A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma

Should a standard lymphadenectomy include the No. 9 lymph nodes for body and tail pancreatic ductal adenocarcinoma?

OBJECTIVES

This study aimed to use a retrospective data base to investigate whether a standard lymphadenectomy during distal pancreatectomy should include the No. 9 lymph nodes (LNs) for resectable pancreatic ductal adenocarcinoma (PDAC) located in the body and tail of the pancreas.

METHODS

Data from 169 patients undergoing curative distal pancreatectomy for PDAC between Jan 1, 2013 and Dec 31, 2016 were collected. According to the tumor location, patients were divided into three groups: pancreatic neck tumor, pancreatic body and tail tumor with margin-to-bifurcation-distance (MTBD) ≤ 2.5 cm and pancreatic body and tail tumor with MTBD > 2.5 cm. The metastatic rate of the No. 9 LNs was compared among the 3 groups. The survival outcomes were analyzed.

RESULTS

The involvement rate for No. 9 LNs was 20.7% (6/29) for pancreatic neck tumors, 17.6% (15/85) for body and tail tumors with MTBD ≤ 2.5 cm and 1.8% (1/55) for MTBD > 2.5 cm. The No. 9 LNs were significantly more frequently involved in neck or body and tail tumors with MTBD ≤2.5 cm than with the cases with MTBD >2.5 cm (OR 0.082, P = 0.016). No. 9 LN involvement was not associated with worse survival compared with survival associated with involvement of other LNs (P = 0.780).

CONCLUSIONS

For PDAC located in the neck or in the body and tail of the pancreas with MTBD ≤ 2.5 cm, the involvement rate for No. 9 LNs is high. Standard lymphadenectomy should include the No. 9 LNs.

Management of pancreatic head adenocarcinoma: From where to where?

Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.

Pancreatic cancer surgical management

Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.

Prognostic Value of Metastatic Lymph Node Ratio in Pancreatic Cancer

Lymph node involvement in pancreatic adenocancer is one of the strongest predictors of prognosis. However, the extent of lymph node dissection is still a matter of debate and number of dissected nodes varies widely among patients. In order to homogenize this diverse group of patients and more accurately predict their prognosis, we aimed to analyze the effect of metastatic lymph node ratio as an independent prognostic factor. We retrospectively analyzed medical recordings of 326 patients with pancreatic cancer who were treated in a tertiary medical oncology center over a 10-year period. Both in univariate and multivariate analyses, metastatic lymph node ratio proved to be a strong predictor of prognosis which was unaffected from heterogeneity of our patient population and can be used to facilitate predict prognosis of patients who underwent lymph node dissection to various extents and with future studies it can emerge as a successful tool for creating prognostic subgroups of the disease.

Accuracy of Nodal Positivity in Inadequate Lymphadenectomy in Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Population Study Using the US SEER Database

Objectives: The optimal number of the examined lymph nodes (ELNs) in pancreaticoduodenectomy for pancreatic ductal adenocarcinoma has been widely studied. However, the accuracy of nodal positivity for the patients with inadequate lymphadenectomy is still unclear. The purpose of our study was to determine the accuracy of the number of positive nodes reported for patients with 1-3 positive nodes and the probability that 4 or more nodes could be positive along with tumor size and number of nodes examined. Methods: We obtained data on patients who underwent pancreaticoduodenectomy for resectable pancreatic ductal adenocarcinoma diagnosed during 2004-2013 from the US Surveillance, Epidemiology, and End Results registry. An mathematical model based on Hypergeometric Distribution and Bayes' Theorem was used to estimate the accuracy. Results: Among the 9,945 patients, 55.6% underwent inadequate lymphadenectomy. Of them, 1,842, 6,049, and 2,054 had T1, T2, and T3 stage disease, respectively. The accuracy of the number of observed positive nodes increased as the number of ELNs increased and the tumor size decreased. To rule out the possibility of N2 stage (4 and more positive nodes), there should be at least 13 ELNs for the patients with 1 observed positive lymph node and 14 for the patients with 2. Conclusion: Inadequate lymphadenectomy could result in underestimation of the N stage, and this would have adverse impact on recurrence, efficacy of postoperative treatment, and even overall survival. This model combined with the observed positive lymph nodes, the number of ELNs, and tumor size could provide a more accurate determination of nodal positivity of these patients.

Three-Dimensional Remnant Pancreatic Volumetry Predicts Postoperative Pancreatic Fistula in Pancreatic Cancer Patients after Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a serious complication that can occur following pancreaticoduodenectomy (PD). Recent studies suggest that remnant pancreatic volume (RPV) values from preoperative multidetector computed tomography (MDCT) are highly predictive of POPF. We performed three-dimensional (3D) surgical simulation of PD including RPV measurements. The aim of this study was to determine whether 3D-measured RPV is predictive of POPF after PD.

