Pancreatic cancer in the remnant pancreas following primary pancreatic resection

Remnant pancreatic carcinoma: The current status

Pancreatic carcinoma is one of the most lethal malignancies and has a dismal prognosis. However, advances in diagnostic modalities and better multidisciplinary management have contributed to improved survival in these patients. Of late, various recurrence patterns have been observed; the most common of them being distant metastasis followed by the pancreatic bed and lymph node recurrence. Recurrence in the remnant pancreas is on the rise due to improved survival in patients who previously underwent surgery for pancreatic cancer. Total remnant pancreatectomy is an appealing option in resectable remnant pancreatic carcinoma without distant metastasis. It is an entity showing an increasing incidence and demanding further in-depth studies to elucidate the exact pathological mechanism and to establish appropriate management protocols.

Meta-analysis of pancreatic re-resection for locally recurrent pancreatic cancer following index pancreatectomy

The role of surgical resection in patients with recurrent pancreatic cancer is unclear. We aimed to evaluate the survival outcomes of pancreatic re-resection for locally recurrent pancreatic cancer following index pancreatectomy. A literature search was carried out in CENTRAL, EMBASE, MEDLINE, CINAHL, and Web of Science. Proportion meta-analysis model was constructed to quantify 1 to 5-year survival after pancreatic re-resection for locally recurrent pancreatic cancer. Random-effects modelling was applied to calculate pooled outcome data. Fifteen retrospective studies were included, reporting a total of 250 patients who underwent pancreatic re-resection for locally recurrent pancreatic cancer following their index pancreatectomy. Pancreatic re-resection was associated with 1-year survival 70.6% (95% confidence interval [CI], 65.0-76.2), 2-year survival 38.8% (95% CI, 28.6-49.0), 3-year survival 20.2% (95% CI, 13.8-26.7), and 5-year survival 9.2% (95% CI, 5.5-12.8). The between-study heterogeneity was insignificant in all outcome syntheses. Repeat pancreatectomy for local recurrence of pancreatic cancer in the remnant pancreas following the index pancreatectomy is associated with acceptable overall patient survival. We recommend selective re-resection of such recurrences in younger patients with favorable tumor size and location. Our findings may encourage more robust studies to be conducted in this context to provide stronger evidence.

Salvage Ablative Radiotherapy for Isolated Local Recurrence of Pancreatic Adenocarcinoma following Definitive Surgery

Introduction: The rate of isolated locoregional recurrence after surgery for pancreatic adenocarcinoma (PDAC) approaches 25%. Ablative radiation therapy (A-RT) has improved outcomes for locally advanced disease in the primary setting. We sought to evaluate the outcomes of salvage A-RT for isolated locoregional recurrence and examine the relationship between subsequent patterns of failure, radiation dose, and treatment volume. Methods: We conducted a retrospective analysis of all consecutive participants who underwent A-RT for an isolated locoregional recurrence of PDAC after prior surgery at our institution between 2016 and 2021. Treatment consisted of ablative dose (BED10 98-100 Gy) to the gross disease with an additional prophylactic low dose (BED10 < 50 Gy), with the elective volume covering a 1.5 cm isotropic expansion around the gross disease and the circumference of the involved vessels. Local and locoregional failure (LF and LRF, respectively) estimated by the cumulative incidence function with competing risks, distant metastasis-free and overall survival (DMFS and OS, respectively) estimated by the Kaplan-Meier method, and toxicities scored by CTCAE v5.0 are reported. Location of recurrence was mapped to the dose region on the initial radiation plan. Results: Among 65 participants (of whom two had two A-RT courses), the median age was 67 (range 37-87) years, 36 (55%) were male, and 53 (82%) had undergone pancreaticoduodenectomy with a median disease-free interval to locoregional recurrence of 16 (range, 6-71) months. Twenty-seven participants (42%) received chemotherapy prior to A-RT. With a median follow-up of 35 months (95%CI, 26-56 months) from diagnosis of recurrence, 24-month OS and DMFS were 57% (95%CI, 46-72%) and 22% (95%CI, 14-37%), respectively, while 24-month cumulative incidence of in-field LF and total LRF were 28% (95%CI, 17-40%) and 36% (95%CI 24-48%), respectively. First failure after A-RT was distant in 35 patients (53.8%), locoregional in 12 patients (18.5%), and synchronous distant and locoregional in 10 patients (15.4%). Most locoregional failures occurred in elective low-dose volumes. Acute and chronic grade 3-4 toxicities were noted in 1 (1.5%) and 5 patients (7.5%), respectively. Conclusions: Salvage A-RT achieves favorable OS and local control outcomes in participants with an isolated locoregional recurrence of PDAC after surgical resection. Consideration should be given to extending high-dose fields to include adjacent segments of at-risk vessels beyond direct contact with the gross disease.

Completion Pancreatectomy. Indications and Outcomes: A Systematic Review

BACKGROUND/OBJECTIVE (S)

Completion pancreatectomy (C.P.) is one acceptable treatment of choice in clinical scenarios such as management of post-pancreatectomy complications and recurrence in the pancreatic remnant. Studies referring to completion pancreatectomy as a distinct operation are limited, without emphasizing at the operation itself, rather reporting completion pancreatectomy as a possible option for treatment of various diseases. The identification of indications of CP in various pathologies and the clinical outcomes are therefore mandatory.

METHODS

A systematic literature search was performed in the Pubmed and Scopus Databases (February 2020),guided by the PRISMA protocol, for all studies reporting CP as a surgical procedure with reference at indications for performing it combined with postoperative morbidity and/or mortality.

