Invasion of the splenic artery is a crucial prognostic factor in carcinoma of the body and tail of the pancreas

Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection

Adenocarcinoma of the body and tail of the pancreas is an aggressive malignancy, and classically there have been few survivors after surgery. Radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection are new procedures for these tumors. Radical antegrade modular pancreatosplenectomy is designed to establish an operation with oncologic rationales both for the dissection planes used to achieve negative margins and the extent of node dissection. The extent of lymph node dissection is based on the descriptions of N1 lymph node drainage, and dissection planes are based on fascial planes of the retroperitoneum. Radical antegrade modular pancreatosplenectomy is modular, adjusting the posterior plane of dissection based on the position of the tumor on preoperative computed tomograms. It is also performed right to left to increase visibility and control blood supply early. Radical antegrade modular pancreatosplenectomy is not an extended pancreatectomy but brings the rationales of the modern Whipple procedure to left-sided tumors. In long-term results from our center in 47 patients, there was a high negative tangential margin rate of 89% and an actuarial overall 5-year survival rate of 35.5%. The actual 5-year survival in 23 patients was 30.4%. Distal pancreatectomy with celiac axis resection is a procedure for cancers that have involved the celiac axis. It is based on the fact that resection of the celiac axis may be performed without devascularizing the liver, which then receives its blood supply by the pancreaticoduodenal arcade. It is an extended pancreatectomy. Mature long term results are just becoming available. Results with distal pancreatectomy with celiac axis resection are mixed with some series reporting few or no long-term survivors, whereas others report long-term survival at approximately 20%.

Clinical significance of clusterin expression in pancreatic adenocarcinoma

BACKGROUND

Clusterin is known to be expressed in many human neoplasms, and is believed to participate in the regeneration, migration, and anti-apoptosis of tumor cells. However, few reports have addressed the relationship between the manifestation of clusterin and clinicopathologic parameters in pancreas cancer patients. In the present study, the authors investigated the expression of clusterin and its clinical significance in pancreatic adenocarcinoma.

METHODS

Immunohistochemical staining was performed for clusterin in tumor tissues obtained from patients who received pancreatic resection with radical intent, and the associations of clusterin expression with various clinicopathologic parameters were analyzed in addition to the relation between its expression and survival.

RESULTS

Immunoreactivity for clusterin was observed in 17 of the 52 (33%) pancreatic adenocarcinomas examined. In addition, clusterin positivity was found to be associated with preoperative serum carcinoembryonic antigen level, perineural invasion, and, most strongly, lymph node metastasis. The survival analysis identified tumor differentiation and lymph node metastasis as the only significant prognostic factors.

CONCLUSION

Although not an independent prognostic factor, clusterin immunoreactivity can be used in conjunction with lymph node metastasis to predict survival in cases of pancreatic adenocarcinoma.

Clinicopathologic study of intrapancreatic cancer spread in carcinoma of the body and tail of the pancreas

OBJECTIVE

The aims of this study were to clarify the type of intrapancreatic spread of cancer of the pancreatic body and tail and to assess whether a 2-cm transection margin is adequate to ensure negative margins.

METHODS

We selected 66 patients who underwent distal pancreatectomy for cancer of the pancreatic body and tail. We investigated intrapancreatic cancer spread in these patients histopathologically and analyzed the relationship between 2-cm-margin positivity and other clinicopathological characteristics.

RESULTS

Two-centimeter-margin positivity was observed in 17 cases. In these, tumors had a tendency to spread toward the pancreatic head along the main pancreatic duct. As a result of statistical analysis, we considered venous invasion (odds ratio [OR], 15.48; 95% confidence interval [CI], 1.61-148.94; P = 0.0177), 2-cm-margin fibrosis (OR, 173.88; 95% CI, 8.96-3375.03; P = 0.0007), and 2-cm-margin hardness (OR, 5.97; 95% CI, 1.07-33.46; P = 0.0420) as being independently related to 2-cm-margin positivity.

CONCLUSIONS

The results suggest that 2 cm is not a safe length to ensure a negative margin. In the future, preoperative and intraoperative evaluation of the degree of fibrosis of pancreatic parenchyma could lead to cancer-free pancreatic cut-end margins.

Long-term results of resection of adenocarcinoma of the body and tail of the pancreas using radical antegrade modular pancreatosplenectomy procedure

BACKGROUND

The radical antegrade modular pancreatosplenectomy (RAMPS) procedure is a modification of standard distal pancreatosplenectomy. It was designed to provide the operative approach developed for cancers of the head of the pancreas to cancers of the body and tail of the pancreas, particularly with respect to the extent of node dissection and emphasis on obtaining microscopically negative tangential margins. The purpose of this report is to provide long-term survival results.

