International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017

Dissecting Tumor Size Underestimation in Pancreatic Cancer: A Comparative Analysis of Preoperative Treatments

BACKGROUND

Tumor size (TS) in pancreatic ductal adenocarcinoma (PDAC) is one of the most important prognostic factors. However, discrepancies between TS on preoperative images (TSi) and pathological specimens (TSp) have been reported. This study aims to evaluate the factors associated with the differences between TSi and TSp.

PATIENTS AND METHODS

We retrospectively analyzed patients with PDAC who underwent surgery at our institution between January 2010 and November 2023. TS discrepancy (TSD[%]) was defined as ([TSp - TSi]/TSp) × 100. Using logistic regression, we generated a receiver operating characteristic (ROC) curve to define the cutoff for TSi underestimation predicting clinical tumor (T) stage migration. Univariate and multivariate analyses were performed to evaluate predictors of TSi underestimation.

RESULTS

Of the 231 patients, 99 (42%) patients received preoperative chemotherapy. The ROC curve determined a TSD underestimation cutoff of 25.9%. The number of TSp > TSi cases was 185 (80%), and TSi underestimation was present in 117 (51%) patients. T stage migration rates were 76%, 26%, and 50% in clinical stage (c) T1, cT2, cT3, respectively, among the patients with chemotherapy, and 93%, 33%, and 14%, respectively, in those without chemotherapy. Multivariate analyses revealed that independent predictors of TSi underestimation were posterior surface invasion in the patients with preoperative chemotherapy and anterior surface invasion in those without chemotherapy.

CONCLUSIONS

TS was more commonly underestimated than overestimated, and cT1 rarely corresponded to pathological (p)T1. The factors contributing to TSi underestimation differed between patients with and without preoperative chemotherapy. Therefore, these two groups should be considered separately for accurate TSi evaluation.

The role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography-derived parameters as prognostic factors in patients undergoing resection for pancreatic ductal adenocarcinoma

BACKGROUND

The aim of this study is to investigate the role of maximum standardized uptake and tumor-to-liver ratio derived from preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma.

METHODS

Patients who underwent pancreatic resection from January 2015 to December 2022 were reviewed. Patients were grouped based on disease-free survival of 1 year, disease-free survival of 6 months, overall survival of 1 year, and resectability.

RESULTS

A total of 133 patients were included in the study. The median maximum standardized uptake was significantly greater in patients with shorter survival than in those with longer survival (disease-free survival <1 year vs >1 year: 7.1 [4.3-9.1] vs 4.9 [3.3-6.5], P < .001; disease-free survival <6 months vs >6 months: 8 [4.5-9.7] vs 5.2 [3.4-6.8], P = .001; overall survival <1 year vs >1 year: 6.9 [4.4-8.8] vs 5 [3.4-6.9], P = .01). Median maximum standardized uptake was significantly greater in patients with intraoperative findings of unresectable disease than in those who underwent surgical resection (7.4 [5.5-9.5] vs 5.5 [3.8-7.8], P = .02). These findings were consistent for tumor-to-liver ratio for all groupings. The area under the curve based on receiver operating characteristic analysis was 0.7 for both maximum standardized uptake and tumor-to-liver ratio for predicting disease-free survival, overall survival, and resectability.

CONCLUSION

Preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography maximum standardized uptake and tumor-to-liver ratio are indicators of resectability, early recurrence, and poor prognosis in patients with pancreatic ductal adenocarcinoma. A maximum standardized uptake value between 5 and 7 is a potential red flag, and further investigations should be considered before proceeding to a pancreatic resection.

Neoadjuvant Chemoradiotherapy Using Moderately Hypofractionated Intensity-Modulated Radiotherapy Versus Upfront Surgery for Resectable Pancreatic Cancer: A Retrospective Cohort Study

BACKGROUND

The efficacy of neoadjuvant chemoradiotherapy for resectable pancreatic ductal adenocarcinoma (R-PDAC) remains unclear. This study was designed to evaluate neoadjuvant chemoradiotherapy by using intensity-modulated radiotherapy (NAC-IMRT) for R-PDAC compared with upfront surgery (UpS).

METHODS

Among 198 patients with R-PDAC who were indicated for resection between 2013 and 2021, 130 were included in this study after excluding patients who underwent neoadjuvant chemotherapy and did not meet the NAC-IMRT criteria (Eligible set). NAC-IMRT was planned for 58 patients, and UpS was planned for 72 patients. Additionally, in 105 patients who could undergo the planned treatment (As-treated set), the surgical, pathological, and oncological outcomes were evaluated.

RESULTS

In the Eligible set, median overall survival (OS) was 50.5 months with NAC-IMRT and 34.7 months with UpS and progression-free survival was 20.4 months with NAC-IMRT and 13.9 months with UpS. In the As-treated set, OS was longer in the NAC-IMRT group (66.7 months vs. 34.7 months, p = 0.007). On multivariate analysis, NAC-IMRT was identified as an independent factor for better OS (hazard ratio 0.617, 95% confidence interval 0.382-0.995, p = 0.047, in the Eligible set). The incidence of postoperative complications did not show a difference between the two groups, and NAC-IMRT suppressed local tumor invasion, including lymphatic, venous, perineural invasion, and lymph node metastases.

CONCLUSIONS

NAC-IMRT may offer superior survival outcomes and manageable toxicity in R-PDAC patients compared with upfront surgery. This study supports the efficacy and safety of NAC-IMRT and recommends its consideration in R-PDAC treatment protocols.

The minimum apparent diffusion coefficient value on preoperative magnetic resonance imaging in resectable pancreatic cancer: a new prognostic factor for biologically borderline resectable pancreatic cancer

PURPOSE

To identify the prognostic factors that can define biologically borderline resectable pancreatic cancer (BRPC) in resectable pancreatic cancer (RPC) patients.

METHODS

This retrospective study included 121 R/BRPC patients who underwent upfront surgery. Univariate and multivariate analyses were conducted to investigate the relationship between preoperative factors and overall survival (OS) for RPC. The OS of RPC patients was stratified based on a score, with each independent prognostic factor receiving 1 point. The OS of the R/BRPC patients was compared based on their scores.

RESULTS

Overall, 113 and eight patients had RPC and BRPC. Serum CA19-9 > 500 U/mL (p = 0.048), maximum tumor diameter > 30 mm (p = 0.01), superior mesenteric/portal vein contact < 180° (p = 0.04), and minimum apparent diffusion coefficient (ADCmin) ≤ 1020 × 10-6 mm2/s (p = 0.01) were identified as independent prognostic factors in RPC patients. RPC patients with a score of 0 had a significantly better prognosis than those with scores of 1 and 2-4 and BRPC patients (median OS: 99.3, 35.1, 19.0, and 8.4 months; p = 0.007, p < 0.001, and p = 0.003, respectively). No significant difference in the prognosis was observed between BRPC and RPC patients with scores of 1 and 2-4.

CONCLUSIONS

Preoperative ADCmin in RPC may be a new prognostic factor for biological BRPC.

Venous Resection During Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma-A Multicentre Propensity Score Matching Analysis of the Recurrence After Whipple's (RAW) Study

Background: Pancreatoduodenectomy with venous resection (PDVR) may be performed to achieve tumour clearance in patients with a pancreatic ductal adenocarcinoma (PDAC) with venous involvement. This study aimed to evaluate the impact of PDVR on PDAC outcomes. Methods: In total, 435 PDAC patients with either R0 status (n = 322) or R1 status within the superior mesenteric vein groove (n = 113) were extracted from the Recurrence After Whipple's (RAW) study dataset. PDVR patients were matched in a 1:2 ratio with standard PD patients. Comparisons were then made between the two groups (surgical radicality and survival). Results: A total of 81 PDVRs were matched with 162 PDs. Neoadjuvant chemotherapy (5.7% vs. 13.6%, p = 0.032) and R1 resection rates (17.9% vs. 42%, p < 0.001) were higher in the PDVR group. Risk factors for R1 resection included venous resection (p < 0.001 for sleeve and p = 0.034 for segmental resection), pT3 (p = 0.007), and pN1 stage (p = 0.045). PDVR patients had lower median overall survival (OS, 21 vs. 30 months (m), p = 0.023) and disease-free survival (DFS, 17 m vs. 24 m, p = 0.043). Among PDVR patients, R status did not impact on OS (R0: 23 m, R1: 21 m, p = 0.928) or DFS (R0: 18 m, R1: 17 m, p = 0.558). Irrespective of R status, systemic recurrence was higher in the PDVR group (p = 0.034). Conclusions: Independent of R status, the PDVR group had lower overall survival and higher systemic recurrence rates.