RESULTS

Out of 1647 studies, 32 studies from 10 countries with 2775 patients in total, of whom 561 (20.2%) CPs met the inclusion criteria and were included in the analysis. Inclusion year ranged from 1964 to 2018 and were published from 1992 until 2019. 17 studies with a total number of 249 CPs were performed for post-pancreatectomy complications. Mortality rate was 44.5% (111 out of 249). Morbidity rate was (72.6%). 12 studies with 225 CPs were performed for isolated local recurrence after initial resection with a morbidity rate of 21.5% and 0% mortality rate in the early postoperative period. Two studies with a total number of 12 patients reported CP as a treatment option for recurrent neuroendocrine neoplasms. The mortality in those studies was 8% (1/12) and the mean morbidity rate was 58.3% (7/12). Finally, CP for refractory chronic pancreatitis was presented in one study with morbidity and mortality rates of 19% and 0%, respectively.

CONCLUSION

Completion pancreatectomy is a distinct treatment option for various pathologies. Morbidity and mortality rates depend on the indications of performing CP, the status performance of the patients and whether the operation is performed electively or urgently.

Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor

BACKGROUND

Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality.

METHODS

This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients.

RESULTS

Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available.

CONCLUSION

In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.

Delayed local recurrence of pancreatic adenosquamous cell carcinoma after curative surgery: A case report

Introduction

Pancreatic adenosquamous cell carcinoma (PASC) is a rare histological type of pancreatic malignancy with a particularly poor prognosis, even after curative surgery. Here, we describe the long-term prognosis of PASC in a patient who developed delayed local recurrence of the remnant pancreas after successful distal pancreatectomy, together with a literature review.

Presentation of case

A 59-year-old woman had a history of hepatitis C. Computed tomography revealed a hypointense mass in the pancreatic body in the arterial phase of the study. Magnetic resonance imaging revealed a tumor (20 mm) in the pancreatic body and dilatation of the main pancreatic duct at the periphery of the tumor. The patient was diagnosed with resectable pancreatic ductal adenocarcinoma and underwent distal pancreatectomy with lymphadenectomy; her postoperative course was uneventful. Immunohistochemical analysis of the resected specimen confirmed the diagnosis of tumor node metastasis [TNM] classification T2N1M0 stage IIB. Five years after curative surgery, following adjuvant systemic chemotherapy with S-1, local recurrence in the remnant pancreas occurred, which invaded the common hepatic artery and celiac pleural plexus. Systemic chemotherapy with gemcitabine and abraxiane is currently underway.

Discussion

Curative surgery significantly affects the prognosis of patients with PASC. Adjuvant chemotherapy may prolong the survival of these patients. Delayed remnant pancreatic recurrence should be considered during the surveillance of pancreatic cancer after curative resection.

Conclusion

We present a case of PASC in a patient who developed local recurrence in the remnant pancreas 5 years after successful distal pancreatectomy. Special attention should be paid not only to early recurrence but also to delayed local recurrence in PASC.

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Pancreatic adenosquamous cell carcinoma (PASC) is a rare histological type of pancreatic malignancy

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We describe the long-term prognosis of PASC in a patient who developed delayed local recurrence of the remnant pancreas after distal pancreatectomy.

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Delayed remnant pancreatic recurrence should be considered during the surveillance of pancreatic cancer after curative resection.

Resection of Recurrent Pancreatic Cancer: Who Can Benefit?

Background

Recurrence after resection of pancreatic cancer occurs in up to 80% of patients in the first 2 years after complete resection. While most patients are not eligible for surgical treatment due to disseminated disease, a certain group of patients can be evaluated for re-resection of local recurrence. This review summarizes the current literature on surgical treatment of recurrent pancreatic cancer and potential prognostic factors.

Summary

Re-resection of recurrent pancreatic cancer provides a significant survival benefit to selected patients with acceptable procedure-related mortality. Median overall survival after re-resection of recurrent pancreatic cancer is up to 28 months. The most relevant clinical parameters associated with a prognostic benefit are young patient age (<65 years), time to initial resection (>10 months), and preoperative chemotherapy before re-resection. Molecular markers are currently under investigation and might help to improve patient selection in the future.

Key Message

Re-resection of recurrent pancreatic cancer is safe and feasible in experienced hands. Selected patients benefit from surgical treatment, but future studies are needed to identify reliable prognostic markers predicting survival.

Surgical Resection or Ablation for Recurrent Pancreatic Ductal Adenocarcinoma: An Analysis of Oncologic Outcomes According to the Recurrence Type

Objective

To evaluate the survival benefits of curative-intent treatment (CIT, including surgery or ablation) for recurrent pancreatic ductal adenocarcinoma (PDAC) depending on the recurrence type and compared the survival outcomes with other treatment modalities.

Background

The treatment for recurrent PDAC is mostly chemotherapy or best supportive care (BSC). Still, the role of CIT for recurrent PDAC is not well established.

Methods

PDAC patients who underwent pancreatectomy between 2004 and 2019 were included. Recurrences were categorized as locoregional (LR), distant, or disseminated. Recurrent PDAC management was classified as CIT, chemotherapy ± radiation therapy (CTX ± RTX), or BSC. The survival after recurrence (SAR) rate was measured from the first day of recurrence to the date of death or last follow-up.

Results

Two hundred eighteen patients had recurrent PDAC and were analyzed (27 CIT, 128 CTX ± RTX, 63 BSC). The 1-, 3-, and 5-year SAR rates were 65.4%, 11.5%, and 11.5% for CIT, 42.1%, 4.0%, and 0% for CTX ± RTX, and 15.9%, 1.6%, and 0% for BSC, respectively. Subgroup analysis indicated the SAR rate was significantly better in the CIT group than in the CTX ± RTX and BSC groups in LR type (P = 0.027) and distant type (P < 0.001). In multivariate analysis, the albumin level at recurrence (hazard ratio, 2.14; 95% confidence interval, 1.15-18.3, P = 0.038) and operation time of the second operation (hazard ratio, 0.98; 95% confidence interval, 0.97-0.99, P = 0.021) were associated with a favorable prognosis of SAR in the CIT group.

