Is there a role for surgical resection in patients with pancreatic cancer with liver metastases responding to chemotherapy? Eur J Surg Oncol. 2016;42:1533-1539. [PMID: 27423449 DOI: 10.1016/j.ejso.2016.06.398]

Is There a Potential Oncologic Role for Local Therapy on Hepatic Metastasis in Patients Who Undergo Curative Pancreatectomy for Pancreatic Cancer?

PURPOSE

In pancreatic cancer, therapeutic investigations targeting liver metastases could improve survival. However, the use of local treatment for oligometastasis in pancreatic cancer remains controversial. This study aimed to investigate the oncological role of local therapy in patients who underwent curative pancreatectomy and subsequently developed liver metastases.

MATERIALS AND METHODS

Data concerning patients who underwent curative pancreatectomy for pancreatic cancer at Severance Hospital in Seoul, South Korea between 2006 and 2018 were retrospectively reviewed. We included patients with one or two liver metastases, as confirmed on imaging. We excluded those with metastases in other organs. The patients were divided into two groups: the NT group, receiving conventional therapy without local treatment; and the LT group, receiving local treatments for liver metastases alongside standard therapy.

RESULTS

Of the 43 included patients (NT group, n=33; LT group, n=10), no significant differences were observed in overall survival (OS) [hazard ratio (HR) 0.846; 95% confidence interval (CI) 0.397-1.804; p=0.665] or post-recurrence survival (HR 0.932; 95% CI 0.437-1.985, p=0.855) between the two groups. In multivariate analysis, early recurrence within 6 months (p<0.001) and the use of 5-fluorouracil (FU)-based adjuvant chemotherapy (CTx) (p=0.011), as well as 5-FU-based CTx after liver metastasis (p=0.008) when compared with gemcitabine-based regimens, were significant predictors of poor OS.

CONCLUSION

The oncologic role of local treatment for hepatic metastasis remains controversial in patients with hepatic metastasis after radical pancreatectomy. In the era of potent chemotherapeutic regimens, further research is needed to clarify the efficacy of such regimens.

Surgical treatment of synchronous liver-only oligometastatic pancreatic adenocarcinoma: a systematic review and meta-analysis of long-term outcomes

BACKGROUND

The potential long-term survival benefits of surgical resection for synchronous liver-only metastases of pancreatic ductal adenocarcinoma (liver oligo-PDAC) remain controversial. This systematic review and meta-analysis aim to compare the current evidence on long-term survival outcomes between surgical treatment of liver oligo-PDAC and conventional systemic chemotherapy.

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted using the PubMed and Scopus databases to identify studies comparing surgery and systemic chemotherapy in terms of long-term survival in oligo-PDAC patients. The search included studies published up to October 2024. The meta-analysis was performed using the Jamovi software.

RESULTS

Eleven retrospective studies were selected for a total of 897 patients: 565(63%) underwent synchronous resection of liver metastases and the primary tumor, while 332(37%) received conventional chemotherapy. The majority of patients presented a pancreatic head tumor, and the median number of liver metastases ranged between 1 and 3 in the surgical cohort and 1 and 2 in the nonsurgical cohort. The rate of major surgical complications was 14.4% while the cumulative incidence of postoperative mortality was 2.8%. The median overall survival(OS) in the surgical group ranged from 7.6 to 18.4 months, while a lower value comprised between 6 and 9.9 months was evidenced in the nonsurgical cohort. Six studies were included in the meta-analysis for the OS evaluation, showing significantly better survival outcomes in the surgical group (OR: 0.286, 95% CI: 0.100-0.409; P < 0.0001). According to the Q-test, there was no significant heterogeneity in the true outcomes ( Q = 4.063, P = 0.541, I2  = 0 %). A sensitivity analysis, conducted by excluding one study at a time, confirmed the robustness of the meta-analysis findings.

CONCLUSIONS

Surgical resection of oligo-PDAC may represent a valuable treatment option with potential long-term survival benefits. However, prospective randomized trials are required to further validate these findings.

Stage IV pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastasis: are there survival benefits in liver resection? A systematic review and meta-analysis

OBJECTIVE

Metastatic PDAC has a very poor prognosis, and surgery has a limited role. The study aims to evaluate the OS of patients with PDAC and synchronous liver metastasis who undergo surgical therapy (ST) versus non-surgical therapies (NST).

METHODS

We performed a random effects meta-analysis. Inclusion criteria were: PDAC histology; studies reporting technically resectable cases with liver metastasis and survival data; absence of extra-hepatic disease. The primary endpoint was to evaluate OS. Results were reported as HR and 95 % CI. We performed a meta-regression analysis to identify factors influencing heterogeneity. We analyzed key covariates in order to predict how changes in these factors affect HR.

RESULTS

Six studies were included. The OS was significantly better in group ST than NST, with HR = 0.41 (95 % CI: 0.32-0.52). Heterogeneity was high (I2 = 64.50 %). As the rate of patients who underwent postoperative CT in the ST group decreased, the difference between the two groups decreased (β = -1.28 ± 0.67; p = 0.003), with almost 87.10 % heterogeneity. The adjusted effect based on meta-regression showed an improved OS in ST group only when both pre- and post-operative systemic CT were administrated (HR 0.18, 95 % CI: 0.08-0.40).

CONCLUSIONS

In highly selected patients with metastatic PDAC who respond to systemic CT and receive post-operative systemic CT, ST could be associated with improved OS. However, the high heterogeneity and retrospective design of included studies limit the ability to draw definitive conclusions.

Clinical implications of disappearing pancreatic cancer liver metastases: Lessons from colorectal liver metastases

BACKGROUND

The efficacy of local control for pancreatic cancer liver metastases (PCLM), including surgical treatment, remains controversial, with no consensus on the management and clinical significance of disappearing liver metastases (DLMs). This study aimed to evaluate the clinical implications of DLMs in treating PCLM after multi-agent chemotherapy, utilizing contrast-enhanced imaging modalities.

METHODS

A retrospective analysis was conducted on patients who underwent curative resection for pancreatic cancer with synchronous or metachronous liver metastases between 2014 and 2023. Surgical indications were based on our recently reported ABCD criteria (Anatomical/Biological/Conditional/Duration). Both contrast-enhanced computed tomography (CE-CT) and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) were used to monitor metastatic lesions in the liver. DLMs were defined as tumors undetected on CE-CT post-chemotherapy.

RESULTS

A total of 58 lesions in 29 patients with PCLM who underwent surgical resection were evaluated. Of the 13 lesions evident on CE-CT, 76.9 % (10/13) contained clinically/pathologically residual tumors. Of the 45 DLMs, 16 (35.6 %) had residual tumors. Twenty-six DLMs (57.8 %) were detected on EOB-MRI or intraoperative screening (contrast-enhanced ultrasonography and palpation), with 42.3 % (11/26) being residual tumors. Nineteen DLMs were undetectable by any modality, of which 26.3 % (5/19) were confirmed to be residual tumors with a median follow-up of 32 months. The median overall survival from initiating treatment for PCLM was 48.5 months.