[Innovations in the German Guideline for Pancreatic Cancer]

After several revisions and updates since its last publication, the third German S3 guideline "Exocrine pancreatic cancer" was published in 2024. In this article, we provide an overview of the most important innovations in diagnosis and treatment.

Clinical Impact of Neoadjuvant Therapy for Resectable Pancreatic Ductal Adenocarcinoma: A Single-Center Retrospective Study

BACKGROUND

Neoadjuvant therapy is recommended for treating resectable pancreatic ductal adenocarcinoma (PDAC); however, its appropriate use in patients with resectable PDAC remains debatable.

OBJECTIVE

This study aimed to identify independent poor prognostic factors and evaluate the clinical significance of neoadjuvant therapy in patients with resectable PDAC.

METHODS

We retrospectively reviewed consecutive patients diagnosed with resectable PDAC at our institute between January 2003 and December 2022. We analyzed poor prognostic factors at the time of diagnosis in patients who underwent upfront surgery using the Cox proportional hazards model for overall survival (OS). The prognostic score was calculated by adding the individual prognostic factor scores.

RESULTS

Overall, 359 patients were included in this study, with 308 patients undergoing upfront surgery and the remaining 51 patients receiving neoadjuvant therapy. The R0 resection rate was significantly higher in the neoadjuvant therapy group (70.6%) than in the upfront surgery group (64.0%). Multivariate analysis in the upfront surgery group revealed the following independent poor prognostic factors: tumor size ≥ 35 mm, serum albumin level ≤ .5 g/dL, neutrophil-to-lymphocyte ratio ≥ 3.5, carbohydrate antigen 19-9 level ≥ 250 U/mL, and Duke pancreatic monoclonal antigen type 2 level ≥ 750 U/mL. Among patients with prognostic scores of 0-1 (n = 263), the intention-to-treat OS did not significantly differ between the neoadjuvant therapy and upfront surgery groups. Among those patients with a prognostic score of ≥ 2 (n = 96), the neoadjuvant therapy group had significantly longer intention-to-treat OS than the upfront surgery group.

CONCLUSIONS

Prognostic score-based stratification can help identify patients who could benefit from neoadjuvant therapy.

Tumor Budding Is an Independent Adverse Prognostic Factor of Pancreatic Ductal Adenocarcinoma Patients Treated by Resection After Preoperative Chemoradiotherapy

OBJECTIVES

To examine the significance of tumor budding as a prognostic factor of resected pancreatic ductal adenocarcinoma (PDAC) specimens after preoperative chemoradiotherapy (CRT).

MATERIALS AND METHODS

Among 162 PDAC patients who underwent pancreatectomy after gemcitabine and S1-based CRT from 2012 to 2019, 131 were evaluated for tumor budding. Tumor buds were counted at the invasive front, where the degree of budding was the greatest (hematoxylin and eosin staining, ×20 magnification). Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were compared between the patients without tumor budding (non-TB group) and those with tumor buddings (TB group). Multivariate Cox proportional hazards analysis was conducted to examine the significance of tumor budding as a prognostic factor.

RESULTS

OS, DSS, and RFS (median survival time) of the non-TB group were significantly longer than those of the TB group (OS: 50.7 vs 27.5 months, P  = 0.014; DSS: 63.3 vs 33.0 months, P  = 0.014; RFS: 20.3 vs 11.3 months, P  = 0.028). Multivariate analysis identified adjuvant chemotherapy ( P  = 0.003) as a favorable prognostic factor of OS and tumor budding ( P  = 0.023) as an adverse prognostic factor of DSS.

CONCLUSIONS

This study revealed that the presence of tumor budding was an independent adverse prognostic factor in PDAC patients resected after gemcitabine and S1-based CRT.

Impact of Surgical Resection After Induction Gemcitabine Plus S-1-Based Chemoradiotherapy in Patients with Locally Advanced Pancreatic Ductal Adenocarcinoma: A Focus on UR-LA Cases

Background: This study aimed to assess the safety and efficacy of gemcitabine plus S-1-based chemoradiotherapy (GS-CRT) among patients with locally advanced pancreatic ductal adenocarcinoma (PDAC), especially among those with unresectable locally advanced (UR-LA) cases. Methods: A total of 351 consecutive PDAC patients were enrolled and prognostic predictors of disease-specific survival (DSS) were identified. Results: The treatment completion rate was 98.9% and Grade 3 or higher adverse events occurred in 181 cases (51.6%). Among 319 re-evaluated patients, pancreatectomy was performed in 184 (57.7%). Based on resectability, the 5-year DSS rates for the entire cohort were 39.6% (R), 43.8% (BR-PV), 21.2% (BR-A) and 13.3% (UR-LA), while the predictors of DSS were performance status (PS), hemoglobin (Hb) level, celiac artery (CA) involvement of ≥180 degrees and JPS 8th T category. In the resected cases, the predictors of DSS were preoperative PS, preoperative CA19-9 level, preoperative JPS-T factor, degree of histological response and adjuvant chemotherapy. In UR-LA resected patients, preoperative prognostic nutritional index (PNI), absence of pathological venous invasion and adjuvant chemotherapy were predictors of DSS. Conclusions: Even though Grade 3 or higher adverse events were encountered in about half of the cases, they were uneventfully managed. Therefore, GS-CRT is safe and highly tolerable with potential to improve patients' prognosis. Preoperative PS, CA19-9 levels and histological response are important prognostic factors, as well as adjuvant therapy. In UR-LA patients, prognostic nutritional index (PNI) and adjuvant chemotherapy were important for curative intent surgery.

Preoperative Prognostic Factors in Resectable Pancreatic Cancer: State of the Art and Prospects

BACKGROUND

Only 15% to 20% of patients with pancreatic ductal adenocarcinoma (PDAC) have access to surgical resection, which represents the only chance of curative treatment. Current resection classifications are almost exclusively anatomic and do not correlate sufficiently with patient survival. It is essential to develop preoperative prognostic factors to distinguish patients at high risk of early postoperative recurrence from those who will have prolonged survival after surgery. In some cases, PDACs may present biomolecular differences reflecting their aggressiveness that are not yet assessable by the current clinical-biologic assessment. This study aimed to assess the preoperative prognostic factors that are already available and the future perspectives being developed.

METHOD

This study reviewed the literature using the PubMed public database for preoperative prognostic factors for resectable PDAC.

CONCLUSION

Validated preoperative prognostic factors, whether clinical, biologic, radiologic, or histologic, are very important in anticipating the course of each patient's disease. The identification of potential new prognostic biomarkers such as genomic, transcriptomic, and proteomic analyses and the dosage of circulating tumor DNA are very serious avenues to be developed, but the extraction and analysis techniques as well as the interpretation of their results need to be standardized in prospective studies.

Effect of travel distance on utilization of ancillary services among patients with pancreatic ductal adenocarcinoma: A single institution study

BACKGROUND

Fragmentation of care among patients with pancreatic cancer between specialized tertiary centers and community centers may be associated with increased patient burden and poorer outcomes. However, the impact of distance from a tertiary center on utilization of key ancillary services such as dietician consultation, and palliative or pain medicine consultation is unclear. We sought to examine how this travel distance influences the utilization of key ancillary services.

METHODS

This retrospective cohort study included 200 consecutive patients who were seen for a diagnosis of pancreatic ductal adenocarcinoma (PDAC) in 2021. Patients were grouped by travel distance: < 12.5, 12.5-49, and > 50 miles. Demographics, disease staging, and use of key ancillary services such as, dietician consultation, palliative, and pain medicine consultation were compared. Multiple logistic regression assessed associations between travel distance and ancillary service utilization.

