Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma--part 3: update on 5-year survival

[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]

BACKGROUND

Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation.

METHODS

This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma).

RESULTS

The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation.

CONCLUSIONS

Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.

Adjuvant therapy and survival after resection of pancreatic adenocarcinoma: a population-based analysis

BACKGROUND

The use of adjuvant chemoradiation for pancreatic adenocarcinoma (PAC) is accepted in North America, but there is a paucity of data to support this practice. The relation between adjuvant therapy and survival was assessed in a population-based cohort of patients with PAC.

METHODS

A review was conducted of all cases of resected PAC from 1996 to 2003 using data from the state cancer registry augmented with data from primary medical record review. Use of adjuvant therapy was ascertained from registry data. Survival was assessed using the Kaplan-Meier method, and a Cox proportional hazards model was developed for multivariate analysis.

RESULTS

A total of 298 patients from 27 hospitals met criteria for inclusion. There were 228 patients (76.5%) who were resected with curative intent, with a median overall survival of 12 months. The 6-month, 1-year, and 5-year survival rates were 80.2%, 58.4%, and 6.7%, respectively. Of the 228 patients resected, 122 (53.5%) received adjuvant treatment and had a median survival of 13.0 months versus 11.0 months for those with no adjuvant treatment (P = .16). After adjustment for surrogates of performance status, significant predictors of overall survival included no weight loss, T1/T2 pathologic stage, a microscopically complete resection (R0), and receipt of adjuvant therapy.

CONCLUSIONS

An R0 resection and adjuvant therapy were found to be independently associated with an increase in overall survival in patients with resected PAC. These data underscore the importance of adjuvant therapy in resected PAC and the need for ongoing clinical trials to refine the efficacy and timing of adjuvant therapy in this disease.

Ten years of experience with resection of left-sided pancreatic ductal adenocarcinoma: evolution and initial experience to a laparoscopic approach

BACKGROUND

With increasing laparoscopic experience, laparoscopic distal pancreatectomy with or without splenectomy is being regarded as a safe and effective treatment for benign and borderline malignant lesions of the pancreas; however, its application for left-sided pancreatic ductal adenocarcinoma (PDAC) is still debatable.

METHODS

We analyzed patients who underwent conventional distal pancreatectomy with splenectomy (DPS) for distal pancreatic cancer at our institution. We have performed laparoscopic DPS partly based on radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided PDAC since 2007. We compared laparoscopic DPS to conventional DPS according to various clinicopathologic factors.

RESULTS

From January 1999 to December 2008, 45 patients underwent conventional DPS for resectable left-sided PDAC, and 18 needed combined adjacent organ resection for potential margin negative (R0) resection. The median survival of resected left-sided PDAC was 27.9 months with a 5-year survival of 28.9%. A small amount of intraoperative bleeding [< or =760 ml Exp(beta) = 6.312, p = 0.001] and R0 resection [Exp(beta) = 4.349, p = 0.090] were the most significant prognostic factors. To achieve bloodless and R0 resection, the potential indication for laparoscopic DPS was suspicious pancreatic cancer confined to the pancreas that could be removed by DPS without resection of the adjacent organs. Five patients underwent laparoscopic/robot-assisted DPS for left-sided PDAC. Compared to conventional DPS, only the operation time (p = 0.011) and tumor size (p = 0.031) were significantly different, but other clinicopathologic variables were comparable. All patients still are alive. Four patients have lived without tumor recurrence (follow-up = 4-22 months), and only one experienced multiple liver metastasis and subsequent retroperitoneal local recurrence.

CONCLUSION

Laparoscopic/robot-assisted modified anterior RAMPS may be technically feasible for well-selected PDAC. The oncologic feasibility still remains to be determined due to limited experience.

Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis

BACKGROUND

Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms.

METHODS

Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed.

RESULTS

The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001).

CONCLUSION

When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.

