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Kimura Y, Nakamura T, Imamura M, Nagayama M, Murakami T, Hayashi T, Kato T, Tanaka K, Yoshida M, Kukita K, Imai K, Yoshida M, Masaki Y, Motoya M, Kuwatani M, Koyama M, Ohnishi H, Takemasa I. Reconsidering resectable oncological conditions in pancreatic tail cancer: A multicenter retrospective study on prognostic factors in pancreatic tail cancer after resection (HOPS Pt-01). Pancreatology 2024; 24:109-118. [PMID: 38103948 DOI: 10.1016/j.pan.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/29/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Pancreatic tail cancer (Pt-PC) is generally considered resectable when metastasis is absent, but doubts persist in clinical practice due to the variability in local tumor extent. We conducted a multicenter retrospective study to comprehensively identify prognostic factors associated with Pt-PC after resection. METHODS We enrolled 100 patients that underwent distal pancreatectomy. The optimal combination of factors influencing relapse-free survival (RFS) was determined using the maximum likelihood method (MLM) and corrected Akaike and Bayesian information criteria (AICc and BIC). Prognostic elements were then validated to predict oncological outcomes. RESULTS Therapeutic interventions included neoadjuvant treatment in 16 patients and concomitant visceral resection (CVR) in 37 patients; 89 patients achieved R0. Median RFS and OS after surgery were 23.1 and 37.1 months, respectively. AICc/BIC were minimized in the model with ASA-PS (≥2), CA19-9 (≥112 U/mL at baseline, non-normalized postoperatively), need for CVR, 6 pathological items (tumor diameter ≥19.5 mm, histology G1, invasion of the anterior pancreatic border, splenic vein invasion, splenic artery invasion, lymph node metastasis), and completed adjuvant treatment (cAT) for RFS. Regarding the predictive value of these 11 factors, area under the curve was 0.842 for 5-year RFS. Multivariate analysis of these 11 factors showed that predictors of RFS include CVR (hazard ratio, 2.13; 95 % confidence interval, 1.08-4.19; p = 0.028) and cAT (0.38, 0.19-0.76; p = 0.006). CONCLUSIONS The MLM identified certain Pt-PC cases warranting consideration beyond resectable during clinical management. Particular attention should be paid to conditions requiring CVR, even though immortal time bias remains unresolved with adjuvant treatment.
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Affiliation(s)
- Yasutoshi Kimura
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Toru Nakamura
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masafumi Imamura
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Minoru Nagayama
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Murakami
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsuyoshi Hayashi
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Toru Kato
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kimitaka Tanaka
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Makoto Yoshida
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Gastroenterological Surgery, Kin-ikyo Chuo Hospital, Sapporo, Japan
| | - Kazuharu Kukita
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Koji Imai
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Makoto Yoshida
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Medical Oncology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshiharu Masaki
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masayo Motoya
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Masaki Kuwatani
- Hokkaido Pancreatic Cancer Study Group, HOPS, Sapporo, Japan; Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masayuki Koyama
- Department of Public Health, Sapporo Medical University School of Medicine, Japan; Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hirofumi Ohnishi
- Department of Public Health, Sapporo Medical University School of Medicine, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
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Sindayigaya R, Barat M, Tzedakis S, Dautry R, Dohan A, Belle A, Coriat R, Soyer P, Fuks D, Marchese U. Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist. Diagn Interv Imaging 2023; 104:455-464. [PMID: 37301694 DOI: 10.1016/j.diii.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Anthony Dohan
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Romain Coriat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Philippe Soyer
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Ugo Marchese
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
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Appropriate Lymph Node Dissection Sites for Cancer in the Body and Tail of the Pancreas: A Multicenter Retrospective Study. Cancers (Basel) 2022; 14:cancers14184409. [PMID: 36139569 PMCID: PMC9497245 DOI: 10.3390/cancers14184409] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
Distal pancreatectomy (DP) with lymphadenectomy is the standard surgery for pancreatic body-tail cancer. However, the optimal lymph node (LN) dissection area for DP remains controversial. Thus, we evaluated the frequency and patterns of LN metastasis based on the tumor site. In this multicenter retrospective study, we examined 235 patients who underwent DP for pancreatic cancer. Tumor sites were classified as confined to the pancreatic body (Pb) or pancreatic tail (Pt). The efficacy index (EI) was calculated by multiplying the frequency of metastasis to each LN station by the five-year survival rate of patients with metastasis to that station. LN metastasis occurred in 132/235 (56.2%) of the patients. Patients with Pb tumors showed no metastasis to the splenic hilum LN. Distal splenic artery LNs and anterosuperior/posterior common hepatic artery LNs did not benefit from dissection for Pb and Pt tumors, respectively. In multivariate analysis, splenic artery LN metastasis was identified as an independent predictor of poor overall survival in patients with pancreatic body-tail cancer. In conclusion, differences in metastatic LN sites were evident in pancreatic body-tail cancers confined to the Pb or Pt. Spleen-preserving pancreatectomy might be feasible for Pb cancer.
