieval in pancreatic adenocarcinoma (PA) patients undergoing pancreaticoduodenectomy (PD). METHODS We utilized the National Cancer Data Base; Cox regression models and logistic regression models were used for statistical evaluation. RESULTS We evaluated 26,792 patients with PA who underwent PD. The mean LN retrieved in LN(-) patients was 10.8 vs 14.4 for LN(+) patients (P < 0.0001). Greater LN retrieval is an independent predictor of a negative microscopic margin and decreased length of stay. The median survival of LN(-) patients exceeded that of LN(+) patients (24.5 vs 15.1 months, P < 0.0001). Increasing LN retrieval is a significant predictor of survival in all patients, and in LN(-) patients. The relationship of increased LN retrieval and enhanced survival is a nearly linear trend. CONCLUSIONS Rather than demonstrating an inflection point that defines the extent of adequate lymphadenectomy, this dataset demonstrates an incremental relationship between LN retrieval and survival.
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Affiliation(s)
- Carlo M Contreras
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA.
| | - Chee Paul Lin
- University of Alabama at Birmingham, Center for Clinical and Translational Science, Birmingham, AL, USA
| | - Robert A Oster
- University of Alabama at Birmingham, Department of Preventive Medicine, Birmingham, AL, USA
| | - Sushanth Reddy
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Thomas Wang
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Selwyn Vickers
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
| | - Martin Heslin
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL, USA
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Adamska A, Domenichini A, Falasca M. Pancreatic Ductal Adenocarcinoma: Current and Evolving Therapies. Int J Mol Sci 2017; 18:E1338. [PMID: 28640192 PMCID: PMC5535831 DOI: 10.3390/ijms18071338] [Citation(s) in RCA: 417] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/01/2017] [Accepted: 06/13/2017] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC), which constitutes 90% of pancreatic cancers, is the fourth leading cause of cancer-related deaths in the world. Due to the broad heterogeneity of genetic mutations and dense stromal environment, PDAC belongs to one of the most chemoresistant cancers. Most of the available treatments are palliative, with the objective of relieving disease-related symptoms and prolonging survival. Currently, available therapeutic options are surgery, radiation, chemotherapy, immunotherapy, and use of targeted drugs. However, thus far, therapies targeting cancer-associated molecular pathways have not given satisfactory results; this is due in part to the rapid upregulation of compensatory alternative pathways as well as dense desmoplastic reaction. In this review, we summarize currently available therapies and clinical trials, directed towards a plethora of pathways and components dysregulated during PDAC carcinogenesis. Emerging trends towards targeted therapies as the most promising approach will also be discussed.
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Affiliation(s)
- Aleksandra Adamska
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
| | - Alice Domenichini
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
| | - Marco Falasca
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
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Lu F, Soares KC, He J, Javed AA, Cameron JL, Rezaee N, Pawlik TM, Wolfgang CL, Weiss MJ. Neoadjuvant therapy prior to surgical resection for previously explored pancreatic cancer patients is associated with improved survival. Hepatobiliary Surg Nutr 2017; 6:144-153. [PMID: 28652997 DOI: 10.21037/hbsn.2016.08.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with pancreatic ductal adenocarcinoma (PDAC) are frequently referred to tertiary centers after unsuccessful attempted resections at other institutions. The outcome of these patients who are ultimately resected is not well understood. METHODS We performed a retrospective review of patients with PDAC who underwent re-exploration between 1995 and 2013 at a single high volume tertiary care institution. We aimed to evaluate the association of neoadjuvant therapy prior to re-exploration on pathologic findings and clinical outcome in previously explored patients with PDAC. RESULTS Between 1995 and 2013, 50 of the 2,062 patients who were surgically explored underwent pancreatic resection following a previous exploration where they were deemed unresectable. The most common reason for unresectability at initial operation was vascular invasion (80%) and a presumed R2 resection. Thirty-seven (74%) patients received neoadjuvant therapy. Neoadjuvant therapy was associated with improved TNM stage (P=0.002), fewer positive lymph nodes (0 vs. 2, P=0.025), and improved median survival (24 vs. 13 months, P=0.044). Compared to R2 resected patients with PDAC who had not previously been explored, re-explored patients had significantly lower pathologic T and N stages (P<0.001) and a longer median survival (19 vs. 10 months, P<0.001). CONCLUSIONS Patients with PDAC deemed unresectable may warrant re-exploration. Treatment with neoadjuvant therapy between operations is associated with improved pathological stage and survival. In this highly selected group of patients, successful resection is associated with improved survival compared to R2 resections.