Methods

We used the SYNAPSE VINCENT® medical imaging system (Fujifilm Medical Co., Ltd., Tokyo, Japan) to construct 3D images after integrating MDCT and magnetic resonance cholangiopancreatography images. RPV was measured using this 3D image, which simulated actual intraoperative pancreatic parenchymal remnant volume. Ninety-one patients who underwent PD were retrospectively enrolled. Using multivariate analysis, RPV and other well-known POPF risk factors were independently assessed.

Results

Multivariate analysis identified high RPV values (hazard ratio [HR] = 8.41, p = 0.01), pancreatic duct diameter < 3.0 mm (HR = 5.48, p < 0.01), no pathological fibrosis (HR = 3.41, p < 0.01), and body mass index > 25 kg/m² (HR = 1.53, p = 0.02) as independent risk factors for POPF.

Conclusion

The present study indicates that preoperative 3D-measured RPV is predictive of POPF after PD.

Clinical Management: Resectable Disease

Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called "borderline resectable pancreatic cancers" have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.

Long-term outcomes and recurrence patterns of standard versus extended pancreatectomy for pancreatic head cancer: a multicenter prospective randomized controlled study

BACKGROUND

Our previous randomized controlled trial revealed no difference in 2-year overall survival (OS) between extended and standard resection for pancreatic adenocarcinoma. The present study evaluated the 5-year OS and recurrence patterns according to the extent of pancreatectomy.

METHODS

Between 2006 and 2009, 169 consecutive patients were prospectively enrolled and randomized to standard (n = 83) or extended resection (n = 86) groups to compare 5-year OS rate, long-term recurrence patterns and factors associated with long-term survival.

RESULTS

The surgical R0 rate was similar between the standard and extended groups (85.5 vs. 90.7%, P = 0.300). Five-year OS (18.4 vs. 14.4%, P = 0.388), 5-year disease-free survival (14.8 vs. 14.0%, P = 0.531), and overall recurrence rates (74.7 vs. 69.9%, P = 0.497) were not significantly different between the two groups, although the incidence of peritoneal seeding was higher in the extended group (25 vs. 8.1%, P = 0.014).

CONCLUSIONS

Extended pancreatectomy does not have better short-term and long-term survival outcomes, and shows similar R0 rates and overall recurrence rates compared with standard pancreatectomy. Extended pancreatectomy does not have to be performed routinely for all cases of resectable pancreatic adenocarcinoma, especially considering its associated increased morbidity shown in our previous study.

How to Reliably Assess Nodal Status in Distal Pancreatectomy for Adenocarcinoma

OBJECTIVES

The optimal number of lymph nodes that need to be analyzed to reliably assess nodal status in distal pancreatectomy for adenocarcinoma is still unknown.

METHODS

Two hundred seventy-eight patients who underwent distal pancreatectomy for adenocarcinoma were retrieved from a retrospective French nationwide database. The relations between the number of analyzed lymph nodes and the nodal status of the tumor were studied. The beta-binomial law was used to estimate the probability of being truly node negative depending on the number of analyzed lymph nodes. Cox proportional hazard model was used for the survival analysis.

RESULTS

The median number of analyzed lymph nodes was 15. There was a positive correlation between the number of positive lymph nodes and the number of lymph nodes analyzed. The curve reached a plateau at approximately 25 lymph nodes. The beta binomial model demonstrated that an analysis of 21 negative lymph nodes shows a probability to be truly N0 at 95%. N+ status was associated with survival, but the number of lymph node analyzed was not.

CONCLUSION

At least 21 lymph nodes should be analyzed to ensure a reliable assessment of the nodal status, but this number may be hard to reach in distal pancreatectomy.

Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer

BACKGROUND

Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer.

METHODS

A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included.

RESULTS

After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months.

CONCLUSION

Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.

Clinical significance of defining borderline resectable pancreatic cancer

Since the introduction of the concept of borderline resectable pancreatic cancer (BRPC), various definitions of this disease entity have been suggested. However, there are several obstacles in defining this disease category. The current diagnostic criteria of BRPC mainly focuses on its expanded 'technical resectability'; however, they are difficult to interpret because of their ambiguity using potential subjective or arbitrary terminology, In addition, limitations in current imaging technology and a lack of evidence in radiological-pathological-clinical correlation make it difficult to refine the criteria. On the other hand, neoadjuvant treatment is usually applied to increase the R0 resection rate of BRPC focusing on the 'oncological curability'. However, evidence is needed concerning the effect of neoadjuvant treatment by quality-controlled prospective randomized clinical trials based on a standardized radiologic and pathologic reporting system. In conclusion, there are two aspects in the current concept of BRPC, which are technical resectability and oncological curability. Although the recent evolution of surgical techniques is expanding the scope of technical resectability, it should not be overlooked that the disease entity must be defined based on the evidence of oncological curability.