CONCLUSION

Integrating EOB-MRI into preoperative evaluations for PCLM enhances the detection of clinically relevant DLMs. Our findings highlight the potential benefits of considering an image-guided surgical approach in selected patients.

Clinical role of intraperitoneal chemotherapy in patients with pancreatic ductal adenocarcinoma concomitant with occult peritoneal dissemination: A multicenter retrospective study

Background

The effectiveness of intraperitoneal chemotherapy using paclitaxel (i.p.‐PTX) in pancreatic ductal adenocarcinoma (PDAC) patients with peritoneal dissemination remains elusive. The aim of this study is to investigate the clinical outcome of patients treated with i.p.‐PTX combined with systemic chemotherapy compared with current standard chemotherapy including gemcitabine plus nab‐paclitaxel and FOLFIRINOX.

Methods

Data of patients with peritoneal dissemination was retrospectively collected and analyzed (i.p.‐PTX, n = 83; control, n = 86). Inverse probability of treatment‐weighted analyses (IPTW) was used to balance baseline characteristics between two groups. Survival curves were estimated using Kaplan–Meier method, and the differences were compared using the log‐rank test.

Results

No significant differences were noted in overall survival (14.9 vs. 15.5 months, p = 0.481) and progression free survival (9.5 vs. 9.1 months, p = 0.267) between i.p.‐PTX and the control groups. Nevertheless, i.p.‐PTX (9.9 months) significantly prolonged the median progression‐free survival (PFS) time compared with the control (8.6 months), among the matched patients using IPTW (hazard ratio 0.666, p = 0.041). Moreover, subgroup analysis among the patients whose primary tumor were evaluated either as resectable or borderline resectable disease revealed significantly better overall survival in the i.p.‐PTX group compared with the control group (21.3 vs. 14.7 months, hazard ratio; 0.532, p = 0.033). Conversion surgery was more frequently performed in the i.p.‐PTX group than the control group (24% vs. 4%, p = 0.006).

Conclusion

The i.p. PTX regimen prolonged PFS but not overall survival, and subgroup analysis suggested the possibility of survival benefit in patients with occult peritoneal dissemination whose primary tumor was classified as resectable/borderline resectable disease.

Surgical Outcomes in Stage IV Pancreatic Cancer with Liver Metastasis Current Evidence and Future Directions: A Systematic Review and Meta-Analysis of Surgical Resection

BACKGROUND/OBJECTIVES

There is increasing evidence that a subset of patients with stage IV pancreatic ductal adenocarcinoma (PDAC) and liver-only metastasis may benefit from surgical resection of both the primary tumor and metastatic lesions.

METHODS

A meta-analysis and systematic review were conducted in patients with stage IV PDAC and hepatic-only metastasis. A comprehensive literature search (January 2015-June 2023) was performed using PubMed with keywords including "pancreatic cancer", "oligometastatic", and "surgery".

RESULTS

Sixteen articles were included in the final review and characterized based on patient selection factors and prognostic indicators. Seven studies reported hazard ratios (HRs) or Kaplan-Meier curves for survival in synchronous resected cohorts versus chemotherapy/palliation alone, which indicated a statistically significant survival benefit in the resection cohorts (pooled HR: 0.41, 95% CI: 0.31-0.53, p < 0.01). Prognostic indicators for synchronous and metachronous resection included lower pre-operative CA19-9, negative margin status of the primary tumor, moderate-to-well-differentiated tumors (grades I-II), and receiving pre-operative chemotherapy.

CONCLUSIONS

Surgical/ablation selection factors are evolving, with priorities on (1) response to induction chemotherapy, (2) ability to achieve R0 resection, and (3) minimally invasive approaches remaining critical to optimal patient selection. Standardized radiologic and tumor marker evaluation and response to neoadjuvant therapy and optimizing performance status are critical to improved outcomes.

Study protocol of the METAPANC trial - intensified treatment in patients with local operable but oligometastatic pancreatic cancer - multimodal surgical treatment versus chemotherapy alone: a randomized controlled trial

BACKGROUND

Based on current guidelines, surgical treatment of hepatic oligometastases in patients with pancreatic ductal adenocarcinoma (PDAC) is not primarily recommended. Systematic chemotherapy is the therapy of choice for these patients. The relevance of subsequent surgical resection after chemotherapy remains unclear. This multicentre, randomized, controlled phase III trial is planned to evaluate whether resection of the primary tumor and liver metastases can improve overall survival in patients with PDAC with hepatic oligometastases in a multimodal treatment setting.

METHODS

After an induction therapy with eight cyles of mFOLFIRINOX and a response assessment after four and eight cycles, patients will be randomized to either Arm 1 (perioperative mFOFIRINOX plus resection of the primary tumor with resection or ablation of all hepatic metastases) or Arm 2 (continuation of 4 cycles of the standard-of-care mFOLFIRINOX chemotherapy). This clinical trial will focus on a well-defined patient group with metastatic disease limited to the liver as the target organ, with a maximum of three metastases.

DISCUSSION

METAPANC is the first international, randomized, controlled, open-label, multicentre, phase III clinical trial for curative intended surgical therapy of oligometastatic pancreatic cancer in Europe and America. The multimodal surgical treatment of patients with oligometastatic pancreatic cancer could significantly extend the overall survival of this patient group. A possible recommendation of this multimodal treatment regimen outside of clinical trials requires data from randomized controlled trials first. To identify patient subgroups that might benefit from multimodal surgical therapy, additional information on tumor genetics could supplement valid parameters.

TRIAL REGISTRATION

EU Clinical Trials No. 2023-503558-10-00.

Is There a Role for Locoregional Therapies for Non-colorectal Gastrointestinal Malignancies?

The liver is the most common site of metastases from solid gastrointestinal tract tumors. Over the past few decades, the role of locoregional therapies, resection and thermal ablation, for neuroendocrine and colorectal liver metastases has been widely studied. However, for liver metastases originating from other gastrointestinal organs, the role of locoregional treatment remains unclear. This review summarizes and discusses the available evidence regarding benefits, risks, and indications for locoregional therapies for non-colorectal and non-neuroendocrine gastrointestinal liver metastases, highlighting the importance of multidisciplinary approach and patient selection.

Survival benefits of adjuvant chemotherapy after conversion surgery in patients with advanced pancreatic cancer

Background

Oncologic outcomes of conversion surgery for advanced pancreatic cancer (PC) have scarcely been reported. Therefore, this study aimed to investigate the outcomes of conversion surgery with preoperative treatment of FOLFIRINOX or gemcitabine with nab-paclitaxel (GnP) for patients with advanced PC including locally advanced or metastatic PC.

Methods

Using the National Health Insurance database between 2005 and 2020, we identified patients who underwent conversion surgery after chemotherapy with FOLFIRINOX or GnP for advanced PC. The patients were categorized based on preoperative treatment. Survival outcomes were evaluated based on the date of cancer diagnosis and conversion surgery.