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Affiliation(s)
- Fengchun Lu
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China
| | - Kevin C Soares
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Rezaee
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Maebayashi T, Ishibashi N, Aizawa T, Sakaguchi M, Sato T, Kawamori J, Tanaka Y. Treatment outcomes of concurrent hyperthermia and chemoradiotherapy for pancreatic cancer: Insights into the significance of hyperthermia treatment. Oncol Lett 2017; 13:4959-4964. [PMID: 28588736 DOI: 10.3892/ol.2017.6066] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 04/05/2017] [Indexed: 12/18/2022] Open
Abstract
Patients with locally advanced unresectable pancreatic cancer (LAUPC) have a poor prognosis. In addition their quality of life impaired by cancer pain and biliary tract infections. Therefore, multimodality therapy and selection of optimal treatment methods are essential for achieving prolonged survival. The present study investigated the significance of using hyperthermia concurrently with multimodality therapy to improve treatment outcomes in patients with LAUPC. In total, 13 patients receiving concurrent hyperthermia and chemoradiotherapy (HCR) or chemoradiotherapy (CR) alone for LAUPC between 2002 and 2013 were analyzed retrospectively. Of the 13 patients, 5 received concurrent HCR and 8 received CR. The chemotherapy regimens were 5-fluorouracil (5-FU) in 5 patients and gemcitabine hydrochloride (GEM) in the other 8. Patients who gave consent for hyperthermia treatment received GEM plus CR. The median overall survival period for all patients was 12 months and the 1-year survival rate was 55%; the corresponding values were 12 months and 57% in the GEM CR group, and 15 months and 80% in the HCR group. Univariate analyses was perfomed to identify factors predicting recurrence after treatment. The potential prognostic factors analyzed were: Age, sex, performance status, location, tumor size, the tumor marker CA 19-9, total radiation dose, chemotherapy and hyperthermia. Univariate analysis for factors associated with outcomes revealed a significant difference favoring the HCR group [relative risk=15.97 (95% confidence interval: 12.87-19.83) P=0.021]. In conclusion, hyperthermia merits active recommendation to pancreatic cancer patients who have a positive attitude toward this treatment and whose performance status is satisfactory.
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Affiliation(s)
- Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan
| | - Takuya Aizawa
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masakuni Sakaguchi
- Department of Radiology, Nihon University School of Medicine, Itabashi-ku, Tokyo 173-8610, Japan
| | - Tsutomu Sato
- Radiology Clinic, Sonoda Medical Corporations, Adachi-ku, Tokyo 121-0064, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Chuo-ku, Tokyo 104-8560, Japan
| | - Yoshiaki Tanaka
- Department of Radiation Oncology, Kawasaki Saiwai Hospital, Kawasaki, Kanagawa 212-0014, Japan
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Too Much Water Drowned the Miller—Does Extended Pancreaticoduodenectomy Benefit the Long-term Survival Outcomes in the Treatment of Pancreatic Cancer? Ann Surg 2017; 265:e39-e41. [DOI: 10.1097/sla.0000000000001154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Junrungsee S, Kittivarakul E, Ko-iam W, Lapisatepun W, Sandhu T, Chotirosniramit A. Prognostic Factors and Survival of Patients with Carcinoma of the Ampulla of Vater after Pancreaticoduodenectomy. Asian Pac J Cancer Prev 2017; 18:225-229. [PMID: 28240523 PMCID: PMC5563104 DOI: 10.22034/apjcp.2017.18.1.225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Although carcinoma of the ampulla of Vater (CAV) is a rare tumor, accounting for just 0.2% of
gastrointestinal cancers, the survival of CAV patients is unfavorable. The five-year rates have ranged from 36.8-75.2% in
previous reports but there is a lack of data relating to Thai people. Also prognostic factors are controversial. Objectives:
This study aimed to determine survival outcomes and to identify prognostic factors for a positive outcome for CAV
patients after surgery. Methods: In this retrospective cohort study, data were collected from CAV patients who underwent
surgery in Chiang Mai University Hospital from 2005 to 2012 for time to event analysis, the log rank test and univariate
and multivariate Cox’s regression analysis. Results: There were 72 CAV patients recruited, 45.8% being male. The mean
age was 65.1 ± 10.5 years and the median waiting time for surgery was 56.5 days (24.5-91.5). The 30 day mortality
rate was 5.6%., while 5-yr survival was 33.3%. The average disease free survival was 14.6 months. Prognostic factors
relating to recurrence were positive lymph nodes (50% VS 19.6% p = 0.015) and advanced stage (44.1% VS 18.4%
p = 0.023). Multivariate analysis showed that the potential prognostic factors for CAV patients included recurrence,
moderate and poor differentiation, comorbidities and a tumor size > 2.0 cm. Conclusions: The findings of the study
indicate that the overall survival of CAV patients after surgery is quite fair, with a tendency for better outcome with
early as compared to advanced lesions. The key prognostic factors were recurrence, moderate and poor differentiation,
comorbidity and tumor size > 2.0 cm.