Pancreatic cancer: progress made

Pancreatic cancer remains a deadly disease. Despite advances on many fronts, surgeons play a leading role in the diagnosis and management of pancreatic cancer. Preoperative staging is best provided by "pancreas-protocol" abdominal CT, although endoscopic ultrasound and diagnostic laparoscopy can add value in selected patients. Surgical resection, which remains the only curative option, is now accomplished with uniformly low perioperative mortality in high-volume centers (<3%), although complications remain frequent. Unfortunately, the long-term prognosis for pancreatic cancer remains poor with 5-year survival rates only 15-23% with median survival of 13 to 18 months. Recent data from randomized trials have supported the role for adjuvant chemotherapy and questioned the traditional role of radiation. Early diagnosis and targeted multimodality treatments would appear essential to optimizing the results of surgical therapy.

The Natural History of Resected Pancreatic Cancer without Adjuvant Chemotherapy

Diagnostic imaging, surgical care, and perioperative morbidity and mortality have significantly improved for patients undergoing resections for pancreatic adenocarcinoma. This study was undertaken to define the natural history and patterns of recurrence of resected pancreatic cancer without neoadjuvant or adjuvant therapies using current standards of care. Sixty-one patients underwent pancreatectomy without neoadjuvant or adjuvant therapy. Tumors were staged according to the American Joint Committee on Cancer (AJCC) classification system. CT scans were obtained every 3 months and recurrence categorized as: liver only, local, distant, multiple sites, or clinical. Median survival after pancreatectomy was 12 months. Cancer recurred in 51 (84%) patients. The radiographic site of initial recurrence did not generally impact survival; patients initially recurring at multiple sites had significantly abbreviated median survival of 5.6 months. AJCC stage was found to correlate with disease-free and overall survival, although tumor size alone did not. The presence of lymphatic metastasis correlated with disease-free but not overall survival. Overall survival after pancreaticoduodenectomy remains poor in the absence of neoadjuvant or adjuvant therapy. AJCC stage is the best predictor of disease-free and overall survival; tumor size, lymph node status, and site of recurrence alone do not impact survival in a meaningful way.

Outcomes in pancreatic cancer surgery

The increase in surgery for pancreatic cancer during the last 3 decades can be correlated with a gradual decline in operative mortality and postoperative complications. Although not all surgeons (nor all hospitals) can have equal outcomes, the definition and tabulation of these outcomes have been difficult. This article asks several pertinent questions: (1) what is the scientific rationale for pancreatic resection? (2) what are the best available results at this time? (3) who should be performing pancreatic resections? The article analyzes results of resection for adenocarcinoma of the exocrine pancreas, and excludes duodenal and ampullary cancers, pancreatic endocrine tumors, and tumors of less malignant potential.

Preoperative assessment of para-aortic lymph node metastasis in patients with pancreatic cancer

BACKGROUND

Para-aortic lymph node (PALN) metastasis is an important prognostic factor in patients with pancreatic cancer, but accurate preoperative diagnosis is difficult. The objective of this study was to assess the accuracy of diagnosis of PALN by computed tomography (CT), magnetic resonance imaging (MRI), and (18)F-fluorodeoxyglucose positron-emission tomography (FDG-PET).

METHODS

From August 2005 to July 2008, 119 patients with invasive ductal adenocarcinoma of the pancreas were included in this study. PALNs with a longer diameter >10 mm on CT or MRI were suspected of being involved by metastasis, whereas FDG uptake exceeding that of the adjacent normal tissue was considered to be positive for metastasis on FDG-PET studies. The imaging findings were compared with the pathological diagnosis of PALN metastasis.

RESULTS

PALN dissection was performed in 71 patients (60.0%). Although histopathological examination revealed metastasis in 6 patients (8.5%), none of these patients was positive in any of the preoperative imaging studies. The longer diameter, the shorter diameter, the ratio of the two diameters, and the calculated lymph node volume showed no significant differences between patients with and without PALN metastasis.