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Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization. Cancers (Basel) 2022; 14:cancers14051254. [PMID: 35267562 PMCID: PMC8909059 DOI: 10.3390/cancers14051254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
DPCAR’s short- and long-term outcomes are highly diverse, while the causes and prevention of ischemic complications are unclear. To assess oncological, surgical, and hemodynamic outcomes of 40 consecutive DPCARs for pancreatic (n37) and gastric tumors (n3) (2009−2021), retrospective analyses of mortality, morbidity, survival, and hemodynamic consequences after DPCAR were undertaken using case history data, IOUS, and pre- and postoperative CT measurements. In postoperative complications (42.5%), the pancreatic fistula was the most frequent event (27%), 90-day mortality was 7.5. With 27 months median follow-up, median overall (OS) and progression-free survival (PFS) for PDAC were 29 and 18 months, respectively; with 1-, 3-, and 5-years, the OS were 90, 60, and 28%, with an R0-resection rate of 92.5%. Liver and gastric ischemia developed in 0 and 5 (12.5%) cases. Comparison of clinical and vascular geometry data revealed fast adaptation of collateral circulation, insignificant changes in proper hepatic artery diameter, and high risk of ischemic gastropathy if the preoperative diameter of pancreaticoduodenal artery was <2 mm. DP CAR can be performed with acceptable morbidity and survival. OS and RFS in this super-selective cohort were compared to those for resectable cancer. The changes in the postoperative arterial geometry could explain the causes of ischemic complications and determine directions for their prevention.
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5
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Chen X, Fu R, Shao Q, Chen Y, Ye Q, Li S, He X, Zhu J. Application of artificial intelligence to pancreatic adenocarcinoma. Front Oncol 2022; 12:960056. [PMID: 35936738 PMCID: PMC9353734 DOI: 10.3389/fonc.2022.960056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer (PC) is one of the deadliest cancers worldwide although substantial advancement has been made in its comprehensive treatment. The development of artificial intelligence (AI) technology has allowed its clinical applications to expand remarkably in recent years. Diverse methods and algorithms are employed by AI to extrapolate new data from clinical records to aid in the treatment of PC. In this review, we will summarize AI's use in several aspects of PC diagnosis and therapy, as well as its limits and potential future research avenues. METHODS We examine the most recent research on the use of AI in PC. The articles are categorized and examined according to the medical task of their algorithm. Two search engines, PubMed and Google Scholar, were used to screen the articles. RESULTS Overall, 66 papers published in 2001 and after were selected. Of the four medical tasks (risk assessment, diagnosis, treatment, and prognosis prediction), diagnosis was the most frequently researched, and retrospective single-center studies were the most prevalent. We found that the different medical tasks and algorithms included in the reviewed studies caused the performance of their models to vary greatly. Deep learning algorithms, on the other hand, produced excellent results in all of the subdivisions studied. CONCLUSIONS AI is a promising tool for helping PC patients and may contribute to improved patient outcomes. The integration of humans and AI in clinical medicine is still in its infancy and requires the in-depth cooperation of multidisciplinary personnel.
