Tumor infiltration in the medial resection margin predicts survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

Intraoperative liquid biopsy as a tool for detecting R1 resection during pancreatoduodenectomy in patients with pancreatic carcinoma: the CETUPANC trial (part II)

INTRODUCTION

A positive surgical margin (R1 resection) is a relevant risk factor for local recurrence in patients with pancreatic ductal adenocarcinoma of the pancreas (PDAC). An intraoperative liquid biopsy (ILB) based on tumor cell mobilization could help to detect R1 resection intraoperatively.

OBJECTIVE

To evaluate the potential role of the intraoperative circulating tumor cells (CTCs) and cluster mobilization on the R0/R1 detection.

METHODS

Sixty-three patients with resectable PDAC of the head of the pancreas were prospective enrolled under the CETUPANC trial. Open pancreaticoduodenectomy (PD) was done in all patients. Intraoperative CTCs and clusters were determined during PD.

RESULTS

The overall rate of R1 resection was 34.9% (22/63 patients). Multivariate analysis showed that factors associated with R1 resection (AUC=0.920) were the presence of undifferentiated G3 tumor (P=0.017), microscopic vascular invasion (P=0.016), and the intraoperative increase of both free CTCs and clusters in portal vein determination from the beginning to the end of the surgery (P=0.002 and P=0.005, respectively). A specific logistic regression model, including delta end to baseline CTCs and cluster mobilization to achieve a combined cut-off to detect R1 detection was calculated (AUC=0.799). The obtained R1-index based on ILB had 84% of sensitivity and 68% of specificity to detect R1 resection.

CONCLUSIONS

The ILB based on the intraoperative mobilization of CTCs and clusters from the beginning to the end of the PD was a predictive factor to detect R1 resection in patients with PDAC.

Prognostic significance of involvement of the circumferential resection margin/surface in patients with pancreatic head cancer: A prospective evaluation of pancreatoduodenectomy specimens using the 0 and 1 mm rules

BACKGROUND/OBJECTIVES

The prognostic significance of circumferential resection margin (CRM) or circumferential surface (CS) in pancreatic head cancer is controversial. We investigated the survival outcomes according to CRM or CS involvement in pancreatoduodenectomy specimens of pancreatic ductal adenocarcinoma (PDAC).

METHODS

A total of 102 pancreatoduodenectomy specimens after upfront surgery for PDAC between 2014 and 2018 were prospectively collected. The superior mesenteric vein/portal vein or superior mesenteric artery margins were classified as CRM, and the anterior or posterior surfaces as CS. Survival outcomes and recurrence were compared according to the CRM/CS status, which was categorized into R10mm, R11mm, and R0 (≥1 mm) by the 0 and 1 mm rules.

RESULTS

For CRM, R10mm had significantly lower overall survival (OS) (P < 0.001) and disease-free survival (P < 0.001) rates than R11mm and R0, with no difference between R11mm and R0. For CS, R0 had a significantly higher OS rate (P < 0.001) than R10mm and R11mm, with no difference between R10mm and R11mm. In multivariable analysis, R10mm CRM was an independent risk factor for OS (hazard ratio 2.410, P = 0.003) and DFS (hazard ratio 5.019, P < 0.001). When CRM/CS were analyzed separately, only the R10mm superior mesenteric artery margin was significantly associated with local recurrence (P = 0.012).

CONCLUSIONS

The results suggest that CRM involvement defined by the 0 mm rule is more appropriate than the 1 mm rule for predicting survival outcomes, but CS involvement defined by the 0 or 1 mm rules is not prognostically significant.

Resection Margin Status and Long-Term Outcomes after Pancreaticoduodenectomy for Ductal Adenocarcinoma: A Tertiary Referral Center Analysis

The influencing role of resection margin (R) status on long-term outcomes, namely overall (OS) and disease-free survival (DFS), after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is not still clear. The aim of this study is to evaluate the prognostic impact of R status after PD and to define tumor characteristics associated with a positive resection margin (R1). All PDs for PDAC performed between 2012 and 2023 were retrospectively enrolled. The effect of R status, patient clinico-demographic features, and tumor features on OS and DFS were assessed. One-hundred and sixty-seven patients who underwent PD for PDAC were included in the study. R0 was achieved in 105 cases (62.8%), while R1 was evidenced in 62 patients (37.1%). R1 was associated with a decreased OS (23 (13-38) months) as compared to R0 (36 (21-53) months) (p = 0.003). Similarly, DFS was shorter in R1 patients (10 (6-25) months) as compared to the R0 cohort (18 (9-70) months) (p = 0.004), with a consequent higher recurrence rate in cases of R1 (74.2% vs. 64.8% in the R0 group; p = 0.04). In the multivariate analysis, R1 and positive lymph nodes (N+) were the only independent influencing factors for OS (OR: 1.6; 95% CI: 1-2.5; p = 0.03 and OR: 1.7; 95% CI: 1-2.8; p = 0.04) and DFS (OR: 1.5; 95% CI: 1-2.1; p = 0.04 and OR: 1.8; 95% CI: 1.1-2.7; p = 0.009). Among 111 patients with N+ disease, R1 was associated with a significantly decreased DFS (10 (8-11) months) as compared to R0N+ patients (16 (11-21) months) (p = 0.05). In conclusion, the achievement of a negative resection margin is associated with survival benefits, particularly in cases of N1 disease. In addition, R0 was recognized as an independent prognostic feature for both OS and DFS. This further outlines the relevant role of radical surgery on long-term outcomes.

Prognostic significance of margin clearance in pancreaticoduodenectomy specimens with pancreatic ductal adenocarcinoma in a Danish population-based nationwide study

BACKGROUND

In this nationwide population-based cohort study, we investigated the overall minimum margin width that is independently associated with improved survival following pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) and evaluated whether certain margins or surfaces hold independent prognostic significance.

METHODS

Data from 367 patients who underwent PD for PDAC in the period 2015-2019 were retrieved from the Danish Pancreatic Cancer Database. Missing data were obtained by review of pathology reports and re-microscopy of resection specimens. Surgical specimens were evaluated using a standardised pathological protocol involving multicolour inking, axial slicing and exact reporting of circumferential margin clearances in 0.5 mm increments.

RESULTS

When categorised according to margin widths of <0.5, <1.0, <1.5, <2.0, <2.5 and <3.0 mm, R1 resections were detected in 34%, 57%, 75%, 78%, 86% and 87% of cases, respectively. In multivariable analyses, an overall margin clearance of ≥1.5 mm was associated with improved survival compared with a clearance of <1.5 mm (HR 0.70 95% CI 0.51-0.97 (p = 0.031)). When evaluating the margins separately, no margin had independent prognostic significance.

CONCLUSION

Margin clearance of at least 1.5 mm was independently associated with improved survival following PD for PDAC.

The impact of resection margin distance on survival and recurrence in pancreatic ductal adenocarcinoma in a retrospective cohort analysis

BACKGROUND

The prognostic effect of resection margin status following pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) remains controversial, even with the implementation of standardized pathological assessment. We therefore investigated the impact of resection margin (RM) status and RM distance in curative resected PDAC on overall survival (OS), disease-free survival (DFS) and recurrence.