Results

Among 69,183 patients with advanced PC, 476 underwent conversion surgery; 430 with FOLFIRINOX and 46 with GnP. The median duration from diagnosis to conversion surgery was 6.4 months. Overall survival (OS) was 31.2 months after cancer diagnosis and 23.5 months after conversion surgery. Adjuvant chemotherapy was a significant factor for OS, with hazard ratios (HRs) of 0.23 [95% CI 0.12-0.44, P < 0.01] from cancer diagnosis and 0.20 [95% CI 0.10-0.37, P < 0.01] from conversion surgery. No significant differences were noted between FOLFIRINOX and GnP. However, maintaining the same regimens as preoperative chemotherapy was a significant factor, with HRs of 0.67 [95% CI 0.47-0.95, P = 0.02] from cancer diagnosis and 0.69 [95% CI 0.49-0.98, P = 0.04] from conversion surgery.

Conclusions

The incorporation of adjuvant chemotherapy with the same preoperative regimen could be an effective strategy for patients with advanced PC who would undergo conversion surgery.

Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy

BACKGROUND

Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC.

METHODS

A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points.

RESULTS

The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months.

CONCLUSIONS

Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.

Emerging role of local treatment in the era of advanced systemic treatment in pancreatic cancer with liver metastasis: A systematic review and meta-analysis

BACKGROUND

Approximately 50% of pancreatic cancer cases are diagnosed with distant metastases, commonly in the liver, leading to poor prognosis. With modern chemotherapy regimens extending patient survival and stabilizing metastasis, there has been a rise in the use of local treatments. However, the effectiveness for local treatment remains unclear.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies reporting the survival outcomes of pancreatic cancer cases with isolated synchronous or metachronous liver metastases who underwent curative-intent local treatment. Hazard ratios were combined using a random-effects model.

RESULTS

The full texts of 102 studies were screened, and 14 retrospective studies were included in the meta-analysis. Among patients with synchronous liver metastases, overall survival was significantly better in those who underwent curative-intent local treatment than in those who did not (hazard ratio [HR]: 0.35, 95% confidence interval [CI]: 0.24-0.52). Among patients with metachronous liver metastases, overall survival was also significantly better in those who underwent curative-intent local treatment than in those who did not (HR 0.37, 95% CI: 0.19-0.73).

CONCLUSIONS

Curative-intent local treatment may be a feasible option for highly selected pancreatic cancer cases with liver metastases. However, the optimal strategy for local treatments should be explored in future studies.

Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

Surgery for Oligometastatic Pancreatic Cancer: Defining Biologic Resectability

Pancreatic ductal adenocarcinoma (PDAC) is most often metastatic at diagnosis. As systemic therapy continues to improve alongside advanced surgical techniques, the focus has shifted toward defining biologic, rather than technical, resectability. Several centers have reported metastasectomy for oligometastatic PDAC, yet the indications and potential benefits remain unclear. In this review, we attempt to define oligometastatic disease in PDAC and to explore the rationale for metastasectomy. We evaluate the existing evidence for metastasectomy in liver, peritoneum, and lung individually, assessing the safety and oncologic outcomes for each. Furthermore, we explore contemporary biomarkers of biological resectability in oligometastatic PDAC, including radiographic findings, biochemical markers (such as CA 19-9 and CEA), inflammatory markers (including neutrophil-to-lymphocyte ratio, C-reactive protein, and scoring indices), and liquid biopsy techniques. With careful consideration of existing data, we explore the concept of biologic resectability in guiding patient selection for metastasectomy in PDAC.

Imaging of pancreatic ductal adenocarcinoma - An update for all stages of patient management

Background

Pancreatic ductal adenocarcinoma (PDAC) is a common and lethal cancer. From diagnosis to disease staging, response to neoadjuvant therapy assessment and patient surveillance after resection, imaging plays a central role, guiding the multidisciplinary team in decision-planning.

Review aims and findings

This review discusses the most up-to-date imaging recommendations, typical and atypical findings, and issues related to each step of patient management. Example cases for each relevant condition are presented, and a structured report for disease staging is suggested.

Conclusion

Despite current issues in PDAC imaging at different stages of patient management, the radiologist is essential in the multidisciplinary team, as the conveyor of relevant imaging findings crucial for patient care.

What would you do? A survey of HPB surgeons practice patterns

BACKGROUND

The surgical decision making for pancreatic adenocarcinoma is complex. Although practice guidelines exist for many scenarios, these do not cover many common eventualities that may be encountered during these cases. We sought to identify the practice pattern variations amongst pancreatic surgeons in response to commonly experienced clinical scenarios.

METHODS

A multiple-choice questionnaire was distributed to all full members of the IHPBA. Participant demographics, training history, and clinical practice information were obtained. The survey provided various operative scenarios and participants were asked how they would likely proceed. Responses were collected and stored anonymously in a secure database. Statistical analysis was performed using Stata 16.0.

RESULTS

164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40-50 years old. When asked about staging laparoscopy, the majority performed it selectively. For most respondents a pathological aorto-caval nodes was a reason to abort the procedure but most would have continued in the setting of a positive hepatic artery node. When encountering a single Segment 2 liver metastasis, participants who practiced in Europe were significantly more likely to resect and proceed compared to those in Asia and North America. Participants who had undergone only a Surgical Oncology fellowship were most likely to abort. With respect to direct colonic invasion, most participants would resect the specimen en bloc. Respondents who participated in fewer that 20 PDAC operations/year were most likely to abort.

CONCLUSIONS

Surgical decision making in PDAC surgery is complex and there is significant disagreement on the correct management. While formal guidelines cannot exist for all situations, this survey highlights the need for consensus on commonly encountered operative scenarios.

Radical resection benefits patients suffering pancreatic ductal adenocarcinoma with liver oligometastases

Purpose

Whether patients suffering liver oligometastases from pancreatic ductal adenocarcinoma (LOPDA) should undergo surgical treatment remains controversial.

Methods

PubMed and Embase databases were systematically reviewed until 2023 June. Survival data were collected from the Kaplan-Meier curves. Safety and survival were evaluated using primary outcomes such as 1-year, 3-year, and 5-year survival rates, and 30-day mortality and morbidity. A subgroup meta-analysis was conducted to compare survival rates post-synchronous resection and resection post-neoadjuvant chemotherapy in LOPDA.

Results

Our analysis of 15 studies involving 1,818 patients (surgical group, 648 and nonsurgical group, 1,170) indicates that radical hepatectomy for LOPDA notably improved 1-year (odds ratio [OR], 3.24; 95% confidence interval [CI], 2.45-4.28; P < 0.001), 3-year (OR, 5.74; 95% CI, 3.36-8.90; P < 0.001), and 5-year (OR, 4.89; 95% CI, 2.56-9.35; P < 0.001) overall survival (OS) rates. A separate analysis of 6 studies with 750 patients demonstrated the safety of LOPDA surgery, with no increase in postoperative complications (P = 0.26 for overall morbidity and P = 0.99 for mortality) compared to the patients with no metastatic disease from the pancreatic ductal adenocarcinoma (NMPDA) group. The NMPDA group showed superior 1-year and 3-year OS rates, but not 5-year OS rates compared to the LOPDA group.