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Affiliation(s)
- Xi Chen
- Department of General Surgery, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Ruibiao Fu
- Department of General Surgery, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Shao
- Department of Surgical Ward 1, Ningbo Women and Children’s Hospital, Ningbo, China
| | - Yan Chen
- Department of General Surgery, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Qinghuang Ye
- Department of General Surgery, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Li
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Xiongxiong He
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, China
| | - Jinhui Zhu
- Department of General Surgery, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Jinhui Zhu,
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Egorov VI, Petrov RV, Amosova EL, Kharazov AF, Petrov KS, Zhurina YA, Kondratyev EV, Zelter PM, Dzigasov SO, Grigorievsky MV. [Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]. Khirurgiia (Mosk) 2021:13-28. [PMID: 34608776 DOI: 10.17116/hirurgia202110113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate safety and postoperative outcomes of DP-CAR with resection of one of the lobar hepatic arteries without arterial reconstruction (extended DP-CAR). MATERIAL AND METHODS Perioperative data and survival after 7 extended DP-CARs R0 were retrospectively analyzed. Arterial blood flow in the liver was assessed using intraoperative ultrasound and postoperative CT angiography. RESULTS Among 40 DP-CARs, resection of left or right hepatic artery was performed in 7 cases of aberrant anatomy including 1 case of portal vein resection. Mortality and ischemic complications were not observed. The main source of blood supply to the «devascularized» liver lobe was interlobar communicating artery or the arcade of the lesser curvature of the stomach. Incidence of pancreatic fistula was 44%, mean blood loss - 230 (100-650) ml, surgery time - 259 (195-310) min, mean hospital-stay - 14 (9-26) days. Median survival of patients with pancreatic ductal adenocarcinoma was 25 months after combined treatment. Three patients died after 26, 28 and 77 months. Other patients are alive without progression for 109, 24, 23 and 12 months after therapy onset. CONCLUSION Extended DP-CAR is advisable and safe procedure if reliable intraoperative control of liver and stomach blood supply is ensured.
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Affiliation(s)
- V I Egorov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | - R V Petrov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | | | - A F Kharazov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | | | | | - E V Kondratyev
- Ilyinskaya Hospital, Krasnogorsk, Russia.,Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - P M Zelter
- Samara State Medical University, Samara, Russia
| | | | - M V Grigorievsky
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Hwang SH, Park MS. [Radiologic Evaluation for Resectability of Pancreatic Adenocarcinoma]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:315-334. [PMID: 36238739 PMCID: PMC9431945 DOI: 10.3348/jksr.2021.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
Imaging studies play an important role in the detection, diagnosis, assessment of resectability, staging, and determination of patient-tailored treatment options for pancreatic adenocarcinoma. Recently, for patients diagnosed with borderline resectable or locally advanced pancreatic cancers, it is recommended to consider curative-intent surgery following neoadjuvant or palliative therapy, if possible. This review covers how to interpret imaging tests and what to consider when assessing resectability, diagnosing distant metastasis, and re-assessing the resectability of pancreatic cancer after neoadjuvant or palliative therapy.
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Brasoveanu V, Barbu I, Ichim F, Balescu I, Bacalbasa N. Distal Pancreatectomy En Bloc With Splenectomy, Celiac Axis and Portal Vein Resection Followed by Arterial Reconstruction Using a Cadaveric Graft - A Case Report and Literature Review. In Vivo 2021; 34:1521-1525. [PMID: 32354957 DOI: 10.21873/invivo.11940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM Locally advanced pancreatic body tumors invading the celiac axis and the portal vein have been considered since long as unresectable lesions; however, due to improvement of surgical techniques, in certain cases surgery with curative intent might be taken in consideration. CASE REPORT We present the case of a 48-year-old female investigated for epigastric pain that was diagnosed with a locally invasive pancreatic body tumor. The patient was submitted to computed tomography which revealed the presence of a locally advanced pancreatic tumor with no demarcation line with the celiac axis and the portal vein. The endoscopic ultrasound raised the suspicion of malignancy and retrieved a biopsy which demonstrated the presence of a pancreatic adenocarcinoma. The patient was submitted to surgery, distal pancreatectomy en bloc with splenectomy, celiac axis and portal vein resection was performed; the hepatic artery was reconstructed by placing a cadaveric graft while the portal vein was sutured per primam by an end to end anastomosis. The postoperative outcome was favorable, and the patient was discharged in the 10th postoperative day. CONCLUSION Multiple vascular resections followed by reconstructions might be needed in order to achieve resection with negative margins in patients with pancreatic body tumors.