CA19-9 level determines therapeutic modality in pancreatic cancer patients with para-aortic lymph node metastasis

BACKGROUND

In general, para-aortic lymph node (LN16) metastasis has been considered as a contraindication for pancreatic resection. However, some pancreatic cancer patients with LN16 metastasis have been reported to survive for longer than expected after pancreatectomy. The purpose of this study was to determine whether pancreatic cancer patients with LN16 metastasis might benefit from surgery.

METHODS

We retrospectively reviewed 201 consecutive patients with invasive pancreatic ductal adenocarcinoma who underwent surgery at Osaka National Hospital between April 2003 and December 2012. These patients included 22 patients with LN16 metastasis who underwent an extended lymphadenectomy and 25 patients who underwent a palliative surgical biliary and gastric bypass. The clinicopathological data and outcomes were evaluated using univariate and multivariate analyses.

RESULTS

The overall survival of the patients with LN16 metastasis was poorer than that of the LN16-negative patients (P = 0.0014). An overall survival analysis of the LN16-positive patients stratified according to the preoperative CA19-9 level showed a significant difference between patients with a low preoperative CA19-9 level (≤360 U/mL) and those with a high preoperative CA19-9 level (>360 U/mL) (P = 0.0301). No significant difference in overall survival of patients was observed between those with LN16 positivity and those who underwent bypass surgery. However, the overall survival of the LN16-positive patients with a CA19-9 level ≤360 U/mL (n = 11) was significantly higher than that of those who underwent bypass surgery (P = 0.0452).

CONCLUSION

Surgical resection and extended lymphadenectomy remains an option for pancreatic cancer patients with LN16-positivity whose CA19-9 level is ≤360 U/mL.

Microscopic Venous Invasion in Pancreatic Cancer

BACKGROUND

Microscopic venous invasion (MVI) and the subsequent peripheral blood circulation of cancer cells are considered to be the primary route for systemic dissemination of pancreatic cancer.

METHODS

Patients who underwent pancreatectomy for invasive ductal carcinoma of the pancreas between January 2007 and December 2015 were retrospectively reviewed. The prognostic significance of MVI was analyzed.

RESULTS

A total of 352 patients underwent pancreatectomy for invasive ductal carcinoma of the pancreas. A pathologic examination showed MVI in 228 (64.5%) of the patients. The median survival time (MST) was 21 months for the patients with MVI and 58 months for those without MVI (p < 0.001). A multivariate analysis showed the following to be significant prognostic factors: non-administration of adjuvant chemotherapy [hazard ratio (HR) 2.37; p < 0.001], lymph node metastasis (HR 2.95; p = 0.001), CA19-9 value of 300 U/ml or higher (HR 1.70; p = 0.018), and MVI (HR 1.84; p = 0.011). The overall survival was clearly stratified into three groups; favorable (MST not reached in stage 1 or 2A without MVI; p = 0.867), moderate (30 months in stage 2A with MVI and 30 months in stage 2B without MVI; p = 0.528), and poor (19 months in stage 2B with MVI and 17 months in stage 4; p = 0.322). The differences between these three groups all were significant.

CONCLUSIONS

Approximately two-thirds of patients with radiologically resectable pancreatic cancer had MVI and were considered to have potentially systemic disease. This study identified MVI as one of the significant factors for a poor prognosis and a valuable complement of tumor-node-metastasis staging.

A case-matched comparison study of total pancreatectomy versus pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma

BACKGROUND

Total pancreatectomy (TP) is considered a viable option in some selected patients with pancreatic ductaladenocarcinoma (PDAC). The aim of this study was to compare the clinical outcomes between TP and pancreaticoduodenectomy (PD) in patients with PDAC.

MATERIALS AND METHODS

A total of 375 patients were selected from our center's database in China and classified into two groups: the PD group (n = 325) and the TP group (n = 50). A matched-pair analysis of the patients was conducted with a ratio of 1:1. Univariate and multivariate survival analyses were performed for overall survival.

RESULTS

Overall morbidity was lower in the PD group than in the TP group (31.4% vs 52%, respectively, P = 0.004). However, no significant difference was observed in major morbidity between the two groups (24.9% vs 30%, P = 0.455). The rates of 5-year overall (P = 0.043) and disease-free (P = 0.037) survival were significantly higher in the PD group. Furthermore, the univariate and multivariate analyses revealed that adjuvant chemotherapy (HR = 0.684, 95%CI = 0.545-0.860, P = 0.001) and margin resection status (HR = 1.666, 95%CI = 1.196-2.321, P = 0.003) were significant prognostic factors. After the matched-pair analysis, there were no significant differences between the two groups regarding postoperative complications and overall survival. However, the matched PD group had greater estimated blood loss (P = 0.037) and blood transfusion (56% vs 36%, P = 0.045).

CONCLUSION

From our study, the postoperative outcomes and survival time of TP are similar to those of matched PD. It seems reasonable to suggest that TP can be considered as safe, feasible, and efficacious as PD for patients with PDAC.