Conclusions

CIT should be considered in recurrent PDAC for LR and distant metastases in selected patients.

Systematic Review and Meta-Analysis of Surgical Treatment for Isolated Local Recurrence of Pancreatic Cancer

PURPOSE

To perform a systematic review and meta-analysis on the outcome of surgical treatment for isolated local recurrence of pancreatic cancer.

METHODS

A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in PubMed, Scopus, and Web of Science.

RESULTS

Six studies concerning 431 patients with recurrent pancreatic cancer met the inclusion criteria and were included in the analysis: 176 underwent redo surgery, and 255 received non-surgical treatments. Overall survival and post-recurrence survival were significantly longer in the re-resected group (ratio of means (ROM) 1.99; 95% confidence interval (CI), 1.54-2.56, I2 = 75.89%, p = 0.006, and ROM = 2.05; 95% CI, 1.48-2.83, I2 = 76.39%, p = 0.002, respectively) with a median overall survival benefit of 28.7 months (mean difference (MD) 28.7; 95% CI, 10.3-47.0, I2 = 89.27%, p < 0.001) and median survival benefit of 15.2 months after re-resection (MD 15.2; 95% CI, 8.6-21.8, I2 = 58.22%, p = 0.048).

CONCLUSION

Resection of isolated pancreatic cancer recurrences is safe and feasible and may offer a survival benefit. Selection of patients and assessment of time and site of recurrence are mandatory.

Site of relapse of ductal adenocarcinoma of the pancreas affects survival after multimodal therapy

BACKGROUND

Ductal adenocarcinoma of the pancreas (PDAC) remains one of the most lethal malignancies. To date, no guidelines exists for isolated resectable metachronous disease. It is still unknown, which patients may benefit from relapse surgery. The aim of our study was to compare disease free survival (DFS) and post relapse survival (PRS) in patients with isolated local recurrence, metachronous hepatic or pulmonary metastases.

METHODS

Patients with isolated resectable local recurrence, metachronous hepatic or pulmonary metastases were included for survival analyses. PRS of surgically treated patients (local (n = 11), hepatic (n = 6) and pulmonary metastases (n = 9)) was compared to conservatively treated patients (local (n = 17), hepatic (n = 37) and pulmonary metastases (n = 8)).

RESULTS

Resected PDAC patients suffering from isolated metachronous hepatic metastases initially had a higher T-stage and venous invasion (V1) compared to the other patients. DFS in the metachronous pulmonary metastases group was longer compared to DFS of the hepatic metastases and local recurrence groups. Surgical resection significantly improved PRS in patients with local recurrence and pulmonary metastases, when compared to patients receiving chemotherapy alone. Very-long term survivors (> 5 years) were detected following secondary resection of local recurrence and 45% of these patients were still alive at the end of our study period.

CONCLUSION

Although DFS in PDAC patients suffering from isolated local recurrence was dismal and comparable to that of patients with isolated hepatic metastases, very-long term survivors were present only in this group. These results indicate that a surgical approach for isolated local recurrence, if anatomically possible, should be considered.

Repeated Pancreatectomy for Isolated Local Recurrence in the Remnant Pancreas Following Radical Pancreatectomy for Pancreatic Ductal Adenocarcinoma: A Pooled Analysis

The mainstream treatment for recurrent pancreatic cancer is potent chemotherapy or chemoradiotherapy. However, recent clinical investigations have suggested a potential oncologic role of local resection of recurrent pancreatic cancer. This systemic review with a pooled analysis aimed to assess the potential role of local repeated pancreatectomy with respect to the survival outcomes for patients with recurrent pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas. The PubMed database was searched, and 15 articles reporting on repeated pancreatectomy for local recurrence of PDAC in the remnant pancreas were identified. The pooled individual data were examined for the clinical outcomes of repeated pancreatectomy for recurrent PDAC. The survival analysis was performed using the Kaplan-Meier method. In the pooled analysis, the mean time interval from initial pancreatectomy to repeated pancreatectomy was 41.3 months (standard deviation (SD), 29.09 months). Completion total pancreatectomy was most commonly performed as repeated pancreatectomy (46 patients, 92.0%), and partial pancreatic resection was performed for only 4 (10.3%) patients. Twenty (40.9%) patients received postoperative chemotherapy following repeated pancreatectomy. The median overall survival was 60 months (95% confidential interval (CI): 45.99-74.01) after repeated pancreatectomy for isolated local recurrence in the remnant pancreas. Overall survival was markedly longer considering the timing of the initial pancreatectomy for pancreatic cancer (median, 107 months (95% CI: 80.37-133.62). The time interval between the initial and subsequent repeated pancreatectomy for pancreatic cancer was not associated with long-term oncologic outcomes (p = 0.254). Repeated pancreatectomy cannot completely replace adjuvant chemotherapy but should be considered for patients with isolated local recurrent PDAC in the remnant pancreas.

Chronic inflammatory changes and oxidative stress in the background of "pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm"

Cases of "pancreatic ductal adenocarcinoma (PDAC) concomitant with intraductal papillary mucinous neoplasm" (IPMN) have multiple PDAC lesions more frequently than cases of "PDAC without IPMN". However, the mechanism of carcinogenesis in this former disease category remains unknown. The main objective of this work was thus to investigate the effects of chronic inflammation on carcinogenesis in PDAC cases. We selected 31 "PDAC concomitant with IPMN" patients and 58 "PDAC without IPMN" patients and pathologically evaluated their background pancreatic parenchyma. Fibrosis and inflammation scores of background pancreas were higher in "PDAC concomitant with IPMN" than in "PDAC without IPMN" (P < 0.0001 and P < 0.0001, respectively), whereas the fatty infiltration score of background pancreas was high in "PDAC without IPMN" (P = 0.0024). Immunohistochemically, the expression of 8-hydroxy-2'-deoxyguanosine (8-OHDG), an oxidative stress marker, in the background pancreas was high in "PDAC concomitant with IPMN" compared with that in "PDAC without IPMN" (P < 0.0001). Chronic inflammation activates oxidative stress in tissue throughout the pancreas and probably confers susceptibility to tumorigenesis in "PDAC concomitant with IPMN".

