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Belfiori G, Crippa S, Pagnanelli M, Gasparini G, Aleotti F, Camisa PR, Partelli S, Pecorelli N, De Stefano F, Schiavo Lena M, Palumbo D, Tamburrino D, Reni M, Falconi M. Very Early Recurrence After Curative Resection for Pancreatic Ductal Adenocarcinoma: Proof of Concept for a "Biological R2 Definition". Ann Surg Oncol 2024; 31:4084-4095. [PMID: 38459416 DOI: 10.1245/s10434-024-15105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/12/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE Very early recurrence after radical surgery for pancreatic ductal adenocarcinoma (PDAC) has been poorly investigated. This study was designed to evaluate this group of patients who developed recurrence, within 12 weeks after surgery, defined as "biological R2 resections (bR2)." METHODS Data from patients who underwent surgical resection as upfront procedure or after neoadjuvant treatment for PDAC between 2015 and 2019 were analyzed. Disease-free, disease-specific survival, and independent predictors of early recurrence were examined. The same analysis was performed separately for upfront and neoadjuvant treated patients. RESULTS Of the 573 patients included in the study, 63 (11%) were classified as bR2. The rate of neoadjuvant treatment was similar in bR2 and in the remaining patients (44 vs. 42%, p = 0.78). After a median follow-up of 27 months, median DFS and DSS for the entire cohort were 17 and 43 months, respectively. Median DSS of bR2 group was 13 months. The only preoperative identifiable independent predictor of very early recurrence was body-tail site lesion, whereas all other were pathological: higher pT (8th classification), G3 differentiation, and high lymph node ratio. These predictors were confirmed for patients undergoing upfront surgery, whereas in the neoadjuvant group the only independent predictor was pT. CONCLUSIONS One of ten patients with "radical" resected PDAC relapses very early after surgery (bR2); hence, imaging must be routinely repeated within 12 weeks. Despite higher biological aggressiveness and worse pathology, this bR2 cluster eludes our preoperative examinations.
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Affiliation(s)
- Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | | | - Giulia Gasparini
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Federico De Stefano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita Salute San Raffaele, Milan, Italy
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Università Vita Salute San Raffaele, Milan, Italy
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Università Vita Salute San Raffaele, Milan, Italy
- Department of Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Università Vita Salute San Raffaele, Milan, Italy.
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2
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Macchini M, Belfiori G, Crippa S, Orsi G, Gasparini G, Tamburrino D, Partelli S, Schiavo Lena M, Palumbo D, De Cobelli F, Falconi M, Reni M. Exploring the optimal therapeutic management of stage ypIA pancreatic ductal adenocarcinoma patients in the era of primary chemotherapy. Dig Liver Dis 2024; 56:343-351. [PMID: 37460371 DOI: 10.1016/j.dld.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Data on the proper post-surgical chemotherapy (PSC) in pancreatic ductal adenocarcinoma (PDAC) patients already treated with neoadjuvant therapy (NAT) are lacking, especially for stage ypIA. AIM AND METHODS We retrospectively analyzed ypT1N0M0 (ypIA) PDAC patients resected after NAT between 2015 and 2020 at our Institution. Primary endpoint was median disease free-survival (DFS) according to PSC treatment. RESULTS Seventy-five out of 363 patients achieved a pathological ypIA after NAT (20.6%) and 72 were analyzed. Among the study population 34 patients (47%) were treated with NAT ≤4 months and 38 (53%) >4 months. After surgery, 10 patients (14%) received PSC using the same multidrug NAT regimen (Group A); 35 (49%) received PSC with a different regimen (Group B), with either single agents in 24 patients (68.5%) or combination schedules in 11 (31.5%); 27 patients (14%) did not receive any PSC (Group C). DFS was longer in group A and C as opposed to group B (p = 0.006). CONCLUSION Patients affected by ypIA PDAC treated with a proper multi-agent chemotherapy for more than 4 months show an improved DFS, regardless of the peri‑operative or totally pre-surgical administration of treatment.