RESULTS

Of the 200 patients, 14.5% traveled < 12.5 miles, 39.5% traveled 12.5-49 miles, and 46% traveled over 50 miles to our institution. Patients living over 50 miles away were significantly more likely to receive chemotherapy and radiation locally (81.8% vs 44.4%, p < 0.001). Importantly, they were less likely to utilize key ancillary services, including registered dietician consultation (Odds Ratio (OR) 0.34, p = 0.03), pancreatic enzyme prescriptions (OR 0.35, p = 0.03), pain medicine consultation (OR 0.20, p < 0.01), and palliative care consultation (OR 0.24, p < 0.01) compared to those living closer.

CONCLUSIONS

Patients living over 50 miles from our institution were significantly less likely to receive key supportive services. Despite similar clinical characteristics, these disparities show how initiatives are necessary to guarantee equitable access to comprehensive cancer care, regardless of geographic location.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Updates in the Surgical Management of Pancreatic Ductal Adenocarcinoma

Surgical management of pancreas cancer is complex, including the timing of surgery, surgical approach, intraoperative techniques, and postoperative management, which are reviewed in detail in this manuscript. Ultimately, referral to a high-volume pancreatic surgeon or pancreatic surgery center is critical to ensuring appropriate short-term and long-term outcomes.

International Validation and Refinement of Oncological Borderline Resectability Criteria for Hepatocellular Carcinoma Using Tumor Burden Score to Predict Survival

Objective

The aim of this study is to externally validate the original borderline resectability (BR) category for predicting overall survival (OS) in hepatocellular carcinoma (HCC) following resection and to assess whether incorporating the tumor burden score (TBS) and other clinical factors could enhance predictive accuracy.

Background

A recent Japanese expert panel introduced a new HCC classification scheme: resectable (R), borderline resectable 1 (BR1), and borderline resectable 2 (BR2).

Methods

Patients undergoing curative-intent hepatectomy for HCC (2000-2023) were classified as R, BR1, and BR2 using the original BR and a novel TBS-BR category. The TBS-BR category replaces BR's categorical tumor morphology factors with the continuous TBS (TBS² = [maximum tumor diameter]² + [number of tumors]²). Multivariable analysis identified oncologic, morphometric, and patient-level factors associated with OS, which were incorporated into an online predictive tool.

Results

Among 1766 patients, the original BR category grouped 1504 (85.2%) as R, 249 (14.1%) as BR1, and 13 (0.7%) as BR2. Utilizing the TBS-BR category, patients were reclassified as TBS-BR R (n = 684, 38.7%), BR1 (n = 1009, 57.1%), and BR2 (n = 73, 4.1%). Both the original and TBS-BR categories correlated with 5-year OS (original: 65.1%, 48.2%, 46.4%; TBS-BR: 70.8%, 58.3%, 40.0%; P < 0.001 for both; area under the curve: 0.54 vs 0.58). On multivariable analysis, TBS-BR1 (hazard ratio [HR]: 1.59 [1.20-2.09]; P = 0.001), TBS-BR2 (HR: 2.45 [1.47-4.07]; P < 0.001, reference: TBS-BR R), American Society of Anesthesiologists (ASA) class >2 (HR: 1.40 [1.09-1.80]; P = 0.007), albumin-bilirubin (ALBI) score (HR: 1.51 [1.21-1.88]; P < 0.001), and log α-fetoprotein (AFP) (HR: 1.07 [1.03-1.11]; P < 0.001) were independently associated with OS. A TBS-BR composite model based on these factors (TBS-BR category, ASA class, ALBI score, and log AFP) was developed and made available online (https://makbn.shinyapps.io/BRHCC/). The model's area under the receiver operating characteristic at 5 years (0.70) outperformed both the original BR (0.57) and Barcelona Clinic Liver Cancer classification (0.64).

Conclusions

The TBS-BR composite model, integrating tumor morphology (TBS), tumor biology (log AFP), overall physical status (ASA class), and liver function (ALBI score) demonstrated superior predictive accuracy for OS compared with the original BR and Barcelona Clinic Liver Cancer classifications.

Multidisciplinary Therapeutic Approaches to Pancreatic Cancer According to the Resectability Status

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers, characterized by late diagnosis, rapid progression, and limited therapeutic options. Despite advancements, only 20% of patients are eligible for surgical resection at diagnosis, the sole curative treatment. Multidisciplinary evaluation is critical to optimize care, stratifying patients based on resectability into resectable, borderline resectable, locally advanced, and metastatic stages. Preoperative imaging, such as computed tomography (CT) and endoscopic ultrasound (EUS), remains central for staging, for vascular assessment, and tissue acquisition. Endoscopic and systemic approaches are pivotal for addressing complications like biliary obstruction and improving outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered for years the gold standard for biliary drainage, although EUS-guided drainage is increasingly utilized due to its efficacy in both resectable and unresectable disease. Systemic therapies play a key role in neoadjuvant, adjuvant, and palliative settings, with ongoing trials exploring their impact on survival and resectability chance. This review highlights the evolving multidisciplinary approaches tailored to the disease stage, focusing on biliary drainage techniques, systemic therapies, and their integration into comprehensive care pathways for PDAC. The continuous refinement of these strategies offers incremental survival benefits and underscores the importance of personalized, multidisciplinary management.

Advancing Immunotherapy in Pancreatic Cancer: A Brief Review of Emerging Adoptive Cell Therapies

Pancreatic cancer has the lowest 5-year survival rate (13%) among major cancers and is the third leading cause of cancer-related deaths in the United States. The high lethality of this cancer is attributed to its insidious onset, late-stage diagnosis, rapid progression, and limited treatment options. Addressing these challenges requires a deeper understanding of the complex tumor microenvironment to identify novel therapeutic targets. Newer approaches like adoptive cell therapy have shown remarkable success in treating hematological malignancies, but their application in solid tumors, particularly pancreatic cancer, is still in the early stages of development. ACT broadly involves isolating immune cells (T lymphocytes, Natural Killer cells, and macrophages) from the patient, followed by genetic engineering to enhance and mount a specific anti-tumor response. Various ACT modalities are under investigation for pancreatic cancer, including chimeric antigen receptor T cells (CAR-T), chimeric antigen receptor NK cells (CAR-NK), tumor-infiltrating lymphocytes (TIL), T-cell receptor (TCR)-engineered T cells, and cytokine-induced killer cells (CIK). Major hurdles have been identifying actionable tumor antigens and delivering focused cellular therapies to overcome the immunosuppressive and dense fibrotic stroma surrounding the pancreatic cancer. Further studies are needed to explore the limitations faced by cellular therapy in pancreatic cancer and identify novel combination treatment approaches in order to improve clinical outcomes.

Most oncological pancreas resections must consider the mesopancreas

BACKGROUND

In preoperative staging for patients with a ductal adenocarcinoma of the pancreatic head (PDAC), resectability is anatomically characterized by the possible clearance of the medial vascular grove. Borderline resectable PDAC patients who retain an increased risk of infiltration to the portomesenteric system and/or arterial vasculate are candidates for neoadjuvant therapy. However, redefined pathological analysis revealed the dorsal resection margin to be similar at risk for R1 resection. Mesopancreatic excision (MPE) aims to secure the integrity of the dorsal and ventral resection margins. The existence of the mesopancreas (MP) is inevitable, since the pancreas is of a secondary retroperitoneal nature and the dorsal as well as ventral fascial coverings define the peripancreatic compartment anatomy. It remains unknown if the MP area is only infiltrated in high-risk PDAC patients or if MPE during pancreatoduodenectomy should be employed for localized PDAC patients as well.

METHODS

Patients who underwent upfront pancreatoduodenectomy were included. CRM evaluation and analysis of the MP was standardized in all patients. Patients were sub-grouped by the infiltration status of the vascular groove (localized disease: LOC). In LOC patients there was evidently no cancerous infiltration into the medial vascular groove (true + primary resectable).