[Surgery for isolated local recurrence and metachronous oligometastasis in pancreatic cancer]

BACKGROUND

Most patients with pancreatic cancer suffer a relapse, which occurs either locally or systemically in the sense of liver and the lung metastases. Surgery for pancreatic cancer has become more radical due to the increased use of multimodal treatment concepts; however, the role of surgery in cases of recurrence remains controversial.

OBJECTIVE

This review summarizes the surgical treatment options for isolated local recurrence and metachronous oligometastatic pancreatic cancer.

MATERIAL AND METHODS

A selective literature search was carried out and the current evidence for surgical treatment is summarized.

RESULTS

There are currently no randomized studies on surgery for metastatic pancreatic cancer. Currently available data, however, show that after surgery long-term survival of up to 32-47 months after metastasectomy can be achieved, especially in patients with local recurrence or isolated pulmonary metastases with low morbidity and mortality. Individualized treatment concepts including surgical resection after initial systemic therapy seem promising even for liver metastases. The greatest survival benefits are consistently shown for all localizations in patients with a long as possible disease-free interval after the first operation.

CONCLUSION

The treatment of isolated local recurrence or metachronous oligometastatic pancreatic cancer is an interdisciplinary challenge that should be performed in specialized pancreatic treatment centers only. Surgical resection embedded in a multimodal treatment concept can be meaningful in selected cases.

Is remnant pancreatic cancer after pancreatic resection more frequent in early-stage pancreatic cancer than in advanced-stage cancer?

AIM

As the prognosis of patients who undergo resection for pancreatic cancer has improved, reports of remnant pancreatic cancer after pancreatic cancer resection have been increasing. Previous studies regarding early-stage pancreatic cancer showed a high incidence of remnant pancreatic cancer in these patients. The aim of this study was to investigate the incidence of remnant pancreatic cancer according to the degree of progression of the initial pancreatic cancer.

METHODS

Patients who underwent partial pancreatic resection for primary pancreatic cancer were retrospectively reviewed and divided into an early-stage group and an advanced-stage group according to the stage of the initial cancer. Patient characteristics and long-term outcomes, including development of remnant pancreatic cancer, were compared between the two groups.

RESULTS

This study included 321 patients who underwent partial pancreatectomy for pancreatic cancer; 32 patients in the early-stage group and 289 patients in the advanced-stage group. Remnant pancreatic cancer developed in 19 patients (5.9%); seven patients (21.9%) in the early-stage group and 12 patients (4.5%) in the advanced-stage group. The cumulative incidence of remnant pancreatic cancer according to the Kaplan-Meier method was comparable between the two groups (5-year cumulative incidence: 20.6% vs 9.9%, early-stage group vs advanced-stage group; P = .1827).

CONCLUSION

Our results suggested that the potential for developing remnant pancreatic cancer was comparable between the early-stage and the advanced-stage groups. Therefore, the incidence of remnant pancreatic cancer may increase along with improved pancreatic cancer treatment.

Concomitant Intraductal Papillary Mucinous Neoplasm in Pancreatic Ductal Adenocarcinoma Is an Independent Predictive Factor for the Occurrence of New Cancer in the Remnant Pancreas

OBJECTIVE

To determine the factors predicting the subsequent development of pancreatic ductal adenocarcinoma in remnant pancreas (PDAC-RP) after partial pancreatectomy for PDAC.

SUMMARY BACKGROUND DATA

PDAC-RP after partial pancreatectomy for PDAC is currently not so rare because of improved prognosis of PDAC patients due to recent advances in surgical techniques and adjuvant therapy. However, the predictive factors related to PDAC-RP remain unknown.

METHODS

We retrospectively reviewed the clinicopathological data of a consecutive series of 379 patients with PDAC treated by partial pancreatectomy between 1992 and 2015; 14 patients (3.69%) had PDAC-RP. Clinicopathological variables were compared between PDAC-RP and non-PDAC-RP.

RESULTS

In univariate analysis, concomitant intraductal papillary mucinous neoplasm (IPMN) (P = 0.0005), cancer location (body/tail) (P = 0.0060), and lower T factor in UICC (P = 0.0039) were correlated with PDAC-RP development. Multivariate analysis revealed concomitant IPMN (P = 0.0135) to be an independent predictive factor for PDAC-RP. PDAC concomitant with IPMN had higher cumulative incidence of PDAC-RP (47.5%/10 yrs) than PDAC without IPMN (9.96%/10 yrs) (P = 0.0071). Moreover, the density of pancreatic intraepithelial neoplasia lesions in the background pancreas of cases of PDAC concomitant with IPMN (1.86/cm) was higher than that of cases of PDAC without IPMN (0.91/cm) (P = 0.0007).

CONCLUSIONS

Concomitant IPMN in PDAC is an independent predictive factor for the development of new PDAC in remnant pancreas. Cancer susceptibility of remnant pancreas after resection for PDAC concomitant with IPMN is probably due to an increased density of pancreatic intraepithelial neoplasia lesions.

