Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer

Extended lymphadenectomy based on the TRIANGLE for pancreatic head cancer: a single-center experience

BACKGROUND

This study was to compare the safety and efficacy of different lymphadenectomy methods in patients with pancreatic head cancer undergoing pancreaticoduodenectomy (PD).

MATERIAL AND METHODS

A total of 150 patients were included in this study. Patients were divided into Group A (n = 79), Group B (n = 44), and Group C (n = 27) according to the different lymphadenectomy methods. The clinical endpoint was time to progression (TTP) and overall survival (OS). Postoperative complications of different lymphadenectomy methods were compared respectively. TTP and OS of the three groups were compared by Kaplan-Meier curves.

RESULTS

There were no significant differences between the three groups in operative time (P = 0.300), death in the hospital (P = 0.253), postoperative hemorrhage (P = 0.863), postoperative pancreatic fistula (POPF) B/C (P = 0.306), bile leakage (P = 0.215), intestinal fistula (P = 0.177), lymphatic leakage (P = 0.267), delayed gastric emptying [(DGE) (P = 0.283)], ICU stay (P = 0.506), and postoperative hospital stay [(PHS) (P = 0.810)]. Median TTP in Groups B and C was significantly longer than in Group A (log-rank test, A vs B: P = 0.0005, A vs C: P = 0.0001). Median OS between the three groups has no statistical difference (P = 0.1546).

CONCLUSIONS

Extended lymphadenectomy methods based on the TRIANGLE do not increase perioperative complications significantly and can effectively delay tumor progression in patients with pancreatic head cancer.

Pancreatic carcinosarcoma: An orthogonal analysis

BACKGROUND

Pancreatic carcinosarcoma is a rare subtype of pancreatic cancer. There are no consensus guidelines regarding its treatment. The current study is an orthogonal analysis of multiple datasets to evaluate prognostic features.

METHODS

A modified Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 systematic review was performed for reported cases of pancreatic carcinosarcoma. All cases of pancreatic carcinosarcoma in the National Cancer Database were identified for analysis. Analyses were compared to previously published data from the Surveillance, Epidemiology, and End Results database to increase validity.

RESULTS

Seventy-one cases of pancreatic carcinosarcoma were reported in the literature. Reports of pancreatic carcinosarcoma increased over time (P = .0075). Tumor size >5.0 cm, metastatic disease, and relapse were associated with decreased disease-specific survival (all log-rank P < .05). Ninety-nine cases of pancreatic carcinosarcoma were analyzed within the National Cancer Database. Pancreatic carcinosarcoma incidence increased over time (P = .0371). Resection + chemotherapy, pathologic lymph node examination, and treatment at an academic center were associated with improved overall survival (all log-rank P < .05), whereas harboring ≥2 positive lymph nodes was associated with decreased overall survival (log-rank P = .0171). Within a multivariable model adjusting for age, sex, comorbid disease, and disease stage, resection + chemotherapy was associated with a decreased hazard of death (hazard ratio .036; confidence Interval .004-.298; P = .0022). Published data from the Surveillance, Epidemiology, and End Results database supported the current analysis regarding the incidence of pancreatic carcinosarcoma, resection, lymph node evaluation, and the impact of metastatic disease.

CONCLUSION

Pancreatic carcinosarcoma is exceedingly rare, with a poor prognosis. Long-term survival is possible with curative resection in the absence of relapse. The number of positive lymph nodes appears to impact prognosis.

Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress

Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.

Surgery

This chapter provides a comprehensive background from basic to applied knowledge of surgical anatomy which is necessary for the surgical treatment of cholangiocarcinoma (CCA) patients. Significant advances that have been made in the surgical treatment of CCA were examined. For instance, in-depth details are provided for appropriate preoperative assessment and treatment to optimize patient status and to improve the outcome of surgical treatment(s). Comprehensive details are provided for the surgical techniques and outcomes of treatments for each type of CCA with clear illustrations and images. This chapter also describes the role of minimally invasive surgery and liver transplantation in CCA treatment.

Clinical value of extended lymphadenectomy in radical surgery for pancreatic head carcinoma at different T stages

BACKGROUND

As the lymph-node metastasis rate and sites vary among pancreatic head carcinomas (PHCs) of different T stages, selective extended lymphadenectomy (ELD) performance may improve the prognosis of patients with PHC.

AIM

To investigate the effect of ELD on the long-term prognosis of patients with PHC of different T stages.

METHODS

We analyzed data from 216 patients with PHC who underwent surgery at our hospital between January 2011 and December 2021. The patients were divided into extended and standard lymphadenectomy (SLD) groups according to extent of lymphadenectomy and into T1, T2, and T3 groups according to the 8^th edition of the American Joint Committee on Cancer’s staging system. Perioperative data and prognoses were compared among groups. Risk factors associated with prognoses were identified through univariate and multivariate analyses.

RESULTS

The 1-, 2- and 3-year overall survival (OS) rates in the extended and SLD groups were 69.0%, 39.5%, and 26.8% and 55.1%, 32.6%, and 22.1%, respectively (P = 0.073). The 1-, 2- and 3-year disease-free survival rates in the extended and SLD groups of patients with stage-T3 PHC were 50.3%, 25.1%, and 15.1% and 22.1%, 1.7%, and 0%, respectively (P = 0.025); the corresponding OS rates were 65.3%, 38.1%, and 21.8% and 36.1%, 7.5%, and 0%, respectively (P = 0.073). Multivariate analysis indicated that portal vein invasion and lymphadenectomy extent were risk factors for prognosis in patients with stage-T3 PHC.