Conclusion

Surgical treatment apparently offers a survival advantage to LOPDA by comparing with nonsurgical groups in 1-, 3-, and 5-year OS rates. Radical resection for LOPDA is a safe treatment without more postoperative complications than NMPDA.

Outcomes of lung oligometastasis in pancreatic cancer

OBJECTIVE

Pancreatic cancer with lung oligometastasis may have favourable overall survival. The aim of this study was to evaluate outcomes of pancreatic cancer with lung oligometastases including both synchronous and metachronous metastases.

METHODS

Consecutive pancreatic cancer patients with lung metastasis treated at our institution between February 2015 and December 2021 were identified from our prospectively maintained database. Clinical characteristics and outcomes were compared and analysed according to the extent of lung metastases. Predictors for overall survival were analysed using the Cox proportional hazards model.

RESULTS

A totoal of 171 patients were included (oligometastasis/polymetastasis/multi-organ metastasis: 34/50/87). Patients with oligometastases were more likely to undergo surgical resection (41% vs. 0% vs. 2%) and showed a longer median overall survival (41.3 vs. 17.6 vs. 13.1 months) compared with those with other types of metastases. Oligometastasis (hazard ratio, 0.43; 95% confidence interval, 0.24-0.76; P = 0.004) was identified as an independent factor predicting favourable overall survival in patients with lung-only metastasis. Disease status (synchronous vs. metachronous) was not associated with survival in patients with oligometastasis (29.4 vs. 41.3 months, P = 0.527) and polymetastasis (17.9 vs. 16.7 months, P = 0.545). Selected patients who underwent surgical resection showed a median overall survival of 52.7 months.

CONCLUSIONS

Patients with lung oligometastases presented a favourable prognosis. Surgical resection in selected patients was associated with a long median overall survival.

Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus

BACKGROUND

Small retrospective series suggest that local consolidative treatment (LCT) may improve survival in oligometastatic pancreatic ductal adenocarcinoma (PDAC). However, no uniform definition of oligometastatic disease (OMD) in PDAC exists; this impedes meaningful conclusions.

PATIENTS AND METHODS

A systematic literature search using PubMed, Web of Science, and Cochrane CENTRAL registries for studies and protocols reporting on definitions and/or LCT of OMD in PDAC was performed. The primary endpoint was the definition of OMD. Levels of agreement were categorized as consensus (≥75% agreement between studies), fair agreement (50%-74%), and absent/poor agreement (<50%).

RESULTS

After screening of 5374 abstracts, the full text of 218 studies was assessed, of which 76 were included in the qualitative synthesis. The majority of studies were retrospective (n = 66, 87%), two were prospective studies and eight were study protocols. Studies investigated mostly liver (n = 38, 51%) and lung metastases (n = 15, 20%). Across studies, less than one-half (n = 32, 42%) reported a definition of OMD, while 44 (58%) did not. Involvement was limited to a single organ (consensus). Additional criteria for defining OMD were the number of lesions (consensus), metastatic site (poor agreement), metastatic size (poor agreement), treatment possibilities (poor agreement), and biomarker response (poor agreement). Liver OMD could involve three or fewer lesions (consensus) and synchronous disease (fair agreement), while lung metastases could involve two or fewer lesions and metachronous disease (consensus). The large majority of studies were at a high risk of bias or did not include any control groups.

CONCLUSION

Definitions of OMD were not used or varied widely between studies hampering across-study comparability and highlighting an unmet need for a consensus. The present study is part of a multistep process that aims to develop an interdisciplinary consensus on OMD in pancreatic cancer.

Survival benefit of local consolidative therapy for patients with single-organ metastatic pancreatic cancer: a propensity score-matched cross-sectional study based on 17 registries

Background

The continuous exploration of oligometastatic disease has led to the remarkable achievements of local consolidative therapy (LCT) and favorable outcomes for this disease. Thus, this study investigated the potential benefits of LCT in patients with single-organ metastatic pancreatic ductal adenocarcinoma (PDAC).

Methods

Patients with single-organ metastatic PDAC diagnosed between 2010 - 2019 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to minimize selection bias. Factors affecting survival were assessed by Cox regression analysis and Kaplan-Meier estimates.

Results

A total of 12900 patients were identified from the database, including 635 patients who received chemotherapy combined with LCT with a 1:1 PSM with patients who received only chemotherapy. Patients with single-organ metastatic PDAC who received chemotherapy in combination with LCT demonstrated extended median overall survival (OS) by approximately 57%, more than those who underwent chemotherapy alone (11 vs. 7 months, p < 0.001). Furthermore, the multivariate Cox regression analysis revealed that patients that received LCT, younger age (< 65 years), smaller tumor size (< 50 mm), and lung metastasis (reference: liver) were favorable prognostic factors for patients with single-organ metastatic PDAC.

Conclusion

The OS of patients with single-organ metastatic pancreatic cancer who received LCT may be prolonged compared to those who received only chemotherapy. Nevertheless, additional prospective randomized clinical trials are required to support these findings.

Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor

BACKGROUND

Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality.

METHODS

This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients.

RESULTS

Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available.

CONCLUSION

In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.

Natural History of Stage IV Pancreatic Cancer. Identifying Survival Benchmarks for Curative-intent Resection in Patients With Synchronous Liver-only Metastases

OBJECTIVE

To evaluate long-term oncologic outcomes of patients with stage IV pancreatic ductal adenocarcinoma and to identify survival benchmarks for comparison when considering resection in these patients.

BACKGROUND

Highly selected cohorts of patients with liver-oligometastatic pancreas cancer have reported prolonged survival after resection. The long-term impact of surgery in this setting remains undefined because of a lack of appropriate control groups.

METHODS

We identified patients with clinical stage IV pancreatic ductal adenocarcinoma with synchronous liver metastases within our cancer registry. We estimated overall survival (OS) among various patient subgroups using the Kaplan-Meier method. To mitigate immortal time bias, we analyzed long-term outcomes of patients who survived beyond 12 months (landmark time) from diagnosis.

RESULTS

We identified 241 patients. Median OS was 7 months (95% CI, 5-9), both overall and for patients with liver-only metastasis (n=144). Ninety patients (38% of liver only; 40% of whole cohort) survived at least 12 months; those who received chemotherapy in this subgroup had a median OS of 26 months (95% CI, 17-39). Of these patients, those with resectable or borderline resectable primary tumors and resectable liver-only metastasis (n=9, 4%) had a median OS of 39 months (95% CI, 13-NR).

CONCLUSIONS

The 4% of our cohort that were potentially eligible for surgery experienced a prolonged survival compared with all-comers with stage IV disease. Oncologic outcomes of patients undergoing resection of metastatic pancreas cancer should be assessed in the context of the expected survival of patients potentially eligible for surgery and not relative to all patients with stage IV disease.