METHOD

108 patients were retrieved from a prospectively maintained database of a certified pancreatic cancer center. Distribution and relationships between circumferential resection margin (CRM) involvement (CRM≤1mm; CRM>1mm; CRM≥2mm) and their prognostic impact on OS and DFS were assessed using Kaplan-Meier statistics and the Log-Rank test. Multivariate logistic regression was used explain the development of a recurrence 12 months after surgery.

RESULTS

63 out of 108 patients had medial RM and 32 posterior RM involvement. There was no significant difference in OS and DFS between CRM≤1mm and CRM>1mm resections. Clearance at the medial margin of ≥2mm had an impact on OS and DFS, (RM≥2mm vs. RM<2mm: median OS 29.8 vs 16.8 months, median DFS 19.6 vs. 10.3 months). Multivariate analysis demonstrated that age, medial RM ≥2mm, lymph node status and chemotherapy were prognostic factors for OS and DFS. Posterior RM had no influence on OS or DFS.

CONCLUSION

Not all RM seem to have the same impact on OS and DFS, and a clearance of 1mm for definition of a negative RM (i.e. CRM>1mm) seems not sufficient. Future studies should include more patients to stratify for potential confounders we could not account for.

TRIAL REGISTRATION

This study was registered with the German Clinical Trials Registry (reference number DRKS0017425).

Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma

Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.

Histopathological evaluation of resected intraductal papillary mucinous neoplasms reveals distinct patterns of invasion in associated carcinomas

Invasive intraductal papillary mucinous neoplasms (inv-IPMNs) have a better prognosis than regular pancreatic ductal adenocarcinoma (PDAC), but no association with status of surgical margins and microscopic infiltration patterns has previously been described. The aim of this study is to review patterns of invasion and the predictive value of clinical guidelines in terms of rates of resection of high-grade dysplasia (HGD) and cancer among intraductal papillary mucinous neoplasms (IPMNs). Consecutively, resected IPMNs between 2011 and 2017 were analyzed. Data were obtained from a prospectively maintained database. A total of 132 patients were identified. Out of these, 38 patients with inv-IPMNs, initially identified as solid lesions suspicious of cancer, were compared with a control group of 101 patients with ordinary PDAC. Lower rates of vascular invasion, perineural invasion, lymph node metastasis, advanced T stage, and R1 status were characteristic of the inv-IPMNs in addition to better overall survival (OS) for a low tumor stage. Furthermore, as novel findings, the PDACs presented with resection margin involvement of 3 or more positive margins (31.3% vs. 9.5%, p = 0.044), associated with poor OS. Of the patients presenting as pT3, the inv-IPMN less often invaded more than one extrapancreatic anatomical structure (40.1% vs. 63.9%, p = 0.03). Regarding the predictive value of clinical guidelines, the frequency of resected HGD in IPMNs with high-risk stigmata (n = 54) and IPMNs with worrisome features was 30.7%, and the frequency of invasive carcinoma was 5.7%. In conclusion, we report a low resection rate of high-risk IPMNs and present novel findings describing inv-IPMNs as a less infiltrative phenotype compared with regular PDAC.

Clinicopathological and prognostic significance of ubiquitin-specific peptidase 15 and its relationship with transforming growth factor-β receptors in patients with pancreatic ductal adenocarcinoma

BACKGROUND AND AIM

Ubiquitin-specific peptidase 15 (USP15) has been correlated to aggressive oncogenic behavior in several types of carcinomas, but its function in pancreatic ductal adenocarcinoma (PDAC) has not been clarified. This study aimed to evaluate the clinicopathological and prognostic value of USP15 and its relationship with transforming growth factor-β (TGF-β) receptors (TβRs) in PDAC.

METHODS

By immunohistochemical staining of tissue microarrays, the expression patterns of USP15 and TβRs were retrospectively analyzed in 287 PDAC patients who underwent radical surgical resection without neoadjuvant therapy. Cancer-specific survival was compared based on USP15 expression, and the correlations between USP15 and TβRs were analyzed.

RESULTS

Ubiquitin-specific peptidase 15 expression in tumor tissues was significantly higher than that in para-tumor tissues (P < 0.0001), and high USP15 expression was associated with the pathological N (pN) stage (P = 0.033). In addition, high USP15 expression was significantly associated with shorter cancer-specific survival (P = 0.019). Univariate analyses showed that high USP15 expression (P = 0.024), a poor histopathological grade (P = 0.003), and the pN1 stage (P = 0.009) were significantly correlated with shorter survival. Although the independent prognostic value of USP15 alone was not established, the combination of USP15 and the histological grade was identified as an independent prognostic factor in multivariate analyses (P = 0.015). USP15 expression was correlated with TβR-I, TβR-II, or TβR-III expression in PDAC.

CONCLUSIONS

High USP15 expression is a potential prognostic indicator in patients with PDAC, and it might affect the TGF-β signaling pathway in PDAC.

Elevated TIAM2 expression promotes tumor progression and is associated with unfavorable prognosis in pancreatic cancer

BACKGROUND AND AIM

As a Rac1 guanine nucleotide exchange factor, T-cell lymphoma invasion and metastasis 2 (TIAM2) has been reported to be correlated with malignant phenotypes in several cancers, but its prognostic significance and function in pancreatic ductal adenocarcinoma (PDAC) was not investigated.

METHODS

The expression patterns of TIAM2 and patient survival were analyzed in a large cohort of 303 patients with radical surgical resection of PDAC, using immunohistochemical staining in tissue microarrays. Data mining was applied to evaluate TIAM2 expression and patient survival at the mRNA level. The function of TIAM2 in proliferation, motility and invasion of pancreactic cancer (PC) cells was also investigated.

RESULTS

TIAM2 expression was significantly increased in PDAC compared with para-tumor tissues (p < .0001). The expression of TIAM2 was associated with histopathological grade (p = .008), tumor location (p = .013), and pathological T stage (p = .029). For survival, patients with high TIAM2 expression had significantly poor prognosis in some subgroups. In addition, multivariate analyses showed that the combination of TIAM2 and the pathological N stage largely enhanced the prognostic efficiency, and was found to be as an independent prognostic indicator in patients with PDAC. Data mining elucidated that TIAM2 mRNA expression level was increased in tumor tissues and correlated with patient survival. Furthermore, high TIAM2 expression was common in PC cells. Downregulation of TIAM2 suppressed cell proliferation, migration and invasion in PC.

CONCLUSIONS

High expression of TIAM2 might be a meaningful prognostic factor for PDAC patients, and TIAM2 participates in tumor progression in PDAC.

Survival benefit of adjuvant chemoradiotherapy for positive or close resection margin after curative resection of pancreatic adenocarcinoma

BACKGROUND

This study was conducted to identify patients who may benefit from adjuvant chemoradiotherapy (CRT) for positive or close resection margin (RM) after curative resection of pancreatic adenocarcinoma.

METHODS

From 2004 to 2015, total of 472 patients with pancreatic adenocarcinoma underwent curative resection. After excluding patients with RM > 2 mm or unknown, remaining 217 patients were retrospectively analyzed. Forty-six (21.2%) patients were treated with adjuvant chemotherapy alone (CTx; mainly gemcitabine-based), 142 (65.4%) with adjuvant CRT (mainly upfront), and 29 (13.4%) patients didn't receive any adjuvant therapy (noTx group).