CONCLUSION

ELD may improve the prognosis of patients with stage-T3 PHC and may be of benefit if performed selectively.

Dynamics Changes of Solids Gastric Emptying Post -Pancreaticoduodenectomy

BACKGROUND: Gastric emptying (GE) is one of the common post-operative complications after pancreaticoduodenectomy (PD). Multiple factors have been involved in this complication. Dynamic studies such as GE scintigraphy (GES) have informed us about changes in the behavior of the stomach before and after the operation. AIM: The objective of this study is a short-term scintigraphic evaluation of GE in post-PD patients for solid food before (baseline) and after the operation for 30 days. METHODS: Between April 2016 and September 2019, 30 patients who underwent PD were investigated for the effect on GE of solids. GE scan GES was performed for the evaluation of solids in GE on pre-operative and post-operative day 30. The operative time, blood loss, the specimens’ pathology and resection margins, the interpretation of the GES study, and finally the hospital course data were all gathered and subjected to statistical analysis. RESULTS: Nineteen patients developed delayed GE (DGE) while four developed rapid GE or dumping. The type of pancreatic reconstruction affected the GE dynamics. DGE was evident in all cases with pancreaticogastrostomy (PG), while it was observed only in 4 patients of 15 with pancreaticojejunostomy (PJ). Seven cases developed a post-operative pancreatic fistula (POPF), 3 after PG versus 4 after PJ, and were all successfully managed conservatively. CONCLUSION: The reconstruction method of the remnant pancreas could affect the dynamics of GE. The DGE to solids was witnessed more in cases reconstructed by PG and less in cases with PJ. Post-operative complications associated, such as POPF, are factors associated with DGE.

Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer

BACKGROUND

Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis.

METHODS

The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis.

RESULTS

The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254).

CONCLUSIONS

Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.

The TRIANGLE operation for pancreatic head and body cancers: early postoperative outcomes

BACKGROUND

Surgical resection is the mainstay of potential cure for patients with pancreatic cancer, however, local recurrence is frequent. Previously, we have described an extended resection technique for pancreatoduodenectomy aiming at a radical resection of the nerve and lymphatic tissue between celiac artery, superior mesenteric artery and mesenteric-portal axis (TRIANGLE operation). Until now, data on postoperative outcome have not been reported, yet.

METHODS

Patients who underwent either partial (PD) or total pancreatoduodenectomy (TP) applying the TRIANGLE procedure were identified. These cohorts were compared to matched historic cohorts with standard resections.

RESULTS

Overall, 330 patients were analysed (PD_TRIANGLE and PD_STANDARD, each n = 108; TP_TRIANGLE and TP_STANDARD, each n = 57). More lymph nodes were harvested in TRIANGLE compared to standard resection (PD: 27.5 (21-35) versus 31.5 (24-40); P = 0.0187, TP: 33 (28-49) versus 44 (29-53); P = 0.3174) and the rate of tumour positive resections margins, R1(direct), dropped. Duration of operation was significantly longer and blood loss higher. Postoperative mortality and complications did not differ significantly.

CONCLUSION

Pancreatoduodenectomy according to the TRIANGLE protocol can be performed without increased morbidity and mortality at a high-volume centre. Long-term survival and quality of life need to be investigated in prospective clinical trials with adequate sample size.

Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.

Radiomics nomogram for the preoperative prediction of lymph node metastasis in pancreatic ductal adenocarcinoma

PURPOSE

To develop and validate a radiomics nomogram for the preoperative prediction of lymph node (LN) metastasis in pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

In this retrospective study, 225 patients with surgically resected, pathologically confirmed PDAC underwent multislice computed tomography (MSCT) between January 2014 and January 2017. Radiomics features were extracted from arterial CT scans. The least absolute shrinkage and selection operator method was used to select the features. Multivariable logistic regression analysis was used to develop the predictive model, and a radiomics nomogram was built and internally validated in 45 consecutive patients with PDAC between February 2017 and December 2017. The performance of the nomogram was assessed in the training and validation cohort. Finally, the clinical usefulness of the nomogram was estimated using decision curve analysis (DCA).

RESULTS

The radiomics signature, which consisted of 13 selected features of the arterial phase, was significantly associated with LN status (p < 0.05) in both the training and validation cohorts. The multivariable logistic regression model included the radiomics signature and CT-reported LN status. The individualized prediction nomogram showed good discrimination in the training cohort [area under the curve (AUC), 0.75; 95% confidence interval (CI), 0.68-0.82] and in the validation cohort (AUC, 0.81; 95% CI, 0.69-0.94) and good calibration. DCA demonstrated that the radiomics nomogram was clinically useful.

CONCLUSIONS

The presented radiomics nomogram that incorporates the radiomics signature and CT-reported LN status is a noninvasive, preoperative prediction tool with favorable predictive accuracy for LN metastasis in patients with PDAC.

Extended lymphadenectomy benefits patients with borderline resectable pancreatic head cancer-a single-center retrospective study

Background

Whether standard lymphadenectomy or extended lymphadenectomy should be performed is still under debate during pancreaticoduodenectomy (PD). We aimed to compare their morbidity and mortality rates among patients with pancreatic head cancer (PHC).

Methods

In this retrospective study, a total of 322 patients were enrolled. According to the scope of intraoperative lymph node dissection, patients were divided into extended lymphadenectomy group (n=120) and standard lymphadenectomy group (n=202). Based on the resectability of the tumor, there were 198 cases of resectable PHC and 124 cases of borderline resectable PHC, respectively, in which further stratified analysis was carried out according to the extent of lymph node dissection.