Nationwide prospective audit of pancreatic surgery: design, accuracy, and outcomes of the Dutch Pancreatic Cancer Audit

BACKGROUND

Auditing is an important tool to identify practice variation and 'best practices'. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery.

METHODS

Performance indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers.

RESULTS

Sixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014-2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien-Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9-18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts.

CONCLUSIONS

The Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.

Increased pancreatic cancer survival with greater lymph node retrieval in the National Cancer Data Base

BACKGROUND

We evaluated the role of lymph node (LN) retrieval in pancreatic adenocarcinoma (PA) patients undergoing pancreaticoduodenectomy (PD).

METHODS

We utilized the National Cancer Data Base; Cox regression models and logistic regression models were used for statistical evaluation.

RESULTS

We evaluated 26,792 patients with PA who underwent PD. The mean LN retrieved in LN(-) patients was 10.8 vs 14.4 for LN(+) patients (P < 0.0001). Greater LN retrieval is an independent predictor of a negative microscopic margin and decreased length of stay. The median survival of LN(-) patients exceeded that of LN(+) patients (24.5 vs 15.1 months, P < 0.0001). Increasing LN retrieval is a significant predictor of survival in all patients, and in LN(-) patients. The relationship of increased LN retrieval and enhanced survival is a nearly linear trend.

CONCLUSIONS

Rather than demonstrating an inflection point that defines the extent of adequate lymphadenectomy, this dataset demonstrates an incremental relationship between LN retrieval and survival.

Institutional variants for lymph node counts after pancreatic resections

BACKGROUND

Lymph node (LN) counts from pancreatectomy are postulated as quality metric for surgical therapy of pancreatic malignancy.

METHODS

Prospectively collected data from a single surgeon's pancreatectomy experience were analyzed for predictors of LN counts.

RESULTS

Of 315 consecutive patients (54% female, median age: 65, range 18-88), 239 had a proven cancer diagnosis (76%). Operations included pancreatoduodenectomy (69%), distal pancreatectomy (26%), total pancreatectomy (1%) and others (4%). Patients were treated in 4 different tertiary cancer center settings (Institution A: 11%; B: 46%; C: 27%; D: 16%) with consistent regional dissection standards. Mean total LN counts differed between institutions for malignancies (A: 18, B: 13, C: 26, D: 26, p < 0.0001) and benign diseases (p = 0.003). At least 15 LNs were reported in 63% of cancer patients (institution range: 34-92%, p < 0.0001).

CONCLUSIONS

Pathologic processing should be standardized if LN numbers are to be adopted as quality metric for pancreatic cancer resections.

Clinical efficacy of gemcitabine combined with intensity modulated radiotherapy in treatment of pancreatic cancer

AIM

To assess the efficacy and safety of gemcitabine combined with intensity modulated radiotherapy (IMRT) in the treatment of pancreatic cancer.

METHODS

Fifty-three patients with locally advanced pancreatic cancer who underwent liver surgery from January 2012 to January 2015 were randomly divided into two groups: an observation group (n = 27) and a control group (n = 26). The observation group was initially treated with gemcitabine (1000 mg/m², intravenous infusion on days 1, 8, and 15, every 28 d) combined with IMRT, and then 2-4 cycles of gemcitabine alone 1 mo after the end of the combination therapy. The control group was treated with gemcitabine alone. Clinical efficacy and safety were than evaluated for the two groups.

RESULTS

The clinical benefit index was significantly higher in the observation group than in the control group (70.37% vs 42.31%, χ² = 4.251, P = 0.029). The total effective rate and the local control rate were also significantly better in the observation group than in the control group (P < 0.05). Four cases in the observation group and one case in the control group are still alive now. Although the 1-year survival rate was significantly higher in the observation group than in the control group (P < 0.05), there was no significant difference between the two groups in the 2-year survival rate (P > 0.05). No grade 4 adverse events occurred in either group.

CONCLUSION

Gemcitabine combined with IMRT is safe and effective in the treatment of pancreatic cancer and can significantly improve the rate of pain relief and quality of life.

Prediction of pancreatic fistula after pancreatoduodenectomy by preoperative dynamic CT and fecal elastase-1 levels

Objective

To validate preoperative dynamic CT and fecal elastase-1 level in predicting the development of pancreatic fistulae after pancreatoduodenectomy.

Materials and methods

For 146 consecutive patients, CT attenuation values of the nontumorous pancreatic parenchyma were retrospectively measured on precontrast, arterial and equilibrium phase images for calculation of enhancement ratios. CT enhancement ratios and preoperative fecal elastase-1 levels were correlated with the development of pancreatic fistulae using independent t-test, logistic regression models, ROC analysis, Youden method and tree analysis.