Three Curative Pancreatectomies for the Metachronous Appearance of Pancreatic Invasive Ductal Adenocarcinoma

We report a rare case of a patient who underwent 3 successful curative operations for the metachronous appearance of pancreatic cancer. In July 2007, a 54-year-old woman underwent pylorus-preserving pancreaticoduodenectomy. In March 2010, a tumor measuring 9 mm in diameter was detected in the tail of the pancreas on computed tomography (CT) and magnetic resonance imaging. The pancreas tail was subsequently resected while preserving the pancreatic body. In February 2011, CT revealed a cystic tumor measuring 2.5 cm in diameter in the remnant pancreatic body without any metastasis; therefore, total resection of the residual pancreas was performed in April 2011. The first resected tumor was histopathologically diagnosed as undifferentiated adenocarcinoma with osteoclast-like giant cells. Additionally, the third resected tumor had similar undifferentiated components. Contrarily, the second resected tumor was diagnosed as a well-differentiated tubular adenocarcinoma. We consider that the tumor from the third operation was an intra-pancreatic metastasis of the primary cancer and that the tumor from the second operation was the second primary cancer. The patient responded well with good control of surgical diabetes for 92 months since the last pancreatectomy. This case suggested that aggressive repeated resection for recurrent pancreatic invasive ductal adenocarcinoma is beneficial in limited cases.

High-risk lesions in the remnant pancreas: fate of the remnant pancreas after pancreatic resection for pancreatic cancer and intraductal papillary mucinous neoplasms

Progress in diagnostic modalities, surgical procedures, and multidisciplinary treatment for pancreatic diseases has increased the number of long-term survivors after pancreatic resection. Several reports have focused on high-risk lesions (HRLs), including high-grade pancreatic intraepithelial neoplasia (PanIN), pancreatic ductal adenocarcinoma, high-grade intraductal papillary mucinous neoplasm (IPMN), and IPMN with an associated invasive carcinoma, in the remnant pancreas after partial pancreatic resection for pancreatic cancer or IPMN. The etiology of HRLs in the remnant pancreas is thought to be either isolated local recurrence of the initial lesion in the remnant pancreas or a newly developed primary lesion. Although it is difficult to distinguish between local recurrence and a new primary lesion, comparison of genetic alterations between two lesions may help with this distinction. Early detection of HRLs in the remnant pancreas may improve the prognosis of patients, and several investigators have proposed predictive factors for HRLs in the remnant pancreas after partial pancreatic resection for pancreatic cancer or IPMN. The reported short- and long-term outcomes of surgical resection of HRLs in the remnant pancreas are relatively favorable. Life-long surveillance of the remnant pancreas is recommended after partial pancreatic resection for pancreatic cancer or IPMN.

Surgery for Recurrent Pancreatic Cancer: Is It Effective?

Despite improvements to surgical procedures and novel combinations of drugs for adjuvant and neoadjuvant therapies for pancreatic adenocarcinoma, the recurrence rate after radical surgery is still high. Little is known about the role of surgery in the treatment of isolated recurrences of pancreatic cancer. The aim of this study was to review the current literature dealing with surgery for recurrent pancreatic cancer in order to examine its feasibility and effectiveness. An extensive literature review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and 14 articles dealing with re-resections for recurrent pancreatic adenocarcinoma were analyzed, focusing on the characteristics of the primary neoplasm and its recurrence, the surgical procedures used, and patient outcomes. Data were retrieved on a total of 301 patients. The interval between surgery for primary pancreatic cancer and the detection of a recurrence ranged from 2 to 120 months. The recurrence was local or regional in 230 patients, and distant in 71. The median overall survival was 68.9 months (range 3-152) after resection of the primary tumor, and 26.0 months (range 0-112) after surgery for recurrent disease. The disease-free interval after the resection of recurrences was 14.2 months (range 4-29). Although data analysis was performed on a heterogeneous and limited number of patients, some of these may benefit from surgery for isolated recurrence of pancreatic adenocarcinoma. Further studies are needed to identify these cases.

Pancreatic cancer arising from the remnant pancreas after pancreatectomy: a multicenter retrospective study by the Kyushu Study Group of Clinical Cancer

BACKGROUND

After initial pancreatic resection, local recurrence of pancreatic cancer (PC) or new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this retrospective study was to clarify the clinical features and establish a treatment strategy for remnant PC.

METHODS

A multicenter retrospective study with the Kyushu Study Group of Clinical Cancer was carried out. Clinical data from 50 patients who developed remnant PC were analyzed. RAS mutation analysis of the initial tumor and of remnant PC was performed in 17 cases.

RESULTS

The initial pancreatic resections were performed for 37 invasive ductal carcinomas, and for 13 other tumors. Thirty-seven patients underwent a second pancreatectomy for remnant PC (resected group), while thirteen patients were not operated (unresected group). The median overall survival times were 42.2 months in the resected group and 12.3 months in the unresected group (HR 0.374; 95% CI 0.17-0.83). In RAS mutation analysis, 14 cases had at least 1 missense variant of KRAS, HRAS, or NRAS in the initial pancreatic tumor and/or remnant PC. The same missense variants between the initial tumor and remnant PC were discovered only in KRAS of one patient, and in HRAS of one patient. No case had completely consistent missense variants between the initial tumor and remnant PC.

CONCLUSIONS

This study found that repeated pancreatectomy for remnant PC can prolong patient survival, and RAS mutation analysis indicated that many remnant PCs are developed from metachronous multifocal origins.

Intrapancreatic recurrence of intraductal tubulopapillary neoplasm (ITPN) 16 years after the initial surgery for noninvasive ITPN: a case report

Background

Intraductal tubulopapillary neoplasm (ITPN) is a rare pancreatic intraductal neoplasm. It is characterized by a tubulopapillary growth pattern, entirely high-grade atypical cells, minimal cytoplasmic mucin, and no obvious luminal mucin secretion. Most of its biological nature remains unclear.