Results

All patients completed the operation successfully, with a perioperative morbidity rate of 27.9% and mortality rate of 0.9%. As for the overall patients, patients in the extended lymphadenectomy group had higher neutrophil-to-lymphocyte ratio (NLR), longer operation time, more intraoperative blood loss, lymph node dissection and patients with borderline resectable pancreatic head cancer (BRPHC) (P<0.05). The 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 71.9%, 50.6%, 30.0% and 70.0%, 32.9%, 21.5%, respectively (P=0.068). With regards to patients with BRPHC, the number of lymph node dissection in the extended lymphadenectomy group was more (P<0.05), and the 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 60.7%, 43.3%, 27.4% and 43.2%, 17.7%, 17.7%, respectively (P=0.007).

Conclusions

Patients with BRPHC tended to have vast lymph node metastasis. Extended lymphadenectomy can improve their long-term survival.

Surgery for pancreatic cancer: current controversies and challenges

Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.

Open irreversible electroporation for isolated local recurrence of pancreatic ductal adenocarcinoma after primary surgery

BACKGROUND/OBJECTIVES

Irreversible electroporation (IRE) is an emerging treatment for locally advanced pancreatic cancer (LAPC) which in some cohorts has been associated with severe complications. Additionally, re-resection of isolated local recurrence (ILR) after pancreatic ductal adenocarcinoma (PDAC) can improve survival. We investigated safety, feasibility and oncologic outcomes in the first report on open IRE for unresectable ILR of PDAC in a staged surgical approach.

METHODS

Records of the prospectively documented institutional database were screened for patients undergoing laparotomy in IRE-standby due to questionable resectability. Endpoints were morbidity, mortality and overall (OS) and progression free survival (PFS). Data of LAPC and ILR were compared statistically for safety and feasibility analysis.

RESULTS

Intraoperative IRE was performed in 11 ILR and 14 LAPC. Six (54.5%) ILR and 10 (71.4%) LAPC patients had postoperative complications, type and frequency did not differ significantly. Major complications occurred in one ILR and two LAPC patients. Median OS was 20.0 months (95% CI: 2.7-37.3) after IRE for ILR and 28 (17.4-38.6) for LAPC. Median PFS after IRE was seven months for both ILR (4.1-9.9; n = 9) and LAPC (2.3-11.7; n = 13).

CONCLUSION

Open IRE for unresectable ILR was associated with acceptable perioperative risk. In this small, highly selected subset of patients with limited therapeutic options ancillary treatment with IRE might improve survival. Randomized treatment studies are required to establish the definitive role of IRE as compared to palliative standards of care in unresectable recurrence of PDAC and inconvertible LAPC.

Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.

Cohort study of the overall survival of patients with pancreatic cancer in a hospital of specialties of Quito-Ecuador in the period 2007–2017

Objectives

Pancreatic cancers in most patients in Ecuador are diagnosed at an advanced stage of the disease, which is associated with lower survival. To determine the characteristics and global survival of pancreatic cancer patients in a social security hospital in Ecuador between 2007 and 2017.

Methods

A retrospective cohort study and a survival analysis were performed using all the available data in the electronic clinical records of patients with a diagnosis of pancreatic cancer in a Hospital of Specialties of Quito-Ecuador between 2007 and 2017. The included patients were those coded according to the ICD 10 between C25.0 and C25.9. Our univariate analysis calculated frequencies, measures of central tendency and dispersion. Through the Kaplan-Meier method we estimated the median time of survival and analyzed the difference in survival time among the different categories of our included variables. These differences were shown through the log rank test.

Results

A total of 357 patients diagnosed with pancreatic cancer between 2007 and 2017 were included in the study. More than two-thirds (69.9%) of the patients were diagnosed in late stages of the disease. The median survival time for all patients was of 4 months (P25: 2, P75: 8).

Conclusions

The statistically significant difference of survival time between types of treatment is the most relevant finding in this study, when comparing to all other types of treatments.

Predictive factors for long-term survival after surgery for pancreatic ductal adenocarcinoma: Making a case for standardized reporting of the resection margin using certified cancer center data

Factors for overall survival after pancreatic ductal adenocarcinoma (PDAC) seem to be nodal status, chemotherapy administration, UICC staging, and resection margin. However, there is no consensus on the definition for tumor free resection margin. Therefore, univariate OS as well as multivariate long-term survival using cancer center data was analyzed with regards to two different resection margin definitions. Ninety-five patients met inclusion criteria (pancreatic head PDAC, R0/R1, no 30 days mortality). OS was analyzed in univariate analysis with respect to R-status, CRM (circumferential resection margin; positive: ≤1mm; negative: >1mm), nodal status, and chemotherapy administration. Long-term survival >36 months was modelled using multivariate logistic regression instead of Cox regression because the distribution function of the dependent data violated the requirements for the application of this test. Significant differences in OS were found regarding the R status (Median OS and 95%CI for R0: 29.8 months, 22.3–37.4; R1: 15.9 months, 9.2–22.7; p = 0.005), nodal status (pN0 = 34.7, 10.4–59.0; pN1 = 17.1, 11.5–22.8; p = 0.003), and chemotherapy (with CTx: 26.7, 20.4–33.0; without CTx: 9.7, 5.2–14.1; p < .001). OS according to CRM status differed on a clinically relevant level by about 12 months (CRM positive: 17.2 months, 11.5–23.0; CRM negative: 29.8 months, 18.6–41.1; p = 0.126). A multivariate model containing chemotherapy, nodal status, and CRM explained long-term survival (p = 0.008; correct prediction >70%). Chemotherapy, nodal status and resection margin according to UICC R status are univariate factors for OS after PDAC. In contrast, long-term survival seems to depend on wider resection margins than those used in UICC R classification. Therefore, standardized histopathological reporting (including resection margin size) should be agreed upon.