CONCLUSIONS

Preoperative detection of PALN metastasis in patients with pancreatic cancer is very difficult. Intraoperative histopathological examination of frozen sections is necessary if radical resection is contemplated.

Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence

Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.

Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis

BACKGROUND

Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms.

METHODS

Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed.

RESULTS

The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001).

CONCLUSION

When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.

Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors

BACKGROUND AND OBJECTIVES

Surgery remains the only curative option for the treatment of pancreatic and ampullary carcinomas. To examine the survival differences between ampullary and pancreatic head carcinomas after pancreaticoduodenectomy.

METHODS

A retrospective review of patients with ampullary or pancreatic head adenocarcinoma undergoing curative resection during a 6-year period prior to 2000.

RESULTS

A total of 104 patients underwent pancreaticoduodenectomy for pancreatic head and ampullary carcinomas (n = 65 and n = 39, respectively). Histologically, pancreatic cancer was worse, with more lymph node involvement and more positive resection margins and vascular and perineural invasions than found in ampullary carcinoma. The median disease-free and overall survival rates were significantly better for ampullary cancer when compared with pancreatic cancer (17 vs. 9 months [P = 0.001] and 35 vs. 24 months [P = 0.006], respectively). The actuarial 5-year disease-free and overall survival rates were 4.4% and 10.5%, respectively, for pancreatic carcinoma and 27.9% and 31.8%, respectively, for ampullary carcinoma. Multivariate analysis showed that microscopic resection margin involvement (P = 0.02) and involvement of over three nodes (P < 0.001) were significant factors affecting the overall survival for pancreatic and ampullary carcinomas, respectively.

CONCLUSIONS

In this study, patients with ampullary carcinoma have a better prognosis and survival than those with pancreatic carcinoma.

Advances in the early diagnosis and therapy of pancreatic cancer

The prevalence of pancreatic cancer has increased dramatically over the past decades. As pancreatic cancer is difficult to detect at an early stage, its prognosis is very poor. Inherited genetic factors and environmental factors are known to be the major causes of pancreatic cancer. Pancreatic intraepithelial neoplasia (PanIN) lesions have been established as the pre-neoplastic changes during pancreatic carcinogenesis. Detection of tumor markers and imaging examinations (computed tomography, magnetic resonance imaging, endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography) are effective means for diagnosis of pancreatic cancer. The combination of surgical resection and adjuvant or neoadjuvant chemotherapy shows promise in prolonging the survival time of patient with pancreatic cancer.

Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009

Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Survival after pancreaticoduodenectomy is not improved by extending resections to achieve negative margins

OBJECTIVE

This study was undertaken to determine the survival benefit of extending resections to obtain microscopically negative margins after positive intraoperative frozen sections.

SUMMARY BACKGROUND DATA

The impact of residual microscopic disease after pancreaticoduodenectomy is currently a point of controversy. It is, however, generally believed that microscopically positive margins negatively impact survival and this may be improved by ultimately achieving negative margins.

METHODS

Since 1995, patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma have been prospectively followed. Margin status has been codified as macro/microscopically negative (R0) or macroscopically negative/microscopically positive (R1). The impact of margin status on survival was evaluated utilizing survival curve analysis. Data are presented as median, mean +/- SD where appropriate.

RESULTS

For pancreatic adenocarcinoma, 202 patients underwent pancreaticoduodenectomy. R0 resections were achieved in 158 patients, 17 of whom required extended resections to achieve complete tumor extirpation after an initially positive intraoperative frozen section (R1 --> R0). R1 resections were undertaken in 44 patients. Median survival for patients undergoing R0 resections was 21 months, 26 +/- 23.4 months versus 13 months, 17 +/- 21.0 months for patients undergoing R1 resections (P = 0.02). Median survival for patients undergoing R1 --> R0 resections was 11 months, 16 +/- 17.3, (P = 0.001). Margin status had a significant correlation with "N" stage and AJCC stage but not "T" stage.