Is surgical resection justified for pancreatic ductal adenocarcinoma with distant abdominal organ metastasis? A position paper by experts in pancreatic surgery at the Joint Meeting of the International Association of Pancreatology (IAP) & the Japan Pancreas Society (JPS) 2022 in Kyoto

Pancreatic ductal adenocarcinoma (PDAC) is a typical refractory malignancy, and many patients have distant organ metastases at diagnosis, such as liver metastasis and peritoneal dissemination. The standard treatment for unresectable PDAC with distant organ metastasis (UR-M) is chemotherapy, but the prognosis remained poor. However, with recent dramatic developments in chemotherapy, the prognosis has gradually improved, and some patients have experienced marked shrinkage or disappearance of their metastatic lesions. With this trend, attempts have been made to resect a small number of metastases (so-called oligometastases) in combination with the primary tumor or to resect the primary and metastatic tumor in patients with a favorable response to anti-cancer treatment after a certain period of time (so-called conversion surgery). An international consensus meeting on surgical treatment for UR-M PDAC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of the Japan Pancreas Society (JPS) in Kyoto in July 2022. The presenters showed their indications for and results of surgical treatment for UR-M PDAC and discussed their advantages and disadvantages with the experts. Although these reports were limited to a small number of patients, findings suggest that these surgical treatments for patients with UR-M PDAC who have had a significant response to chemotherapy may contribute to a prognosis of prolonged survival. We hope that this article summarizing the discussion and agreements at the meeting will serve as the basis for future trials and guidelines.

Oncologic resection of pancreatic cancer with isolated liver metastasis: Favorable outcomes in select patients

BACKGROUND

Patients with pancreatic ductal adenocarcinoma (PDAC) and liver metastasis are treated with palliative chemotherapy, whereas similar patients with metastatic colorectal cancer are considered for aggressive surgery.

METHODS

Using an institutional database, PDAC patients undergoing liver resection for isolated metastasis were identified. Their overall survival (OS), treatment factors, and clinicopathological variables associated with survival were also evaluated.

RESULTS

Forty-seven patients underwent curative-intent surgery for metastatic PDAC to the liver between 2000 and 2019. Median OS was 21.9 months from diagnosis. Fourteen patients underwent unplanned resection of radiographically occult liver metastasis during pancreatectomy with median OS of 8.7 months. On the other hand, 29 patients received systemic chemotherapy followed by planned resection; this cohort had the most favorable prognosis following aggressive surgery with median OS being 38.1 months from diagnosis and 24.1 months from surgery. Preoperative chemotherapy (HR = 7.1; p = .002) and moderate to well differentiation of the primary tumor (HR = 3.7; p = .003) were associated with prolonged survival in multivariate analysis, whereas lymph node metastases, response to preoperative therapy, number of liver metastasis, and extent of liver surgery were not.

CONCLUSIONS

In select patients with PDAC and isolated liver metastasis, curative-intent surgery can result in meaningful survival. This aggressive approach seems most beneficial in patients following induction chemotherapy.

Essential updates 2021/2022: Surgical outcomes of oligometastasis in pancreatic ductal adenocarcinoma

Oligometastatic disease has been proposed as an intermediate state between localized and polymetastatic disease that can benefit from multimodal treatment, including surgery. There is a growing concern about performing surgery for oligometastatic pancreatic ductal adenocarcinoma, although there is still little evidence. We reviewed articles published between 2021 and 2022, focusing mainly on surgical outcomes. Furthermore, we summarized the current status of surgery in the multidisciplinary treatment of oligometastatic pancreatic cancer and discuss future perspectives. In liver oligometastasis, multimodal treatment including surgery achieved favorable long-term survival, especially in patients with good responses to preoperative chemotherapy, with a median survival time from 25.5 to 54.6 months. In addition, the data from the National Cancer Database in the United States showed that patients who underwent surgery for oligometastatic liver metastases had a significantly longer overall survival than those who received chemotherapy alone. Prognostic biomarkers were identified, including carbohydrate antigen 19-9 (CA19-9) levels at diagnosis and preoperative chemotherapy with normalization of CA19-9 levels or favorable radiological response. Patients with lung oligometastasis had a more favorable long-term prognosis than those with other recurrence sites, and the updated literature further confirmed the previous studies. Overall survival was favorable, with 84 months after initial surgery and 29.2 months after metastasectomy, and a 5-year survival rate of 60.6% was also reported. In peritoneal oligometastasis, the results of conversion surgery after good responses to preoperative treatment with intraperitoneal therapy or systematic chemotherapy were reported, and the conversion rate and long-term prognosis were favorable. There is a growing concern about performing surgery for oligometastatic pancreatic ductal adenocarcinoma. We reviewed articles published between 2021 and 2022, focusing mainly on surgical outcomes. Furthermore, we summarize the current status of surgery in multidisciplinary treatment of oligometastatic pancreatic cancer and discuss future perspectives.

Oncological Outcome of Conversion Surgery After Preoperative Chemotherapy for Metastatic Pancreatic Cancer

OBJECTIVE

To investigate the outcome of conversion surgery in patients with metastatic pancreatic cancer (mPDAC) and to identify patients who may benefit from this approach.

BACKGROUND

The role of conversion surgery in patients with mPDAC and exceptional response to chemotherapy remains unclear.

METHODS

Patients who underwent surgical exploration for mPDAC following chemotherapy between 2006 and 2019 were included. Data on demographics, oncologic treatment, pathology, and postoperative outcomes were analyzed. Univariate and multivariate survival analyses were performed.

RESULTS

Some 173 patients received preoperative chemotherapy and underwent surgical exploration. Ninety-three patients underwent resection of the primary tumor and metastatic sites, 80 patients underwent exploration only. In the resection subgroup, 45 patients had complete pathological response of metastases (ypM0) and 48 patients had residual metastases (ypM1). ypM0 status was associated with lower carcinoembryonic antigen levels and lower ypN stage. Overall survival after resection was 25.5 months in ypM0, 10.7 months in ypM1, and 8.1 months in patients without resection ( P <0.001). Additional adjuvant chemotherapy was significantly associated with prolonged survival in resected patients (29.0 vs 14.8 mo, P =0.024) as well as in ypM0 (29.1 vs 19.2 mo, P =0.047). Multivariable analysis identified conversion surgery, carbohydrate antigen 19-9 (CA19-9) and time of resection as independent prognostic markers for the entire cohort. CA19-9, ypM0 and adjuvant treatment were independent predictors of survival in the resection subgroup.

CONCLUSION

In patients with mPDAC and ypM0 status after chemotherapy, surgical resection is associated with encouraging survival. mPDAC patients with exceptional response to chemotherapy may be candidates for exploration and for resection in ypM0. Adjuvant chemotherapy may provide an additional survival advantage.