Survival impact on triple-modal strategy comprising hyperthermia, external radiation, and chemotherapy for unresectable locally advanced (UR-LA) pancreatic ductal adenocarcinoma

BACKGROUND

Present treatment strategy for unresectable locally advanced (UR-LA) pancreatic ductal adenocarcinoma (PDAC) patients is controversial. Hence, a triple-modal therapy, which is a multidisciplinary strategy, was designed for patients with UR-LA PDAC by adding hyperthermia to conventional chemoradiotherapy at our institution. In this study we aimed to evaluate the effectiveness of this strategy.

METHODS

Data of 21 UR-LA PDAC patients who underwent the triple-modal treatment were retrospectively analyzed for evaluating the safety and oncological effect of the treatment. The treatment schedule included, five concurrent infusions of gemcitabine (800 mg/m²) followed by hyperthermia (1 h) and X-ray (2 Gy) or proton beam radiation (2.7 Gy) on days 1, 8, 15, 29, and 36. Additional radiotherapies applied a total dose of 50 Gy/25 fr for X-ray radiation or 67.5 Gy/25 fr for proton beam radiation.

RESULTS

Median overall survival (OS) was 23.6 months. Conversion surgery was performed in 5 patients (23.8%), and a R0 margin could be achieved in 4 of them; however, their median OS (16.3 months) tended to be shorter than that of the patients who did not undergo resection (23.6 months, p = 0.562). Further, the median OS of patients who underwent proton beam radiation (28.0 months) was significantly longer than that of patients who underwent X-ray radiation (13.9 months, p = 0.045). Most adverse events were manageable, except for one grade 3 gastric ulcer. The median tumor size and marker reduction rates were -17% and -91%, respectively. The tumor responses were partial response, stable disease, and progressive disease in 3, 15, and 3 patients, respectively.

CONCLUSION

Triple-modal strategy, especially when combined with proton beam radiation, is feasible and results in favorable survival outcomes in patients with UR-LA PDAC.

Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma

BACKGROUND

Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins.

OBJECTIVES

To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes.

MAIN RESULTS

We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.

Optimal Range of Lymphadenectomy in Pathological Stage T1 and T2 Esophageal Squamous Cell Carcinoma

BACKGROUND

Lymph node metastasis is a primary contributor to tumor progression in esophageal squamous cell carcinoma (ESCC), and the optimal extent of lymphadenectomy during esophagectomy remains controversial. This study aimed to investigate the appropriate number of lymph nodes to be dissected in pT1-2Nany stage ESCC to achieve the best prognosis and avoid missing positive lymph nodes (PLNs).

METHODS

A total of 497 patients with pT1 to pT2 esophageal cancer from two institutions were retrospectively analyzed and their surgical and pathological records were critically reviewed. Stepwise analyses were conducted by calculating a serial of hazard ratios and odd ratios to determine the optimal range of lymphadenectomy for overall survival (OS).

RESULTS

The best survival outcome can be obtained when the number of lymph node examined (NLNE) is 10-18 in pT1N0 ESCC, while the NLNE should exceed 24 in pT2N0 diseases. In patients with pT1-2Nany and pT2Nany ESCC, resection of 15-25 and 24-37 lymph nodes, respectively, could provide significant added value for identifying positive nodal metastasis. When the NLNE exceeds this appropriate range, resection of extra lymph node is not helpful to improve the probability of finding PLNs.

CONCLUSIONS

For ESCC patients undergoing radical esophagectomy, the optimal extent of lymphadenectomy is 15-25 for pT1Nany disease and 24-37 for pT2Nany disease.

Complete Lymphadenectomy Around the Entire Superior Mesenteric Artery Improves Survival in Artery-First Approach Pancreatoduodenectomy for T3 Pancreatic Ductal Adenocarcinoma

BACKGROUND

Artery-first approach pancreatoduodenectomy (AFA-PD) is an important technique for treating pancreatic ductal adenocarcinoma (PDAC). However, it remains unknown whether performing complete lymphadenectomy around the entire superior mesenteric artery (SMA) is associated with better outcomes. In this retrospective study, we aimed to investigate whether this approach improved overall and recurrence-free survival in patients with PDAC.

METHODS

We identified 88 patients with T3 PDAC who underwent PD at St. Marianna University School of Medicine, Kawasaki, Japan, between April 2005 and October 2017. Two groups were defined: an "AFA-PD group" (n = 45) who had undergone AFA-PD in addition to complete lymphadenectomy around the entire SMA, and a "conventional PD group" (n = 43) in whom complete lymphadenectomy had not been performed (conventional group). Univariate and multivariate survival analyses were performed to identify risk factors for overall and disease-free survival.

RESULTS

The AFA-PD group had a longer median survival time (40.3 vs. 22.6 months; p = 0.0140) and a higher 5-year survival rate (40.3% vs. 5.9%, p = 0.005) than the conventional PD group. Multivariate analysis showed that AFA-PD with complete lymphadenectomy around the entire SMA was an independent factor for improved overall survival (p = 0.022). Recurrences around the SMA were significantly less frequent in the AFA-PD group than in the conventional group (22.2% vs. 44.2%, p = 0.041).