RESULTS

Two hundred eighty-four consecutive patients who underwent pancreatoduodenectomy were included (169 LOC patients). In LOC patients the MP infiltration rate remained high but was significantly lower when compared to advanced PDAC patients (MP + 69.2% vs. 83.5%, p = 0.005). In LOC patients, CRM resection status of the dorsal resection status remained significantly affected by the MP infiltration status (R0CRM- 80.5% vs. 62.8%, p = 0.019).

CONCLUSION

These important findings clearly show underestimated tumor extensions into the mesopancreas even in localized, primary resectable PDAC patients who are currently amenable for upfront resection. Synergistically to total mesorectal or mesocolic excision, which is applied to all stages of colorectal disease, MPE is justified in primary resectable patients as well. Therefore, MPE should be employed in all PDAC patients. Since the infiltration status of the mesopancreas was a significant factor for incomplete resection in primary resectable PDAC patients, neoadjuvant treatment options for must be discussed.

Preoperative Chemotherapy With Gemcitabine for Pancreatic Cancer Causes Zinc Deficiency

OBJECTIVES

The aim of this study was to investigate how preoperative chemotherapy affected the serum zinc concentrations in patients with pancreatic cancer (PC).

MATERIALS AND METHODS

Two hundreds thirty-one patients with PC who underwent pancreatectomy at our department from 2013 to 2019 were enrolled in this study and measured for the serum zinc concentrations before pancreatectomy. Patient characteristics, course of treatment, and laboratory data were analyzed.

RESULTS

One hundred thirty-five patients underwent upfront pancreatectomy and 58 received preoperative gemcitabine + S1 (GEM + S1) and 29 received gemcitabine + nab-paclitaxel (GEM + nab-PTX). Comparing the serum zinc concentrations before and after preoperative treatment, it was found to decrease after treatment with statistical difference (79.3 μg/dL vs 68.7 μg/dL, P < 0.001). The result was consistent with the investigation for both the patients who received GEM + S1 and those who received GEM + nab-PTX ( P = 0.019, P < 0.001, respectively).

CONCLUSIONS

The preoperative chemotherapy consistently reduced the serum zinc concentrations in the PC patients, regardless of their regimen such as GEM + S1 and GEM + nab-PTX. Monitoring the serum zinc concentration and appropriate zinc supplementation may be essential for PC patients undergoing preoperative chemotherapy and pancreatectomy.

Overcoming the technical challenge of venous resection with pancreatectomy: Which factors determine survival?

BACKGROUND

Pancreatectomy with venous resection (PVR) is nowadays considered standard. However, there is still concern about increased postoperative morbidity and impaired long-term outcome depending on the type of venous resection and reconstruction. The aim was to investigate the predictors of morbidity and long-term survival in patients undergoing PVR in a high-volume center.

METHODS

All consecutive patients undergoing PVR at a single center between January 2008 and January 2019 were retrieved from a prospectively maintained database. Factors associated with postoperative complications and long-term survival were analyzed.

RESULTS

Of 290 patients with isolated PVRs, 188 (65 %) were performed for pancreatic ductal adenocarcinoma (PDAC). Surgical complications developed in 56 % of patients (n = 163), and 11 % (n = 36) had severe complications (Clavien-Dindo>3a). The 90-day mortality was 4.1 %. Venous thrombosis occurred in 4.8 % (n = 14), resulting in one mortality (0.3 %). No technical factors were predictive for the development of severe complications. Longer vein segments >3 cm could be resected with similar short- and long-term outcome as shorter segments. The survival of patients undergoing PVR for resectable, borderline and locally advanced PDAC was similar (median of 18, 14, and 23 months, p = 0.7). On multivariate analysis, elevated CA19-9>200 U/mL and ASA score≥3 were independent predictors of survival (p = 0.02), but not resectability at diagnosis nor type of venous reconstruction.

CONCLUSION

The type of venous resection/reconstruction does not influence outcome and should be tailored according to patients' and tumors' characteristics during PVR. The long-term survival after PVR for PDAC is influenced by tumor-and patient-related characteristics, and not technical vascular-resection associated factors.

Long-term survival analysis based on tumor location in patients with pancreatic ductal adenocarcinoma who underwent pancreatectomy following neoadjuvant chemoradiotherapy

BACKGROUND

The study aimed at assessing whether long-term survival outcomes were different based on tumor location in pancreatic ductal adenocarcinoma (PDAC) patients who underwent pancreatectomy following neoadjuvant chemoradiotherapy (CRT).

METHODS

Following CRT, resection rate was 60.5% (286/473) and the resected patients had pancreatic head (n = 218), body (n = 34) and tail (n = 34) tumors. Survival analyses were conducted, independent predictors of disease-free survival (DFS) and overall survival (OS) were identified, and then survival outcomes were stratified by the predictors of DFS and OS.

RESULTS

Resection rates were; 64.7% (head) vs. 46.6% (body) and 54.0% (tail) cases, p = 0.009. Among these cases, pancreatic head patients exhibited a higher incidence of initial clinical stage 3 tumors; 48.2% (head) vs. 29.4% (body) and 0% (tail) cases, p < 0.001 with more unresctable-locally advanced tumors; 22.0% (head) vs. 11.8% (body) and 0% (tail), p < 0.001, but demonstrated a better response to CRT; Evans grades 3/4 in 49.1% (head) vs. 23.5% (body) and 26.5% (tail), p = 0.012. Five-year DFS rates were; 19.9% (head) vs. 11.8% (body) vs. 24.6% (tail), p = 0.565 and OS rates; 25.4% (head) vs. 27.7% (body) vs. 32.0% (tail), p = 0.341. Significant predictors of DFS and OS included post-CRT CA19-9 levels, tumor differentiation, resection margins and pathological portal vein invasion. Based on these predictors, survival outcomes were also comparable. Pathological nodal invasion influenced DFS, while pathological stage impacted OS.

CONCLUSION

Pancreatic head patients had the best resection rate and long-term survival outcomes were comparable, attributable to the better response to CRT by pancreatic head than the body and tail PDAC patients.

3D modeling to predict vascular involvement in resectable pancreatic adenocarcinoma

Background

Current management of patients with borderline resectable pancreatic adenocarcinoma (BR-PDAC) depends on the degree of involvement of the major arterial and venous structures. The aim of this study was to evaluate 3D segmentation and printing to predict tumor size and vascular involvement of BR-PDAC to improve pre-operative planning of vascular resection and better select patients for neoadjuvant therapy.

Methods

We retrospectively evaluated 16 patients with BR-PDAC near vascular structures who underwent pancreatoduodenectomy (PD) with or without vascular resection between 2015 and 2021. The pre-operative computed tomography (CT) images were processed by segmentation with 3D reconstruction and printed as 3D models. Two radiologists specialized in pancreatic imaging and two pancreatic surgeons blindly and independently analyzed the pre-operative CT scans and 3D models using a defined checklist. Their evaluations were compared to the pre-operative 2D-CT reports utilized for patient management. A positive delta was defined by the 3D analysis resulting in greater accuracy in predicting vascular involvement as proven intraoperatively or histopathologically.

Results

Fourteen PD, one total pancreatectomy, and one exploratory laparotomy were performed. Ten patients had a positive delta concerning vascular involvement of the superior mesenteric or portal vein. Tumor extension was also more accurately evaluated by 3D modeling than by 2D-CT (p < 0.05).

Conclusions

Our pilot study demonstrates that 3D segmentation can provide additional information for choosing the best treatment strategy and surgical plain in patients with BR-PDAC. Especially for upcoming mini-invasive techniques like laparoscopic and robotic resections, better pre-operative planning is essential to allow safety and prevent vascular injury.

Thrombosis and anticoagulation after portal vein reconstruction during pancreatic surgery: a systematic review

BACKGROUND

Portal vein (PV) resection and reconstruction, which includes the resection and reconstruction of the PV and superior mesenteric vein, enable surgical removal of borderline resectable and locally advanced pancreatic cancer. Thrombosis of the reconstructed PV represents a major cause of early postoperative and long-term morbidity and mortality. No universally accepted standard for anticoagulation exists. This study aimed to assess early and late thrombosis rates after PV reconstruction with special regard to the type of PV reconstruction and anticoagulation regimen and to comprehensively assess thrombotic events and their clinical effect in patients receiving pancreatic surgery with venous resection and reconstruction.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies reporting on PV resection and reconstruction providing data on thrombosis rates were included. The following parameters were assessed: study type, year of publication, number of patients, type/number of PV reconstruction, follow-up period, postoperative mortality, thrombosis rate of the reconstructed PV axis, intraoperative blood loss, and anticoagulation.