Case presentation

We herein report a case of intrapancreatic recurrence of ITPN in the remnant pancreas of a patient who underwent pancreatoduodenectomy 16 years previously for a noninvasive intraductal pancreatic head tumor. We reexamined the primary tumor and compared it with the most recently resected specimen. Histologically, the primary tumor showed a tubulopapillary growth of high-grade atypical cells with scanty cytoplasmic mucin, which was similar to the recently resected specimen except for the invasive area. Immunohistochemically, the neoplastic cells in both specimens showed focal staining of MUC1 and positivity for MUC6 but negativity for MUC2, MUC5AC, CDX2, and trypsin. Molecular analysis revealed no KRAS/GNAS/BRAF/PIK3CA mutations in either of the specimens.

Conclusions

These findings of the original tumor and recently resected tumor were compatible with the features of ITPN. Thus, recurrence is possible even for a primary noninvasive ITPN, and long-term surveillance is recommended.

Resection for recurrent pancreatic cancer in the remnant pancreas after pancreatectomy is clinically promising: Results of a project study for pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND

A therapeutic strategy has not been established for recurrent pancreatic cancer in the remnant pancreas. The purpose of this multicenter survey was to clarify the clinical features of remnant pancreatic cancer and to assess the appropriate operative indications.

METHODS

Clinical data from 114 patients with remnant pancreatic cancer after initial pancreatectomy were collected retrospectively. Clinicopathologic factors and overall survival curves were analyzed, and multivariate Cox proportional hazard models were evaluated.

RESULTS

Variate analysis revealed that age (≥65 years), body mass index (<20 kg/m²), tumor size (≥20 mm), distance from the pancreatic stump (<10 mm), and resection of the remnant pancreatic cancer were significant prognostic factors. The median survival times of the resected (n = 90) and the nonresected group (n = 24) were 26 and 14 months, respectively (hazard ratio: 0.56; P = .012). When the patients were classified based on recurrence patterns after a second pancreatectomy, the median survival times were 30.5 months in the no recurrence group, 32.0 in the local recurrence group, and 23.0 in the distant metastasis group. A total of 8.9% of the patients had a postoperative complication of Clavien-Dindo classification III or higher, and the 90-day mortality rate was 1.1%.

CONCLUSION

Resection of the remnant pancreatic cancer could offer a favorable outcome and a chance for a cure. In particular, a young and healthy patient with a relatively small tumor at least 10 mm away from the pancreatic stump appears to be the best candidate for reoperation. Furthermore, the safety profile of resection is acceptable.

The mitochondrial one-carbon metabolic pathway is associated with patient survival in pancreatic cancer

The expression levels of one-carbon metabolic enzymes were investigated and observed to be correlated with clinicopathological parameters in patients with pancreatic cancer. Mitochondrial one-carbon metabolism comprises a network of biological reactions that integrate nutrient status with nucleotide synthesis, amino acid metabolism, antioxidant reduced nicotinamide adenine dinucleotide phosphate production and epigenetic methylation processes. Previous studies have reported that the hyper-activation of mitochondrial one-carbon metabolism serves a significant role in malignant cancer phenotypes. A total of 103 patients underwent surgical resection of pancreatic ductal adenocarcinomas (PDAC) at Osaka University Hospital between April 2007 and December 2013 and were enrolled in this study. Subsequently, the expression of the one-carbon metabolic enzymes methylenetetrahydrofolate dehydrogenase 2 (MTHFD2), aldehyde dehydrogenase 1 family member L2 (ALDH1L2), and serine hydroxymethyltransferase (SHMT2) was examined using immunohistochemical analysis. The immunohistochemical analyses demonstrated that patients with high expression levels of MTHFD2, ALDH1L2 or SHMT2 had significantly poor overall survival (OS) and disease-free survival (DFS) rates, as compared with patients with low expression levels. Furthermore, multivariate Cox proportional hazards analysis indicated that MTHFD2 and ALDH1L2 were independent prognostic factors for OS and DFS, whereas SHMT2 was not predictive of DFS. However, high and low expression levels of all three folate metabolic enzymes were significantly associated with improved OS and DFS, compared with the high expression of one or two folate metabolic enzymes. The expression levels of mitochondrial one-carbon metabolic enzymes are independent prognostic factors and potential therapeutic targets for future pancreatic cancer treatments.

Clinical Outcome of Resected Remnant Pancreatic Cancer After Resection of the Primary Pancreatic Cancer

Purpose: Pancreatic cancer (PC) has high morbidity and mortality rates, with a poor prognosis and frequent recurrence. The postresection survival rate has increased but remains low, and remnant PC is becoming more common. This review evaluates the current literature pertaining to the clinical outcomes of patients with resected remnant PC. Material and Methods: We reviewed publications on remnant PC that included repeated and completion pancreatectomy. Clinicophysiological data were analyzed, and survival rates were calculated using the Kaplan-Meier method. Remnant PC was defined by negative margins at the initial operation, a cancer-free interval >1 year, and presence in the remnant pancreas. Results: Forty-nine cases of remnant PC selected from the literature were examined. Primary and remnant PCs had the same histopathological features in 29 of 45 patients (64.4%). The median disease-free interval was 44.3 months (12-143 months). The 1- and 3-year survival rates after repeat pancreatectomy were 81.5% and 50%, respectively, and the median survival time was 32 months. The age of the patient at the time of the first operation independently predicted survival in a multivariate analysis. Conclusion: In long-term survivors after curative resection for PC, resectable remnant PCs should be aggressively removed to improve prognosis.

Stereotactic Body Radiation Therapy for Isolated Local Recurrence After Surgical Resection of Pancreatic Ductal Adenocarcinoma Appears to be Safe and Effective

BACKGROUND

A standardized treatment regimen for unresectable isolated local recurrence (ILR) of pancreatic ductal adenocarcinoma has not been established. This study evaluated the outcomes for patients with ILR who underwent stereotactic body radiation therapy (SBRT).