CONCLUSIONS

AFA-PD with complete lymphadenectomy around the entire SMA can prevent recurrences around the SMA and may prolong overall survival in patients with PDAC.

Periarterial divestment in pancreatic cancer surgery

BACKGROUND

Modern pancreatic cancer surgery changed with the introduction of effective neoadjuvant therapies. Complete tumor resection is the mainstay for long-term, disease-free, and overall survival and has been a prerequisite for decreasing local recurrence. The medial resection margin in the area of the superior mesenteric vessels limits the radicalness of the resection, especially in borderline and locally advanced cases. Therefore, the periarterial soft tissue around the peripancreatic visceral arteries must be completely cleared. This procedure, namely periarterial divestment, is technically demanding but often represents an alternative to arterial resection.

OBJECTIVE

Here we describe the technique and our initial experience with periarterial divestment along the peripancreatic visceral arteries during pancreatic surgery. This technique, in combination with previously published resection strategies, such as artery first maneuver and mesenterico-portal venous bypass first, enables tumor resection in locally advanced pancreatic cancer.

CONCLUSION

Periarterial divestment can prevent the need for arterial resection in borderline and locally advanced pancreatic cancer, especially after neoadjuvant therapy. The feasibility, improved safety, and oncologic equivalence of arterial divestment versus arterial resection for pancreatic cancer surgery must be evaluated by clinical trials.

Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy

BACKGROUND

There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy.

METHODS

Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared.

RESULTS

There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage.

CONCLUSION

Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.

The Necessity of Dissection of No. 14 Lymph Nodes to Patients With Pancreatic Ductal Adenocarcinoma Based on the Embryonic Development of the Head of the Pancreas

Objectives: Pancreaticoduodenectomy (PD) followed by lymphadenectomy is performed for patients with pancreatic ductal adenocarcinoma (PDAC) located in the head of the pancreas. Because the head of the pancreas could be divided into dorsal or ventral primordium in relation to embryonic development, the metastasis of lymph node (LN) may differ. In this retrospective study, we evaluated the impact of extended or standard LN dissection for PDAC located in ventral or dorsal primordia of the pancreatic head.

Methods: From February 2016 to November 2018, 178 patients who underwent PD for PDAC were enrolled at the Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University. According to the tumor location and the range of LN dissection, all patients were divided into three groups: ventral primordium with extended lymphadenectomy (VE group), ventral primordium with standard lymphadenectomy (VS group), and dorsal primordium with extended lymphadenectomy (DE group). Clinical and pathological features were retrospectively analyzed as were the long-term survival outcomes.

Results: More patients in the VE group were detected with metastasis in the lymph nodes around the superior mesenteric artery (LN14) than those in the DE group (LN along the right side of the superior mesenteric artery, LN14ab): 22.9 vs. 5.9%, p = 0.005; (LN along the left side of the superior mesenteric artery, LN14cd): 10.0 vs. 0.0%, p = 0.022. LN14 was involved in more patients in the VE group than in the VS group (22.9 vs. 5.0%, p = 0.015). For IIb-stage patients in the VE group, the overall survival time (18.3 vs. 9.3 months, p < 0.001) and disease-free survival time (12.2 vs. 5.1 months, p = 0.045) were longer in those with LN14cd (–) than those with LN14cd (+).

Conclusion: This study suggested that patients with PDAC located in the ventral head of the pancreas had higher risk of LN14 involvement compared with those at dorsal. Thus, a thorough dissection of LN14 in PDAC located in the ventral head of the pancreas is recommended to optimize the regional extended lymphadenectomy.

White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.

Induction chemotherapy in pancreatic cancer: CA 19-9 may predict resectability and survival

BACKGROUND

Preoperative/Neoadjuvant treatment (NT) is increasingly used in unresectable pancreatic cancer (PDAC). However, ∼40% of patients cannot be resected after NT and reliable preoperative response evaluation is currently lacking. We investigated CA 19-9 levels and their dynamics during NT for prediction of resectability and survival.

METHODS

We screened our institution's database for patients who underwent exploration or resection after NT with gemcitabine-based therapy (GEM) or FOLFIRINOX (FOL). Pre- and post-NT CA 19-9, resection rate and survival were analyzed.

RESULTS

Of 318 patients 165 (51.9%) were resected and 153 (48.1%) received exploration. In the FOL group (n = 103; 32.4%), a post-NT CA 19-9 cutoff at 91.8 U/ml had a sensitivity of 75.0% and a specificity of 76.9% for completing resection with an AUC of 0.783 in the ROC analysis (95% CI: 0.692-0.874; p < 0.001. PPV: 84.2%, NPV: 65.2%). Resected patients above the cutoff did not benefit from resection. Post-NT CA 19-9 <91.8 U/ml (OR 11.63, p < 0.001) and CA 19-9 ratio of <0.4 (OR 5.77, p = 0.001) were independent predictors for resectability in FOL patients.

DISCUSSION

CA 19-9 levels after neoadjuvant treatment with FOLFIRINOX predict resectability and survival of PDAC more accurately than dynamic values and should be incorporated into response evaluation and surgical decision-making.

Efficacy of extended versus standard lymphadenectomy in pancreatoduodenectomy for pancreatic head adenocarcinoma. An update meta-analysis

BACKGROUND

Surgical resection is the only possible cure for pancreatic cancer, it remains controversial whether extend lymphadenectomy in pancreatoduodenectomy (EPD) is better than standard lymphadenectomy in pancreatoduodenectomy (SPD). The aim of this study was to compare the efficacy of EPD with SPD for pancreatic head adenocarcinoma.