Results

The mean value of enhancement ratio on equilibrium phase was significantly higher (p = 0.001) in the patients without pancreatic fistula (n = 107; 2.26±3.63) than in the patients with pancreatic fistula (n = 39; 1.04±0.51); in the logistic regression analyses, it was significant predictor for the development of pancreatic fistulae (odds ratio = 0.243, p = 0.002). The mean preoperative fecal elastase-1 levels were higher (odds ratio = 1.003, p = 0.034) in the pancreatic fistula patients than other patients, but there were no significant differences in the areas under the curve between the prediction values of CT enhancement ratios and fecal elastase-1 combined and those of CT enhancement ratios alone (P = 0.897, p = 0.917) on ROC curve analysis. Tree analysis revealed that the CT enhancement ratio was more powerful predictor of pancreatic fistula than fecal elastase-1 levels.

Conclusion

The preoperative CT enhancement ratio of pancreas acquired at equilibrium phase regardless of combination with fecal elastase-1 levels might be a useful predictor of the risk of developing a pancreatic fistula following pancreatoduodenectomy.

Posterior Superior Mesenteric Artery First Dissection Versus Classical Approach in Pancreaticoduodenectomy: Outcomes of a Case-Matched Study

OBJECTIVES

Posterior superior mesenteric artery (SMA) first dissection in pancreaticoduodenectomy (PD) may allow for early assessment of resectability and aberrant anatomy. Study objectives were to compare resection margins, perioperative outcomes, disease-free survival (DFS) and overall survival (OS) in patients undergoing a posterior SMA first dissection PD to a classical technique PD.

METHODS

Patients (n = 77) who underwent a posterior SMA first PD for adenocarcinoma were case matched for patient and tumor characteristics with patients undergoing a classical approach PD from 2006 to 2014 (n = 177).

RESULTS

The SMA first patients had an improved negative resection margin rate (27 [35.1%] vs 14 [18.2%], P = 0.042) and a higher lymph node yield (median 28 [22-34] vs 21 [17-27], P < 0.001) compared with the classical approach group. No difference was demonstrated in serious complications or 30-day mortality between the SMA first and classical approach patients (Clavien-Dindo 3/4 16 [20.8%] vs 11 [14.3%], P = 0.336; 30-day mortality 3 [3.9%] vs 3 [3.9%], P = 1.00 respectively). Median DFS and OS was similar in SMA first compared with classical approach patients (DFS, 1.6 vs 1.1 years, P = 0.122; OS, 2.5 vs 1.5 years, P = 0.220 respectively).

CONCLUSIONS

A posterior SMA first approach is a comparably safe technique that may improve oncological results in PD compared with classical approach dissection.

Recurrence after resection with curative intent for distal cholangiocarcinoma

BACKGROUND

Few studies have been conducted on patterns of recurrence after resection for distal cholangiocarcinoma (DCC). The aim of this study was to investigate the incidence and pattern of recurrence after resection of DCC, and to evaluate prognostic factors for time to recurrence and recurrence-free survival (RFS).

METHODS

Patients who underwent pancreatoduodenectomy with curative intent for DCC between 2001 and 2010 at one of 30 hospitals in Japan were reviewed retrospectively, with special attention to recurrence patterns. The Cox proportional hazards model was used for multivariable analysis.

RESULTS

In the study interval, 389 patients underwent pancreatoduodenectomy for DCC with R0/M0 status. Recurrence developed in 213 patients (54·8 per cent). The estimated cumulative probability of recurrence was 54·3 per cent at 5 years. An initial locoregional recurrence occurred in 55 patients (14·1 per cent) and initial distant recurrence in 168 (43·2 per cent), most commonly in the liver. Isolated initial locoregional recurrence occurred in 45 patients (11·6 per cent). Independent prognostic factors for time to recurrence and RFS were perineural invasion (P = 0·001 and P = 0·009 respectively), pancreatic invasion (both P < 0·001) and lymph node metastasis (both P < 0·001). RFS worsened as the number of risk factors increased: the 5-year RFS rate was 70·6 per cent for patients without any risk factors, 50·3 per cent for patients with one factor, 31·8 per cent for those with two factors, and 13·4 per cent when three factors were present.

CONCLUSION

More than half of patients with DCC experienced recurrence after R0 resection, usually within 5 years. Perineural invasion, pancreatic invasion and positive nodal involvement are risk factors for recurrence.

Recent Advances in Pancreatic Cancer Surgery of Relevance to the Practicing Pathologist

Recent advances in pancreatic surgery have the potential to improve outcomes for patients with pancreatic cancer. We address 3 new, trending topics in pancreatic surgery that are of relevance to the pathologist. First, increasing awareness of the prognostic impact of intraoperatively detected extraregional and regional lymph node metastases and the international consensus definition on lymph node sampling and reporting. Second, neoadjuvant chemotherapy, which is capable of changing 10% to 20% of initially unresectable, to resectable disease. Third, in patients who remain unresectable following neoadjuvant chemotherapy, local ablative therapies may change indications for treatment and improve outcomes.

Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions

Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.

Techniques of Vascular Resection and Reconstruction in Pancreatic Cancer

Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care.