Nomograms for Predicting the Risk and Prognosis of Liver Metastases in Pancreatic Cancer: A Population-Based Analysis

The liver is the most prevalent location of distant metastasis for pancreatic cancer (PC), which is highly aggressive. Pancreatic cancer with liver metastases (PCLM) patients have a poor prognosis. Furthermore, there is a lack of effective predictive tools for anticipating the diagnostic and prognostic techniques that are needed for the PCLM patients in current clinical work. Therefore, we aimed to construct two nomogram predictive models incorporating common clinical indicators to anticipate the risk factors and prognosis for PCLM patients. Clinicopathological information on pancreatic cancer that referred to patients who had been diagnosed between the years of 2004 and 2015 was extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate logistic regression analyses and a Cox regression analysis were utilized to recognize the independent risk variables and independent predictive factors for the PCLM patients, respectively. Using the independent risk as well as prognostic factors derived from the multivariate regression analysis, we constructed two novel nomogram models for predicting the risk and prognosis of PCLM patients. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve, the consistency index (C-index), and the calibration curve were then utilized to establish the accuracy of the nomograms’ predictions and their discriminability between groups. Using a decision curve analysis (DCA), the clinical values of the two predictors were examined. Finally, we utilized Kaplan–Meier curves to examine the effects of different factors on the prognostic overall survival (OS). As many as 1898 PCLM patients were screened. The patient’s sex, primary site, histopathological type, grade, T stage, N stage, bone metastases, lung metastases, tumor size, surgical resection, radiotherapy, and chemotherapy were all found to be independent risks variables for PCLM in a multivariate logistic regression analysis. Using a multivariate Cox regression analysis, we discovered that age, histopathological type, grade, bone metastasis, lung metastasis, tumor size, and surgery were all independent prognostic variables for PCLM. According to these factors, two nomogram models were developed to anticipate the prognostic OS as well as the risk variables for the progression of PCLM in PCLM patients, and a web-based version of the prediction model was constructed. The diagnostic nomogram model had a C-index of 0.884 (95% CI: 0.876–0.892); the prognostic model had a C-index of 0.686 (95% CI: 0.648–0.722) in the training cohort and a C-index of 0.705 (95% CI: 0.647–0.758) in the validation cohort. Subsequent AUC, calibration curve, and DCA analyses revealed that the risk and predictive model of PCLM had high accuracy as well as efficacy for clinical application. The nomograms constructed can effectively predict risk and prognosis factors in PCLM patients, which facilitates personalized clinical decision-making for patients.

Outcomes of pancreatic cancer with liver oligometastasis

BACKGROUND

Liver oligometastatic pancreatic cancer (PC) may have favorable outcomes. This study aims to evaluate outcomes and factors associated with overall survival (OS) of these patients.

METHODS

We retrospectively investigated consecutive PC patients with liver metastasis treated at our institution between 2013 and 2020. Clinical characteristics and outcomes were compared and analyzed according to the extent of liver metastasis. Cox proportional hazards model was used to identify prognostic factors for OS.

RESULTS

A total of 417 patients were included (multi-organ metastasis/polymetastasis/oligometastasis 174/158/85). Oligometastasis showed a longer OS compared to other types of metastases (7.7 vs 8.2 vs 13.1 months). Age <70 years, performance status of 0, modified Glasgow prognostic score of 0, carbohydrate antigen 19-9 <1000 U/mL were identified as significant prognostic factors for OS. A prognostic index consisting of these four factors successfully stratified the prognosis of these patients (prognostic index; high vs low, 19.9 vs 8.3 months). Highly selected patients who underwent surgical resection showed a median OS of 54.6 months.

CONCLUSIONS

Oligometastasis presented a relatively favorable outcome. Our new prognostic index was useful in stratifying the prognosis of these patients. Multimodal treatment including surgery may have additional survival benefits for highly selected patients.

Primary Tumor Resection for Metastatic Colorectal, Gastric and Pancreatic Cancer Patients: In Search of Scientific Evidence to Inform Clinical Practice

The management of the primary tumor in metastatic colorectal, gastric and pancreatic cancer patients may be challenging. Indeed, primary tumor progression could be associated with severe symptoms, compromising the quality of life and the feasibility of effective systemic therapy, and might result in life-threatening complications. While retrospective series have suggested that surgery on the primary tumor may confer a survival advantage even in asymptomatic patients, randomized trials seem not to definitively support this hypothesis. We discuss the evidence for and against primary tumor resection for patients with metastatic gastrointestinal (colorectal, gastric and pancreatic) cancers treated with systemic therapies and put in context the pros and cons of the onco-surgical approach in the time of precision oncology. We also evaluate current ongoing trials on this topic, anticipating how these will influence both research and everyday practice.

SURGICAL TREATMENT AS AN INCREASE IN THE SURVIVAL OF PATIENTS WITH LIVER OLIGOMETASTASIS OF DUCTAL ADENOCARCINOMA OF THE PANCREAS. PATIENT SELECTION CRITERIA. REVIEW

The work is based on the analysis of the literature data on the problems of treating patients with metastatic pancreatic cancer, identifying a group of patients with more favorable treatment prognosis. The objectives of this review are to study diagnostic criteria, to determine the optimal algorithm for the diagnosis and treatment of patients with oligometastatic pancreatic disease. According to the Global Cancer Observatory (GLOBOCAN) in the world, in 2020 the incidence of pancreatic cancer among men and women was about 7.2 and 5.0 per 100 thousand, with a mortality rate of 6.7 and 4.6 %, respectively [1]. At the same time, in most cases, the disease is diagnosed at stage IIIIV, so the results of treatment remain unsatisfactory, 2/3 of patients die within 1 year after the diagnosis is made. The "gold standard" for the treatment of this group of patients today is only systemic antitumor therapy according to the FOLFRINOX regimen, in which the average overall survival is about 11.1 months. Thanks to the development of ideas about the mechanisms of tumor progression, the improvement of diagnostic methods and antitumor treatment, the concept of oligometastatic disease has appeared and is being actively studied. According to the current theory, this group of patients with stage IV tumors can potentially have a better prognosis. The analysis of modern domestic and foreign literature is carried out. According to scientific studies, careful selection and implementation of combined treatment can significantly increase the survival rate of this group of patients. Based on numerous studies, some authors have proposed optimal algorithms for the diagnosis and treatment of patients with oligometastatic pancreatic disease.

Resection of pancreatic adenocarcinomas with synchronous liver metastases: A retrospective study of prognostic factors for survival

BACKGROUND

This study aimed to evaluate the results of synchronous liver resection for metastatic pancreatic ductal adenocarcinomas and to identify prognostic factors for overall survival.

METHODS

We retrospectively reviewed clinical data from patients who underwent the synchronous resection of pancreatic adenocarcinoma with liver metastases. Cox analyses were used to identify factors prognostic of overall survival.

RESULTS

Of the 92 patients included in this study, preoperative chemotherapy was administered to 52 patients. The median overall survival was 18.26 months (95% confidence interval: 14.7-22.7) (from diagnosis) and 12.68 months (95% confidence interval: 9.5-15.57) from surgery; overall survival at 1, 3, and 5 years was 70%, 10%, and 0%, respectively. Twenty-eight patients (30.4%) had median overall survival >18 months after surgery. The median overall survival from diagnosis was longer in patients undergoing preoperative treatment (22.7 vs 13.8 months; P = .01) but similar after surgery (12.6 vs 13.8 months; P = .86). Multivariate Cox analysis found CA19-9 levels <500 kU/L (hazard ratio: 0.35; 95% confidence interval: 0.17-0.70; P = .003), R0 resection (hazard ratio: 0.46; 95% confidence interval: 0.24-0.88; P = .020), and adjuvant chemotherapy (hazard ratio: 0.39; 95% confidence interval: 0.17-0.88; P = .024) as independent prognostic factors for overall survival.