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Affiliation(s)
- Vladislav Brasoveanu
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania.,"Titu Maiorescu" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ion Barbu
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Ichim
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Center of Excellence in Translational Medicine, Fundeni Clinical Institute, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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Factors predicting survival in patients with locally advanced pancreatic cancer undergoing pancreatectomy with arterial resection. Updates Surg 2020; 73:233-249. [PMID: 32978753 PMCID: PMC7889566 DOI: 10.1007/s13304-020-00883-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Pancreatectomy with arterial resection is a treatment option in selected patients with locally advanced pancreatic cancer. This study aimed to identify factors predicting cancer-specific survival in this patient population. A single-Institution prospective database was used. Pre-operative prognostic factors were identified and used to develop a prognostic score. Matching with pathologic parameters was used for internal validation. In a patient population with a median Ca 19.9 level of 19.8 U/mL(IQR: 7.1–77), cancer-specific survival was predicted by: metabolic deterioration of diabetes (OR = 0.22, p = 0.0012), platelet count (OR = 1.00; p = 0.0013), serum level of Ca 15.3 (OR = 1.01, p = 0.0018) and Ca 125 (OR = 1.02, p = 0.00000137), neutrophils-to-lymphocytes ratio (OR = 1.16; p = 0.00015), lymphocytes-to-monocytes ratio (OR = 0.88; p = 0.00233), platelets-to-lymphocytes ratio (OR = 0.99; p = 0.00118), and FOLFIRINOX neoadjuvant chemotherapy (OR = 0.57; p = 0.00144). A prognostic score was developed and three risk groups were identified. Harrell’s C-Index was 0.74. Median cancer-specific survival was 16.0 months (IQR: 12.3–28.2) for the high-risk group, 24.7 months (IQR: 17.6–33.4) for the intermediate-risk group, and 39.0 months (IQR: 22.7–NA) for the low-risk group (p = 0.0003). Matching the three risk groups against pathology parameters, N2 rate was 61.9, 42.1, and 23.8% (p = 0.04), median value of lymph-node ratio was 0.07 (IQR: 0.05–0.14), 0.04 (IQR:0.02–0.07), and 0.03 (IQR: 0.01–0.04) (p = 0.008), and mean value of logarithm odds of positive nodes was − 1.07 ± 0.5, − 1.3 ± 0.4, and − 1.4 ± 0.4 (p = 0.03), in the high-risk, intermediate-risk, and low-risk groups, respectively. An online calculator is available at www.survivalcalculator-lapdac-arterialresection.org. The prognostic factors identified in this study predict cancer-specific survival in patients with locally advanced pancreatic cancer and low Ca 19.9 levels undergoing pancreatectomy with arterial resection.
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10
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Systematic review and meta-analysis of contemporary pancreas surgery with arterial resection. Langenbecks Arch Surg 2020; 405:903-919. [PMID: 32894339 PMCID: PMC7541389 DOI: 10.1007/s00423-020-01972-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/19/2020] [Indexed: 12/19/2022]
Abstract
Objective Advances in multimodality treatment paralleled increasing numbers of complex pancreatic procedures with major vascular resections. The aim of this meta-analysis was to evaluate the current outcomes of arterial resection (AR) in pancreatic surgery. Methods A systematic literature search was carried out from January 2011 until January 2020. MOOSE guidelines were followed. Predefined outcomes were morbidity, pancreatic fistula, postoperative bleeding and delayed gastric emptying, reoperation rate, mortality, hospital stay, R0 resection rate, and lymph node positivity. Duration of surgery, blood loss, and survival were also analyzed. Results Eight hundred and forty-one AR patients were identified in a cohort of 7111 patients. Morbidity and mortality rates in these patients were 66.8% and 5.3%, respectively. Seven studies (579 AR patients) were included in the meta-analysis. Overall morbidity (48% vs 39%, p = 0.1) and mortality (3.2% vs 1.5%, p = 0.27) were not significantly different in the groups with or without AR. R0 was less frequent in the AR group, both in patients without (69% vs 89%, p < 0.001) and with neoadjuvant treatment (50% vs 86%, p < 0.001). Weighted median survival was shorter in the AR group (18.6 vs 32 months, range 14.8–43.1 months, p = 0.037). Conclusions Arterial resections increase the complexity of pancreatic surgery, as demonstrated by relevant morbidity and mortality rates. Careful patient selection and multidisciplinary planning remain important. Electronic supplementary material The online version of this article (10.1007/s00423-020-01972-2) contains supplementary material, which is available to authorized users.
