The basal nutritional state of PDAC patients is the dominant factor for completing adjuvant chemotherapy

Efficacy of 1-Kestose Supplementation in Patients with Pancreatic Ductal Adenocarcinoma: A Randomized Controlled Pilot Study

Less than half of all patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) respond to chemotherapy, and the prognosis of PDAC is poor, which may be mediated by the gut microbiota. We investigated the clinical improvement effects of 1-kestose, a fructooligosaccharide, on PDAC chemotherapy in this single-center, randomized, controlled pilot trial conducted at Fujita Health University Hospital, which enrolled patients with PDAC. The trial included 1-kestose administration and non-administration groups. The 1-kestose group received 9 g of 1-kestose daily for 12 weeks, and their blood markers, imaging studies, physical findings, and gut microbiota were evaluated. In the 1-kestose administration group, the cancer marker CA19-9 significantly decreased, and there was a reduction in the neutrophil-to-lymphocyte ratio (NLR). There was also suppression of the reduction of albumin levels and of an increase in C-reactive protein. Additionally, Escherichia coli, which typically increases in PDAC, significantly decreased in the 1-kestose group. Thus, 1-kestose altered the gut microbiota and improved the prognostic factors for PDAC. Large-scale, long-term trials of 1-kestose interventions for PDAC are thus warranted to improve the prognosis of PDAC.

Results of a Randomized Clinical Study of Gemcitabine Plus Nab-Paclitaxel Versus Gemcitabine Plus S-1 as Neoadjuvant Chemotherapy for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma (RCT, CSGO-HBP-015)

BACKGROUND

The optimal neoadjuvant chemotherapy (NAC) regimen for patients with localized pancreatic ductal adenocarcinoma (PDAC) remains uncertain. This trial aimed to evaluate the efficacy and safety of two neoadjuvant chemotherapy (NAC) regimens, gemcitabine plus nab-paclitaxel (GA) and gemcitabine plus S-1 (GS), in patients with resectable/borderline-resectable (R/BR) PDAC.

PATIENTS AND METHODS

Treatment-naïve patients with R/BR-PDAC were enrolled and randomly allocated. They received two cycles (2 months) of each standard protocol, followed by radical surgery for those without tumor progression in general hospitals belonging to our intergroup. The primary endpoint was to determine the superior regimen on the basis of achieving a 10% increase in the rate of patients with progression-free survival (PFS) at 2 years from allocation.

RESULTS

A total of 100 patients were enrolled, with 94 patients randomly assigned to the GS arm (N = 46) or GA arm (N = 48). The 2-year PFS rates did not show the stipulated difference [GA, 31% (24-38%)/GS, 26% (18-33%)], but the Kaplan-Myer analysis showed significance (median PFS, GA/GS 14 months/9 months, P = 0.048; HR 0.71). Secondary endpoint comparisons yielded the following results (GA/GS arm, P-value): rates of severe adverse events during NAC, 73%/78%, P = 0.55; completion rates of the stipulated NAC, 92%/83%, P = 0.71; resection rates, 85%/72%, P = 0.10; average tumor marker (CA19-9) reduction rates, -50%/-21%, P = 0.01; average numbers of lymph node metastasis, 1.7/3.2, P = 0.04; and median overall survival times, 42/22 months, P = 0.26.

CONCLUSIONS

This study found that GA and GS are viable neoadjuvant treatment regimens in R/BR-PDAC. Although the GA group exhibited a favorable PFS outcome, the primary endpoint was not achieved.