RESULTS

A total of 23 studies with 2751 patients were included in the final analysis. Of note, 670 patients received tangential resection of the PV with venorrhaphy or patch repair, 1505 patients had segmental resection with end-to-end reconstruction, and 576 patients received reconstruction with an interposition graft/conduit. The pooled overall thrombosis rate was 15%. Reconstruction of tangential defects with either venorrhaphy or patch repair and end-to-end repair of segmental defects resulted in a thrombosis rate of 12%. Subgroup analysis according to the type of graft reconstruction revealed the highest occlusion rates of 55% in patients with allogeneic grafts, followed by up to 27% in patients with synthetic PV conduits. Autologous conduits had a thrombosis rate of 10%. Early thrombotic events were detected in 5% of patients after venorrhaphy/patch reconstruction and end-to-end reconstruction. Early events were most common in the allogeneic graft subgroup (22%), followed by synthetic conduits (15%). There were fewer early events in the autologous graft group (7%). Early PV thrombosis was associated with relevant mortality of up to 26%. Anticoagulation regimens varied between studies.

CONCLUSION

The overall thrombosis rate after PV resection is low. However, among the different reconstruction techniques, allogeneic interposition grafts/conduits had the highest thrombosis rates among the different types of reconstruction after PV resection. No specific anticoagulation strategy can be considered beneficial based on the existing literature.

Neoadjuvant Treatment with Changes in Chemotherapy Regimens According to Carbohydrate Antigen 19-9 Level for Resectable/Borderline Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

The response of carbohydrate antigen (CA) 19-9 to neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) may contribute to outcomes. This study aimed to investigate the effect of changes in NAT regimens based on CA19-9 level.

METHODS

This single-center retrospective study included patients with resectable/borderline resectable (R/BR)-PDAC undergoing NAT from 2008 to 2022. A CA19-9 level lower than 150 IU/mL after NAT was the criterion for resection. If the level did not decrease, the chemotherapy regimen was changed to satisfy the criterion. The patient cohort was divided into group A (satisfied criterion without changing chemotherapy), group B (did not receive chemotherapy change, could not satisfy the criterion), group C (received chemotherapy change, satisfied the criterion), and group D (received chemotherapy change, could not satisfy the criterion).

RESULTS

The study cohort included 283 patients. After first-line chemotherapy, 112 (39.6%) patients did not satisfy the criterion (groups B [n = 64], C [n = 32], and D [n = 16]). Of the 283 patients, 48 (17%) received a chemotherapy change (groups C and D). The patients in groups C and D showed significantly better overall survival (OS, 35.9 months) than the group B patients (25.7 months) (P = 0.035). The OS of the group C patients (63.8 months) was similar to the OS of the group A patients (n = 171: 56.3 months; P = 0.430). Multivariate analysis of the patients in groups B, C, and D identified chemotherapy change as an independent prognostic factor for OS and progression-free survival.

CONCLUSION

Changing the chemotherapy targeting the CA19-9 level can improve the outcome of R/BR-PDAC patients with poor biologic response to first-line NAT.

Causes, management, and prognosis of severe gastrointestinal bleedings in critically ill patients with pancreatic cancer: A retrospective multicenter study

BACKGROUND

Gastrointestinal (GI) bleeding is a leading cause of intensive care unit (ICU) admission in pancreatic cancer patients.

AIMS

To analyze causes, ICU mortality and hemostatic treatment success rates of GI bleeding in pancreatic cancer patients requiring ICU admission.

METHODS

Retrospective multicenter cohort study between 2009 and 2021. Patients with a recent pancreatic resection surgery were excluded.

RESULTS

Ninety-five patients were included (62 % males, 67 years-old). Fifty-one percent presented hemorrhagic shock, 41 % required mechanical ventilation. Main GI bleeding causes were gastroduodenal tumor invasion (32 %), gastroesophageal varices (21 %) and arterial aneurysm (12 %). Arterial aneurysms were more frequent in patients with previous pancreatic resection (36 % vs 2 %, p < 0.001). Hemostatic procedures included gastroduodenal endoscopy in 81 % patients and arterial embolization in 28 % patients. ICU mortality was 19 %. Multivariate analysis identified four variables associated with mortality: performance status >2 (OR 9.34, p = 0.026), mechanical ventilation (OR 14.14, p = 0.003), treatment success (OR 0.09, p = 0.010), hemorrhagic shock (OR 11.24, p = 0.010). Treatment success was 46 % and was associated with aneurysmal bleeding (OR 29.89, p = 0.005), ongoing chemotherapy (OR 0.22, p = 0.016), and prothrombin time ratio (OR 1.05, p = 0.001).

CONCLUSION

In pancreatic cancer patients with severe GI bleeding, early identification of aneurysmal bleeding (particularly in case of previous resection surgery) and coagulopathy management may increase the treatment success and reduce mortality.

Novel Predictive Strategy Using CA19-9 and Fecal Elastase Levels to Make Treatment Decisions for Resectable Pancreatic Cancer: A Retrospective Study

Background: Carbohydrate antigen 19-9 (CA19-9) is used as a marker to predict recurrence and survival of patients with pancreatic ductal adenocarcinoma (PDAC). Recently, fecal elastase-1 (FE-1) has been shown to correlate with prognosis in patients with PDAC. Method: A total of 536 patients who underwent curative intent surgery between 2010 and 2019 were included in the study. The cutoff points of preoperative CA19-9 and FE-1 levels were extracted from the Youden index and previous studies. Cox proportional hazard models were used to investigate the association between preoperative tumor marker levels and survival after surgery. Results: Patients with CA19-9 ≥ 385 had more advanced T-/N-stages and lower survival rates compared to those with CA19-9 < 385. Multivariate Cox analyses demonstrated that combining preoperative tumor markers was associated with worse 3-year overall survival (both CA19-9 and FE-1 low, HR = 1.41, p = 0.044; both high, HR = 1.44, p = 0.047; CA19-9 high and FE-1 low, HR = 2.00, p < 0.001; and p for trend < 0.001). The same trend was confirmed in the analysis with recurrence-free survival. Conclusions: This study presents a new predictive strategy using combined CA19-9 and FE-1 levels to determine the treatment for resectable pancreatic cancer.

The Past, Present, and Future of Biomarkers for the Early Diagnosis of Pancreatic Cancer

Pancreatic cancer is one of the most aggressive cancers with a very poor 5-year survival rate and reduced therapeutic options when diagnosed in an advanced stage. The dismal prognosis of pancreatic cancer has guided significant efforts to discover novel biomarkers in order to anticipate diagnosis, increasing the population of patients who can benefit from curative surgical treatment. CA 19-9 is the reference biomarker that supports the diagnosis and guides the response to treatments. However, it has significant limitations, a low specificity, and is inefficient as a screening tool. Several potential biomarkers have been discovered in the serum, urine, feces, and pancreatic juice of patients. However, most of this evidence needs further validation in larger cohorts. The advent of advanced omics sciences and liquid biopsy techniques has further enhanced this field of research. The aim of this review is to analyze the historical evolution of the research on novel biomarkers for the early diagnosis of pancreatic cancer, focusing on the current evidence for the most promising biomarkers from different body fluids and the novel trends in research, such as omics sciences and liquid biopsy, in order to favor the application of modern personalized medicine.

Prognostic role of systemic inflammation response index (SIRI) in patients with pancreatic cancer: a meta-analysis

Background

The significance of the systemic inflammation response index (SIRI) in predicting the prognosis of patients with pancreatic cancer (PC) has been extensively explored; however, findings remain controversial. As such, this meta-analysis was performed to more precisely determine the utility of the SIRI in predicting PC prognosis.