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Mizutani S, Taniai N, Furuki H, Shioda M, Ueda J, Aimoto T, Motoda N, Nakamura Y, Yoshida H. Treatment of Advanced Pancreatic Body and Tail Cancer by En Bloc Distal Pancreatectomy with Transverse Mesocolon Resection Using a Mesenteric Approach. J NIPPON MED SCH 2020; 88:301-310. [PMID: 32863347 DOI: 10.1272/jnms.jnms.2021_88-408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. METHODS There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). RESULTS From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. CONCLUSIONS We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.
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Affiliation(s)
- Satoshi Mizutani
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Nobuhiko Taniai
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Hiroyasu Furuki
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Mio Shioda
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Junji Ueda
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Takayuki Aimoto
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Norio Motoda
- Department of Pathology, Nippon Medical School Musashikosugi Hospital
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
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12
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Tong Z, Liu Y, Ma H, Zhang J, Lin B, Bao X, Xu X, Gu C, Zheng Y, Liu L, Fang W, Deng S, Zhao P. Development, Validation and Comparison of Artificial Neural Network Models and Logistic Regression Models Predicting Survival of Unresectable Pancreatic Cancer. Front Bioeng Biotechnol 2020; 8:196. [PMID: 32232040 PMCID: PMC7082923 DOI: 10.3389/fbioe.2020.00196] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Prediction models for the overall survival of pancreatic cancer remain unsatisfactory. We aimed to explore artificial neural networks (ANNs) modeling to predict the survival of unresectable pancreatic cancer patients. Methods: Thirty-two clinical parameters were collected from 221 unresectable pancreatic cancer patients, and their prognostic ability was evaluated using univariate and multivariate logistic regression. ANN and logistic regression (LR) models were developed on a training group (168 patients), and the area under the ROC curve (AUC) was used for comparison of the ANN and LR models. The models were further tested on the testing group (53 patients), and k-statistics were used for accuracy comparison. Results: We built three ANN models, based on 3, 7, and 32 basic features, to predict 8 month survival. All 3 ANN models showed better performance, with AUCs significantly higher than those from the respective LR models (0.811 vs. 0.680, 0.844 vs. 0.722, 0.921 vs. 0.849, all p < 0.05). The ability of the ANN models to discriminate 8 month survival with higher accuracy than the respective LR models was further confirmed in 53 consecutive patients. Conclusion: We developed ANN models predicting the 8 month survival of unresectable pancreatic cancer patients. These models may help to optimize personalized patient management.
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Affiliation(s)
- Zhou Tong
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Liu
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongtao Ma
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Jindi Zhang
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Bo Lin
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Xuanwen Bao
- Technical University Munich (TUM), Munich, Germany
| | - Xiaoting Xu
- Department of Medical Oncology, Tai He People's Hospital, Fuyang, China
| | - Changhao Gu
- Internal Medicine, Cangnan Traditional Chinese Medicine Hospital, Wenzhou, China
| | - Yi Zheng
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lulu Liu
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weijia Fang
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Shuiguang Deng
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
| | - Peng Zhao
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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13
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Delpero JR, Sauvanet A. Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019. Front Oncol 2020; 10:40. [PMID: 32117714 PMCID: PMC7010716 DOI: 10.3389/fonc.2020.00040] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019). Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system. Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion). Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.
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Affiliation(s)
- Jean Robert Delpero
- Institut Paoli-Calmettes (IPC), Marseille, France.,Faculté de Médecine, Aix Marseille Université, Marseille, France
| | - Alain Sauvanet
- Hôpital Beaujon, Clichy, France.,Université Paris VII - Denis Diderot, Paris, France
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14
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Oba A, Bao QR, Barnett CC, Al-Musawi MH, Croce C, Schulick RD, Del Chiaro M. Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC. Scand J Surg 2020; 109:18-28. [PMID: 31960765 DOI: 10.1177/1457496919900413] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable. MATERIALS AND METHODS This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction. RESULTS Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification. CONCLUSION The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.