Surgical Therapy for Pancreatic and Periampullary Cancer

Surgery is the key component of treatment for pancreatic and periampullary cancers. Pancreatectomy is complex, and there are numerous perioperative and intraoperative factors that are important for achieving optimal outcomes. This article focuses specifically on key aspects of the surgical management of periampullary and pancreatic cancers.

Technical Details of an Anterior Approach to the Superior Mesenteric Artery During Pancreaticoduodenectomy

INTRODUCTION

Use of central vascular ligation during dissection around the superior mesenteric artery (SMA) in pancreaticoduodenectomy (PD) for periampullary malignancies has rarely been documented.

METHODS

We developed the SMA hanging technique (SHT) to facilitate central vascular ligation during PD. Briefly, SMA dissection was initiated using the supracolic anterior approach, followed by left-sided dissection. The SMA was taped under finger guidance immediately after right-sided dissection. The ligament of Treitz was detached from the SMA during left-sided dissection, facilitating adequate lymph node dissection while preserving the nerve plexus around the SMA. Forty-seven consecutive patients who underwent PD for periampullary malignancies were divided into two groups: 23 underwent SHT and 24 underwent conventional dissection. Patients' clinical results were assessed to evaluate the feasibility and validity of SHT.

RESULTS

Blood loss volume, operation duration, and the incidence of bleeding during SMA dissection were significantly lower in the SHT group than in the conventional group. The short-term and oncological results were similarly acceptable in both groups.

CONCLUSIONS

SHT is a feasible and safe technique with acceptable short-term outcomes. We propose the use of this procedure to standardize en bloc dissection around the SMA.

Number of evaluated lymph nodes and positive lymph nodes, lymph node ratio, and log odds evaluation in early-stage pancreatic ductal adenocarcinoma: numerology or valid indicators of patient outcome?

BACKGROUND

We evaluated the prognostic significance and universal validity of the total number of evaluated lymph nodes (ELN), number of positive lymph nodes (PLN), lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in a relatively large and homogenous cohort of surgically treated pancreatic ductal adenocarcinoma (PDAC) patients.

METHODS

Prospectively accrued data were retrospectively analyzed for 282 PDAC patients who had pancreaticoduodenectomy (PD) at our institution. Long-term survival was analyzed according to the ELN, PLN, LNR, and LODDS.

RESULTS

Of these patients, 168 patients (59.5 %) had LN metastasis (N1). Mean ELN and PLN were 13.5 and 1.6, respectively. LN positivity correlated with a greater number of evaluated lymph nodes; positive lymph nodes were identified in 61.4 % of the patients with ELN ≥ 13 compared with 44.9 % of the patients with ELN < 13 (p = 0.014). Median overall survival (OS) and 5-year OS rate were higher in N0 than in N1 patients, 22.4 vs. 18.7 months and 35 vs. 11 %, respectively (p = 0.008). Mean LNR was 0.12; 91 patients (54.1 %) had LNR < 0.3. Among the N1 patients, median OS was comparable in those with LNR ≥ 0.3 vs. LNR < 0.3 (16.7 vs. 14.1 months, p = 0.950). Neither LODDS nor various ELN and PLN cutoff values provided more discriminative information within the group of N1 patients.

CONCLUSIONS

Our data confirms that lymph node positivity strongly reflects PDAC biology and thus patient outcome. While a higher number of evaluated lymph nodes may provide a more accurate nodal staging, it does not have any prognostic value among N1 patients. Similarly, PLN, LNR, and LODDS had limited prognostic relevance.

Factors predicting adequate lymph node yield in patients undergoing pancreatoduodenectomy for malignancy

Background

Most pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The purpose of this study was to investigate factors affecting the likelihood of adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment.

Methods

Six hundred sixty-two patients subject to pancreatoduodenectomy between 1990 and 2013 for pancreatic, ampullary, and common bile duct cancers were reviewed. Predictors of yielding at least 12 lymph nodes were evaluated with a logistic regression model, and a survival analysis was carried out to verify the prognostic implications of nodal counts.

Results

The median number of evaluated nodes was 17 (interquartile range 11 to 25), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients. Tumor diameter ≥20 mm (odds ratio [OR] 2.547, 95 % confidence interval [CI] 1.225 to 5.329, P = 0.013), lymph node metastases (OR 2.642, 95 % CI 1.378 to 5.061, P = 0.004), and radical lymphadenectomy (OR 5.566, 95 % CI 2.041 to 15.148, P = 0.01) were significant predictors of retrieving 12 or more lymph nodes. Lymph node counts did not influence the overall prognosis of the patients. However, a subgroup analysis carried out for individual cancer sites demonstrated that removing at least 12 lymph nodes is associated with better prognosis for pancreatic cancer.

Conclusions

Few variables affect adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Considering the ambiguities related to the only modifiable factor identified, appropriate pathology training should be considered to increase nodal yield rather than more aggressive lymphatic dissection.