CONCLUSION

Survival after pancreaticoduodenectomy is not improved by extending pancreatic resections to achieve negative margins after initially positive intraoperative frozen sections. Tumor-specific factors beyond the presence of disease at a surgical margin are responsible for the abbreviated survival seen in patients undergoing R1 resections.

The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer

INTRODUCTION

Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio.

METHODS

Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier and Cox methods.

RESULTS

In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7-80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0-22). Median LN ratio was 0.1 (0-0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio > or = 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio > or = 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio > or = 0.2 (p < 0.02; relative risk RR 1.6), LN ratio > or = 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved.

CONCLUSIONS

Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies.

Preliminary experience with the hanging maneuver for pancreaticoduodenectomy

BACKGROUND

Malignant periampullary tumours often invade retroperitoneal peripancreatic tissues and a positive resection margin following pancreaticoduodenectomy (PD) is associated with a poor survival. The margin most frequently invaded is the retroperitoneal margin (RM). Among the different steps of PD one of the most difficult and less codified is the resection of the RM with high risk of bleeding. We have developed a surgical technique - "hanging maneuver" - which allows at the same time a standardization of this step, a complete resection of the RM, and an optimal control of bleeding.

PATIENTS/METHODS

We described the surgical technique, and we reported our preliminary experience. Surgical data, postoperative outcome and pathological results of patients submitted to PD for pancreatic carcinoma using "hanging maneuver" technique between January 2007 and December 2007 were reviewed.

RESULTS

The hanging maneuver was performed in 20 patients without any intraoperative complication and massive bleeding. No patient required blood transfusion. After had inked the surgical margins, retroperitoneal peripancreatic tissue was invaded in 12 out of 17 patients with malignant diseases (70.5%). In only one case (6%), the retroperitoneal margin was involved by the tumour (R1 resection).

CONCLUSION

The "hanging maneuver" is a useful and safe technical variant and should be considered in the armamentarium of the pancreatic surgeons in order to achieve negative retroperitoneal margins.

Crossing the Rubicon: when pancreatic resection with curative intent ends in an R2 status. Impact of "desmoplastic pseudo-pancreatitis" and anatomical site of irresectability

AIM

To analyze the impact of pancreatitis-mimicking, concomitant alterations on intraoperative assessment of curative resectability, the anatomical site of irresectability, and outcome after nonintentional R2 resection in pancreatic cancer.

METHODS

Of 1,099 patients subjected to pancreatic resection for cancer, 40 (4%) underwent R2 resection (group A). The site where tumors turned out to be irresectable and the coincident presence of potentially misleading, fibro-desmoplastic alterations were analyzed. Outcome after resection was compared with 40 bypass patients matched for age, gender, histopathology, and use of additive chemotherapy (group B).

RESULTS

R2 resection was due to misjudgment regarding resectability in 38 patients (95%) and to uncontrollable hemorrhage in 2 patients (5%). Group A patients had significantly longer operative times (P < 0.0001), required more blood units (P < 0.0001), and had longer hospital stay than group B patients (P = 0.049). Despite a significantly higher relaparotomy rate of 20% (n = 8) in group A versus 5% (n = 2) in group B, perioperative mortality was equal (n = 2, each). Median survival was 11.5 months in group A and 7.5 months in group B (P = 0.014). "Pancreatitis-like" lesions were assessed in 70% (n = 28/40, group A) and 25% (10/40, group B; P = 0.014). The superior mesenteric artery proximal to its jejunal branches was the most likely site of irresectability (60%), followed by its peripheral course (22.5%) and the lower aspects of the celiac trunk (17.5%).

CONCLUSIONS

Concomitant "pancreatitis-like" alterations hamper the assessment of local resectability in pancreatic cancer. Although palliative resection results in elevated perioperative morbidity compared with bypass procedures, mortality is equal, while survival is prolonged.