Methods

A comprehensive literature search of the PubMed, Web of Science, Embase, and Cochrane Library databases for relevant studies, published up to June 25, 2024, was performed. The primary and secondary endpoints were overall survival (OS) and progression-free survival (PFS), respectively. The prognostic utility of the SIRI in predicting PC prognosis was estimated by calculating pooled hazard ratios (HRs) and corresponding 95% confidence intervals (CIs).

Results

Seven studies comprising 1160 patients were included in the present meta-analysis. Pooled findings revealed that elevated SIRI was as a prominent prognostic marker of OS (HR 2.40 [95% CI 1.88-3.05]; p<0.001) and PFS (HR 1.95 [95% CI 1.19-3.21]; p=0.008) in patients diagnosed with PC. According to subgroup analysis, the SIRI remained an outstanding prognostic marker for OS, irrespective of region, sample size, study center, study design, TNM stage, cancer type, cut-off value, treatment, or survival analysis type (all p<0.05). Moreover, based on subgroup analysis, the SIRI demonstrated significant utility in predicting PFS, irrespective of region and threshold value (p<0.05).

Conclusion

Results of the present meta-analysis revealed that an increased SIRI significantly predicted OS and PFS in patients diagnosed with PC. Considering its cost-effectiveness and availability, the SIRI may be a promising biomarker for predicting prognosis in patients with PC.

Prognostic significance of creatine kinase in resected pancreatic cancer

BACKGROUND

Creatine kinase (CK) levels decrease with cancer progression and muscle wasting, but its association with pancreatic ductal adenocarcinoma (PDAC) remains unclear. The aim of this study was to investigate CK as a prognostic biomarker and surrogate marker for muscle mass in patients with PDAC.

METHODS

A retrospective analysis of 476 patients with PDAC was conducted. CK levels were categorized into low and high groups using receiver-operating characteristic (ROC) curve analysis.

RESULTS

Among the 476 patients, 200 (42.0%) and 276 (58.0%) were classified into the low and high CK groups, respectively. The low CK group had significantly poorer overall survival (p < .001) and recurrence-free survival (p < .001) compared to the high CK group. Multivariate analysis identified low CK as an independent poor prognostic factor (p < .001). The low CK group had significantly lower skeletal muscle index (p = .048) than the high CK group; however, the difference was slight and not significantly associated with sarcopenia. Additionally, combined risk assessment incorporating CK and resectability facilitated a more nuanced prognostic stratification.

CONCLUSIONS

CK served as a reliable prognostic marker independent from resectability but was less effective as a marker for sarcopenia in PDAC.

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.

Pancreatoduodenectomy after Ivor-Lewis Santi oesophagectomy with gastric tube reconstruction. An European multicentre experience

BACKGROUND

Pancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes.

METHODS

We have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes.

RESULTS

Eight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14-24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases.

CONCLUSION

Performing pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed.

Embolize, supercharge, resect: Embolization to enhance hepatic vascularization prior to en-bloc pancreas and arterial resection

INTRODUCTION

Embolization could increase the resectability of pancreatic tumors by supercharging visceral arterial perfusion prior to pancreatic surgery with arterial en-bloc resection. Its indications, however, are controversial.

METHODS

We retrospectively analyzed the results of a single-center database of patients undergoing pancreatic surgery with arterial resection (AR) after preoperative arterial embolization (PAE) to increase hepatic vascular flow and spare arterial reconstruction.

RESULTS

PAE was planned in 15 patients with arterial involvement due to pancreatic tumors. Three patients were excluded due to the finding of irresectable disease during surgery. Twelve cases were resected because of pancreatic cancer (10), distal cholangiocarcinoma (1), and pancreatic neuroendocrine tumor (1). Arterial involvement in these cases required embolization of the substitute right hepatic artery (RHA) (5), left hepatic artery (1), and common hepatic artery (CHA) (6) to enhance liver vascularization. Two patients presented migration of the vascular plug after PAE. Six pancreatoduodenectomies and 6 distal pancreatectomies were performed, the latter associated with en-bloc celiac trunk and CHA resection. R0 was achieved in 7 out of 12 patients, and pathological vascular involvement was confirmed in 8. Postoperative complications included one patient who developed gastric ischemia and underwent gastrectomy, and one patient who underwent reoperation for acute cholecystitis with liver abscesses.

CONCLUSION

Preoperative arterial embolization before pancreatic surgery with hepatic arterial resection enables surgeons to precondition hepatic vascularization and prevent hepatic ischemia. In addition, this avoids having to perform arterial anastomosis in the presence of pancreatic suture.

Factors associated with favourable pathological tumour response after neoadjuvant chemotherapy in patients with pancreatic ductal adenocarcinoma

INTRODUCTION

Pathological response of pancreatic ductal adenocarcinoma (PDAC) to neoadjuvant chemotherapy (NAT) has been associated with oncological outcome. The aim of the study was to investigate factors associated with favourable tumour regression in patients undergoing pancreatic resection for PDAC.

METHODS

Patients who received NAT before undergoing PDAC resection at two institutions were reviewed. Tumour regression grading (TRG) was scored according to the College of American Pathologists (CAP) system. Interactions between chemotherapy, tumour and surgical factors with TRG were explored.

RESULTS

54 patients were identified, with 12 (22%) displaying a favourable response to NAT. The type of chemotherapy agent received, the number of cycles or a dose reduction during NAT course was not significantly different between the groups. The time from diagnosis to chemotherapy and time from end of chemotherapy to surgery were also similar between the groups. A favourable TRG was associated with greater disease-free survival median 33.2 months vs. 10.3 months; p = 0.0) but not overall survival (median 43.8 months vs. 32.3 months; p = 0.200), which may be due to small sample size.

CONCLUSIONS

Chemotherapy factors were not significantly related to a favourable response to NAT. Future studies should seek to identify modifiable factors associated with a favourable TRG.

Oncological Resectability Criteria for Hepatocellular Carcinoma in the Era of Novel Systemic Therapies: The Japan Liver Cancer Association and Japanese Society of Hepato-Biliary-Pancreatic Surgery Expert Consensus Statement 2023

Recent advances in systemic therapy for hepatocellular carcinoma (HCC) have led to debates about the feasibility of combination therapies, such as systemic therapy combined with surgery or transarterial chemoembolization, for patients with advanced HCC. However, a lack of consensus on the oncological resectability criteria has hindered discussions of "conversion therapy" and the optimal management in patients with HCC. To address this issue, the Japan Liver Cancer Association (JLCA) and the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) established a working group and discussed the concept of borderline resectable HCC. Herein, we present a consensus statement from this expert panel on the resectability criteria for HCC from the oncological standpoint under the assumption of technically and liver-functionally resectable situations. The criteria for oncological resectability in HCC are classified into three grades: resectable, representing an oncological status for which surgery alone may be expected to offer clearly better survival outcomes as compared with other treatments; borderline resectable 1, representing an oncological status for which surgical intervention as a part of multidisciplinary treatment may be expected to offer survival benefit; and borderline resectable 2, representing an oncological status for which the efficacy of surgery is uncertain and the indication for surgery should be determined carefully under the standard multidisciplinary treatment. These criteria aim to provide a common language for discussing and analyzing the treatment strategies for advanced HCC. It is also expected that these criteria will be optimized, modified, and updated based on further advancements in systemic therapies and future validation studies.

Characteristics and prognosis of patients with pancreatic adenocarcinoma not expressing CA19-9: Analysis of the National Cancer Database

BACKGROUND

Around 5-10 % of pancreatic cancer patients are non-expressors of carbohydrate antigen 19-9 (CA 19-9), which has an unknown impact on the aggressiveness and prognosis of pancreatic adenocarcinoma (PDAC). This study aimed to evaluate the characteristics and the prognosis of PDAC patients who do not express CA 19-9.

METHODS

Patients with PDAC diagnosed between 2010 and 2018 were identified in the National Cancer Database. Clinical characteristics were compared according to CA 19-9 levels stratified in four different groups: non-expressors (≤1.0 U/mL), normal range (1.1-37.0 U/mL), mildly elevated (37.1-97.9 U/mL), and CA 19-9 ≥98.0 U/mL. The characteristics were analyzed in the whole cohort and overall survival (OS) was evaluated in a subgroup of upfront resected patients who had cT1-3 tumors without distant metastases.