RESULTS

Locoregional recurrence rate was significantly lower in the CRT group (43.7%) than in the CTx group (71.7%) or noTx group (65.5%) (p = 0.001). Significant survival benefits of CRT over CTx (HR 0.602, p = 0.020 for overall survival (OS); HR 0.599, p = 0.016 for time to any recurrence (TTR)) were demonstrated in multivariate analysis. CRT group had more 5-year survivors than other groups. In the subgroup analysis, such benefits of adjuvant CRT over CTx was observed only in patients with head tumor & vascular RM > 0.5 mm, but not in patients with body/tail tumor or vascular RM ≤ 0.5 mm. In the CRT group, radiation dose≥54 Gy was significantly associated with better TTR and OS.

CONCLUSIONS

Adjuvant CRT could improve TTR and OS compared to adjuvant CTx alone in patients with close RM under 2 mm. Radiation dose escalation may be beneficial when feasible. Modern CRT regimen-based randomized evidence is needed for these high-risk patients.

Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions

BACKGROUND

Surgical resection remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). The prognostic value of resection margin status following pancreatoduodenectomy (PD) remains controversial. Standardised pathological assessment increases positive margins but limited data is available on the significance of involved margins. We investigated the impact of resection margin status in PDAC on patient outcome.

METHOD

We identified all patients with PD for PDAC at one pancreatic cancer centre between August 2008 and December 2014. Demographic, operative, adjuvant therapeutic and survival data was obtained. Pathology data including resection margin status of specific anatomic margins was collected and analysed.

RESULTS

107 patients were included, all pathologically staged as T3 with 102 N1. 87.9% of patients were R1 of which 53.3% showed direct extension to the resection margin. Median survival for R0 patients versus R1<1 mm and R1 = 0 mm was 28.4 versus 15.4 and 25.1 versus 13.4 months. R1 = 0 mm status remained a predictor of poor outcome on multivariate analysis. Evaluation of individual margins (R1<1 mm) showed the SMV and SMA margins were associated with poorer overall survival. Multiple involved margins impacted negatively on outcome. SMA margin patient outcome with R1 = 1-1.9 mm was similar to R1=>2 mm.

CONCLUSION

Using an R1 definition of <1 mm and standardised pathology we demonstrate that R1 rates in PDAC can approach 90%. R1 = 0 mm remained an independent prognostic factor for overall survival. Using R1<1 mm we have shown that involvement of medial margins and multiple margins has significant negative impact on overall survival. We conclude that not all margin positivity has the same prognostic significance.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Background

Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.

Methods

This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.

Results

A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004).

Conclusion

RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

Impact of resection margins on long-term survival after pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND

The impact of resection margin status on long-term survival after pancreaticoduodenectomy (PD) for patients with pancreatic head carcinoma remains controversial and depends on the method used in the histopathological study of the resected specimens. This study aimed to examine the impact of resection margin status on the long-term overall survival of patients with pancreatic head carcinoma after PD using the tumor node metastasis standard.

METHODS

Consecutive patients with pancreatic head carcinoma who underwent PD at the Chinese People's Liberation Army General Hospital between May 2010 and May 2016 were included. The impact of resection margin status on long-term survival was retrospectively analyzed.

RESULTS

Among the 124 patients, R0 resection was achieved in 85 patients (68.5%), R1 resection in 38 patients (30.7%) and R2 resection in 1 patient (0.8%). The 1- and 3-year overall survival (OS) rates were significantly higher for the patients who underwent R0 resection than the rates for those who underwent R1 resection (1-year OS rates: 69.4% vs 53.0%; 3-year OS rates: 26.9% vs 11.7%). Multivariate analysis showed that resection margin status and venous invasion were significant risk factors for OS.

CONCLUSION

Resection margin was an independent risk factor for OS for patients with pancreatic head carcinoma after PD. R0 resection was associated with significantly better OS after surgery.

Comparison of pathology sampling protocols for pancreatoduodenectomy specimens

Pancreatoduodenectomy is one of the most challenging surgical specimens for pathologists. Recently, two different, standardized protocols have been proposed: the axial slicing Leeds protocol (LP) and the bi-valving Adsay protocol (AP). Comparison between standardized and non-standardized protocols (NSP) was performed with emphasis on margin involvement and lymph node yield. Pancreatoduodenectomy cases were retrospectively recruited: 46 sampled with LP, 52 cases with AP and 46 cases with NSP. Clinico-pathologic data and rates of margin/surface involvement were collected and their prognostic influence on survival was assessed. Statistical differences between NSP and AP and LP were seen for nodal yield (p = 0.0001), N+ (p = 0.0001) and lymph node ratio - LNR (p < 0.0008) but not between AP and LP. Differences in R1/R0 status were statistically significant between NSP group (R1-15%) and both the LP (R1-73.9%) and AP (R1-70%) groups (p = 0.0001) but not between LP and AP groups. At univariate survival analysis, grade (p = 0.0023) and number of involved margins (p = 0.0096) in AP and "N-category" (p = 0.0057) "resection margin status" (p = 0.0094), "stage" (p = 0.0143), and "number of involved margins" (p = 0.00398) in LP were statistically significant, while no variable was significant in the NSP group. At multivariate analysis "N category," "resection margin status," "stage," "number of involved margins," and "LNR" retained significance for the LP group. These results show that both LP and AP perform better than non-standardized sampling making standardization mandatory in pancreatoduodenectomy cut up. Both AP and LP show strengths and weaknesses, and these may impact on the choice of protocol in different institutions.

Physiological functions of Wilms' tumor 1-associating protein and its role in tumourigenesis

The Wilms' tumor-associated gene WT1 encodes a tumor suppressor gene, which is implicated in renal differentiation and development of adult urogenital system. Wilms' tumor 1-associating protein (WTAP) is initially identified as a nuclear protein that specifically interacts with WT1 in both in vitro and in vivo assays. WTAP is ubiquitously expressed in different tissues and various growth periods, and its expression is involved in cell cycle, RNA splicing and stabilization, N6-methyladenosine RNA modification, cell proliferation, and apoptosis as well as embryonic development. In the present review, we aimed to summarize the functions of WTAP in various physiological and pathological processes, in particular with regard to the current knowledge about the role of WTAP in tumorigenesis of different cancers.

Plasminogen Activator Inhibitor 1 as a Poor Prognostic Indicator in Resectable Pancreatic Ductal Adenocarcinoma

Background

Plasminogen activator inhibitor 1 (PAI-1) was previously established to impact several phenotypes in many kinds of cancer, including pancreatic cancer. However, its prognostic significance in pancreatic ductal adenocarcinoma (PDAC) needs support of further evidence. This study was designed to address the issue.

Methods

PAI-1 expression was detected by tissue microarray-based immunohistochemical staining in formalin-fixed paraffin-embedded specimens from 93 PDAC patients with surgical resection from September 2004 to December 2008. Its relationships with clinicopathologic variables and tumor-specific survival (TSS) were further evaluated using Chi-square, Kaplan-Meier, log-rank, as well as Cox regression analyses.