STUDY DESIGN

Forty-seven patients had RAMPS between 1999 and 2008. The decision to perform anterior vs posterior RAMPS was based on the position of the tumor as assessed by preoperative computed tomograms. Patients were entered in a prospective database and followed at intervals.

RESULTS

Thirty-two patients had anterior RAMPS and 15 had posterior RAMPS. Twenty-four patients had resection of 33 organs in addition to the left adrenal gland in the posterior RAMPS. Specimens were inked in the operating room. Mean tumor size was 4.4 cm. Negative tangential margins were obtained in 89% of specimens. Overall, the R0 rate was 81%. Mean lymph node count was 18. There were no 30-day or in-hospital mortalities. Mean and median follow-up times of living patients were 44.4 and 26.4 months. Median survival was 26 months and 5-year overall actuarial survival was 35.5%. The actual survival of 23 patients whose surgery was performed more than 5 years before the time of analysis was 30.4%.

CONCLUSIONS

RAMPS is associated with high negative tangential margin rates and very satisfactory survival rates for this aggressive tumor.

Laparoscopic versus open distal pancreatectomy: a single-institution case-control study

BACKGROUND

Laparoscopic distal pancreatic surgery has gained popularity in the last decade. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution case-control study comparing outcomes of LDP to ODP.

METHODS

From a prospectively accruing database, 104 patients who underwent distal pancreatectomy for pancreatic pathologies were eligible. Of these, 30 LDPs were matched with 30 ODPs using a 1:1 case-match design. Matching criteria were final histopathologic diagnosis and lesion size. Twelve LDPs were excluded from analysis because of lack of adequate ODP controls. In all cases, an attempt was made at conservation of the spleen.

RESULTS

There were more females in the LDP group (p = 0.001). Other clinicopathologic characteristics of the LDP and ODP groups such mean age (52.4 ± 17.2 vs. 59 ± 12.8, p = 0.104), prior history of upper abdominal surgery (6.7% vs. 20.0%, p = 0.254) or pancreatitis (13.3% vs. 10.0%, p = 1.000), histopathologic diagnosis (p = 1.000), lesion size on imaging (3.7 ± 2.7 vs. 4.4 ± 2.4 cm, p = 0.170), and histopathology (3.8 ± 2.3 vs. 4.3 ± 2.3, p = 0.386) were comparable. There were no significant differences in postoperative complication rates (50.0% vs. 43.3%, p = 0.604), major complication rates (20% vs. 20%, p = 0.829), grade B/C pancreatic fistula rates (16.7% vs. 13.3%, p = 0.717), or reoperation rates (3.3% vs. 6.7%, p = 1.000) between LDP and ODP groups, respectively. There was a significantly higher rate of splenic conservation in the LDP group (70% vs. 30%, p = 0.002). The intraoperative blood loss (294 ± 245 vs. 726 ± 709 ml, p < 0.001) and mean duration of hospitalization (8.7 ± 4.2 vs. 12.6 ± 8.7 days, p = 0.009) were significantly lower in the LDP group compared to the ODP group.

CONCLUSION

LDP is a safe and feasible option for distal pancreatic resections in experienced centers. The postoperative complication rate is comparable to that of ODP. LDP is associated with lower operative blood loss, higher rate of splenic conservation, and shorter duration of hospitalization. These encouraging results demand further validation in prospective randomized trials.

Pattern of lymph node metastasis spread in pancreatic cancer

OBJECTIVES

We aimed to clarify the detailed pattern of lymph node (LN) metastasis spread in patients with pancreatic cancer.

METHODS

This retrospective study enrolled 429 patients who underwent pancreatectomy with extended lymphadenectomy for pancreatic cancer. The prognostic implications of LN metastasis were evaluated, and the position, frequency, and association with other clinicopathologic factors were investigated.

RESULTS

Lymph node metastasis was confirmed pathologically in 289 patients (67.4%). The prognosis of patients with LN metastasis was significantly poorer than that of patients without LN metastasis (P < 0.001). Distant LN metastasis occurred frequently, regardless of the tumor site. Patients classified with T1 or T2 only had regional LN metastasis, whereas there was a high rate of distant LN metastasis, including the para-aortic LNs, in patients with T3 or higher-stage tumors. Para-aortic LN metastasis was significantly associated with arterial and perineural invasion (P = 0.006 and P < 0.001, respectively). Lymph node metastasis in the hepatic portal region was a strong predictor of para-aortic LN metastasis in pancreatic head cancer.