RESULTS

In total, 88,749 patients were included, of which 4.5 % were CA 19-9 non-expressors. The non-expressors had a higher risk of having distant metastasis at diagnosis, compared to patients with normal-range or mildly elevated CA 19-9 levels. In resected patients (n = 4008), CA 19-9 non-expressors had shorted median OS compared to patients with normal-range CA 19-9 levels (29.3 vs 34.4 months, p = 0.024). This OS association remained in a multivariable Cox regression model (adjusted HR 1.22, 95 % CI 1.04-1.44).

CONCLUSIONS

CA 19-9 non-expression is associated with distant metastatic disease at diagnosis and with death in resected non-metastatic patients compared to normal-range CA 19-9 levels. This clinically relevant subgroup requires alternative biomarkers, and may need consideration of more extensive preoperative staging and intensive perioperative systemic therapy.

Survival after vascular resections in patients with borderline resectable or locally advanced pancreatic head cancer: A systematic review

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumors, and the most common cause of cancer-related deaths. In the past, vascular infiltration of the tumor rendered the disease unresectable. However, today, venous or arterial involvement of a PDAC is classified as borderline resectable (BR) or locally advanced (LA) disease. Pancreaticoduodenectomy (PD) with vascular resections is a promising intervention intended for complete resection of BR- and LA-PDAC. This study aims to assess the overall survival of patients undergoing PD with vascular resections, compared to those without. A PubMed search was conducted for cohort studies that included patients with BR- or LA-PDAC treated with vascular resections. The retrieved publications were screened following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The study protocol was registered at the International Prospective Register for Systematic Reviews (PROSPERO). Sixteen cohort studies were included in our systematic review. Fourteen of them included patients undergoing PD with venous-only resections for PDAC. The 5-year overall survival rates ranged from 8.0% to 22.2% for vascular resection patients, and 4.0% to 24.3% for standard PD patients. Three cohorts included patients with PDAC and arterial and/or venous involvement who were treated with arterial resections. Their median overall survival ranged from 13.7 to 17.0 months, similar to that of patients who did not undergo vascular resections. PD with vascular resections in patients with BR- and LA-PDAC could lead to similar overall survival to that after standard PD.

The Evolving Role of Neoadjuvant Radiation Therapy in Pancreatic Adenocarcinoma

BACKGROUND/OBJECTIVES

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers. Surgical resection is the most reliable chance for cure, but high rates of positive margins and local failure persist. Neoadjuvant therapies (NAT), including chemotherapy and radiation therapy (RT), are being explored to improve surgical outcomes, particularly in borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC). This review aims to summarize the current landscape and future directions for neoadjuvant RT (NART) in PDAC.

METHODS

The review includes a detailed analysis of past and ongoing clinical trials investigating various NART approaches in PDAC, with an emphasis on different RT techniques, fractionation schemes, and their integration into multimodal treatment strategies.

RESULTS

Early evidence suggests that NART can improve resection margins and local control. However, recent trials, including the Alliance A021501 and LAP-07 trials, have failed to demonstrate significant survival benefits with the addition of RT to NAT. Nevertheless, nuances in trial design and execution continue to keep the question of NART open. Newer approaches, such as stereotactic magnetic resonance-guided adaptive radiation therapy (SMART), show promise in improving local control and survival, but further phase 3 trials are needed.

CONCLUSIONS

While NART has shown potential in improving local control in PDAC, its impact on overall survival remains unclear. Ongoing trials, particularly those utilizing advanced techniques like SMART, are critical in defining the role of RT in the neoadjuvant setting for PDAC. Collaboration across multidisciplinary teams is essential to optimize treatment strategies and trial outcomes.

The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

New Biomarkers to Define a Biological Borderline Situation for Pancreatic Adenocarcinoma: Results of an Ancillary Study of the PANACHE01-PRODIGE48 Trial

OBJECTIVE

To investigate in patients treated for a resectable pancreatic ductal adenocarcinoma [pancreatic adenocarcinoma (PA)], the prognostic value of baseline carbohydrate antigen 19.9 (CA19-9) and circulating tumor DNA (ctDNA) for overall survival (OS), to improve death risk stratification, based on a planned ancillary study from PANACHE01-PRODIGE 48 trial.

BACKGROUND

Biological borderline situation that was first used by the MD Anderson, became a standard practice following the international consensus conference in 2016 to manage PA. Regarding the risk of systemic disease, especially in the setting of "markedly elevated" CA19-9, neoadjuvant therapy is advised to avoid unnecessary surgery, with a risk of early recurrence. To best define biological borderline situations, new biomarkers are needed.

METHODS

Characteristics at diagnosis and OS were compared between patients with or without ctDNA status available. OS was estimated with the Kaplan-Meier method and compared with a log-rank test. The restricted cubic spline approach was used to identify the optimal threshold for biological parameters for death risk stratification. Univariate and multivariate Cox proportional hazard models were estimated to assess the association of ctDNA status and other parameters with OS.

RESULTS

Among the 132 patients from the primary population for analysis in the PANACHE01 -PRODIGE 48 trial, 92(71%) were available for ctDNA status at diagnosis. No selection bias was identified between patients with or without ctDNA status. Fourteen patients (15%) were ctDNA+ and exhibited a higher risk for death [ P = 0.0188; hazard ratio (95% CI): 2.28 (1.12-4.63)]. In the 92 patients with ctDNA status available among the other parameters analyzed, only CA19-9 was statically associated with OS in univariate analysis. Patients with a log of CA19-9 equal or superior to 4.4 that corresponds to a CA19-9 of 80 UI/mL were identified at higher risk for death [ P = 0.0143; hazard ratio (95% CI): 2.2 (1.15-4.19)]. In multivariate analysis, CA19-19 remained independently associated with OS ( P = 0.0323). When combining the 2 biomarkers, the median OS was 19.4 [IC 95%: 3.8-not reached (NR)] months, 30.2 (IC 95%: 17.1-NR) months and NR (IC 95%: 39.3-NR) for "CA19-9 high and ctDNA+ group," "CA19-9 high or ctDNA+ group," and "CA19-9 low and ctDNA- group," respectively (log-rank P = 0.0069).

CONCLUSIONS

Progress in the management of potentially operable PA remains limited, relying solely on strategies to optimize the sequence of complete treatment, based on modern multidrug chemotherapy (FOLFIRINOX, GemNabPaclitaxel) and surgical resection. The identification of risk criteria, such as the existence of systemic disease, is an important issue, currently referred to as "biological borderline disease." Few data, particularly from prospective studies, allow us to identify biomarkers other than CA19-9. Combining ctDNA with CA19-9 could be of interest to best define biological borderline situations in PA.

Olaparib as maintenance therapy in non resectable pancreatic adenocarcinoma associated with homologous recombination deficiency profile: A French retrospective multicentric AGEO real-world study

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis. The POLO trial showed that olaparib (PARP inhibitor) improved progression-free survival (PFS) but not overall survival (OS), when used as maintenance therapy after ≥ 16 weeks of disease control with first-line platinum-based chemotherapy in patients with germline (g) BRCA 1 or 2 pathogenic variants (PV) metastatic PDAC. However, real-world data on the effectiveness of olaparib are missing.

METHODS

Patients with unresectable PDAC associated with somatic (s) or (g)BRCA1/2 and (g)non-BRCA-HRD PV (i.e. other homologous recombination deficiency/HRD genes) who were treated with olaparib between 2020-2023 were included. The primary objective was to describe treatment patterns. Secondary exploratory objectives included OS and PFS in patients treated with olaparib according to the POLO trial or not, OS and PFS in patients with (g)HRD PV-associated PDAC versus (s)PVs, olaparib safety profile and factors associated with olaparib poor outcomes.