Long-term nutrition in patients candidate to neoadjuvant and adjuvant treatments

To improve outcomes, to decrease the rate of local recurrence and development of distant metastases neoadjuvant and adjuvant therapies are employed in cancer patients in forms of radiation, chemo-, endocrine-, targeted-, and immunotherapy or their combination. Nutrition therapy plays important role in all phases of the cancer journey. From neoadjuvant therapy to prehabilitation, early postoperative nutrition, and long-term nutrition care during the adjuvant phase and survivorship determines the survival and quality of life of cancer patients. During the neoadjuvant phase patients may be in poor nutritional condition which can be aggravated by the applied oncological treatment. Beside this apparent threat this period also gives an excellent opportunity to maintain or even improve the nutritional status of the patients by nutrition therapy. After surgery the burdening effects of the operation may jeopardize the execution of adjuvant therapy. After early postoperative feeding a long-term nutrition strategy should be developed for cancer patients in order to avoid nutritional deterioration during the usually lengthy postoperative therapy. In this narrative review we discuss how preoperative nutritional status and medical nutrition therapy influence the results of surgery and after the operation what is the available evidence about nutritional status and outcome and the potentials to influence them by nutrition therapy.

C-Reactive Protein-to-Albumin Ratio to Predict Tolerability of S-1 as an Adjuvant Chemotherapy in Pancreatic Cancer

Adjuvant chemotherapy (AC) with S-1 after radical surgery for resectable pancreatic cancer (PC) has shown a significant survival advantage over surgery alone. Consequently, ensuring that patients receive a consistent, uninterrupted S-1 regimen is of paramount importance. This study aimed to investigate whether the C-reactive protein-to-albumin ratio (CAR) could predict S-1 AC completion in PC patients without dropout due to adverse events (AEs). We retrospectively enrolled 95 patients who underwent radical pancreatectomy and S-1 AC for PC between January 2010 and December 2022. A statistical analysis was conducted to explore the correlation of predictive markers with S-1 completion, defined as continuous oral administration for 6 months. Among the 95 enrolled patients, 66 (69.5%) completed S-1, and 29 (30.5%) failed. Receiver operating characteristic curve analysis revealed 0.05 as the optimal CAR threshold to predict S-1 completion. Univariate and multivariate analyses further validated that a CAR ≥ 0.05 was independently correlated with S-1 completion (p < 0.001 and p = 0.006, respectively). Furthermore, a significant association was established between a higher CAR at initiation of oral administration and acceptable recurrence-free and overall survival (p = 0.003 and p < 0.001, respectively). CAR ≥ 0.05 serves as a predictive marker for difficulty in completing S-1 treatment as AC for PC due to AEs.

Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

Experience of living with symptom clusters in postoperative pancreatic cancer patients

OBJECTIVE

The purpose of this study was to describe symptom clusters (SCs), and symptom experiences in early postoperative patients with pancreatic cancer who are recovering at home.

METHODS

From October 2021 and April 2022,15 patients following pancreatic cancer surgery were recruited from a tertiary hospital in Jiangsu Province by maximum variation sampling. Semi-structured interviews were performed to collect data and thematic analysis was conducted to analyze the data.

RESULTS

Three themes were extracted from the data. The first theme "difference in symptom perception and cognition" illustrated factors such as patient knowledge, expected recovery status, and risk perception could influence patient symptom experience. Most patients actually reported fewer and less severe symptoms than previous studies. The second theme "the results of symptom cluster" demonstrated anorexia-distress SC, bowel-digestive related SC and sleep disturbance related SC, and anorexia-distress SC should be considered as the priority SC given its multidimensional significance for patients. The last theme described the patient's positive attitudes, behaviours and barriers to coping with symptoms, namely "symptom self-management experience".

CONCLUSION

There are differences in the perception and interpretation of SCs in postoperative pancreatic cancer patients. Understanding the meaning of individual differences in the experience of symptoms can assist patients in the management of SCs. Medical staff should combine patient self-management strategies and evidence-based data to provide appropriate support at different stages to improve patient symptom management and quality of life.