METHODS

A specific search of online databases including PubMed, Web of Science, Embase, and Cochrane library was conducted from January 1990 to October 2018. Relative perioperative outcomes were synthesized. Single-arm meta-analysis was also performed.

RESULTS

A total of eight studies involving 687 (342 vs 345) patients were included for analysis in our study. The number of lymph nodes harvested [24.54 vs 13.29; weighted mean difference (WMD) -10.69, P = 0.000], operative time (469.84 min vs 354.85 min; WMD -99.09, P = 0.000), and diarrhea (postoperative three months) [45.1% vs 18.2%; odds radio (OR) 0.20, P = 0.014] were significantly higher in patients who underwent EPD than SPD. The perioperative complications (35% vs 28.8%; OR 0.79, P = 0.186), tumor size (3.27 cm vs 3.248 cm; WMD -0.11, P = 0.256), lymph node metastasis (66% vs 55.9%; OR 0.71, P = 0.105), and positive margin (10.4% vs 11.3%; OR 1.28, P = 0.392) were no significant differences between EPD group and SPD group. Extended lymphadenectomy in pancreatoduodenectomy dose not contribute to the overall survival of patients with adenocarcinoma of the pancreatic head [hazard ratio (HR) 0.95; 95% CI 0.78-1.15; P = 0.61].

CONCLUSION

The update meta-analysis shows that EPD failed to improve the overall survival, may even lead to increased morbidity.

Relationship Between Radiomics and Risk of Lymph Node Metastasis in Pancreatic Ductal Adenocarcinoma

OBJECTIVE

The objective of this study was to explore the exact relationship between the arterial radiomics score (rad-score) and lymph node (LN) metastasis in pancreatic ductal adenocarcinoma (PDAC).

METHODS

A total of 225 patients with pathologically confirmed PDAC who underwent multislice computed tomography within 1 month of resection from December 2016 to August 2017 were retrospectively studied. For each patient, 1029 radiomics features of arterial phase were extracted, which were reduced using the least absolute shrinkage and selection operator logistic regression algorithm. Multivariate logistic regression models were used to analyze the association between the arterial rad-score and LN metastasis.

RESULTS

Lymph node-negative and LN-positive patients accounted for 107 (47.56%) and 118 (52.44%) of the cohort, respectively. The rad-score, which consisted of 12 selected features of the arterial phase, was significantly associated with LN status (P < 0.05). Univariate analysis revealed that the arterial rad-score and T stage were independently and positively associated with risk of LN metastasis (P < 0.05). Multivariate analyses revealed a significant association between the arterial rad-score and the LN metastasis (P < 0.0001). Higher arterial rad-score was associated with LN metastasis (P for trend <0.0001).

CONCLUSIONS

The arterial rad-score is independently and positively associated with the risk of LN metastasis in PDAC.

Prognostic Significance of Lymph Node Metastasis and Micrometastasis Along the Left Side of Superior Mesenteric Artery in Pancreatic Head Cancer

BACKGROUNDS AND OBJECTIVES

Although metastasis in lymph nodes along the left side of superior mesenteric artery (SMA-LNs-lt) is sometimes found, survival benefit of SMA-LN-lt dissection for pancreatic head cancer is still unclear. The purpose of this study is to evaluate the prognostic significance of SMA-LN-lt metastasis and micrometastasis.

METHODS

A total of 166 patients with pancreatic head cancer who underwent pancreatectomy with lymphadenectomy including SMA-LNs-lt between 2002 and 2017 were reviewed retrospectively. Micrometastasis was evaluated by immunohistochemistry.

RESULTS

Twenty patients (12%) had SMA-LN-lt metastasis detected by hematoxylin and eosin (HE) staining, and eight patients (5%) had micrometastasis. Patients with SMA-LN-lt HE-positive or micrometastasis group experienced significantly shorter overall survival (OS) than those without (p = .015). In multivariate analysis, SMA-LN-lt HE-positive or micrometastasis (p = .034), portal vein resection (p = .002), histologic grade 2/3 (p = .046), LN metastasis (p = .002), and lack of adjuvant chemotherapy (p < .001) were independent risk factors. Within a subset of SMA-LN-lt HE-positive or micrometastasis group, lack of adjuvant chemotherapy (p = .003) was the independent poor prognostic factor.

CONCLUSIONS

In pancreatic head cancer, the rate of SMA-LN-lt HE-positive and micrometastasis was found in 12% and 5%, respectively. Adjuvant chemotherapy may contribute to improvement of prognosis in patients with LN metastasis including SMA-LN-lt metastasis and micrometastasis.

Management of chylous ascites following pancreaticobiliary surgery

Background

Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon.

Method

We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture.

Results

Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage.

Conclusion

Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.

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.

A single-arm, phase II trial of neoadjuvant gemcitabine and S1 in patients with resectable and borderline resectable pancreatic adenocarcinoma: PREP-01 study

BACKGROUND

Neoadjuvant chemotherapy (NAC) represents a promising alternative to pancreatic ductal adenocarcinoma (PDAC) planned resection, but the survival impact remains undefined. To assess the feasibility and survival outcomes of NAC with gemcitabine and S1 (GS) for PDAC planned resection by prospective study.

METHODS

Patients with resectable or borderline resectable PDAC received 2 cycles of NAC-GS and were offered curative resection followed by gemcitabine adjuvant. The primary endpoint was 2-year overall survival (OS). Adverse events during NAC, radiological and tumor marker responses, resection rate, and surgical safety were evaluated as secondary endpoints (UMIN000004148).