Pancreatoduodenectomy with or without pyloric preservation: a clinical outcomes comparison

Pyloric preservation (PP) can frequently be performed at the time of pancreatoduodenectomy (PD), although some reports have linked it to inferior outcomes such as delayed gastric emptying (DGE). We reviewed records in a single-surgeon practice to assess outcomes after PD with or without PP. There were 133 PDs with 67 PPPDs and 66 PDs. Differences between PPPD and PD groups included cancer frequency, tumor size, OR time, blood loss, and transfusion rate. However, postoperative morbidity rate and grade, NG tube duration, NGT reinsertion rate, DGE, and length of stay were similar. There was no difference among patients with pancreatic cancer. No detrimental outcomes are associated with pyloric preservation during PD. Greater intraoperative ease and superior survival in the PPPD group are due to confounding, tumor-related variables in this nonrandomized comparison. Nevertheless, we intend to continue the use of PP with our technique in patients who meet the stated criteria.

Prognostic factors after resection of pancreatic cancer

OBJECTIVES

The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient's general condition.

METHODS

Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses.

RESULTS

The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration>100 U/ml (HR=1.84, p=0.0074), a tumor size>3 cm (HR=1.74, p=0.0235), venous involvement (HR=2.39, p=0.0006), a transfusion requirement of >or=1000 ml (HR=2.23, p=0.0006), and a serum albumin concentration on 1 postoperative month (1POM)<3 g/dl (HR=2.40, p=0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p=0.0041), extended nerve plexus resection around the superior mesenteric artery (p=0.0456), and a longer postoperative hospital stay (p=0.0063).

CONCLUSION

To improve long-term survival, preserving the patient's general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.

[Not Available]

A. Sauvanet Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.

[Not Available]

A. Sauvanet Several factors argue for extended lymphadenectomy in surgery for pancreatic adenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumor recurrences are only loco-regional suggesting that initial resection was insufficient; 3) some retrospective studies suggest that extension of lymphadenectomy improves post-resection survival. Extended lymphadenectomy, including circumferential dissection of both the celiac axis and the superior mesenteric artery and resection of para-aortic nodes, was evaluated by 4 randomized trials; globally there was no survival benefit. Extended lymphadenectomy increases, at least transiently, the risk of post-operative diarrhea. Its influence on the rate of loco-regional recurrences has not been evaluated. However, this technique should not be definitively and globally precluded since a more radical resection was associated with a trend toward better long-term survival in the trial with the largest number of patients.

Borderline resectable pancreatic cancer: on the edge of survival

BACKGROUND

Patients with borderline resectable pancreatic cancer are at high risk of having positive surgical margins due to involvement of the tumor with adjacent vasculature. This article reviews the management of this subset of pancreatic cancer patients.

METHODS

The authors review the current definitions of borderline resectable pancreatic cancer and how it is diagnosed and staged. The history, current approaches, and future directions in neoadjuvant therapy for borderline resectable pancreatic cancer are also reviewed with emphasis on various chemotherapy regimens that have been used. The application of intensity-modulated radiation therapy and image-guided radiation therapy that accounts for respiratory motion to targeting the gross tumor volume in the pancreas are discussed, and the promise of integrating targeted therapies in neoadjuvant treatment programs is highlighted.

RESULTS

The use of neoadjuvant treatment programs that employ gemcitabine-based chemotherapy regimens followed by chemoradiation increases the likelihood of subsequent margin-negative resection in borderline resectable pancreatic cancer.

CONCLUSIONS

There has been progress in the imaging, staging, surgical technique, and the use of chemotherapy and chemoradiotherapy in the management of borderline resectable pancreatic cancer. Patients can benefit from multidisciplinary management at high-volume pancreatic cancer treatment centers.