Strategy of Pancreatectomies for Pancreatic Ductal Adenocarcinoma in Patients with a History of Gastrectomy

Recently, the incidence of pancreatectomy for patients with a history of upper abdominal surgery has been increasing. The clinical courses of 307 patients who underwent the pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) were retrospectively reviewed to clarify the impact of a history of gastrectomy in patients undergoing a pancreatectomy for PDAC. Among 307 patients, 28 (9.1%) had a history of gastrectomy, while 279 did not. We compared the difference in clinical course and prognostic outcomes between the groups. In patients with a history of gastrectomy, the 5-year survival rate was 17.6%, which was relatively poorer than that of patients without it (33.4%, P = 0.1329). A multivariate analysis of factors associated with the overall survival rate identified the low preoperative body mass index [BMI < 20.3 kg/m2, hazard ratio (HR) 1.646, P = 0.0190] and adjuvant chemotherapy (not-completed, HR 1.652, P = 0.0170) as independent prognostic factors. In patients with a history of gastrectomy, there were significantly more patients with poor prognostic factors, including a low preoperative BMI (P = 0.0009) and low completion rate of adjuvant chemotherapy (P = 0.0294) as compared with those without a history of gastrectomy. A low preoperative BMI significantly reduced the completion rate of adjuvant chemotherapy (P = 0.0186), which may lead to poor prognostic outcomes. In conclusion, perioperative nutritional management is important to reduce postoperative BMI loss and obtain a better prognosis after a pancreatectomy for PDAC in patients with a history of gastrectomy.

The impact of nutritional status on pancreatic cancer therapy

INTRODUCTION

Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive disease with poor outcomes. One of the reasons for the dismal prognosis resides in its impressive ability to alter the nutritional status of patients who develop malnutrition, cachexia, anorexia, and sarcopenia in most cases. The ideal way to measure such changes in PDAC patients, in order to readily identify them and avoid complications or discontinuations of treatment is a relatively unexplored area. In addition, most PDAC patients experience pancreatic exocrine insufficiency (PEI) that contributes to the complex puzzle of malnutrition and that can be treated with Pancreatic Enzyme Replacement Therapy (PERT).

AREAS COVERED

We review current knowledge on the impact of nutritional status on both surgical and medical treatments for PDAC, reporting available data on the causes of malnutrition, characteristics, and advantages of different tools to investigate nutritional status and possible strategies to improve patient outcomes.

EXPERT OPINION

All PDAC patients should receive a careful nutritional assessment at diagnosis, and this should be repeated alongside their treatment path. Screening tools and biochemical variables or scores are associated with prognosis, but bioimpedance vector analysis (BIVA) and radiological assessment of body composition seem more accurate in predicting clinical outcomes and postoperative complications.

Prospective trial to evaluate the prognostic value of different nutritional assessment scores for survival in pancreatic ductal adenocarcinoma (NURIMAS Pancreas SURVIVAL)

BACKGROUND

Malnutrition is associated with poor survival in pancreatic cancer patients. Nutritional scores show great heterogeneity diagnosing malnutrition. The aim of this study was to find the score best suitable to identify patients with malnutrition related to worse survival after surgery for pancreatic ductal adenocarcinoma (PDAC). This study represents a follow-up study to the prospective NURIMAS Pancreas trial that evaluated short term impact of nutritional score results after surgery.

METHODS

Risk of malnutrition was evaluated preoperatively using 12 nutritional assessment scores. Patients were followed-up prospectively for at least 3 years. Patients at risk for malnutrition were compared with those not at risk according to each score using Kaplan-Meier survival statistics.

RESULTS

A total of 116 patients receiving a PDAC resection in curative intent were included. Malnutrition according to the Subjective Global Assessment score (SGA), the Short Nutritional Assessment Questionnaire (SNAQ), and the INSYST2 score was associated with worse overall survival (SGA: at-risk: 392 days; not at-risk: 942 days; P = 0.001; SNAQ: at-risk: 508 days; not at-risk: 971 days; P = 0.027; INSYST2: at-risk: 538 days; not at risk: 1068; P = 0.049). In the multivariate analysis, SGA (hazard ratio of death 2.16, 95% confidence interval 1.34-3.47, P = 0.002) was associated with worse overall survival.

CONCLUSIONS

Malnutrition as defined by the Subjective Global Assessment is independently associated with worse survival in resected PDAC patients. The SGA should be used to stratify PDAC patients in clinical studies. Severely malnourished patients according to the SGA profit from intensified nutritional therapy should be evaluated in a randomized controlled trial.