RESULTS

We enrolled 104 patients between 2010 and 2012, with 101 patients treated using NAC-GS as the full analysis set (FAS). Of the 101 patients, 88% received the planned 2 cycles of NAC. Grade 3 neutropenia was common (35%). Radiological partial response and decreased carbohydrate antigen 19-9 concentration (> 50% decrease) were noted in 13% and 41%, respectively. R0/1 resections with M0 were performed in 65 patients without surgical mortality. Of the 65 patients, 44 received planned gemcitabine adjuvant for 6 months as the on-protocol cohort. The primary endpoint for the 2-year OS rate was 55.9% in the FAS (n = 101) and 74.6% in the on-protocol cohort (n = 44).

CONCLUSIONS

NAC-GS was feasible and actively prolonged survival following PDAC planned resection. Randomized control trials are needed to further clarify the survival benefit of NAC-GS in addition to surgery followed by adjuvant therapy.

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.

Cervical or thoracic anastomosis for patients with cervicothoracic esophageal squamous cell carcinoma

Background

For cervical and higher-level esophageal tumors, the choice of cervical anastomosis or thoracic anastomosis is still controversial. The goal of this study was to explore the optimal surgical approach for cervicothoracic esophageal squamous tumors.

Methods

We retrospectively analyzed 3,802 consecutive patients with esophageal squamous cell tumors in Nanjing Drum Tower Hospital from Jan 2001 to Jan 2017. Twenty-six patients with cervical anastomosis and twenty-eight patients with thoracic anastomosis were evaluated.

Results

The cervical anastomosis group exhibited a greater number of resected lymph nodes (36.5±7.3 vs. 19.9±5.7, P<0.001). In addition, the cervical anastomosis group exhibited a higher recurrence rate (71.4% vs. 41.7%, P=0.047) and increased locoregional recurrence (P=0.040). Overall survival was not significantly different between groups (P=0.331). Moreover, multivariate Cox regression analysis revealed that postoperative locoregional recurrence is an independent risk factor for survival (P=0.031, 95% CI: 1.114-8.952).

Conclusions

Thoracic anastomosis led to satisfactory results in patients with cervicothoracic esophageal squamous tumors.

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.

Chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma since 2000: A single-center experience with 2,029 patients

BACKGROUND

To identify chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma based on diagnosis and treatment strategy development since 2000.

METHODS

Among 2,029 patients enrolled in this study, 746 and 1,283 were treated between 2000 and 2009 (group 1) and between 2010 and 2016 (group 2), respectively. We used patient clinicopathologic, biologic, and molecular factors to assess the prognostic factors.

RESULTS

Group 2 had a better survival outcome than group 1 (median survival time: 24.9 versus 18.4 months; 5-year survival rate: 27.6% versus 22.3%). The tendency for early diagnosis (lower CA19-9 levels, smaller size, and earlier T stage), use of neoadjuvant chemotherapy, decreased morbidity, early recovery (lesser hospital stay and more minimally invasive surgery), and standardization of surgical techniques appeared to improve patient survival. Multivariable analysis for prognosis revealed that tumor biologic factors (increased preoperative serum CA19-9 level, tumor size, tumor differentiation, N stage, and presence of lymphovascular invasion), operational factors (status of the resection margin, type of operation, and year of operation), and genetic factors (K-ras mutations) correlated with patient survival.

CONCLUSION

Early diagnosis and combined efforts, such as neoadjuvant chemotherapy and an established system of patient care, have gradually enhanced patient survival after operative resection for pancreatic ductal adenocarcinoma. Hence, multiplex prognostic parameters could provide additional information for improved prognostic estimation of pancreatic cancer exhibiting heterogeneous results.

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.

Prognostic role of nodal ratio, LODDS, pN in patients with pancreatic cancer with venous involvement

Background

The UICC/AJCC TNM staging system classifies lymph nodes as N0 and N1 in pancreatic cancer. Aim of the study is to determine whether the number of examine nodes, the nodal ratio (NR) and the logarithm odds of positive lymph nodes (LODDS) may better stratify the prognosis of patients undergoing pancreatectomy combined with venous resection for pancreatic cancer with venous involvement.

Methods

A multicenter database of 303 patients undergoing pancreatectomy in 9 Italian referral centers was analyzed. The prognostic impact of number of retrieved and examined nodes, NR, LODDS was analyzed and compared with ROC curves analysis, Pearson test, univariate and multivariate analysis.

Results

The number of metastatic nodes, pN, the NR and LODDS was significantly correlated with survival at multivariate analyses. The corresponding AUC for the number of metastatic nodes, pN, the NR and LODDS were 0.66, 0.69, 0.63 and 0.65, respectively. The Pearson test showed a significant correlation between the number of retrieved lymph nodes and number of metastatic nodes, pN and the NR. LODDS had the lower coefficient correlation. Concerning N1 patients, the NR, the LODDS and the number of metastatic nodes were able to significantly further stratify survival (p = 0.040; p = 0.046; p = 0.038, respectively).

Conclusions

The number of examined lymph nodes, the NR and LODDS are useful for further prognostic stratification of N1 patients in the setting of pancreatectomy combined with PV/SMV resection. No superiority of one over the others methods was detected.