Synthetic extracellular matrix enhances tumor growth and metastasis in an orthotopic mouse model of pancreatic adenocarcinoma

Individuals with pancreatic cancer have one of the poorest survival rates among the major cancers, suggesting the need to develop new therapeutic approaches. An effective animal model that mimics the progression and metastases of human pancreatic adenocarcinoma does not exist. The goal of this investigation was to develop a model that would compare the growth and metastasis of orthotopically injected pancreatic cancer cells to cells encapsulated within a synthetic extracellular matrix (sECM). The hypotheses tested were that the cells within the sECM would grow more quickly and more frequently develop metastasis to distant organs. MiaPaCa-2 cells expressing red fluorescent protein, either in serum-free media or within a hyaluronan-based hydrogel, were injected into the pancreas of nude mice. Tumors were monitored for 8 weeks via intravital red fluorescent protein imaging. Cells encapsulated within the sECM grew more quickly and produced larger tumors compared with the cells alone. In addition, the cells within the sECM developed metastasis more frequently. Therefore, the encapsulation of human pancreatic cancer cells within an injectable sECM improved the rate of tumor growth and metastasis in an orthotopic mouse model. The advantages of this new approach can be utilized to investigate the mechanisms of tumor progression and test novel therapeutic agents in vivo.

Surgical management of carcinoma of the head of pancreas: extended lymphadenectomy or modified en bloc resection?

Pancreatoduodenectomy for the treatment of periampullary cancer was described over 70 years ago. The technique has evolved in an attempt to improve the dismal prognosis for patients with pancreatic cancers. Radical regional resection has been proposed to decrease the incidence of local recurrence as well as to improve survival. These extended resections have failed to show a significant survival benefit in prospective randomized controlled studies. Furthermore, extended pancreatic resections may be associated with increased morbidity. The concept of modified en bloc resection has been advocated and is soundly based on anatomical and pathological principals. This procedure is a modification of the radical regional resection previously described. It involves resection of the peripancreatic retroperitoneal tissue and lymph nodes en bloc with the head of pancreas, in order to achieve an R0 resection but without the morbidity associated with an extended lymphadenectomy. Conceptually, this procedure may be the most appropriate technique for the management of pancreatic head cancers although the ultimate effect on long-term survival can only be judged after further clinical studies.

The role of extended lymphadenectomy for adenocarcinoma of the head of the pancreas: strength of the evidence

With improvements in the safety of Whipple resection in recent decades, surgeons have continued to explore the role of more extensive lymphadenectomy in hope of improving long-term survival. A systematic literature search of level I evidence addressing the role of the extent of lymphadenectomy was undertaken. Only reports of prospective, randomized controlled trials comparing pancreaticoduodenectomy with standard lymphadenectomy to pancreaticoduodenectomy with extended lymphadenectomy where information regarding survival, morbidity, mortality, the number of resected lymph nodes in each group and detailed operative technique were included. Four prospective, randomized trials comprising some 424 patients and one meta-analysis were identified. In aggregate, these studies confirmed that the number of resected lymph nodes was significantly higher in the pancreaticoduodenectomy with extended lymphadenectomy group. Morbidity and mortality rates were comparable. Postoperative diarrhea in the early months after operation was problematic in patients undergoing extended lymphadenectomy. In none of the studies was a benefit in long-term survival demonstrated. Standard pancreaticoduodenectomy continues to be the operation of choice for adenocarcinoma of the head of the pancreas.

Survival after resection of ampullary carcinoma: a national population-based study

BACKGROUND

Ampullary cancer is the second most common periampullary cancer, with a resection and survival rate more favorable than that for pancreatic cancer. However, most reports have been conducted at single institutions with small sample sizes, and results may not reflect the practices and outcomes in the community. Our objective was to complete a population-based analysis of patients undergoing resection for ampullary carcinoma and compare it with outcomes in the published literature.