CONCLUSION

Survival after resection of oligometastatic liver disease remains limited, reflecting the dismal prognosis of metastatic disease even after aggressive treatment. Preresection CA19-9 serum levels represent a useful tool for patient selection, and administration of adjuvant chemotherapy has a major impact on overall survival. Large comparative studies with exclusive chemotherapy are needed to validate this approach and to identify optimal candidates.

Geographic variation in attitudes regarding management of locally advanced pancreatic cancer

Background

Recent literature suggests wide variations exist in the international management of locally advanced pancreatic cancer. This study sought to evaluate how geography contributes to variations in management of locally advanced pancreatic cancer.

Methods

An electronic survey investigating preferences for the evaluation and management of locally advanced pancreatic cancer was distributed to an international cohort of pancreatic surgeons. Surgeons were classified according to geographic location of practice, and survey responses were compared across locations.

Results

A total of 153 eligible responses were received from 4 continents: North and South America (n = 94, 61.4%), Europe (n = 25, 16.3%), and Asia (n = 34, 22.2%). Preferences for the use and duration of neoadjuvant chemotherapy and radiotherapy varied widely. For example, participants in Asia commonly preferred 2 months of neoadjuvant chemotherapy (61.8%), whereas North and South American participants preferred 4 months (52.1%), and responses in Europe were mixed (P = .006). Participants in Asia were less likely to consider isolated liver or lung metastases contraindications to exploration and consequently had a greater propensity to consider exploration in a vignette of oligometastatic disease (56.7% vs North and South America: 25.6%, Europe: 43.5%; P = .007).

Conclusion

In an international survey of pancreatic surgeons, attitudes regarding locally advanced pancreatic cancer and metastatic disease management varied widely across geographic locations. Better evidence is needed to define optimal management of locally advanced pancreatic cancer.

Prognostic Factors After Pancreatectomy for Pancreatic Cancer Initially Metastatic to the Liver

Background

Resection of initially oligometastatic pancreatic ductal adenocarcinoma (PDAC) following response to first-line chemotherapy is controversial. We herein updated a previous case series to investigate the oncologic outcomes and preoperative factors that could drive the decision-making process.

Methods

This retrospective analysis was limited to patients with liver-only synchronous metastases who experienced complete regression of the metastatic component and underwent pancreatectomy between October 2008 and July 2020 at two high-volume institutions. Clinical-pathologic variables were captured, and inflammation-based prognostic scores were calculated. Recurrence and survival analyses were performed using standard statistical methods.

Results

Overall, 52 patients were included. FOLFIRINOX was the most employed chemotherapy regimen (63.5%). Post-treatment tumor size, serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) were significantly decreased relative to baseline evaluation. The median time from diagnosis to pancreatectomy was 10.2 months, while the median time from chemotherapy completion to pancreatectomy was 2 months. Major postoperative complications occurred in 26.9% of patients, while postoperative mortality was nil. The median disease-free survival (DFS) and overall survival (OS) from pancreatectomy were 16.5 and 23.0 months, respectively, and the median OS from diagnosis was 37.2 months. At multivariable analysis, vascular resection, operative time, prognostic nutrition index (PNI) and neutrophil-to-lymphocyte ratio (NLR) were associated with OS. Operative time, platelet × neutrophil/lymphocyte count (SII), and PNI were associated with DFS.

Conclusions

We confirm promising outcomes of selected patients who underwent pancreatectomy following downstaging of liver metastases. The absence of vascular involvement of the primary tumor, good nutritional status, and low inflammatory index scores could be useful to select candidates for resection.

[Liver metastases-Non-colorectal, non-endocrine]

In contrast to colorectal and neuroendocrine liver metastases, liver surgery has not yet gained the same status for non-colorectal non-endocrine (NCNE) liver metastases. The main explanation is a different tumor biology but is also due to the lack of effective systemic treatment options for some tumor entities in the past. Even selected chemotherapy-naive patients with NCNE liver metastases can benefit from liver resection. Due to the sometimes dramatic improvements in systemic treatment in recent years, multimodality treatment concepts should be increasingly considered for several diseases in which modern liver surgery will become an integral part.

Surgical treatment of hepatic oligometastatic pancreatic ductal adenocarcinoma: An analysis of the National Cancer Database

BACKGROUND

Patients with liver-only metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone. Recent studies have explored the role of surgical resection among patients with limited metastatic disease. National practice patterns and the impact of surgery among these patients remains unknown.

METHODS

The National Cancer Database was queried for all patients with pancreatic adenocarcinoma between 2010 and 2015. The primary outcome was overall survival from the time of diagnosis. Patients with liver-only metastatic disease were included. Univariable and multivariable logistic regression models were constructed to determine the association of patient, hospital, and regional factors with receipt of surgical resection. A propensity score-matched cohort (1:1) was generated by matching patient- and tumor-related factors (age, sex, race, comorbidity burden, primary tumor site, primary tumor size) among patients with liver-only stage IV pancreatic adenocarcinoma who received chemotherapy alone compared to those who received chemotherapy and underwent pancreatectomy and liver metastatectomy.

RESULTS

Among 312,426 patients who met the study criteria, one half (n = 140,043, 50.4%) had stage IV disease; metastatic sites included bone (n = 5493, 3.1%), brain (n = 620, 0.4%), lung (n = 16,580, 9.5%), and liver (n = 62,444, 35.7%). Patients with stage IV disease were more likely to be younger (odds ratio: 1.10, 95% confidence interval: 1.0-1.2; P = .03) and have poorly (odds ratio: 2.1, 95% confidence interval: 1.8-2.5; P < .001) or undifferentiated (odds ratio: 3.1, 95% confidence interval: 2.3-4.1; P < .001) tumors. Among stage IV patients with liver-only disease (n = 47,785, 14.9%), 891 patients (1.9%) underwent pancreatic resection. Patients who underwent resection were more likely to be younger (odds ratio 1.4, 95% confidence interval: 1.0-1.8; P = .03) and treated at an academic/research center (odds ratio 2.1, 95% confidence interval: 1.2-3.5; P = .006). Median overall survival among patients who underwent resection was 10.74 months versus 3.4 months among patients who did not undergo resection. After controlling for patient and disease-related factors, patients who underwent surgical resection had a lower risk of death versus patients who did not undergo surgery (hazard ratio: 0.5, 95% confidence interval: 0.4-0.6; P < .001). After propensity score matching, patients who received multimodality treatment for liver-only metastatic pancreatic adenocarcinoma (surgery, chemotherapy) had a longer median overall survival (15.6 months vs 8.1 months) compared to those who received chemotherapy alone (P < .001).

CONCLUSION

This study suggests that pancreatic resection in patients with liver metastases, in combination with chemotherapy and/or chemoradiation, may be associated with improved survival in well-selected patients. However, attempts at an aggressive surgical approach for patients with liver-only stage IV pancreatic adenocarcinoma patients should only be performed only under a well-designed prospective clinical trial.