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Affiliation(s)
- Marina Macchini
- Division of Medical Oncology; Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute University, Milan, Italy
| | - Giulia Orsi
- Division of Medical Oncology; Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute University, Milan, Italy
| | - Marco Schiavo Lena
- Division of Pathology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Division of Radiology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Italy; Vita-Salute University, Milan, Italy
| | - Francesco De Cobelli
- Division of Radiology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Italy; Vita-Salute University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute University, Milan, Italy.
| | - Michele Reni
- Division of Medical Oncology; Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute University, Milan, Italy
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Ferrari C, Leon P, Falconi M, Boggi U, Piardi T, Sulpice L, Cavaliere D, Rosso E, Chirica M, Ravazzoni F, Memeo R, Pessaux P, De Blasi V, Mascherini M, De Cian F, Navarro F, Panaro F. Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: a multicenter retrospective analysis from European countries. Langenbecks Arch Surg 2023; 408:386. [PMID: 37776339 DOI: 10.1007/s00423-023-03110-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors. Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease. METHODS We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020. Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients. RESULTS Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250 min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4% in the MVR group vs. 62.2% in the control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827). After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519). CONCLUSIONS Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.
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Affiliation(s)
- Cecilia Ferrari
- HPB and Transplant Unit, University of Montpellier, Montpellier, France.
- Ospedale Policlinico San Martino, Genova, Italy.
| | - Piera Leon
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
| | - Massimo Falconi
- Chirurgia Pancreatica, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Ugo Boggi
- Chirurgia HPB e Trapianto di Fegato, Ospedale Cisanello, Università degli Studi di Pisa, Pisa, Italy
| | | | | | | | - Edoardo Rosso
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | | | | | | | | | - Vito De Blasi
- Service de Chirurgie Générale et Mini-Invasive, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | | | | | - Francis Navarro
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
| | - Fabrizio Panaro
- HPB and Transplant Unit, University of Montpellier, Montpellier, France
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Salinas-Miranda E, Healy GM, Grünwald B, Jain R, Deniffel D, O'Kane GM, Grant R, Wilson J, Knox J, Gallinger S, Fischer S, Khokha R, Haider MA. Correlation of transcriptional subtypes with a validated CT radiomics score in resectable pancreatic ductal adenocarcinoma. Eur Radiol 2022; 32:6712-6722. [PMID: 36006427 DOI: 10.1007/s00330-022-09057-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/14/2022] [Accepted: 07/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Transcriptional classifiers (Bailey, Moffitt and Collison) are key prognostic factors of pancreatic ductal adenocarcinoma (PDAC). Among these classifiers, the squamous, basal-like, and quasimesenchymal subtypes overlap and have inferior survival. Currently, only an invasive biopsy can determine these subtypes, possibly resulting in treatment delay. This study aimed to investigate the association between transcriptional subtypes and an externally validated preoperative CT-based radiomic prognostic score (Rad-score). METHODS We retrospectively evaluated 122 patients who underwent resection for PDAC. All treatment decisions were determined at multidisciplinary tumor boards. Tumor Rad-score values from preoperative CT were dichotomized into high or llow categories. The primary endpoint was the correlation between the transcriptional subtypes and the Rad-score using multivariable linear regression, adjusting for clinical and histopathological variables (i.e., tumor size). Prediction of overall survival (OS) was secondary endpoint. RESULTS The Bailey transcriptional classifier significantly associated with the Rad-score (coefficient = 0.31, 95% confidence interval [CI]: 0.13-0.44, p = 0.001). Squamous subtype was associated with high Rad-scores while non-squamous subtype was associated with low Rad-scores (adjusted p = 0.03). Squamous subtype and high Rad-score were both prognostic for OS at multivariable analysis with hazard ratios (HR) of 2.79 (95% CI: 1.12-6.92, p = 0.03) and 4.03 (95% CI: 1.42-11.39, p = 0.01), respectively. CONCLUSIONS In patients with resectable PDAC, an externally validated prognostic radiomic model derived from preoperative CT is associated with the Bailey transcriptional classifier. Higher Rad-scores were correlated with the squamous subtype, while lower Rad-scores were associated with the less lethal subtypes (immunogenic, ADEX, pancreatic progenitor). KEY POINTS • The transcriptional subtypes of PDAC have been shown to have prognostic importance but they require invasive biopsy to be assessed. • The Rad-score radiomic biomarker, which is obtained non-invasively from preoperative CT, correlates with the Bailey squamous transcriptional subtype and both are negative prognostic biomarkers. • The Rad-score is a promising non-invasive imaging biomarker for personalizing neoadjuvant approaches in patients undergoing resection for PDAC, although additional validation studies are required.