Results

Expression of PAI-1 was much higher in tumor than that in nontumor tissues, based on comparison of all samples and 74 matched ones (95 [47.5, 180] vs. 80 [45, 95], Z = -2.439, P = 0.015 and 100 [46.9, 182.5] vs. 80 [45, 95], Z = -2.594, P = 0.009, respectively). In addition, tumoral PAI-1 expression was positively associated with N stage (22/35 for N1 vs. 21/51 for N0, χ² = 3.903, P = 0.048). Univariate analyses showed that TSS of patients with high PAI-1 tumors was significantly poorer than that of those with low PAI-1 tumors (log rank value = 19.00, P < 0.0001). In multivariate Cox regression test, PAI-1 expression was identified as an independent predictor for long-term prognosis of resectable PDAC (hazard ratio = 2.559, 95% confidence interval = 1.499-4.367, P = 0.001).

Conclusion

These results suggest that expression of PAI-1 is upregulated in PDAC and might serve as a poor prognostic indicator.

High nuclear Survivin expression as a poor prognostic marker in pancreatic ductal adenocarcinoma

BACKGROUND

Survivin, one of the key regulators of mitosis and apoptosis, has long been well recognized to play important biological roles in many neoplasms, including pancreatic ductal adenocarcinoma (PDAC). However, its prognostic value in PDAC remains controversial.

PATIENTS AND METHODS

Nuclear expression of Survivin was detected, using tissue microarray-based immunohistochemistry, in paired-tumor and nontumor samples from 306 patients with radically resected PDAC. The staining H scores were further correlated with clinicopathologic features and disease-specific survival (DSS).

RESULTS

Nuclear Survivin expression was much higher in tumor than in nontumor tissues (P < 0.001). No significant association between tumoral Survivin expression and clinicopathologic variables was found. For prognosis, high Survivin expression was associated with shortened DSS in all eligible patients and four subgroups, that is, male and nondiabetic patients as well as those with head-located and G1-2 tumors, shown by univariate analyses. In addition, a statistically marginal significance was revealed in eight subgroups. For the entire cohort and two subgroups, nuclear Survivin expression was also multivariate identified as an independent predictor for DSS. For patients with G1-2 tumors, it was the single prognostic marker.

CONCLUSION

Our data suggest an association between high nuclear Survivin expression and poor prognosis in PDAC. However, further confirmation might be necessary.

Tumour origin and R1 rates in pancreatic resections: towards consilience in pathology reporting

To evaluate differences in the R1 rates of ampullary (AC), pancreatic (PC), and distal bile duct (DBD) cancers in pancreatoduodenectomies (PD) using standardised pathology assessment. Data of PD (2010-2011) analysed in accordance with the Royal College of Pathologists (UK) protocol, were retrieved. Clinicopathologic features, including frequency, topography, and mode of margin involvement in AC (n = 87), PC (n = 18), and DBD (n = 5) cancers were evaluated. The R1 rate was 7%, 67%, and 20% in the AC, PC, and DBD cancers (p < 0.001). Within the PC cohort, R1 rate was heterogeneous (chemo-naïve, 77%; post-neoadjuvant, 40%). Commonest involved margins were as follows: posterior in overall PD (35%), AC (43%), overall PC (33%), and post-neoadjuvant PC (100%); superior mesenteric artery margin in chemo-naïve PC (38%) and common bile duct margin in DBD (100%) cancers. In AC, majority (66%) of R1 were signet ring cell type. Indirect margin involvement due to tumour within lymph node, perineural sheath or lymphovascular space was observed in 26% cases, and altered R1 rate in AC, PC, and DBD cohorts by 1%, 12%, and 0%, respectively. Although not statistically significant, patients with R1 had lower disease-free survival than those with R0 (mean, 25.4 months versus 44.4 months). Tumour origin impacts R1 data in PD necessitating its accurate classification by pathologists. Indirect involvement, histology, and neoadjuvant therapy influence the R1 rate, albeit in a minority of cases. Generating cogent R1 data based on standardised pathology reporting is the foremost need of the hour.

Intra-Operative Frozen Section Histology of the Pancreatic Resection Margins and Clinical Outcome of Patients with Adenocarcinoma of the Head of the Pancreas Undergoing Pancreaticoduodenectomy

BACKGROUND The aim of this study was to compare the clinical outcome in patients with pancreatic ductal adenocarcinoma who underwent frozen section and paraffin section histology of the surgical resection margins during pancreaticoduodenectomy. MATERIAL AND METHODS Frozen section and routine paraffin section histopathology were performed using the following categories: R0 (no tumor cells at the surgical resection margin), R1 (tumor cells at, or within 1 mm, of the surgical resection margin), and R2 (tumor seen macroscopically at the surgical resection margin). R1 and R2 patients underwent additional resection to achieve R0. RESULTS Of 346 patients who underwent pancreaticoduodenectomy, frozen section histology showed positive resection margins in 22 patients (9.2%) and paraffin section histology was positive in 20 patients (8.4%). The OS was nine months in frozen section-positive patients and 20 months in frozen section-negative patients (p=0.001). The OS rates were significantly different between the paraffin section-positive and paraffin section-negative patients (11 months vs. 21 months) (p=0.001). Univariate and multivariate analysis showed that increased tumor size, high tumor grade, lymph node metastases, a positive superior mesenteric artery and retroperitoneal margin, and a positive resection margin on frozen section were significantly correlated with reduced OS (p<0.05). Twenty-two patients with positive resection margins on frozen section histology underwent further resection; R0 was achieved in 14 patients, with no significant difference in OS. CONCLUSIONS For patients who underwent pancreaticoduodenectomy for pancreatic carcinoma with positive resection margins on frozen section, further surgical resection to achieve R0 had no significant positive impact on OS.

Pathological Margin Clearance and Survival After Pancreaticoduodenectomy in a US and European Pancreatic Center

BACKGROUND

The optimal definition of a margin-negative resection and its exact prognostic significance on survival in resected pancreatic adenocarcinoma remains unknown. This study was designed to assess the relationship between pathological margin clearance, margin type, and survival.

METHODS

Patients who underwent pancreaticoduodenectomy with curative intent at two academic institutions, in Amsterdam, the Netherlands, and Boston, Massachusetts, between 2000 and 2014 were retrospectively evaluated. Overall survival, recurrence rates, and progression-free survival (PFS) were assessed by Kaplan-Meier estimates and multivariate Cox proportional hazards analysis, according to pathological margin clearance and type of margin involved.

RESULTS

Of 531 patients identified, the median PFS was 12.9, 15.4, and 24.1 months, and the median overall survival was 17.4, 22.9, and 27.7 months for margin clearances of 0, < 1, and ≥1 mm, respectively (all log-rank p < 0.001). On multivariate analysis, patients with a margin clearance of ≥1 mm demonstrated a survival advantage relative to those with 0 mm clearance [hazard ratio (HR) 0.71, p < 0.01], whereas survival was comparable for patients with a margin clearance of < 1 mm versus 0 mm (HR: 0.93, p = 0.60). Patients with involvement (0 or < 1 mm margin clearance) of the SMV/PV margin demonstrated prolonged median overall survival (25.7 months) relative to those with SMA involvement (17.5 months).

CONCLUSIONS

In patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, a margin clearance of ≥1 mm correlates with improved survival relative to < 1 mm clearance and may be a more accurate predictor of a complete margin-negative resection in pancreatic cancer. The type of margin involved also appears to impact survival.

High expression of GRK3 is associated with favorable prognosis in pancreatic ductal adenocarcinoma

BACKGROUND

It was found that G-protein-coupled receptor kinase 3 (GRK3) played key biological roles in some cancers. However, its associations with clinicopathologic features and prognosis in pancreatic ductal adenocarcinoma (PDAC) remain unknown.