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Affiliation(s)
- Sunhawit Junrungsee
- Division of Hepatobiliarypancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai,
Thailand.
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Kasumova GG, Conway WC, Tseng JF. The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery. Ann Surg Oncol 2016; 25:51-58. [DOI: 10.1245/s10434-016-5676-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Indexed: 12/19/2022]
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Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:6839687. [PMID: 27847403 PMCID: PMC5099466 DOI: 10.1155/2016/6839687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.
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Survival Determinants after Pancreatectomy With Vascular Resection for Pancreatic Cancer. Int Surg 2016. [DOI: 10.9738/intsurg-d-15-00210.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To investigate the morbidity, mortality, and survival of patients with pancreatic cancer after pancreatectomy with vascular resection and to clarify the favorable prognostic survival factors. Pancreatic cancer is a malignant tumor. Many revisions have been made to surgical procedures to improve the prognosis of resectable pancreatic cancer. Several studies have compared no-vein and vein resection with pancreaticoduodenectomy, recording their feasibility and equal rates of operative mortality, incidence, and survival. Factors identified as potentially relevant to survival outcomes include population, perioperative treatment, and clinical pathologic factors, but these are still controversial. From January 1, 2003, to December 31, 2010, 63 patients with advanced pancreatic cancer underwent pancreatectomy with vascular resection. They were divided into 2 groups: one group had a survival time of <2 years (group 1) and the other a survival time of >2 years (group 2). Their clinical data, surgical techniques, perioperative parameters, and histopathologic data from a prospective database were analyzed. Major venous resection with reconstruction was performed in 61 patients (96.83%); major venous and artery resection with reconstruction in 1 patient (1.58%); and arterial resection with reconstruction in another patient (1.58%). The median survival time and the actuarial 1-, 2-, and 3-year survival rates for all patients are 19.94 months and 45.0%, 27.4%, and 17.6%, respectively. Group 1 contained 42 patients and group 2 contained 21 patients. A multivariate analysis identified tumor size, tumor differentiation, lymph-node status, nerve invasion, and metastasis (TNM) staging of the pancreatic cancer, tumor grade, operating time, and chemotherapy after surgery as independent predictors of long-term survival. TNM staging, tumor grade, operating time, and chemotherapy are independent predictors of survival after pancreatectomy.
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Delitto D, Black BS, Cunningham HB, Sliesoraitis S, Lu X, Liu C, Sarosi GA, Thomas RM, Trevino JG, Hughes SJ, George TJ, Behrns KE. Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer. Am J Surg 2016; 212:195-201.e1. [PMID: 27260793 DOI: 10.1016/j.amjsurg.2016.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/27/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Durable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer. METHODS Seventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program. RESULTS Standardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005). CONCLUSIONS Standardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Brian S Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Holly B Cunningham
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Sarunas Sliesoraitis
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Xiaomin Lu
- Department of Biostatistics & Children's Oncology Group, College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Chen Liu
- Department of Pathology, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA.
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Peparini N. Para-Aortic Dissection in Pancreaticoduodenectomy with Mesopancreas Excision for Pancreatic Head Carcinoma: Not Only an N-Staging Matter. J Gastrointest Surg 2016; 20:1080-1. [PMID: 27000126 DOI: 10.1007/s11605-016-3131-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/09/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Nadia Peparini
- Nadia Peparini, Azienda Sanitaria Locale Roma H-Distretto 3, via Mario Calò, 5, 00043, Ciampino, Rome, Italy.
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Abstract
Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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Fink DM, Steele MM, Hollingsworth MA. The lymphatic system and pancreatic cancer. Cancer Lett 2015; 381:217-36. [PMID: 26742462 DOI: 10.1016/j.canlet.2015.11.048] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/16/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
This review summarizes current knowledge of the biology, pathology and clinical understanding of lymphatic invasion and metastasis in pancreatic cancer. We discuss the clinical and biological consequences of lymphatic invasion and metastasis, including paraneoplastic effects on immune responses and consider the possible benefit of therapies to treat tumors that are localized to lymphatics. A review of current techniques and methods to study interactions between tumors and lymphatics is presented.
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Affiliation(s)
- Darci M Fink
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
| | - Maria M Steele
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA
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