METHODS

The records of patients with ILR who underwent SBRT between 2010 and 2016 were retrospectively reviewed. Symptom palliation and treatment-related toxicity were recorded. Associations between patient or treatment characteristics and overall survival (OS), progression-free survival (PFS), and local progression-free survival (LPFS) were assessed.

RESULTS

The study identified 51 patients who received SBRT for ILR. Of the 51 patients, 26 (51%) had not received radiation therapy before SBRT. The median OS was 36 months after diagnosis. From the first day of SBRT, the median OS, PFS, and LPFS were respectively 16, 7, and 10 months. Patients with a recurrence-free interval of 9 months or longer after surgery had superior OS (P = 0.019). Maintenance chemotherapy after SBRT was associated with superior OS (P < 0.001) and LPFS (P = 0.027). In the multivariable analysis, poorly differentiated tumor grade [hazard ratio (HR) 11.274], positive surgical margins (HR 0.126), and reception of maintenance chemotherapy (HR 0.141) were independently associated with OS. Positive surgical margins (HR 0.255) and maintenance chemotherapy (HR 0.299) were associated with improved LPFS. Of 16 patients, 10 (63%) experienced abdominal pain relief after SBRT. Four patients (8%) experienced grade 3 gastrointestinal toxicity, and one patient experienced grade 4 gastrointestinal toxicity.

CONCLUSIONS

Use of SBRT for ILR improved pain for a majority of the patients with acceptable acute and late toxicity. The findings show that SBRT is a feasible treatment for select patients with ILR. For those who receive SBRT, maintenance chemotherapy should be considered.

Pancreatic Cancer Arising From the Remnant Pancreas: Is It a Local Recurrence or New Primary Lesion?

Local recurrence of pancreatic cancer (PC) can occur in the pancreatic remnant. In addition, new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this review was to describe the characteristics and therapeutic strategy regarding remnant PC. A literature search was performed using Medline published in English according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The incidence of remnant PC has been reported to be 3% to 5%. It is difficult to distinguish local recurrence from new primary PC. Genetic diagnosis such as Kirsten rat sarcoma viral oncogene homolog mutation may resolve this problem. For patients with remnant PC, repeated pancreatectomy can be performed. Residual total pancreatectomy is the most common procedure. Recent studies have described the safety of the operation because of recent surgical progress and perioperative care. The patients with remnant PC without distant metastasis have shown good long-term outcomes, especially those who underwent repeated pancreatectomy. Adjuvant chemotherapy may contribute to longer survival. In conclusion, this review found that both local recurrence and new primary PC can develop in the pancreatic remnant. Repeated pancreatectomy for the remnant PC is a feasible procedure and can prolong patient survival.

Resectable adenocarcinoma developing in the remnant pancreas 7 years after partial pancreatoduodenectomy for invasive ductal adenocarcinoma of the pancreas: a case report

BACKGROUND

Pancreatic adenocarcinoma still has an excessively high mortality rate and resection is the only potentially curative treatment. The postoperative 5-year survival rate is approximately 20% and recurrence develops generally within 2 years. We report a case of a localized recurrent pancreatic adenocarcinoma in the remnant pancreas, 7 years after initial resection.

CASE PRESENTATION

In 2008 an abdominal computed tomography scan showed a mass in the pancreas of a 70-year-old white woman, who presented with occlusive jaundice and abdominal pain in her right upper quadrant. A pancreatoduodenectomy was performed for a clinically suspected pancreatic adenocarcinoma. Histology confirmed a ductal adenocarcinoma. Afterwards, she received adjuvant chemotherapy with gemcitabine. In 2015 a follow-up positron emission tomography-computed tomography scan showed a single lesion in her remnant pancreas. Subsequently, a partial re-resection was performed. Histology confirmed once again a ductal adenocarcinoma. She received adjuvant chemotherapy with gemcitabine again and is still alive almost 9 years after she had first been diagnosed as having pancreatic cancer.

CONCLUSIONS

In selected cases re-resection for pancreatic recurrence is feasible and provides a survival benefit. In cases involving late recurrence, it is difficult to distinguish between true recurrence and the development of a new tumor. In order to detect recurrences at an early stage in long-term survivors, follow-up needs to occur on a regular and long-term basis.

Systematic review on the treatment of isolated local recurrence of pancreatic cancer after surgery; re-resection, chemoradiotherapy and SBRT

BACKGROUND

The majority of patients who have undergone a pancreatic resection for pancreatic cancer develop disease recurrence within two years. In around 30% of these patients, isolated local recurrence (ILR) is found. The aim of this study was to systematically review treatment options for this subgroup of patients.

METHODS

A systematic search was performed in PubMed, Embase and the Cochrane Library. Studies reporting on the treatment of ILR after initial curative-intent resection of primary pancreatic cancer were included. Primary endpoints were morbidity, mortality and survival after ILR treatment.

RESULTS

After screening 1152 studies, 18 studies reporting on 313 patients undergoing treatment for ILR were included. Treatment options for ILR included surgical re-resection (8 studies, 100 patients), chemoradiotherapy (7 studies, 153 patients) and stereotactic body radiation therapy (SBRT) (4 studies, 60 patients). Morbidity and mortality were reported for re-resection (29% and 1%, respectively), chemoradiotherapy (54% and 0%) and SBRT (3% and 1%). Most patients had a prolonged disease-free interval before recurrence. Median survival after treatment of ILR of up to 32, 19 and 16 months was reported for re-resection, chemoradiotherapy and SBRT, respectively.

CONCLUSION

In selected patients, treatment of ILR following pancreatic resection for pancreatic cancer seems safe, feasible and associated with relatively good survival.

Second pancreatectomy for recurrent pancreatic ductal adenocarcinoma in the remnant pancreas: A pooled analysis

OBJECTIVES

The aim of this study was to examine the outcomes of second pancreatectomy for the treatment of recurrent pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas.