METHODS AND METHODS

Expression of GRK3 was detected, using tissue microarray-based immunohistochemistry, in paired formalin-fixed paraffin-embedded tumor and non-tumor samples from 165 patients with PDAC after curative resection, and was further correlated with clinicopathologic parameters and cancer-specific survival (CSS).

RESULTS

It was shown that GRK3 expression was much lower in tumor than in non-tumor tissues. Moreover, expression of GRK3 in tumor tissues was significantly associated with gender and T stage. Univariately, high GRK3 expression was predictive for favorable CSS, along with some conventional clinicopathologic variables. In multivariate Cox regression test, GRK3 expression remained to be a significant prognostic marker for PDAC. Finally, combination of GRK3 with some clinicopathologic variables, especially N stage, obtained more precise prediction for CSS.

CONCLUSIONS

Our data suggested that expression of GRK3 was down-regulated in PDAC and was an independent prognostic factor.

Pancreatic adenocarcinoma: A simple CT score for predicting margin-positive resection in patients with resectable disease

BACKGROUND

Negative-margin status is a prognostic indicator for long-term survival following curative intent resection for pancreatic adenocarcinoma. Patients at increased risk for positive-margin resections may benefit from neoadjuvant chemotherapy prior to resection.

METHODS

We retrospectively analyzed preoperative computed-tomography (CT) scans in 108 consecutive patients that underwent curative intent resection for a resectable pancreatic ductal adenocarcinoma from 2009 to 2016 in two academic hospitals. Two radiologists independently staged the tumor, including tumor location, size, and tumor-to-superior mesenteric/portal vein (SMV/PV) contact. Uni and multivariate analysis were performed to identify independent predictors of an R1 resection.

RESULTS

Twenty-nine patients had an R1 resection (26.9%). Tumor size, location, and presence of tumor-to-SMV/PV contact were significantly associated with an R1 resection. In multivariate analysis, the independent parameters associated with resection status were: tumor size (R²=9.7), and tumor location (neck R²=6.6; pancreaticoduodenal interface R²=4.4; uncinate process R²=4.1), but not tumor-to-SMV/PV contact (R²=0.1, p=0.7). A simple CT score was built based on tumor size and location. Patients with an R0 resectability score ≥3, i.e. patients with tumor size ≥30mm (except when tumor location is at the pancreatico-duodenal interface) or patients with tumor size ≥20mm AND tumor located in the uncinate process or neck, were at high-risk of an R1 resection (AUC, 0.82; sensitivity, 79%; specificity, 76%). This score also showed good diagnostic performances for predicting an R1 resection involving the medial resection margin only (AUC, 0.85).

CONCLUSIONS

A simple score based on tumor location and size can accurately predict patients at high-risk of an R1 resection.

Reporting the margin in pancreaticoduodenectomies: R0 versus R1

AIM

This study was conducted to analyze the changes in margin positivity in pancreaticoduodenectomies, on using a standardized protocol, which bread loafs the pancreas and duodenum in the axial plane for adenocarcinomas arising in the pancreatic head, ampulla, terminal common bile duct (CBD), and duodenum, and then to assess whether these tumor subsets involve the margins in different ways.

METHODS

The analysis was performed on 70 consecutive specimens, the pre-protocol specimens serving as the control group.

RESULTS AND CONCLUSIONS

Tumors originating from the pancreatic head, ampulla, terminal CBD, and duodenum showed a consistent increase in their R1 incidence, post-protocol. Ampullary tumors showed the greatest upward change in R1 positivity. The highest incidence of margin positivity was seen in pancreatic head adenocarcinomas (80%), then distal CBD tumors (60%), and finally the ampullary tumors (39%). In pancreatic head adenocarcinomas, R1 increased from 55% to 80%, distal CBD from 50% to 60%, and ampullary from 17% to 39%. Duodenal adenocarcinomas had no R1 in both pre- and post-protocol groups. The tumors also had different patterns of margin involvement. Ampullary tumors involved only the posterior margin, pancreatic adenocarcinomas involved the superior mesenteric vein (SMV) groove more often than the posterior margin, and distal CBD tumors involved the posterior margin and SMV groove equally. The size of the tumor made a significant difference in pancreatic head carcinomas with tumor size less than or equal to 2 cm, showing an R1 incidence of 38%, while those above 2 cm had an R1 incidence of 68%.

WT1-associated protein is a novel prognostic factor in pancreatic ductal adenocarcinoma

Although Wilms tumor 1 (WT1)-associated protein (WTAP) was initially found to be a specific WT1-binding protein, it has increasingly attracted attention because of its oncogenic role in various types of malignancies, including cholangiocarcinoma, glioblastoma and acute myeloid leukemia. However, the clinical impact of WTAP on pancreatic ductal adenocarcinoma (PDAC) is still unknown. A total of 145 patients who underwent surgical treatment from 2004 to 2008 were enrolled in the present study. The cytoplasmic and nuclear expression of WTAP in tumor and adjacent normal tissues was examined by immunohistochemical analysis in order to investigate the relationship between WTAP and the clinicopathological factors and prognosis of patients with PDAC. The nuclear and cytoplasmic expression of WTAP in tumor tissues was significantly higher compared with non-tumor tissues (P<0.001). High expression of WTAP in the nucleus was significantly associated with gender (P=0.010) and tumor stage (P=0.020), while high expression of WTAP in the cytoplasm was significantly associated with gender (P=0.018), histological grade (P=0.047) and perineural invasion (P=0.028). In addition, a univariate analysis revealed that high nuclear expression of WTAP in tumor tissues was significantly associated with poor overall survival (P<0.001), as well as several clinicopathological variables, including gender and N stage. In a multivariate Cox regression analysis, nuclear WTAP expression was identified as an independent prognostic indicator for PDAC (relative risk, 1.855; 95% confidence interval, 1.033–3.333; P=0.039). The results of the present study indicated that high nuclear expression of WTAP is a valuable molecular biomarker of a poor prognosis among patients with PDAC.

Redefining the R1 resection in patients with pancreatic ductal adenocarcinoma

Most cases of pancreatic ductal adenocarcinoma (PDAC) are lethal. Margin-negative surgical resection is a mainstay of treatment and the only chance of a cure. Differences in pathological reporting, surgical technique, definitions of resection margin, and group stratification all affect outcome analyses. Furthermore, there are controversial issues influencing the clinical interpretation of resection margin after pancreatectomy. There is no standardized definition of margin involvement in resected specimens of PDAC. The non-standardized pathologic approach explains the wide range of positive resection margin rates (13-71%) that have previously been reported. A standardized pathologic evaluation needs to be developed for proper assessment of resection margin after oncologic pancreatectomy. This manuscript reviews the current controversial issues in assessing resection margin in order to enhance understanding of the current status and potential role of pathological evaluation in patients with PDAC.