Randomized phase II study of gemcitabine and S-1 combination therapy versus gemcitabine and nanoparticle albumin-bound paclitaxel combination therapy as neoadjuvant chemotherapy for resectable/borderline resectable pancreatic ductal adenocarcinoma (PDAC-GS/GA-rP2, CSGO-HBP-015)

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease, and multimodal strategies, such as surgery plus neoadjuvant chemotherapy (NAC)/adjuvant chemotherapy, have been attempted to improve survival in patients with localized PDAC. To date, there is one prospective study providing evidence for the superiority of a neoadjuvant strategy over upfront surgery for localized PDAC. However, which NAC regimen is optimal remains unclear.

METHODS

A randomized, exploratory trial is performed to examine the clinical benefits of two chemotherapy regimens, gemcitabine plus S-1 (GS) and gemcitabine plus nab-paclitaxel (GA), as NAC for patients with planned PDAC resection. Patients are enrolled after the diagnosis of resectable or borderline resectable PDAC. They are randomly assigned to either NAC regimen. Adjuvant chemotherapy after curative resection is highly recommended for 6 months in both arms. The primary endpoint is tumor progression-free survival time, and secondary endpoints include the rate of curative resection, the completion rate of protocol therapy, the recurrence type, the overall survival time, and safety. The target sample size is set as at least 100.

DISCUSSION

This study is the first randomized phase II study comparing GS combination therapy with GA combination therapy as NAC for localized pancreatic cancer.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000021484 . This trial began in April 2016.

Controlling Nutritional Status score is superior to Prognostic Nutritional Index score in predicting survival and complications in pancreatic ductal adenocarcinoma: a Chinese propensity score matching study

Preoperative nutritional status plays an important role in predicting postoperative outcomes. Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) are good tools to assess patients' nutritional status. They have been used in predicting outcomes in various malignancies, but few studies have focused on pancreatic adenocarcinoma (PDAC) patients. Totally, 306 PDAC patients were enrolled. The propensity score matching (PSM) method was introduced to eliminate the baseline inequivalence. Patients with different PNI (or CONUT) scores showed inequivalence baseline characteristics, and patients with compromised nutritional status were related with a more advanced tumour stage. After PSM, the baseline characteristics were well balanced. Both low PNI (≤45) and high CONUT (≥3) were independent risk factors for poor overall survival (P < 0·05), and the result remained the same after PSM. Survival analysis demonstrated both patients with low PNI and high CONUT score were associated with poorer survival, and the result remained the same after PSM. The results of AUC indicated that CONUT might have a higher sensitivity and specificity in predicting complications and survival. Preoperative low PNI (≤45) and high CONUT (≥3) scores might be reliable predictors of prognosis and surgical complications in PDAC patients. Compared with PNI, CONUT might be more effective.

Application of C. elegans cancer screening test for the detection of pancreatic tumor in genetically engineered mice

Pancreatic ductal adenocarcinoma (PDAC) exhibits a very early onset of metastasis. Thus, early detection and treatment are pivotal to successful eradication of pancreatic cancers. Economical and non-invasive cancer screening systems is indispensable for this purpose. Previously our group developed a novel method to detect various kinds of human cancer using nematode Caenorhabditis elegans (C. elegans) that respond to cancer odor in urine; however, whether this method is useful for non-human species remains to be understood. In this study, we examined its effectiveness in the detection of murine pancreatic tumor spontaneously generated in genetically-engineered mice. We generated pancreas-specific Kras ^G12D and/or c-Met deletion mutant mice and measured the probability of spontaneous tumor generation in these mice. The chemotactic indexes of C. elegans to the urine samples of these mutant mice were measured. As previously described, oncogenic Kras^G12D was necessary to induce pancreatic intraepithelial neoplasia in this mouse model, while c-Met mutation did not show further effect. The chemotactic analysis indicated that C. elegans avoids urine of healthy recipient mice, while they tended to be attracted to urine of mice with Kras^G12D . Our study demonstrated that C. elegans can recognize the odor of pancreatic cancer in urine of Kras^G12D model mouse, suggesting the similarity of cancer odor between species. Our result facilitates further studies on mechanism of cancer detection by C. elegans.

