A simple risk score for detecting radiological occult metastasis in patients with resectable or borderline resectable pancreatic ductal adenocarcinoma

Scoring system to predict positive peritoneal cytology in patients with resectable and borderline resectable pancreatic cancer

BACKGROUND

The aim of this study was to evaluate factors to predict positive peritoneal cytology, whcih would determine the indication for staging laparoscopy in pancreatic cancer.

METHODS

A total of 430 patients that underwent pancreatectomy for resectable and borderline resectable pancreatic cancer were retrospectively reviewed.

RESULTS

Among 430 patients, 36 had positive cytology (8.4%). Median survival time in negative cytology was 24.7 months, compared with 15.1 months in positive cytology (p = .004). Factors to predict positive cytology in pancreatic cancer according to multivariate analysis were tumor location (body, tail; OR 2.66; 95% CI: 1.21-5.85; p = .015), tumor size ≥30 mm (OR 2.95; 95% CI: 1.35-6.47; p = .007) and radiographic other-organ invasion (HR 2.79; 95% CI: 1.01-7.67; p = .047). Patients were scored 0 to 3 corresponding with these factors. Rates of positive cytology increases in each score were: score 0: 2.9%, score 1: 6.7%, score 2: 18.3%, score 3: 36.8%.

CONCLUSIONS

Tumor location (body or tail), tumor size ≥30 mm, and radiographic other-organ invasions were risk factors for positive cytology in pancreatic cancer. This scoring system might be a useful indicator to perform staging laparoscopy to diagnose positive cytology.

Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer

Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.

Evaluating staging laparoscopy indications for pancreatic cancer based on resectability classification and treatment strategies for patients with positive peritoneal washing cytology

Introduction

The prognosis of pancreatic ductal adenocarcinoma (PDAC) in patients with positive peritoneal washing cytology (CY1) is poor. We aimed to evaluate the results of staging laparoscopy (SL) and treatment efficacy in CY1 patients based on a resectability classification.

Methods

We retrospectively reviewed 250 patients with PDAC who underwent SL before the initial treatment between 2017 and 2023 at the University of Toyama.

Results

The breakdown of cases by resectability classification was resectable (R):borderline resectable (BR):unresectable locally advanced (UR-LA) = 131:48:71 cases. The frequency of CY1 increased in proportion to the degree of local progression (R:BR:UR-LA = 20:23:34%), but the frequencies of liver metastasis or peritoneal dissemination were comparable (R:BR:UR-LA = 6.9:6.3:8.5%). Most CY1 patients received gemcitabine along with nab-paclitaxel therapy. The CY-negative conversion rates (R:BR:UR-LA = 70:64:52%) and conversion surgery rates (R:BR:UR-LA = 40:27:9%) were inversely proportional to the degree of local progression.Comparing H0P0CY1 factors for each classification, patients with H0P0CY1 had significantly more pancreatic body or tail carcinoma and tumor size ≥32 mm in R patients, whereas in BR patients, duke pancreatic monoclonal antigen type 2 (DUPAN-2) ≥ 230 U/mL was a significant factor. In contrast, no significant factors were observed in UR-LA patients.

Conclusion

The CY1 rates, CY-negative conversion rates, and conversion surgery rates varied according to local progression. In the case of R and BR, SL could be considered in patients with pancreatic body or tail carcinoma, large tumor size, or high DUPAN-2 level. In UR-LA, SL might be considered for all patients.

Efficacy of staging laparoscopy for resectable pancreatic cancer on imaging and the therapeutic effect of systemic chemotherapy for positive peritoneal cytology

BACKGROUND

The frequency and prognosis of positive peritoneal washing cytology (CY1) in resectable pancreatic ductal adenocarcinoma (R-PDAC) remains unclear. The objective of this study was to identify the clinical implications of CY1 in R-PDAC and staging laparoscopy (SL).

METHODS

We retrospectively analyzed 115 consecutive patients with R-PDAC who underwent SL between 2018 and 2022. Patients with negative cytology (CY0) received radical surgery after neoadjuvant chemotherapy, while CY1 patients received systemic chemotherapy and were continuously evaluated for cytology.

RESULTS

Of the 115 patients, 84 had no distant metastatic factors, 22 had only CY1, and nine had distant metastasis. Multivariate logistic regression revealed that larger tumor size was an independent predictor of the presence of any distant metastatic factor (OR: 6.30, p = .002). Patients with CY1 showed a significantly better prognosis than patients with distant metastasis (MST: 24.6 vs. 18.9 months, p = .040). A total of 11 CY1 patients were successfully converted to CY-negative, and seven underwent conversion surgery. There was no significant difference in overall survival between patients with CY0 and those converted to CY-negative.