Survival Determinants after Pancreatectomy With Vascular Resection for Pancreatic Cancer

To investigate the morbidity, mortality, and survival of patients with pancreatic cancer after pancreatectomy with vascular resection and to clarify the favorable prognostic survival factors. Pancreatic cancer is a malignant tumor. Many revisions have been made to surgical procedures to improve the prognosis of resectable pancreatic cancer. Several studies have compared no-vein and vein resection with pancreaticoduodenectomy, recording their feasibility and equal rates of operative mortality, incidence, and survival. Factors identified as potentially relevant to survival outcomes include population, perioperative treatment, and clinical pathologic factors, but these are still controversial. From January 1, 2003, to December 31, 2010, 63 patients with advanced pancreatic cancer underwent pancreatectomy with vascular resection. They were divided into 2 groups: one group had a survival time of &lt;2 years (group 1) and the other a survival time of &gt;2 years (group 2). Their clinical data, surgical techniques, perioperative parameters, and histopathologic data from a prospective database were analyzed. Major venous resection with reconstruction was performed in 61 patients (96.83%); major venous and artery resection with reconstruction in 1 patient (1.58%); and arterial resection with reconstruction in another patient (1.58%). The median survival time and the actuarial 1-, 2-, and 3-year survival rates for all patients are 19.94 months and 45.0%, 27.4%, and 17.6%, respectively. Group 1 contained 42 patients and group 2 contained 21 patients. A multivariate analysis identified tumor size, tumor differentiation, lymph-node status, nerve invasion, and metastasis (TNM) staging of the pancreatic cancer, tumor grade, operating time, and chemotherapy after surgery as independent predictors of long-term survival. TNM staging, tumor grade, operating time, and chemotherapy are independent predictors of survival after pancreatectomy.

Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement

Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria.

MATERIAL AND METHODS

All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed.

RESULTS

Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups.

CONCLUSION

Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.

Prognostic value of lymph node metastases detected during surgical exploration for pancreatic or periampullary cancer: a systematic review and meta-analysis

BACKGROUND

Hepatic-artery and para-aortic lymph node metastases (LNM) may be detected during surgical exploration for pancreatic (PDAC) or periampullary cancer. Some surgeons will continue the resection while others abort the exploration.

METHODS

A systematic search was performed in PubMed, EMBASE and Cochrane Library for studies investigating survival in patients with intra-operatively detected hepatic-artery or para-aortic LNM. Survival was stratified for node positive (N1) disease.

RESULTS

After screening 3088 studies, 13 studies with 2045 patients undergoing pancreatoduodenectomy were included. No study reported survival data after detection of LNM and aborted surgical exploration. In 110 patients with hepatic-artery LNM, median survival ranged between 7 and 17 months. Estimated pooled mean survival in 84 patients with hepatic-artery LNM was 15 [95%CI 12-18] months (13 months in PDAC), compared to 19 [16-22] months in 270 patients with N1-disease without hepatic-artery LNM (p = 0.020). In 192 patients with para-aortic LNM, median survival ranged between 5 and 32 months. Estimated pooled mean survival in 169 patients with para-aortic LNM was 13 [8-17] months (11 months in PDAC), compared to 17 (6-27) months in 506 patients with N1-disease without para-aortic LNM (p < 0.001). Data on the impact of (neo)adjuvant therapy on survival were lacking.

CONCLUSION

Survival after pancreatoduodenectomy in patients with intra-operatively detected hepatic-artery and especially para-aortic LNM is inferior to patients undergoing pancreatoduodenectomy with other N1 disease. It remains unclear what the consequence of this should be since data on (neo-)adjuvant therapy and survival after aborted exploration are lacking.

Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct

PURPOSE

We performed three-dimensional (3D) surgical simulation of pancreatic surgery, including the size and location of the main pancreatic duct on the resected pancreatic surface.

METHODS

The subjects of this retrospective analysis were 162 patients who underwent pancreatic surgery. This cohort was sequentially divided into a "without-3D" group (n = 81) and a "with-3D" group (n = 81). We compared the pancreatic duct diameter and its location, using nine sections in a grid pattern, with the intraoperative findings. The perioperative outcomes were also compared between patients who underwent pancreaticoduodenectomy (PD) and those who underwent distal pancreatectomy (DP).

RESULTS

There were no significant differences in the main pancreatic duct diameter between the 3D-simulated values and the operative findings. The 3D-simulated main pancreatic duct location was consistent with its actual location in 80 % of patients (65/81). In comparing the PD and DP groups, the intraoperative blood loss was 1174 ± 867 and 817 ± 925 ml in the without-3D group, and 828 ± 739 and 307 ± 192 ml in the with-3D group, respectively (p = 0.024, 0.026).

CONCLUSION

The 3D surgical simulation provided useful information to promote our understanding of the pancreatic anatomy, including details on the size and location of the main pancreatic duct.