Cigarette Smoking and Mortality in Patients With Pancreatic Cancer: A Systematic Review and Meta-analysis

Current evidence on cigarette smoking associated with pancreatic cancer mortality is limited. We searched MEDLINE, Web of Science, and Embase databases to identify relevant studies published through January 31, 2018. A random-effects model was used to estimate summary hazard ratios (HRs) and 95% confidence intervals (CIs). A total of 20 studies were retrieved, involving 2,517,623 participants. Of these, more than 15,341 patients with pancreatic cancer died. Compared with never smokers, current (summary HR, 1.56; 95% CI, 1.34-1.83) and former (summary HR, 1.15; 95% CI, 1.06-1.26) smokers had elevated risk of total mortality in patients diagnosed with pancreatic cancer. This effect of cigarette smoking is observed both in the Western regions and the Asia-Pacific regions. This effect of smoking is independent of alcohol use, body mass index, and history of diabetes but is modified by tumor stage and study settings. Dose-response associations between smoking and pancreatic cancer mortality were revealed for smoking intensity, cumulative amount of cigarettes smoked, and duration of smoking. Cigarette smoking was associated with an increase in total mortality for patients with pancreatic cancer. Future studies should further clarify the role of smoking as an effect modifier in treatment trials of pancreatic cancer.

Role of histone deacetylase 1 in distant metastasis of pancreatic ductal cancer

Current therapies for pancreatic ductal cancer (PDAC) do not sufficiently control distant metastasis. Thus, new therapeutic targets are urgently needed. Numerous studies have suggested that the epithelial-mesenchymal transition (EMT) is pivotal for metastasis of carcinomas. The fact that the EMT is reversible suggests the possibility that it is induced by an epigenetic mechanism. In this study, we aimed to investigate the role of histone deacetylase 1 (HDAC1), which is an epigenetic mechanism on distant metastasis of PDAC. We investigated the HDAC1 expression in 103 resected PDAC specimens obtained from patients who were treated with/without preoperative therapy using immunohistochemistry. To validate the findings in the clinical samples, we evaluated the HDAC1 activity, the EMT-associated genes and the migration/invasion ability in vitro, and performed an HDAC1 inhibitor assay. The high expression of HDAC1 in clinical samples was significantly associated with poor progression-free survival, especially distant metastasis-free survival. In vitro, HDAC1 inhibitors decreased the invasion ability and reversed the EMT change; the only factor to show a concomitant decrease was the expression of SNAIL. We confirmed that the HDAC1 expression was associated with the SNAIL expression in clinical samples. Moreover, the resistant cells and parental cells did not show any significant differences in the expression of HDAC1; this was consistent with the finding that preoperative therapy did not alter the HDAC1 expression in clinical samples. The targeting of HDAC1, which could suppress metastasis by inhibiting the EMT, is a promising treatment option for PDAC.

The investigation of the survival time after recurrence in patients with pancreatic ductal adenocarcinoma for individualization of adjuvant chemotherapy

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease; however, the frequency of recurrence can be reduced if curative surgery following adjuvant chemotherapy is applied. At present, adjuvant chemotherapy is uniformly performed in all patients, as it is unclear which tumor types are controlled best or worst. We investigated patients with recurrence to establish the optimum treatment strategy.

METHODS

Of 138 patients who underwent curative surgery for PDAC, 85 developed recurrence. Comprehensive clinicopathological factors were investigated for their association with the survival time after recurrence (SAR).

RESULTS

The median SAR was 12.6 months. Treatments for recurrence included best supportive care, GEM-based therapy and S-1. The performance status [hazard ratio (HR) 0.12, P < 0.001], histological invasion of lymph vessels (HR 0.27, P < 0.001), kind of treatment for recurrence (HR 5.0, P < 0.001) and initial recurrence site (HR 2.9, P < 0.001) were independent significant risk factors for the SAR. The initial recurrence sites were the liver (n = 21, median SAR 8.8 months), lung (n = 10, 14.9 months), peritoneum (n = 6, 1.7 months), lymph nodes (n = 6, 14.7 months), local site (n = 17, 13.9 months) and multiple sites (n = 25, 10.1 months). A shorter recurrence-free survival (< 1 year) and higher postoperative CA19-9 level were significantly associated with critical recurrence (peritoneal/liver).