METHOD

Search of the PubMed database was undertaken to identify relevant English language studies. Pooled individually data were examined for clinical outcomes after second pancreatectomy for recurrent PDAC.

RESULTS

A total of 19 articles involving 55 patients were eligible for inclusion. The median disease-free interval after initial resection was 33 (range 7-143) months. Of the 55 patients reported, 52 (94.5%) patients underwent completion total pancreatectomy in the second operation for recurrences, including 15 patients who developed recurrences more than 5 years after the initial operation. There was no perioperative death. The 1-, 3- and 5-year overall survival rate after the second pancreatectomy was 82.2%, 49.2% and 40.6% respectively.

CONCLUSION

Second pancreatectomy for recurrent PDAC can be performed safely with long-term survival in selected patients.

Original Scientific Reports: Clinicopathological Findings of Remnant Pancreatic Cancers in Survivors Following Curative Resections of Pancreatic Cancers

Background

This retrospective study aimed to evaluate clinicopathological findings of remnant pancreatic cancers in survivors of invasive ductal adenocarcinomas of the pancreas (PDAC).

Methods

A group of 23 patients out of 826 who had curative resections for PDAC between 1980 and 2011 was identified and treated for metachronous pancreatic cancer.

Results

The following tubular adenocarcinomas were found at the first surgery: 3 well differentiated, 17 moderately differentiated, 1 papillary, and 1 poorly differentiated. Treatments for the remnant pancreas consisted of remnant pancreatectomy in 12 patients, chemotherapy in 6, and the best supportive care in 5. The mean time to treatment was 74.2 months. The 12 patients who received remnant resections had 10 PDACs and 2 intraductal papillary mucinous carcinomas. The median survival time was 31.6 months, and 8 patients are still alive.

Conclusions

Long-term survivors after curative resection for pancreatic cancer should receive follow-up for remnant pancreatic cancer, and aggressive resection should be considered for more favorable prognosis of PDAC.

Second primary pancreatic ductal carcinoma in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma: High cumulative incidence rates at 5 years after pancreatectomy

OBJECTIVES

The aim of this study was to determine the incidence rate and clinical features of second primary pancreatic ductal carcinoma (SPPDC) in the remnant pancreas after pancreatectomy for pancreatic ductal carcinoma (PDC).

METHODS

Data of patients undergoing R0 resection for PDC at a single high-volume center were reviewed. SPPDC was defined as a tumor in the remnant pancreas after R0 resection for PDC, and SPPDC met at least one of the following conditions: 1) the time interval between initial pancreatectomy and development of a new tumor was 3 years or more; 2) the new tumor was not located in contact with the pancreatic stump. We investigated the clinical features and treatment outcomes of patients with SPPDC.

RESULTS

This study included 130 patients who underwent surgical resection for PDC between 2005 and 2014. Six (4.6%) patients developed SPPDC. The cumulative 3- and 5-year incidence rates were 3.1% and 17.7%, respectively. Four patients underwent remnant pancreatectomy for SPPDC. They were diagnosed with the disease in stage IIA or higher and developed recurrence within 6 months after remnant pancreatectomy. One patient received carbon ion radiotherapy and survived 45 months. One patient refused treatment and died 19 months after the diagnosis of SPPDC.

CONCLUSIONS

The incidence rate of SPPDC is not negligible, and the cumulative 5-year incidence rate of SPPDC is markedly high. Post-operative surveillance of the remnant pancreas is critical for the early detection of SPPDC, even in long-term survivors after PDC resection.

Computed Tomography-Guided Cryoablation of Local Recurrence after Primary Resection of Pancreatic Adenocarcinoma

The optimal management of local recurrences after primary resection of pancreatic cancer still remains to be clarified. A 58-year-old woman developed an isolated recurrence of pancreatic cancer six year after distal pancreatectomy. Re-resection was attempted but the lesion was deemed unresectable at surgery. Then chemotherapy was administrated without obtaining a reduction of the tumor size nor an improvement of the patient's symptoms. Thus the patient underwent percutaneous cryoablation under computed tomography (CT)-guidance obtaining tumor necrosis and a significant improvement in the quality of life. A CT scan one month later showed a stable lesion with no contrast enhancement. While the use of percutaneous cryoblation has widened its applications in patients with unresectable pancreatic cancer, it has never been described for the treatment of local pancreatic cancer recurrence after primary resection. Percutaneous cryoablation deserves further studies in the multimodality treatment of local recurrence after primary pancreatic surgery.

Stromal SLIT2 impacts on pancreatic cancer-associated neural remodeling

Pancreatic ductal adenocarcinoma (PDA) is a critical health issue in the field of cancer, with few therapeutic options. Evidence supports an implication of the intratumoral microenvironment (stroma) on PDA progression. However, its contribution to the role of neuroplastic changes within the pathophysiology and clinical course of PDA, through tumor recurrence and neuropathic pain, remains unknown, neglecting a putative, therapeutic window. Here, we report that the intratumoral microenvironment is a mediator of PDA-associated neural remodeling (PANR), and we highlight factors such as 'SLIT2' (an axon guidance molecule), which is expressed by cancer-associated fibroblasts (CAFs), that impact on neuroplastic changes in human PDA. We showed that 'CAF-secreted SLIT2' increases neurite outgrowth from dorsal root ganglia neurons as well as from Schwann cell migration/proliferation by modulating N-cadherin/β-catenin signaling. Importantly, SLIT2/ROBO signaling inhibition disrupts this stromal/neural connection. Finally, we revealed that SLIT2 expression and CAFs are correlated with neural remodeling within human and mouse PDA. All together, our data demonstrate the implication of CAFs, through the secretion of axon guidance molecule, in PANR. Furthermore, it provides rationale to investigate the disruption of the stromal/neural compartment connection with SLIT2/ROBO inhibitors for the treatment of pancreatic cancer recurrence and pain.