Total mesopancreas excision for the treatment of pancreatic head cancer

Mesopancreas is a controversial structure. This study aimed to explore the anatomical characteristics of the mesopancreas, define the range of the total mesopancreas excision (TMpE), and evaluate the feasibility, safety and effectivity of TMpE in the treatment of pancreatic head cancer. The clinical and pathological data of 58 consecutive patients undergoing TMpE for pancreatic head carcinoma from January 2013 to December 2015 were analyzed prospectively. The perioperative morbidity, mortality and clinical outcomes of patients undergoing TMpE were compared with the patients undergoing conventional pancreaticoduodenectomy. The mesopancreas was located in the retropancreatic area, extending from the head, neck, and uncinated process of pancreas to the aorto-caval groove, in which there were loose areolar tissue, adipose tissue, nerve plexus, lymphatic and capillaries. We observed significantly higher R0 rate (94.8% vs. 81.4%, P=0.035), more lymph nodes (16.2 vs. 11.4, P=0.000), lower total and local recurrence rate (half-year local recurrence rate 7.8% vs. 23.7%, P=0.036, one-year 18.2% vs. 39.5%, P=0.018) and longer disease-free survival (16.9 vs. 13.4 months, P=0.044) in TMpE group than in control group. In conclusion, mesopancreas is different from mesorectum because there is no fascial envelop or anatomical boundary in this area. TMpE could be safely and feasibly performed for the treatment of pancreatic head cancer to increase the R0 resection rate and improve the clinical outcomes.

Para-aortic lymph node metastases in pancreatic cancer should not be considered a watershed for curative resection

No international consensus regarding the resection of the para-aortic lymph node (PALN) station Ln16b1 during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) has been reached. The present retrospectively investigated 264 patients with PDAC who underwent curative pancreatoduodenectomy or total pancreatectomy between 2005–2015. In 95 cases, the PALN were separately labelled and histopathologically analysed. Metastatic PALN (PALN+) were found in 14.7% (14/95). PALN+ stage was associated with increased regional lymph node metastasis. The median overall survival (OS) of patients with metastatic PALN and with non-metastatic PALN (PALN−) was 14.1 and 20.2 months, respectively. Five of the PALN+ patients (36%) survived >19 months. The OS of PALN+ and those staged pN1 PALN− was not significantly different (P = 0.743). Patients who underwent surgical exploration or palliative surgery (n = 194) had a lower median survival of 8.8 (95% confidence interval: 7.3–10.1) months. PALN status could not be reliably predicted by preoperative computed tomography. We concluded that the survival data of PALN+ cases is comparable with advanced pN+ stages; one-third of the patients may expect longer survival after radical resection. Therefore, routine refusal of curative resection in the case of PALN metastasis is not indicated.

Intestinal autotransplantation

Most abdominal neoplasms involving the root of the superior mesenteric artery and/or celiac artery are difficult to manage with conventional operative techniques because of limited intestinal ischemia times and poor accessibility to the tumor region. Ex vivo surgery followed by intestinal autotransplantation (IATx) is a relatively novel surgical strategy to offer chances for complete resection in such hopeless circumstances. This review aims to assess potential surgical indications, operative techniques and clinical outcomes after IATx. Currently the main indications reported for IATx broadly include pancreatic, mesenteric and retroperitoneal neoplasms closely involving the superior mesenteric vessels. The preliminary results show that radical resection can be effectively achieved in carefully selective patients. Although perioperative morbidity and mortality are relatively high, there are several long-term survivors, particularly after complete resection of benign and low-grade tumor. Early tumor recurrence, however, remains a major problem in patients with high-grade tumor, particularly pancreatic ductal carcinoma. In conclusion, IATx allows patients with selected abdominal neoplasms involving the major mesenteric vessels to be completely resected. However, this aggressive approach is associated with a considerable operative risk, and should only be performed at experienced centers. Additional and adjunctive treatment therapies are required to improve the efficacy of this treatment.

Laparoscopic uncinate process first pancreatoduodenectomy-feasibility study of a modified 'artery first' approach to pancreatic head cancer

PURPOSE

The aim of this study was to discuss the feasibility of laparoscopic 'uncinate first' pancreatoduodenectomy.

METHODS

The analysis included prospectively collected data from 12 consecutive patients undergoing elective pure laparoscopic 'uncinate process first' pancreatoduodenectomy (Group 1). They were compared with patients previously operated on with a classical laparoscopic approach (Group 2). The primary outcome was the quality of the resected specimen (lymph node (LN) yield, R0 rate, involved resection margins). Secondary outcomes were perioperative parameters.

RESULTS

The LN yield in Group 1 was 19.3 and in Group 2 it was 13.9 (p = 0.03). R0 resection rates did not vary (66.7 vs. 63.2%, p = 0.84). Although the involvement of the superior mesenteric artery margin and uncinate process margin seemed lower in Group 1, the difference was not significant. Total operative time (467 vs. 425 min, p = 0.13) and resection time (221 vs. 232 min, p = 0.34) were similar in both groups. The estimated blood loss in Group 1 was 408 ml, whereas in Group 2 it was 392 ml (p = 0.33). Complication rates were 66.7% in Group 1 and 63.2% in Group 2 (p = 0.84). Median length of stay was 9 days in both groups (p = 0.36). Postoperative complication rates did not differ between groups.

CONCLUSIONS

Laparoscopic uncinate first approach is a feasible method for pancreatic head neoplasms. Achieved quality of the specimen is comparable with the traditional laparoscopic approach, whereas intra- and postoperative course is not inferior. However, further studies on larger cohorts are required to fully establish whether the novel approach has potential advantages over classical access in pancreatic head cancer.