Top-down approach to the superior mesenteric artery and the mesopancreas during pancreatoduodenectomy for pancreatic cancer

Complete surgical resection with microscopically tumor-free resection margins (R0) is the most important survival determinant for patients with localized pancreatic cancer. The medial and posterior resection margins are the dominant sites of microscopic tumor involvement, and outline the so-called mesopancreas. In this study, we present a modified surgical approach to the superior mesenteric artery, celiac trunc, and mesopancreas during pancreatoduodenectomy, which enables a comfortable exposure and radical en bloc clearance of the mesopancreas and the tissue adjacent to the superior mesenteric artery. The dissection of the mesopancreas is directed from the ventral aspect of the portal vein downward along the superior mesenteric artery and the celiac trunc, before the transection of the duodenal mesentery is accomplished. The described technique complements the established surgical approaches to pancreatic head tumors, and is indicated in the absence of portal vein infiltration. J. Surg. Oncol. 2016;113:668-671. © 2016 Wiley Periodicals, Inc.

Mesopancreatic Stromal Clearance Defines Curative Resection of Pancreatic Head Cancer and Can Be Predicted Preoperatively by Radiologic Parameters: A Retrospective Study

Pancreatic ductal adenocarcinoma (PDAC) is characterized by a strong fibrotic stromal reaction and diffuse growth pattern. Peritumoral fibrosis is often evident during surgery but only distinguishable from tumor by microscopic examination. The aim of this study was to investigate the role of clearance of fibrotic stromal reaction at the mesopancreatic resection margin as a criterion for radical resection and preoperative assessment of resectability.Mesopancreatic stromal clearance status (S-status) was defined as the presence or absence (S+/S0) of fibrotic stromal reaction at the mesopancreatic resection margin. Detailed retrospective clinicopathologic re-evaluation of margin status and preoperative cross-sectional imaging was performed in a cohort of 91 patients operated for pancreatic head PDAC from 2001 to 2011.Conventional margin positive resection (R+, tumor cells directly at the margin) was found in 36%. However, S-status further divided the margin negative (R0) group into patients with median survival of 14 months versus 31 months (S+ versus S0, P = 0.005). Overall rate of S+ was 53%. S-status and lymph node ratio constituted the only independent predictors of survival. Stranding of the superior mesenteric artery fat sheath was the only independent radiologic predictor of S+ resection, and achieved a 71% correct prediction of S-status.Mesopancreatic stromal clearance is a major determinant of curative resection in PDAC, and preoperative prediction by cross-sectional imaging is possible, setting the basis for a new definition of borderline resectability.

The importance of surgical margins in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive disease with a grim prognosis. Surgical resection offers the best chance for long-term survival, yet recurrence rates are high and outcomes are poor. The influence of margin status in PDAC is controversial, as conflicting data have been plagued by a lack of standardization in margin definitions, pathologic analysis, and reporting. Despite recent efforts, international consensus is still needed for this disease.

Resection margin clearance in pancreatic cancer after implementation of the Leeds Pathology Protocol (LEEPP): clinically relevant or just academic?

BACKGROUND AND OBJECTIVES

The aim of this study was to assess the overall survival (OS) after R0/R1 resections in patients with pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head after implementation of a standardized histopathologic protocol (Leeds Pathology Protocol, LEEPP).

METHODS

One hundred and twenty-five patients underwent surgical resection because of PDAC of the pancreatic head. Patients were histopathologically examined according to a standardized protocol. Their oncologic outcome and clinicopathologic data were compared with those of a patient group before implementation of the LEEPP (n = 116).

RESULTS

The R1 rate increased significantly from 13 to 52 %. There was no significant difference in OS between R0 and R1 resections. The median OS in patients with a tumor clearance of less than 2 mm from the resection margin was 15.1 months (12.1-18.1 months) versus 22.2 months (7.8-36.7 months) (P = 0.046). Multivariate analysis revealed a margin clearance or 2 mm and more as an independent prognosticator for OS.

CONCLUSIONS

With applying the LEEPP, there was still no significant correlation between the R-status and OS in patients with PDAC. However, since a margin clearance of 2 mm or more is a predictive factor for OS, the R1 definition might have to be adapted in PDAC.

Artery first approach to pancreatoduodenectomy: current status

BACKGROUND

The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival.

METHODS

An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic.

RESULTS

Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection.

CONCLUSION

The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.

Pancreatic cancer: current management and treatment strategies

The 5-year survival of patients with pancreatic cancer is poor and, despite oncological advances over the past two decades, has not significantly improved. However, there have been several surgical and oncological advances which have improved morbidity and mortality in surgery and more efficacious chemotherapy regimens, resulting in a better patient experience and an increase in survival by a number of months. Most patients have a tumour at the head of the pancreas and those with resectable disease undergo a pancreaticoduodenectomy, which can be performed laparoscopically. Those who have a pancreatic resection have an increased survival in comparison with those receiving oncological treatment only; however, only a quarter of patients have resectable disease at diagnosis. Some centres are now performing venous resections and/or arterial resections in order to increase the number of patients eligible for curative surgery. Innovative techniques using ablation technologies to downstage tumours for resection are also being investigated. After surgery, all patients should be offered adjuvant gemcitabine-based chemotherapy. Those with locally advanced tumours not suitable for surgery should be offered FOLFIRINOX chemotherapy, after which the tumour may be suitable for surgical resection. The use of radiotherapy in this group of patients is controversial but offered by a few centres. Patients with metastatic disease at diagnosis should also be offered FOLFIRINOX chemotherapy, which can improve survival by a few months. As our knowledge of the tumour biology of pancreatic cancer progresses, a number of new agents targeting specific genes and proteins are under investigation and there is hope that median survival will continue to improve over the next decade.

N-wasp in pancreatic ductal adenocarcinoma: associations with perineural invasion and poor prognosis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has long been acknowledged to have a dismal prognosis. Therefore, prognostic markers, especially molecular ones, are of interest. So far, expression of Neural Wiskott-Aldrich syndrome protein (N-WASP) and its associations with clinicopathologic variables and prognosis for patients with PDAC remain unknown.

METHODS

N-WASP expression was detected by immunohistochemical staining in a tissue microarray consisted of tumor and nontumor samples from 86 patients with PDAC. The correlations of N-WASP expression with clinicopathologic features and overall survival were evaluated. In addition, risk factors of perineural invasion (PNI) were identified.

RESULTS

High expression of N-WASP was more frequent in tumor than in nontumor tissues of PDAC patients (45.3 vs. 19.8%, p < 0.001). The rank of N-WASP grading was significantly higher in tumor tissues than in nontumor tissues (p = 0.048). Also, high expression of N-WASP in tumor tissues was significantly associated with PNI, and lymph node status had a marginally significant relation to tumoral N-WASP expression. Univariate analyses showed that, in addition to conventional clinicopathologic variables, including sex, histologic grade, PNI and lymph node metastasis, high tumoral N-WASP expression was an independent marker of PNI and served as a significant predictor of poor overall survival. The prognostic implication of N-WASP expression was not proven In the multivariate analysis.

CONCLUSIONS

Our data showed highly up-regulated expression of N-WASP in PDAC tissues, its correlations with PNI, and its association with an unfavorable prognosis.