CONCLUSIONS

Pancreatic cancer frequently metastasized to distant LNs via a complex pathway and developed into systemic disease. Aggressive multimodality therapy, including neoadjuvant therapy, is essential to improve the long-term survival of patients at substantial risk of distant LN metastasis.

Splenic artery invasion in pancreatic adenocarcinoma of the body and tail: a novel prognostic parameter for patient selection

BACKGROUND

The value of splenic vessels invasion (which identified T3 tumors) in prognosis after resection for pancreatic ductal adenocarcinoma (PDA) of the body and tail has not been extensively investigated. The goal of this study was to evaluate prognostic factors in PDA of the body/tail, emphasizing the role of splenic vessels infiltration.

METHODS

Between 1990 and 2008, 87 patients who underwent distal pancreatectomy (DP) for histologically proven PDA of the body and tail were analyzed. Clinicopathological prognostic factors for survival were evaluated. Univariate and multivariable analyses were performed.

RESULTS

Postoperative morbidity was 31% with no mortality. The 1-, 3-, and 5-year overall survival rates were 77%, 48%, and 24.5%, respectively. Invasion of the splenic artery (SA) was observed in 19 patients (22%). Patients with SA invasion had a significantly poorer prognosis compared with those without SA invasion (median survival: 15 vs. 39 months, P = 0.014). On multivariable analysis, adjuvant therapy, poor differentiation (G3/G4), R2 resection, the presence of lymph node metastases, and SA invasion were independent predictors of survival.

CONCLUSIONS

Along with other well-known prognostic factors, invasion of SA is an independent predictor of poor survival in PDA of the body/tail. In case of the presence of SA infiltration, neoadjuvant treatment should be considered. SA infiltration might be reclassified from a T3 to T4 tumor.

Enhancing pancreatic adenocarcinoma delineation in diffusion derived intravoxel incoherent motion f-maps through automatic vessel and duct segmentation

Diffusion-based intravoxel incoherent motion imaging has recently gained interest as a method to detect and characterize pancreatic lesions, especially as it could provide a radiation- and contrast agent-free alternative to existing diagnostic methods. However, tumor delineation on intravoxel incoherent motion-derived parameter maps is impeded by poor lesion-to-pancreatic duct contrast in the f-maps and poor lesion-to-vessel contrast in the D-maps. The distribution of the diffusion and perfusion parameters within vessels, ducts, and tumors were extracted from a group of 42 patients with pancreatic adenocarcinoma. Clearly separable combinations of f and D were observed, and receiver operating characteristic analysis was used to determine the optimal cutoff values for an automated segmentation of vessels and ducts to improve lesion detection and delineation on the individual intravoxel incoherent motion-derived maps. Receiver operating characteristic analysis identified f = 0.28 as the cutoff for vessels (Area under the curve (AUC) = 0.901) versus tumor/duct and D = 1.85 μm(2) /ms for separating duct from tumor tissue (AUC = 0.988). These values were incorporated in an automatic segmentation algorithm and then applied to 42 patients. This yielded clearly improved tumor delineation compared to individual intravoxel incoherent motion-derived maps. Furthermore, previous findings that indicated that the f value in pancreatic cancer is strongly reduced compared to healthy pancreatic tissue were reconfirmed.

Is the need for an arterial resection a contraindication to pancreatic resection for locally advanced pancreatic adenocarcinoma? A case-matched controlled study

BACKGROUND AND OBJECTIVES

Arterial resection (AR) has traditionally been considered as a contraindication to pancreatic resection for locally advanced pancreatic adenocarcinoma. The objective was to evaluate if pancreatic resection with AR was worthwhile.

METHODS

Between January 1990 and December 2008 the records of 26 consecutive patients who underwent a curative-intent pancreatic resection for adenocarcinoma of the pancreas with AR (AR+ group) were matched 1:1 to those of the whole series of pancreatic resection performed in our institution. The final study population (n = 52) included two groups of patients: the study group AR+ = 26 and the control group AR- = 26.

RESULTS

The 1- and 3-year survival rates were similar in the two groups (65.9% and 22.1%, median 17 months for the group AR + , versus 50.0% and 17.6%, median 12 months, for the group AR-; P = 0.581). The multivariate analysis showed that: arterial wall invasion at the site of AR, the total number of resected lymph nodes of ≤15, and perineural invasion were independent prognostic factors for survival.

CONCLUSION

Pancreatic resections with AR for adenocarcinoma allowed to obtain a 3-survival rate similar to that of a matched group of patients not requiring AR.