CONCLUSIONS

Several risk factors for SAR were detected in this study. Further investigations are needed to individualize the adjuvant chemotherapy for each patient with PDAC.

Association of iron metabolic enzyme hepcidin expression levels with the prognosis of patients with pancreatic cancer

Hepcidin and ferroportin, which are known as key iron regulators, may be used in future treatments of pancreatic ductal adenocarcinoma. Iron is essential for life support; it helps oxygen molecules bind to hemoglobin and acts as an important catalytic enzyme center. However, iron overload is a risk factor for cancer, possibly through the generation of reactive oxygen species (ROS). Hepcidin, which is a peptide hormone mainly generated by the liver, inhibits iron absorption via enterocytes and iron release from macrophages. Notably, hepcidin regulates iron homeostasis in the body by regulating the iron transporter ferroportin. In the present study, it was assumed that high hepcidin expression and low ferroportin expression result in malignancy. Therefore, it was examined whether hepcidin and ferroportin expression levels were correlated with the prognosis of pancreatic cancer in patients. Results revealed that high hepcidin expression levels and low ferroportin expression levels in pancreatic cancer tissue were significantly associated with poor prognosis in the analyses of overall survival (P=0.0140 and 0.0478, respectively). Additionally, there was no significant difference in disease-free survival in the hepcidin- and ferroportin-staining groups. Hepcidin expression correlated with the pathological stage and vascular invasion (P=0.0493 and 0.0400, respectively), and ferroportin expression was correlated with age (P=0.0372). Multivariate analysis of overall survival in the hepcidin-staining group revealed that pathological N factor (pN), adjuvant chemotherapy, and hepcidin expression were independent prognostic factors (P=0.0450, 0.0002, and 0.0049, respectively). Similarly, multivariate analysis of overall survival in the ferroportin-staining group revealed that vascular invasion, and ferroportin expression were independent prognostic factors (P=0.0028, P<0.0001, and P=0.0056, respectively). Thus, hepcidin and ferroportin expressions might be novel prognostic indicators for pancreatic cancer.

Patients Treated with Preoperative Chemoradiation for Pancreatic Ductal Adenocarcinoma have Impaired Bone Density, a Predictor of Distant Metastasis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a lethal neoplasm that spreads to surrounding tissue or distant sites. This study investigated distant metastases in PDAC patients with or without preoperative chemoradiation therapy (CRT), focusing on vitamin D levels and bone density.

METHODS

This study included 146 patients with PDAC who underwent surgery from 2007 to 2014. Bone density was evaluated using computed tomography, and the preoperative vitamin D level was calculated by enzyme-linked immunosorbent assay (ELISA) for patients with available plasma (48 cases).

RESULTS

When the patients were divided into two groups according to the change in bone density, the group with decreased bone density had a shorter distant metastasis-free survival time (DMFS) after surgery than the other group (p < 0.05). Low vitamin D was a weak predictor of DMFS, but the difference was not significant (p = 0.08), perhaps because of the sample size. Multivariate analysis indicated three significant factors associated with distant metastasis: a decrease in bone density (hazard ratio [HR], 2.17; p = 0.04), normalization of the Dupan-2 value after surgery (hazard ratio [HR], 0.39; p = 0.02), and completion of adjuvant chemotherapy (HR, 0.29; p < 0.01). Univariate analysis showed that a low vitamin D concentration (<20 pg/ml) was a risk factor (p = 0.04) for bone density change. Multivariate analysis found that preoperative CRT was the only factor associated (±, OR, 5.8; p = 0.04) with bone density change, suggesting that preoperative CRT significantly decreases bone density in patients with insufficient vitamin D.