METHODS

Patients diagnosed with ampullary cancer reported in the Surveillance, Epidemiology, and End Results program (1988-2003) were collected. Primary outcome was survival (5-year), and secondary outcome was stage at presentation. Comparisons were made with outcomes reported in the literature (resection rate, perioperative mortality, and 5-year survival).

RESULTS

Of the 3292 ampullary cancer patients, 1301 (40%) underwent resection. Thirty-seven percent presented with stage I tumors. Perioperative mortality (30 day) was 7.6% after resection, and 5-year survival was 36.8%. Few patients died if they survived at least 5 years. The cancer registry data showed less early stage disease, higher perioperative mortality, and lower 5-year survival compared with published reports.

CONCLUSIONS

This is the largest population-based analysis of ampullary carcinoma. Resection rates and survival at the national level are lower, in general, compared with cancer center reports, which may have implications for regionalizing these procedures. Many patients surviving at least 5 years seem to be cured by surgical resection.

New markers of pancreatic cancer identified through differential gene expression analyses: claudin 18 and annexin A8

BACKGROUND

New markers to distinguish benign reactive glands from infiltrating ductal adenocarcinoma of the pancreas are needed.

DESIGN

The gene expression patterns of 24 surgically resected primary infiltrating ductal adenocarcinomas of the pancreas were compared with 18 non-neoplastic samples using the Affymetrix U133 Plus 2.0 Arrays and the Gene Logic GeneExpress Software System. Gene fragments from 4 genes (annexin A8, claudin 18, CXCL5, and S100 A2) were selected from the fragments found to be highly expressed in infiltrating adenocarcinomas when compared with normal tissues. The protein expression of these genes was examined using immunohistochemical labeling of tissue microarrays.

RESULTS

Claudin 18 labeled infiltrating carcinomas in a membranous pattern. When compared with normal and reactive ducts, claudin 18 was overexpressed, at least focally, in 159 of 166 evaluable carcinomas (96%). Strong and diffuse claudin 18 overexpression was most often seen in well-differentiated carcinomas (P=0.02). Claudin 18 was overexpressed in 51 of 52 cases (98%) of pancreatic intraepithelial neoplasia. Annexin A8 was at least focally overexpressed in 149 of 154 evaluable infiltrating carcinomas (97%). S100 A2 was at least focally overexpressed in 118 of 154 evaluable infiltrating carcinomas (77%). Non-neoplastic glands also frequently expressed S100 A2 diminishing its potential diagnostic utility. Immunolabeling with antibodies directed against CXCL5 did not reveal any significant differences in protein expression between infiltrating adenocarcinomas and normal pancreatic ducts.

CONCLUSIONS

Claudin 18 and annexin A8 are frequently highly overexpressed in infiltrating ductal adenocarcinomas when compared with normal reactive ducts, suggesting a role for these molecules in pancreatic ductal adenocarcinomas. Furthermore, these may serve as diagnostic markers, as screening tests and as therapeutic targets.

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

BACKGROUND

There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head.

METHODS

All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival.

RESULTS

Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%-32.0%; P < .0001) and total pancreatectomy (TP; range, .04%-19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3-13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival.

CONCLUSIONS

In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.

Surgery insight: surgical management of pancreatic cancer

Pancreatic ductal adenocarcinoma is a common malignancy of the gastrointestinal tract. The number of new cases diagnosed and the number of deaths each year are almost identical, demonstrating the particularly dismal prognosis for patients affected by this disease. Despite recent advances in the field of medical and radiation oncology, and the introduction of neoadjuvant and adjuvant regimens, surgery remains the single most important modality for the treatment of pancreatic ductal adenocarcinoma. Surgery for pancreatic cancer is widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality. Many aspects of surgery for pancreatic cancer, such as the extent of resection, the value of vascular resection, the use of laparoscopy, and the importance of treatment at high-volume centers, are currently under debate. This Review describes the current status of surgical treatment for pancreatic ductal adenocarcinoma, and highlights the new developments in this field.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.