The Results of Pancreatic Resections and Long-Term Survival for Pancreatic Ductal Adenocarcinoma: A Single-Institution Experience

OBJECTIVES

Since the early 1990s, low long-term survival rates following pancreatic surgery for pancreatic ductal adenocarcinoma have challenged us to improve treatment. In this series, we aim to show improved survival from pancreatic ductal adenocarcinoma during the era of centralized pancreatic surgery.

METHODS

Analysis of all pancreatic resections performed at Helsinki University Hospital and survival of pancreatic ductal adenocarcinoma patients during 2000-2013 were included. Post-operative complications such as fistulas, reoperations, and mortality rates were recorded. Patient and tumor characteristics were compared with survival data.

RESULTS

Of the 853 patients undergoing pancreatic surgery, 581 (68%) were pancreaticoduodenectomies, 195 (21%) distal resections, 28 (3%) total pancreatectomies, and 49 (6%) other procedures. Mortality after pancreaticoduodenectomy was 2.1%. The clinically relevant B/C fistula rate was 7% after pancreaticoduodenectomy and 13% after distal resection, and the re-operation rate was 5%. The 5- and 10-year survival rates for pancreatic ductal adenocarcinoma were 22% and 14%; for T1-2, N0 and R0 tumors, the corresponding survival rates were 49% and 31%. Carbohydrate antigen 19-9 >75 kU/L, carcinoembryonic antigen >5 µg/L, N1, lymph-node ratio >20%, R1, and lack of adjuvant therapy were independent risk factors for decreased survival.

CONCLUSION

After centralization of pancreatic surgery in southern Finland, we have managed to enable pancreatic ductal adenocarcinoma patients to survive markedly longer than in the early 1990s. Based on a 1.7-million population in our clinic, mortality rates are equal to those of other high-volume centers and long-term survival rates for pancreatic ductal adenocarcinoma have now risen to some of the highest reported.

Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer

BACKGROUND

Durable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer.

METHODS

Seventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program.

RESULTS

Standardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005).

CONCLUSIONS

Standardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.

The prognostic impact of para-aortic lymph node metastasis in pancreatic cancer: A systematic review and meta-analysis

PURPOSE

To evaluate by a meta-analytic approach the long-term prognostic impact of para-aortic lymph node (PALN) involvement in resected ductal adenocarcinoma of the pancreas.

METHODS

MEDLINE, Embase, PubMed and the Cochrane Library were searched from January 1990 to June 2015. Trials reporting Kaplan-Meier curves and comparing overall long-term survival of negative and metastatic PALN in patients who underwent resection for pancreatic cancer were included. Lymph nodes were classified according to the Japan Pancreatic Society rules and identified using hematoxylin and eosin staining. Hazard ratios (HRs) and 95%CI were estimated for each trial and pooled in a meta-analysis.

RESULTS

Thirteen eligible studies including 2141 patients (364 positive PALN; 1777 negative PALN) were identified. Most of the studies were retrospective. Heterogeneity among trials was high (I(2) = 98.7%; p < .001). PALN metastasis was associated with increased mortality when compared with patients with negative PALN regardless regional nodal status [HR 1.85, 95%CI 1.48-2.31; p < .001]. Median survival was significantly decreased in patients with positive PALN (WMD = -4.92 months 95%CI -6.40; -3.43; p < .001). Moreover, metastatic PALN affected mortality also when regional lymph nodes were positive [HR 1.67, 95%CI 1.34-2.08; p < .001]. No publication bias was detected.

CONCLUSIONS

PALN metastasis appears to correlate with poor prognosis in patients with pancreatic adenocarcinoma. The assessment of PALN status may be considered for a more accurate staging of the disease and appropriated subgroup survival reporting. However, the definitive avoidance of the resection in case of intraoperative metastatic PALN needs further investigation.

Systemic Review of the Feasibility and Advantage of Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined.

METHODS

A systematic literature search was performed using the Embase, Medline, and PubMed databases to identify all studies published up to March 2015. Articles written in English containing the keywords: "pancreaticoduodenectomy" or "Whipple operation" combined with "laparoscopy," "laparoscopic," "robotic," "da vinci," or "minimally invasive surgery" were selected. Furthermore, to increase the power of evidence, articles describing more than ten MIPDs were selected for this review.

RESULTS

Twenty-six articles matched the review criteria. A total of 780 LPDs and 248 RPDs were included in the current review. The overall conversion rate to open surgery was 9.1 %. The weighted average operative time was 422.6 min, and the weighted average blood loss was 321.1 mL. The weighted average number of harvested lymph nodes was 17.1, and the rate of microscopically positive tumor margins was 8.4 %. The cumulative morbidity was 35.9 %, and a pancreatic fistula was reported in 17.0 % of cases. The average length of hospital stay was 12.4 days, and the mortality rate was 2.2 %.

CONCLUSIONS

In conclusion, after reviewing one-thousand cases in the current literature, we conclude that MIPD offers a good perioperative, postoperative, and oncologic outcome. MIPD is feasible and safe in well-selected patients.