CONCLUSION

Patients treated with preoperative CRT tend to have impaired bone density, which is a predictor of distant metastasis. Thus, vitamin D supplementation may decrease distant metastasis.

Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.

Expression of podoplanin in stromal fibroblasts plays a pivotal role in the prognosis of patients with pancreatic cancer

Purpose

To investigate the role of podoplanin (PDPN) expression in invasive ductal carcinoma of the pancreas (IDCP) in humans.

Methods

Tumor samples were obtained from 95 patients with IDCP. Immunohistochemical staining was done to evaluate the expression of PDPN in cancer tissues.

Results

PDPN was detected predominantly in stromal fibroblasts, stained with α-smooth muscle actin. The cutoff value of PDPN-positive areas was calculated according to a histogram. There was no significant difference in clinicopathologic factors between patients with high vs. those with low PDPN expression. The high PDPN group showed significantly poorer disease-free and disease-specific survival rates than the low PDPN group. Among patients from the high PDPN group, those with lymph node metastases and those with a tumor larger than 20 cm in diameter had significantly poorer prognoses than similar patients from the low PDPN group. Multivariate Cox proportional hazards analysis indicated that a high expression of PDPN was an independent risk factor for disease-specific survival.

Conclusions

PDPN expression in cancer-related fibrotic tissues is associated with a poor prognosis, especially in patients with large tumors or lymph node metastases.

Successful removal of an internal pancreatic stent that migrated into the bile duct using double-balloon enteroscopy after pancreaticoduodenectomy

PURPOSE

Internal stents used during pancreaticoduodenectomy (PD) are generally spontaneously passed through the rectum by defecation. However, we encountered six patients with internal stents that migrated into the bile duct after PD. We herein report the outcomes of these six patients and the usefulness of double-balloon enteroscopy (DBE) for removal of such stents from the bile duct.

METHODS

An internal stent was placed across pancreaticojejunostomy in 416 (68.8%) of 605 consecutive patients undergoing PD between 2005 and 2015. This study evaluated the characteristics and outcomes of the six patients whose internal stent migrated into the bile duct.

RESULTS

Migration of an internal stent into the bile duct was found during follow-up computed tomography (CT) in 6 (1.4%) of 416 patients who had an internal stent placed during PD. Three patients developed stent-induced cholangitis, and two had bile duct stones. Excluding one patient whose internal stent spontaneously slipped out and disappeared from the bile duct, all patients underwent successful removal of a stent from the bile duct by a single instance of biliary intervention involving DBE.

CONCLUSIONS

Removal of a stent from the bile duct using DBE is a feasible and useful procedure that should be considered if an internal stent is detected during follow-up CT after PD.

Risk factors of postoperative pancreatic fistula after distal pancreatectomy using a triple-row stapler

PURPOSE

Postoperative pancreatic fistula (POPF) is one of the major complications in patients who undergo distal pancreatectomy (DP). Recently, dividing the pancreas by stapler is a commonly performed technique, however, POPF still occurs. Therefore, the purpose of this study was to investigate the risk factors for POPF after DP using a triple-row stapler.

METHODS

A total of 75 patients underwent DP using a triple-row stapler (Endo GIA™ Reloads with Tri-Staple™ Technology 60 mm; COVIDIEN, North Haven, CT, USA) at Yamanashi University from December 2012 to December 2016. The clinical risk factors for POPF after DP using a triple-row stapler were identified based on univariate and multivariate analyses.

RESULTS

Clinical POPF (ISGPF Grade B and C) was seen in 7 of 75 patients (9.3%). The body mass index (BMI) was significantly higher in the patients with POPF (26.8 ± 0.5 kg/m²) compared with the patients without POPF (21.4 ± 0.4 kg/m²; a cut-off value; 25.7 kg/m²). In addition, the patients with POPF were significantly younger than the patients without POPF (56.4 ± 5.6 vs 67.0 ± 1.5; a cut-off value was 57.0 years old).

CONCLUSIONS

BMI and age were found to be significant risk factors for POPF after DP using a triple-row stapler.