Expression of c-fos was associated with clinicopathologic characteristics and prognosis in pancreatic cancer

It has long been regarded that pancreatic cancer (PC) is a life-threatening malignant tumor. Thus, much attention has been paid for factors, especially relative molecules, predictive for prognosis of PC. However, c-fos expression in PC was less investigated. In addition, its association with clinicopathologic variables and prognosis remains unknown. In the present study, expression of c-fos was detected by tissue microarray-based immunohistochemical staining in cancer and adjacent tissues from 333 patients with PC. The staining results were correlated with clinicopathologic parameters and overall survival. Furthermore, prognostic significance of c-fos in subsets of PC was also evaluated. It was shown that low expression of c-fos was more often in cancer than in adjacent tissues of PC (P<0.001). Besides, high cancerous c-fos expression was significantly associated with tumor site and T stage, whereas peri-neural invasion was of a borderline significant relevance. Log-rank test revealed that high expression of c-fos in cancer tissues was a significant marker of poor overall survival, accompanied by some conventional clinicopathologic variables, such as sex, grade, peri-neural invasion, T and N stages. More importantly, cancerous c-fos expression was identified as an independent prognosticator in multivariate analysis. Finally, the prognostic implication of c-fos expression was proven in four subsets of patients with PC. These data suggested that c-fos expression was of relationships with progression and dismal prognosis of PC.

Surgical management of adenocarcinoma of the pancreatic uncinate process in a cancer hospital in egypt

INTRODUCTION

Pancreatic carcinoma affecting the uncinate process is a challenging surgical condition. Several considerations affect the management plan, including the need for vascular resection and the ability to achieve a clear margin.

METHODS

The data of 19 patients who had curative resection for pancreatic adenocarcinoma of the uncinate process were reviewed. Operative mortality and morbidity, and disease-free survival (DFS) were calculated.

RESULTS

The study population included 13 male and 6 female patients with a mean age of 55 years. Nine patients (47.4%) had stage I disease, seven patients (36.8%) had stage II disease, and three patients (15.8%) had stage III disease. A total of 12 patients had Whipple procedure and 7 patients had total pancreatectomy. In total, there were 9 R0 and 10 R1 resections. Operative mortality rate was 10.5% (2/19), postoperative leakage rate was 21.1% (4/19), and wound sepsis rate was 21.1%. Median DFS was 19.2 months. Survival was superior in the Whipple procedure group than in the total pancreatectomy group (median survival 19 months vs 4 months, respectively). Vascular resection and retroperitoneal safety margin status did not affect disease relapse.

CONCLUSION

Non-metastatic pancreatic adenocarcinoma of the uncinate process should be offered R0 or R1 resection whenever technically feasible.

Prognostic significance of epidermal growth factor-like domain 7 in pancreatic cancer

BACKGROUND

Recent studies have shown the clinical significance of epidermal growth factor-like domain 7 (EGFL7) in a variety of cancers. However, the relationship between EGFL7 and the prognosis of pancreatic cancer (PC) remains unclear. The present study was undertaken to investigate the role of EGFL7 in the prognosis of PC.

METHODS

The expression of EGFL7 in nine PC cell lines was first determined by Western blotting analysis. Tissue microarray-based immunohistochemical staining was performed in paired formalin-fixed paraffin-embedded tumor and non-tumor samples from 83 patients with PC. Finally, correlations between EGFL7 expression and clinicopathological variables as well as overall survival were evaluated.

RESULTS

EGFL7 was widely expressed in all PC cell lines tested. EGFL7 expression in tumor tissues was significantly higher than that in non-tumor tissues (P=0.040). In addition, univariate analysis revealed that high EGFL7 expression in tumor tissues was significantly associated with poor overall survival, accompanied by several conventional clinicopathological variables, such as gender, histological grade and lymph node metastasis. In a multivariate Cox regression test, EGFL7 expression was identified as an independent marker for long-term outcome of PC.

CONCLUSION

Our data showed that EGFL7 is extensively expressed in PC and that EGFL7 is associated with poor prognosis.

Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: results of the first prospective randomized phase II trial

Background

In nonrandomized trials, neoadjuvant treatment was reported to prolong survival in patients with pancreatic cancer. As neoadjuvant chemoradiation is established for the treatment of rectal cancer we examined the value of neoadjuvant chemoradiotherapy in pancreatic cancer in a randomized phase II trial. Radiological staging defining resectability was basic information prior to randomization in contrast to adjuvant therapy trials resting on pathological staging.

Patients and methods

Patients with resectable adenocarcinoma of the pancreatic head were randomized to primary surgery (Arm A) or neoadjuvant chemoradiotherapy followed by surgery (Arm B), which was followed by adjuvant chemotherapy in both arms. A total of 254 patients were required to detect a 4.33-month improvement in median overall survival (mOS).

Results

The trial was stopped after 73 patients; 66 patients were eligible for analysis. Twenty nine of 33 allocated patients received chemoradiotherapy. Radiotherapy was completed in all patients. Chemotherapy was changed in 3 patients due to toxicity. Tumor resection was performed in 23 vs. 19 patients (A vs. B). The R0 resection rate was 48 % (A) and 52 % (B, P = 0.81) and (y)pN0 was 30 % (A) vs. 39 % (B, P = 0.44), respectively. Postoperative complications were comparable in both groups. mOS was 14.4 vs. 17.4 months (A vs. B; intention-to-treat analysis; P = 0.96). After tumor resection, mOS was 18.9 vs. 25.0 months (A vs. B; P = 0.79).

Conclusion

This worldwide first randomized trial for neoadjuvant chemoradiotherapy in pancreatic cancer showed that neoadjuvant chemoradiation is safe with respect to toxicity, perioperative morbidity, and mortality. Nevertheless, the trial was terminated early due to slow recruiting and the results were not significant. ISRCTN78805636; NCT00335543.

Electronic supplementary material

The online version of this article (doi: 10.1007/s00066-014-0737-7) contains supplementary material, which is available to authorized users.

Is arterial infiltration still a criterion for unresectability in pancreatic adenocarcinoma?

As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centers, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the last years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumor biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.

Surgical techniques for improving outcomes in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is a devastating disease with extremely poor survival despite patients undergoing potentially curative resections and improvements in chemotherapeutic agents. Surgery for operable cancer in the head of the pancreas typically involves an open pancreaticoduodenectomy with a post-operative median survival of 21 months. Newer surgical techniques, however, aim to improve patient outcomes in terms of both their hospital experience and better oncological results. This article focuses on the evidence to date for some of these surgical techniques including laparoscopic and robotic surgery, the no-touch technique, venous and arterial resection, intra-operative radiofrequency ablation and intra-operative irreversible electroporation. With the increased use of these techniques we hope to see better quality of life and survival for these patients.

MicroRNAs cooperatively inhibit a network of tumor suppressor genes to promote pancreatic tumor growth and progression

BACKGROUND & AIMS

There has not been a broad analysis of the combined effects of altered activities of microRNAs (miRNAs) in pancreatic ductal adenocarcinoma (PDAC) cells, and it is unclear how these might affect tumor progression or patient outcomes.

METHODS

We combined data from miRNA and messenger RNA (mRNA) expression profiles and bioinformatic analyses to identify an miRNA-mRNA regulatory network in PDAC cell lines (PANC-1 and MIA PaCa-2) and in PDAC samples from patients. We used this information to identify miRNAs that contribute most to tumorigenesis.

RESULTS

We identified 3 miRNAs (MIR21, MIR23A, and MIR27A) that acted as cooperative repressors of a network of tumor suppressor genes that included PDCD4, BTG2, and NEDD4L. Inhibition of MIR21, MIR23A, and MIR27A had synergistic effects in reducing proliferation of PDAC cells in culture and growth of xenograft tumors in mice. The level of inhibition was greater than that of inhibition of MIR21 alone. In 91 PDAC samples from patients, high levels of a combination of MIR21, MIR23A, and MIR27A were associated with shorter survival times after surgical resection.