Surgical management of pancreatic cancer liver oligometastases

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer, which commonly metastasizes to the liver. The current standard of care for metastatic PDAC is systemic chemotherapy, however there are limited emerging data regarding surgical resection of pancreatic oligometastases in select patients. Here we review the literature addressing resection of PDAC liver oligometastases.

[Better Therapy for Pancreatic Cancer through More Radical Surgery?]

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.

Neoadjuvant therapy for pancreatic cancer

Multimodal treatment including surgery and chemotherapy is considered the gold standard treatment of pancreatic cancer by most guidelines. Neoadjuvant therapy (NAT) has been seen as a possible treatment option for resectable, borderline resectable and locally advanced PaC. The aim of this paper is to offer a state-of-the-art review on neoadjuvant treatments in the setting of pancreatic ductal adenocarcinoma. A systematic literature search was performed using PubMed, Cochrane, Web of Science and Embase databases, in order to identify relevant studies published up to and including July 2021 that reported and analyzed the role of neoadjuvant therapy in the setting of pancreatic carcinoma. Most authors are concordant on the strong role of neoadjuvant therapy in the setting of borderline resectable pancreatic cancers. Recent randomized trials demonstrated improvement of R0 rate and survival after NAT in this setting. Patients with locally advanced cancers may become resectable after NAT, with better results than those obtained with palliative therapies. Even in the setting of resectable cancers, NAT is being evaluated by ongoing randomized trials. Chemotherapy regimens in the setting of NAT and response to NAT are discussed. NAT has an important role in the multimodal treatment of patients with borderline resectable pancreatic cancer. It has a role in patients with locally advanced tumors as it can allow surgical resection in a relevant proportion of patients. For resectable pancreatic cancers, the role of NAT is under evaluation by several randomized trials.

Survival Benefit of Resection Surgery for Pancreatic Ductal Adenocarcinoma with Liver Metastases: A Propensity Score-Matched SEER Database Analysis

Simple Summary

Pancreatic ductal adenocarcinoma is a devastating illness but guidelines consider it unresectable once metastasized. However, resection of the primary tumor is carried out in select cases and retrospective analyses indicate that this may improve survival. Even so, these analyses are limited to single centers or fail to account for biased patient selection. We overcome these limitations with a propensity score-matched SEER database analysis that reliably demonstrates surgery can extend overall survival. Furthermore, we identify prognostic factors that could aid the selection of patients for randomized controlled trials. Thus, this study paves the way for future work that aims to update treatment guidelines in accordance with surgical developments.

Abstract

Guidelines do not recommend resection surgery for oligometastatic pancreatic ductal adenocarcinoma (PDAC). However, reports in small samples of selected patients suggest that surgery extends survival. Thus, this study aims to gather evidence for the benefits of cancer-directed surgery (CDS) by analyzing a national cohort and identifying prognostic factors that aid the selection of candidates for CDS or recruitment into experimental trials. Data for patients with PDAC and hepatic metastasis were extracted from the population-based Surveillance, Epidemiology, and End Results database (SEER). The bias between CDS and non-CDS groups was minimized with Propensity Score Matching (PSM), and the prognostic role of CDS was investigated by comparing Kaplan-Meier estimators and Cox proportional hazard models. A total of 12,018 patients were extracted from the database, including 259 patients who underwent CDS that were 1:1 propensity score-matched with patients who did not receive CDS. CDS appeared to significantly prolong median overall survival from 5 to 10 months. Multivariate analysis revealed chemotherapy as a protective prognostic, whilst survival was impaired by old age and tumors that were poorly differentiated (Grades III–IV). These factors can be used to select patients likely to benefit from CDS treatment, which may facilitate recruitment into randomized controlled trials.

Evolving pancreatic cancer treatment: From diagnosis to healthcare management

The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.

Local treatment of pancreatic cancer metastases: A multicenter French study of the AGEO group

OBJECTIVE

This study reports the efficacy and safety of local treatment of metastases of pancreatic ductal adenocarcinoma (PDAC), with a curative intent.

METHODS

We retrospectively included patients with histologically proven PDAC, who underwent a local treatment for metastases between January 1, 2000 and December 31, 2017, from 11 French hospitals. Complications of local treatment were reported. Univariate Cox models were performed to identify prognosis factors associated with overall survival (OS) and disease-free survival (DFS).

RESULTS

We included 52 patients treated for 68 metastases; 33 (64%) of whom had metachronous metastases. Metastatic sites treated were: 39 (57%) hepatic, 18 (27%) pulmonary and 11 (16%) others. Metastases treatments were: 45 (66%) surgery, 9 (13%) radiofrequency and 14 (21%) other procedures. The rates of severe complications and mortality were respectively 10% and 4%. The median OS and DFS after local treatment were 36.5 months and 12.7 months, respectively. Prognosis factors associated with a shorter OS were: liver metastases when compared with lung metastases (HR 4.04; 95%CI: 1.18-13.81), N2 status of primary pancreatic tumor when compared to N0-N1 (HR 9.43; 95%CI: 2.44-36.36) and synchronous metastases when compared to metachronous metastases (HR 2.34; 95%CI: 1.05-5.23). N2 status of primary pancreatic tumor was associated with a shorter DFS when compared to N0-N1 (HR 2.82; 95%CI: 1.05-7.58).

CONCLUSION

In this series of highly selected patients, local treatment of metastases from PDAC is associated with prolonged survival. The rate of severe complications was low. Factors associated with shorter OS were liver metastases, N2 status and synchronous metastases.

Individualized Prediction of Survival Benefits of Pancreatectomy Plus Chemotherapy in Patients With Simultaneous Metastatic Pancreatic Cancer

Background

Metastatic pancreatic cancer (mPC) is a highly lethal malignancy with poorer survival. However, chemotherapy alone was unable to maintain long-term survival. This study aimed to evaluate the individualized survival benefits of pancreatectomy plus chemotherapy (PCT) for mPC.

Methods

A total of 4546 patients with mPC from 2004 to 2015 were retrieved from the Surveillance, Epidemiology, and End Results database. The survival curve was calculated using the Kaplan-Meier method and differences in survival curves were tested using log-rank tests. Cox proportional hazards regression analyses were performed to evaluate the prognostic value of involved variables. A new nomogram was constructed to predict overall survival based on independent prognosis factors. The performance of the nomogram was measured by concordance index, calibration plot, and area under the receiver operating characteristic curve.

Results

Compared to pancreatectomy or chemotherapy alone, PCT can significantly improve the prognosis of patients with mPC. In addition, patients with well/moderately differentiated tumors, age ≤66 years, tumor size ≤42 mm, or female patients were more likely to benefit from PCT. Multivariate analysis showed that age at diagnosis, sex, marital status, grade, tumor size, and treatment were independent prognostic factors. The established nomogram has a good ability to distinguish and calibrating.

Conclusion

PCT can prolong survival in some patients with mPC. Our nomogram can individualize predict OS of pancreatectomy combined with chemotherapy in patients with concurrent mPC.