RESULTS

Among 85 patients, 45.9 % received olaparib as defined by the POLO trial. No difference in OS and PFS was observed between patients who received olaparib according to the POLO trial versus not. Patients with (g)HRD PV-associated PDAC had better OS compared to others (22.3 versus 10.5 months, p = 0.038). Factors associated with olaparib poor outcomes included a high neutrophil-to-lymphocyte ratio and the use of olaparib outside the recommendations of the POLO trial. Few grade ≥ 3 adverse events were reported (9.4 %).

CONCLUSION

Patients with (g)HRD PV-associated PDAC had longer OS than those with (s)HRD PV. Olaparib use beyond the scope of the POLO trial was associated with poor outcomes.

Impact of the radiological morphology of the mesopancreas on the outcome after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: retrospective study

BACKGROUND

The most frequently invaded margins on pancreatoduodenectomy specimens for pancreatic ductal adenocarcinoma are vascular margins, particularly the superior mesenteric artery (or mesopancreatic) margin. Due to limited exploration of the radiological aspect of the mesopancreas, the aim of this study was to evaluate mesopancreatic infiltration through imaging of patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy, to correlate these findings with histopathology and evaluate their impact on survival.

METHODS

Data for all patients who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma from 2015 to 2021 were reviewed, including review of surgical margin histopathology and blinded review of preoperative diagnostic imaging. According to qualitative radiological assessment, the mesopancreas was characterized as having normal fat, fat stranding, or solid infiltration. Survival data were analysed using Cox regression.

RESULTS

A total of 149 patients were included. At baseline imaging, mesopancreatic fat stranding or solid infiltration was present in 47 patients (31.5%) and 20 patients (13.4%) respectively. Median overall survival and disease-free survival were significantly lower with mesopancreatic solid infiltration (17 and 8 months) compared with normal fat (30 and 14 months) and fat stranding (29 and 16 months) (P = 0.017 and 0.028 respectively). In multivariable analysis, pathological tumour size was an independent prognostic factor for overall survival, and tumour location in the uncinate process and pathological tumour size were independent prognostic factors for disease-free survival.

CONCLUSION

At diagnostic imaging, solid infiltration (but not fat stranding) of the mesopancreas is associated with a poor prognosis for pancreatic ductal adenocarcinoma patients who undergo pancreatoduodenectomy. Pathological tumour size significantly influences the prediction of overall survival, and tumour location in the uncinate process and pathological tumour size significantly influence the prediction of disease-free survival, suggesting further exploration of underlying mechanisms related to retroperitoneal tumoral invasion of vascular margins and the mesopancreas.

Oncological Outcomes of Open Versus Minimally Invasive Surgery for Ductal Adenocarcinomas of Pancreatic Head: A Propensity Score Matching Analysis

BACKGROUND

Minimally invasive pancreatic resections (MIPRs) have been shown to be safe and feasible, but there is still a lack of high-level evidence on oncological outcomes for cephalic pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to compare the oncological outcomes of patients undergoing MIPR and open pancreatic resection (OPR) for pancreatic head cancer in a single high-volume center.

METHODS

Data from a prospectively collected database of patients who underwent radical-intent surgery for resectable and borderline resectable PDAC of the head at our institution between January 2013 and May 2023 were retrieved and analyzed, comparing the surgical and oncological outcomes of MIPR and OPR, using a propensity score matching analysis.

RESULTS

In the study period, 220 patients were selected. After matching, a total of 81 MIPRs and 81 OPRs were compared. No difference was found regarding R0 rate (OPR 83.9% vs. MIPR 74.1%, p = 0.122). Median overall survival (24 and 31 months for the OPR and MIPR groups, respectively; log rank p = 0.665) and disease-free survival (12 and 21 months for the OPR and MIPR groups, respectively; log rank p = 0.118) did not differ between the groups. The MIPR group was associated with a greater number of harvested lymph nodes (22 vs. 16, p = 0.0008), longer operative time (565 vs. 420 min, p < 0.0001), and shorter length of stay (12 vs. 18 days; p = 0.0001). No differences between the groups were found regarding all other postoperative and pathological outcomes.

CONCLUSIONS

Regarding oncological outcomes, MIPR appeared to be comparable to OPR for treating patients with PDAC of the head. Despite an increased operative time, MIPR was associated with a greater number of LNs harvested and a shorter length of stay.

Nationwide trends over 10 years in epidemiology and management of pancreatic ductal adenocarcinoma: A real-world study from the French administrative database

BACKGROUND & AIMS

Significant progress has been made in the management of pancreatic ductal adenocarcinoma (PDAC) in recent years. In this population-based study, we aimed to compare incidence, therapeutic strategies, and survival outcomes of PDAC patients in France over a decade.

METHODS

This study was performed using a nationwide French database. All patients receiving care for PDAC during years 2009, 2014 and 2018 were included. Treatment modalities and survival outcomes were analyzed.

RESULTS

A total of 8143/8771/10494 patients were considered in 2009/2014/2018, respectively. Incidence increased mainly among patients aged >60 years. In localized PDAC, the proportion of patients receiving best supportive care (BSC) only decreased at 43.6/36.4/32.4 % and 27.8/29.1/34.3 % received chemo(radio)therapy alone. The rate of upfront surgery remained stable while 3/8/18 % of operated patients received neoadjuvant therapy. Median overall survival (OS) was 7.0/7.9/8.5 months in the overall population. Among treated patients, 1-year OS was 61.4/67.7/68.8 % and 30.3/36.3/38.8 % for localized and metastatic PDAC, respectively.

CONCLUSIONS

This study confirms the rising incidence of PDAC. Improved outcomes were seen in localized PDAC, with a wider use of chemotherapy and neoadjuvant strategies, and in treated metastatic patients. A modest survival gain was seen overall, hindered by the still high rate of patients receiving BSC only.

Futility of Up-Front Resection for Anatomically Resectable Pancreatic Cancer

Importance

There are currently no clinically relevant criteria to predict a futile up-front pancreatectomy in patients with anatomically resectable pancreatic ductal adenocarcinoma.

Objectives

To develop a futility risk model using a multi-institutional database and provide unified criteria associated with a futility likelihood below a safety threshold of 20%.

Design, Setting, and Participants

This retrospective study took place from January 2010 through December 2021 at 5 high- or very high-volume centers in Italy. Data were analyzed during April 2024. Participants included consecutive patients undergoing up-front pancreatectomy at the participating institutions.

Exposure

Standard management, per existing guidelines.

Main Outcomes and Measures

The main outcome measure was the rate of futile pancreatectomy, defined as an operation resulting in patient death or disease recurrence within 6 months. Dichotomous criteria were constructed to maintain the futility likelihood below 20%, corresponding to the chance of not receiving postneoadjuvant resection from existing pooled data.

Results

This study included 1426 patients. The median age was 69 (interquartile range, 62-75) years, 759 patients were male (53.2%), and 1076 had head cancer (75.4%). The rate of adjuvant treatment receipt was 73.7%. For the model construction, the study sample was split into a derivation (n = 885) and a validation cohort (n = 541). The rate of futile pancreatectomy was 18.9% (19.2% in the development and 18.6% in the validation cohort). Preoperative variables associated with futile resection were American Society of Anesthesiologists class (95% CI for coefficients, 0.68-0.87), cancer antigen (CA) 19.9 serum levels (95% CI, for coefficients 0.05-0.75), and tumor size (95% CI for coefficients, 0.28-0.46). Three risk groups associated with an escalating likelihood of futile resection, worse pathological features, and worse outcomes were identified. Four discrete conditions (defined as CA 19.9 levels-adjusted-to-size criteria: tumor size less than 2 cm with CA 19.9 levels less than 1000 U/mL; tumor size less than 3 cm with CA 19.9 levels less than 500 U/mL; tumor size less than 4 cm with CA 19.9 levels less than 150 U/mL; and tumor size less than 5 cm with CA 19.9 levels less than 50 U/mL) were associated with a futility likelihood below 20%. Both disease-free survival and overall survival were significantly longer in patients fulfilling the criteria.

Conclusions and relevance

In this study, a preoperative model (MetroPancreas) and dichotomous criteria to determine the risk of futile pancreatectomy were developed. This might help in selecting patients for up-front resection or neoadjuvant therapy.