CONCLUSIONS

In an integrated data analysis, we identified functional miRNA-mRNA interactions that contribute to growth of PDACs. These findings indicate that miRNAs act together to promote tumor progression; therapeutic strategies might require inhibition of several miRNAs.

Mesopancreas: a boundless structure, namely R1 risk in pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND

The mesopancreatic resection margin after pancreaticoduodenectomy for carcinoma of the head of the pancreas is of great interest with respect to curative resection, since the neoplastic involvement of this margin was shown to be the primary site for R1 resection. In this review the current knowledges of the surgical anatomy of the so-called mesopancreas and the mesopancreas excision techniques are summarized.

METHODS

References were identified by searching Pubmed database using the search terms "mesopancreas" and "meso-pancreatoduodenum" until June 2013 and through searches of the authors' own files. Five studies were included in this review.

RESULTS

Original contributions with regard to the anatomy of the retropancreatic area and specific technical descriptions of so-called "total mesopancreas excision" provided by published studies are pointed out.

CONCLUSIONS

Because there is no "meso" of the pancreas, and due to the continuity of the mesopancreatic and para-aortic areas, surgical dissection should be extended to the left of the superior mesenteric artery and include the para-aortic area to achieve the most complete possible resection of the so-called mesopancreas and minimize the rate of R1 resections due to mesopancreatic margin involvement. This extended mesopancreatic resection cannot be accomplished en bloc even if the removal of the dissected mesopancreatic tissues is performed en bloc with the head, uncus, and neck of the pancreas, i.e., with the pancreaticoduodenectomy specimen.

Is it time to stop checking frozen section neck margins during pancreaticoduodenectomy?

BACKGROUND

Residual disease after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) adversely impacts survival. The value of taking additional neck margin after a positive frozen section (FS) to achieve a negative margin remains uncertain.

METHODS

All patients who underwent PD for PDAC from January 2000 August 2012 were identified and classified as negative (R0) or positive (R1) based on final neck margin. We examined factors for association with a positive FS neck margin and overall survival (OS). We assessed the value of converting an R1 neck margin to R0 via additional parenchymal resection.

RESULTS

A total of 382 patients had FS neck margin analysis, of which 53 (14 %) were positive. Positive FS neck margin was associated with decreased OS (11.1 vs. 17.3 months, p = 0.01) on univariate analysis. On multivariate analysis poor histologic grade (p = 0.007), increased tumor size (p = 0.003), and a positive retroperitoneal margin (p = 0.009) were independently associated with decreased OS, but positive FS neck margin was not. Of the 53 patients with positive FS, 41 underwent additional neck resection and 23 were converted to R0. On permanent section, R0 neck margin was achieved in 322 patients (84 %), R1 in 37 patients (10 %), and R1 converted to R0 in 23 patients (6 %). Both the converted and the R1 groups had significantly poorer OS than the R0 group (11.3 vs. 11.1 vs. 17.3 months respectively; p = 0.04).

CONCLUSIONS

Positive FS margin at the pancreatic neck during PD for PDAC is associated with poor survival. Extending the neck resection after a positive FS to achieve R0 margin status does not appear to improve OS.

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

BACKGROUND

Over recent years, use of the LigaSure™ vessel sealing device has increased in major abdominal surgery to include pancreaticoduodenectomy (PD). LigaSure™ use during PD has expanded to include all steps of the procedure, including the division of the uncinate margin. This introduces the potential for thermal major vascular injury or margin positivity. The aim of the present study was to evaluate the safety and efficacy of LigaSure™ usage in PD in comparison to established dissection techniques.

METHODS

One hundred and forty-eight patients who underwent PD from 2007 to 2012 at Robert Wood Johnson University Hospital were identified from a retrospective database. Two groups were recognized: those in which the LigaSure™ device was used (N = 114), and in those it was not (N = 34). Peri-operative outcomes were compared.

RESULTS

Vascular intra-operative complications directly caused by thermal injury from LigaSure™ use occurred in 1.8% of patients. Overall vascular intra-operative complications, uncinate margin positivity, blood loss, length of stay, and complication severity were not significantly different between groups. The mean operative time was 77 min less (P < 0.010) in the LigaSure™ group. Savings per case where the LigaSure™ was used amounted to $1776.73.

CONCLUSION

LigaSure™ usage during PD is safe and effective. It is associated with decreased operative times, which may decrease operative costs in PD.

Conditionally replicative adenoviral vectors for imaging the effect of chemotherapy on pancreatic cancer cells

Pancreatic cancer has a poor prognosis after complete macroscopic resection combined with chemotherapy. Even after neoadjuvant chemotherapy, R0 resection is often not possible. Moreover, current imaging techniques cannot reliably distinguish viable cancer cells from scar tissue at the resectional margin. We investigated the use of a conditionally replicative adenovirus (CRAd), Ad5/3Cox2CRAd-ΔE3ADP-Luc, for imaging the effects of chemotherapy. The CRAd infectivity of pancreatic cancer cells was enhanced by a chimeric Ad5/3 fiber, E1A expression was under the control of the Cox2 promoter, and the luciferase gene was inserted adjacent to the adenovirus death protein (ADP) gene. Subcutaneous xenografts of the pancreatic cancer cell line MiaPaCa-2 were established in 24 BALB/c nu/nu mice. When xenografts reached a diameter of 4-6 mm (day 1), the mice were injected i.p. with either PBS (group A; n = 12) or 1000 mg/kg gemcitabine (group B; n = 12), weekly. On days 19, 26, 33, and 40, CRAd were injected intratumorally into three mice in groups A and B. Bioluminescence was imaged 72 h after CRAd injection, and gross tumor volumes were measured then tumors were removed for ex vivo histopathology using H&E and Ki-67 staining. Correlations between gross tumor volume, pathological evaluation of the percentage of viable tumor area, and CRAd bioluminescence were analyzed. Bioluminescence correlated closely with the percentage of viable tumor area (R = 0.96), but not with gross tumor volume (R = 0.31). Therefore, CRAds might be reliable imaging tools for monitoring chemotherapy in pancreatic cancer, and could improve our ability to distinguish viable tumor cells from scar tissue.

Is there a 'margin' for error in pancreatic cancer surgery?

Evaluation of: Gnerlich JL, Luka SR, Deshpande AD et al. Microscopic margins and patterns of treatment failure in resected pancreatic adenocarcinoma. Arch. Surg. 147(8), 753-760 (2012). Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease with one of the worst 5-year survival rates of any malignancy. Even after potentially curative surgical resection, disease may progress rapidly. It is therefore important to identify clinicopathologic factors that influence survival and may be modified to improve outcomes. The evaluated article presents data from a retrospective review of patients who underwent surgical resection for PDAC. Local recurrence (LR), distant recurrence and survival were compared between patients with a negative resection margin (R0) and those with a positive resection margin (R1). Patients with R1 posterior margins, in particular, were more likely to have LR and worse LR-free survival. In addition, this was more pronounced if patients had lymph-node involvement. Similar results have been reported in other studies and this study illustrates that standardized pathological reporting of PDAC specimens may allow further investigation of factors affecting R1 patients.