CONCLUSION

SL is effective even for R-PDAC. The prognosis of CY1 patients converted to CY-negative is expected to be similar to that of CY0 patients.

Prognostic role of radiological splenic vessel involvement in patients with resectable pancreatic ductal adenocarcinoma of the body and tail: A retrospective analysis based on a large population

BACKGROUND

Tumors located in the pancreatic body or tail are more likely to invade splenic vessels; however, splenic artery (SpA) or vein (SpV) involvement is not included in the criteria for resectability. We aimed to analyze the prognostic role of radiological splenic vessel involvement in patients with resectable pancreatic ductal adenocarcinoma (PDAC) of the body and tail.

METHODS

Patients with resetable PDAC were retrospectively reviewed and analyzed. SpA and SpV involvement were graded as clear, abutment and encasement. Multivariate Cox and logistic regression analyses were used to identify prognostic factors for overall survival (OS) and risk factors for early recurrence, respectively.

RESULTS

Of the 234 patients, 94 patients had radiologic SpA invasion, including abutment in 47 patients and encasement in 47 patients, while 123 patients had radiological SpV invasion, including abutment in 69 patients and encasement in 54 patients. Patients with SpA or SpV encasement showed a significantly worse OS and recurrence-free survival than those with SpA or SpV clear (P < 0.001, respectively). In multivariate analysis, both SpA and SpV encasement were independently associated with poor OS (SpA: hazard ratio [HR] 1.89, P = 0.010; SpV: HR 2.01, P = 0.001) and early recurrence (SpA: odds ratio [OR] 4.98, P < 0.001; SpV: OR 3.71, P = 0.002).

CONCLUSION

Radiological SpA or SpV encasement independently decreases OS, and is associated with early recurrence of resectable PDAC of the body/tail.

Nomogram for Predicting Distant Metastasis of Pancreatic Ductal Adenocarcinoma: A SEER-Based Population Study

(1) Background: The aim of this study was to identify risk factors for distant metastasis of pancreatic ductal adenocarcinoma (PDAC) and develop a valid predictive model to guide clinical practice; (2) Methods: We screened 14328 PDAC patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. Lasso regression analysis combined with logistic regression analysis were used to determine the independent risk factors for PDAC with distant metastasis. A nomogram predicting the risk of distant metastasis in PDAC was constructed. A receiver operating characteristic (ROC) curve and consistency-index (C-index) were used to determine the accuracy and discriminate ability of the nomogram. A calibration curve was used to assess the agreement between the predicted probability of the model and the actual probability. Additionally, decision curve analysis (DCA) and clinical influence curve were employed to assess the clinical utility of the nomogram; (3) Results: Multivariate logistic regression analysis revealed that risk factors for distant metastasis of PDAC included age, primary site, histological grade, and lymph node status. A nomogram was successfully constructed, with an area under the curve (AUC) of 0.871 for ROC and a C-index of 0.871 (95% CI: 0.860-0.882). The calibration curve showed that the predicted probability of the model was in high agreement with the actual predicted probability. The DCA and clinical influence curve showed that the model had great potential clinical utility; (4) Conclusions: The risk model established in this study has a good predictive performance and a promising potential application, which can provide personalized clinical decisions for future clinical work.

Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma

Objectives

To investigate the risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma.

Methods

All data were retrospectively collected from patients with resectable pancreatic ductal adenocarcinoma who had undergone pancreatoduodenectomy at the Department of Surgery, Phramongkutklao Hospital, from January 2015 to December 2020. The preoperative and perioperative risk factors were included into the analysis.

Results

In total, 34 patients were included in the study. The median time for recurrence and median survival time were 17 and 20 months, respectively. The 1, 3, and 5 year disease-free survival rates were 59.6%, 23.87%, and 23.87%, respectively, while the 1, 3, and 5 year overall survival rates were 81%, 24.7%, and 12.4%, respectively. Seventeen patients (50%) from a total of 34 patients had recurrence, and ten patients (29.41%) had recurrence within 12 months. The independent preoperative risk factor associated with adverse disease-free survival was tumor size > 4 cm (hazard ratio [HR], 14.34, p=0.022). The perioperative risk factors associated with adverse disease-free survival were pathological lymphovascular invasion (HR, 4.31; p=0.048) and non-hepatopancreatobiliary surgeon (HR, 5.9; p=0.022). Risk factors associated with poor overall survival were microscopical margin positive (R1) resection (HR, 3.68; p=0.019) and non-hepatopancreatobiliary surgeon (HR, 3.45; p=0.031).

Conclusions

Tumor size > 4 cm from the preoperative imaging study was a poor prognostic factor for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma indicated that they may have radiological occult metastasis, thus, staging laparoscopy may reduce the number of unnecessary laparotomies and avoid missing radiologically negative metastases.