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Affiliation(s)
- Emmanuel Salinas-Miranda
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada.,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada
| | - Gerard M Healy
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada.,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada.,Department of Medical Imaging, University of Toronto, 263 McCaul St 4th Floor, Toronto, ON, M5T 1W5, Canada
| | - Barbara Grünwald
- Department of Pathology, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada.,PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada
| | - Rahi Jain
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Dominik Deniffel
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada
| | - Grainne M O'Kane
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Robert Grant
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Julie Wilson
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada
| | - Jennifer Knox
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Steven Gallinger
- PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada.,Hepatobiliary Pancreatic Surgical Oncology Program, University Health Network, 190 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada
| | - Sandra Fischer
- Department of Pathology, University Health Network, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Rama Khokha
- Department of Medical Biophysics, Princess Margaret Cancer Centre, University Health Network, University of Toronto, 610 University Ave, Toronto, ON, M5G 2C1, Canada
| | - Masoom A Haider
- Lunenfeld Tanenbaum Research Institute, Sinai Health System, Mount Sinai Hospital, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, 6th Floor, Office 6 200, Toronto, ON, M5G 1X5, Canada. .,Joint Department of Medical Imaging, University Health Network/Sinai Health System, 600 University Ave, 5th Floor, Toronto, ON, M5G1X5, Canada. .,Department of Medical Imaging, University of Toronto, 263 McCaul St 4th Floor, Toronto, ON, M5T 1W5, Canada. .,PanCuRx Translational Research Initiative, Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, ON, M5G 0A3, Canada.
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5
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Coppola A, La Vaccara V, Fiore M, Farolfi T, Ramella S, Angeletti S, Coppola R, Caputo D. CA19.9 Serum Level Predicts Lymph-Nodes Status in Resectable Pancreatic Ductal Adenocarcinoma: A Retrospective Single-Center Analysis. Front Oncol 2021; 11:690580. [PMID: 34123859 PMCID: PMC8190389 DOI: 10.3389/fonc.2021.690580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
Background The choice between upfront surgery or neoadjuvant treatments (NAT) for resectable pancreatic ductal adenocarcinoma (R-PDAC) is controversial. R-PDAC with potential nodal involvement could benefit from NT. Ca (Carbohydrate antigen) 19.9 and serum albumin levels, alone or in combination, have proven their efficacy in assessing PDAC prognosis. The objective of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC. Methods Preoperative Ca 19.9, as well as serum albumin levels, of 165 patients selected for upfront surgery have been retrospectively collected and correlated to pathological nodal status (N), resection margins status (R) and vascular resections (VR). We further performed ROC curve analysis to identify optimal Ca 19.9 cut-off for pN+, R+ and vascular resection prediction. Results Increased Ca 19.9 levels in 114 PDAC patients were significantly associated with pN+ (p <0.001). This ability, confirmed in all the series by ROC curve analysis (Ca 19.9 ≥32 U/ml), was lost in the presence of hypoalbuminemia. Furthermore, Ca 19.9 at the cut off >418 U/ml was significantly associated with R+ (87% specificity, 36% sensitivity, p 0.014). Ca 19.9, at the cut-off >78 U/ml, indicated a significant trend to predict the need for VR (sensitivity 67%, specificity 53%; p = 0.059). Conclusions In R-PDAC with normal serum albumin levels, Ca 19.9 predicts pN+ and R+, thus suggesting a crucial role in deciding on NAT.
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Affiliation(s)
| | | | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Tommaso Farolfi
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
| | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, Campus Bio-Medico University, Rome, Italy
| | - Roberto Coppola
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
| | - Damiano Caputo
- Department of Surgery, Campus Bio-Medico University, Rome, Italy
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