Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality

Current surgical management of pancreatic cancer

En bloc resection is the treatment of choice for localized pancreatic cancer. While the perioperative mortality associated with resection is low, it still carries a significant morbidity rate of up to 50% in certain high-risk subsets of patients. With advances in perioperative care, radical resection with inclusion of adjacent vascular structure to achieve negative margin status can be performed with comparable mortality and morbidity in high-volume centers. Early results with the use of minimally invasive technique in pancreatic surgery are promising. Recent data on perioperative care to decrease morbidity with pancreatic surgery will also be discussed.

Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial

BACKGROUND

The value of pancreatoduodenectomy (PD) with extended lymphadenectomy for pancreatic cancer has been evaluated by many retrospective studies and 3 randomized controlled trials (RCT). However, the protocols used and the results found in the 3 RCTs were diverse. Therefore, a multicenter RCT was proposed in 1998 to evaluate the primary end point of long-term survival and the secondary end points of morbidity, mortality and quality of life of patients undergoing standard versus extended lymphadenectomy in radical PD for pancreatic cancer.

METHODS

From March 2000 to May 2003, 112 patients with potentially curable pancreatic head cancer were enrolled and intraoperatively randomized to a standard or extended lymphadenectomy group. No resected patients received any adjuvant treatments.

RESULTS

A hundred and one eligible patients were analyzed. Demographic and histopathological characteristics of the two groups were similar. The mean operating time, intraoperative blood loss and number of retrieved lymph nodes were greater in the extended group, but the other operative results were comparable.

CONCLUSIONS

Although this multicenter RCT was conducted in a strict setting, extended lymphadenectomy in radical PD did not benefit long-term survival in patients with resectable pancreatic head cancer and led to levels of morbidity, mortality and quality of life comparable to those found after standard lymphadenectomy.

TRAIL-engineered pancreas-derived mesenchymal stem cells: characterization and cytotoxic effects on pancreatic cancer cells

Mesenchymal stem cells (MSCs) have attracted great interest in cancer therapy owing to their tumor-oriented homing capacity and the feasibility of autologous transplantation. Currently, pancreatic cancer patients face a very poor prognosis, primarily due to the lack of therapeutic strategies with an effective degree of specificity. Anticancer gene-engineered MSCs specifically target tumor sites and can produce anticancer agents locally and constantly. This study was performed to characterize pancreas-derived MSCs and investigate the effects of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-engineered MSCs on pancreatic cancer cells under different culture conditions. Pancreas-derived MSCs exhibited positive expression on CD44, CD73, CD95, CD105, negative on CD34 and differentiated into adipogenic and osteogenic cells. TRAIL expression was assessed by both enzyme-linked immunosorbent assay and western blot analysis. Different patterns of TRAIL receptor expression were observed on the pancreatic cancer cell lines, including PANC1, HP62, ASPC1, TRM6 and BXPC3. Cell viability was assessed using a real-time monitoring system. Pancreatic cancer cell death was proportionally related to conditioned media from MSC(nsTRAIL) and MSC(stTRAIL). The results suggest that MSCs exhibit intrinsic inhibition of pancreatic cancer cells and that this effect can be potentiated by TRAIL-transfection on death receptor-bearing cell types.

Sentinel lymph node mapping in tumors of the pancreatic body: preliminary report

Aim of the study

Actual lymphatic drainage of pancreatic body neoplasms and the proper extent of lymphadenectomy remain unknown. The aim of the study was to define the exact lymphatic draining pattern using the dye mapping method.

Material and methods

The study enrolled patients who were operated on for tumor of the pancreatic body in the Department of General and Transplant Surgery of the Medical University of Lodz during 2010, with injection of 1 ml of blue dye (Patent Blue, Guerbet) in the centre of the neoplasm and sentinel node identification. Radical surgical management included distal pancreatectomy, whereas gastrojejunal or triple bypass anastomoses were performed in irresectable cases.

Results

The study group consisted of 13 patients with locally advanced tumors of the pancreatic body (T3 and T4, mean tumor size 4.9 cm). Lymphatic mapping was able to identify sentinel nodes in 5 of 13 cases (38.46%). A sentinel node was found in station 11p (3 cases) and 9 (1 case). Skip metastasis to the left gastric artery node (group 7) was noted. All identified sentinel nodes were metastatic; tumor deposits were confirmed in non-sentinel nodes as well.

Conclusions

In advanced pancreatic body tumors feasibility of sentinel node navigation is considerably restricted. Further studies in smaller tumors using optimized newer markers may define the exact lymphatic draining pattern.