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Affiliation(s)
- A Oba
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Q R Bao
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - C C Barnett
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Surgery, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - M H Al-Musawi
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - C Croce
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - R D Schulick
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
| | - M Del Chiaro
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
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15
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Chen Y, Wang YR, Deng GC, Dai GH. CA19-9 decrease and survival according to platelet level in patients with advanced pancreatic cancer. BMC Cancer 2019; 19:860. [PMID: 31470818 PMCID: PMC6716806 DOI: 10.1186/s12885-019-6078-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 08/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background CA19–9 decrease during treatment has been associated with superior survival of pancreatic cancer in several studies. The evidence to show the correlation of high platelet level with inferior survival is insufficient in pancreatic cancer. It also remains unclear whether the association between CA19–9 decrease and survival was corresponded to different levels of platelet in metastatic pancreatic cancer. Methods We measured CA19–9 serum concentration and platelet level at baseline and after the second cycle of chemotherapy for 200 advanced pancreatic cancer patients. A Cox proportional hazards model was used to compute mortality hazard ratios (HRs) for CA19–9 decrease, adjusting for potential confounders, including age, sex, KPS, prediagnosis body mass index, Diabetes Mellitus, tumor location, first-line chemotherapy regimen, and radiotherapy. Results We found that the association of CA19–9 decrease with superior overall survival was stronger in advanced pancreatic cancer with a low level of platelet (Pinteraction < 0.001) compared with intermediate and high level of platelet. Multivariable-adjusted hazard ratios per unit decrease of CA19–9 change was 0.45 [95% confidence interval (CI), 0.33 to 0.62] in cases with low platelet level, 0.74 (95% CI, 0.50 to 1.09) in cases with intermediate platelet level, and 0.94 (95% CI, 0.74 to 1.10) in cases with high platelet level. A similar differential association was found between CA19–9 decrease and progression-free survival in strata of platelet level (Pinteraction = 0.034). Conclusion The association of CA19–9 decrease with superior pancreatic cancer survival appeared to be pronounced in patients with a low platelet level. This finding could provide supports for the underlying mechanisms of CA19–9 involved in platelet / tumor cell interaction. Electronic supplementary material The online version of this article (10.1186/s12885-019-6078-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Y Chen
- Department of Medical Oncology, Chinese People's Liberation Army (PLA) General Hospital and Chinese PLA Medical School, Beijing, 100853, China.,Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital and Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China
| | - Y R Wang
- Department of Medical Oncology, Chinese People's Liberation Army (PLA) General Hospital and Chinese PLA Medical School, Beijing, 100853, China
| | - G C Deng
- Department of Medical Oncology, Chinese People's Liberation Army (PLA) General Hospital and Chinese PLA Medical School, Beijing, 100853, China
| | - G H Dai
- Department of Medical Oncology, Chinese People's Liberation Army (PLA) General Hospital and Chinese PLA Medical School, Beijing, 100853, China.
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16
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Bradley A, Van Der Meer R, McKay CJ. A systematic review of methodological quality of model development studies predicting prognostic outcome for resectable pancreatic cancer. BMJ Open 2019; 9:e027192. [PMID: 31439598 PMCID: PMC6707674 DOI: 10.1136/bmjopen-2018-027192] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To assess the methodological quality of prognostic model development studies pertaining to post resection prognosis of pancreatic ductal adenocarcinoma (PDAC). DESIGN/SETTING A narrative systematic review of international peer reviewed journals DATA SOURCE: Searches were conducted of: MEDLINE, Embase, PubMed, Cochrane database and Google Scholar for predictive modelling studies applied to the outcome of prognosis for patients with PDAC post resection. Predictive modelling studies in this context included prediction model development studies with and without external validation and external validation studies with model updating. Data was extracted following the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) checklist. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were all components of the CHARMS checklist. Secondary outcomes included frequency of variables included across predictive models. RESULTS 263 studies underwent full text review. 15 studies met the inclusion criteria. 3 studies underwent external validation. Multivariable Cox proportional hazard regression was the most commonly employed modelling method (n=13). 10 studies were based on single centre databases. Five used prospective databases, seven used retrospective databases and three used cancer data registry. The mean number of candidate predictors was 19.47 (range 7 to 50). The most commonly included variables were tumour grade (n=9), age (n=8), tumour stage (n=7) and tumour size (n=5). Mean sample size was 1367 (range 50 to 6400). 5 studies reached statistical power. None of the studies reported blinding of outcome measurement for predictor values. The most common form of presentation was nomograms (n=5) and prognostic scores (n=5) followed by prognostic calculators (n=3) and prognostic index (n=2). CONCLUSIONS Areas for improvement in future predictive model development have been highlighted relating to: general aspects of model development and reporting, applicability of models and sources of bias. TRIAL REGISTRATION NUMBER CRD42018105942.
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Affiliation(s)
- Alison Bradley
- Management Science, University of Strathclyde Business School, Glasgow, UK
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
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17
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Usefulness of Amplatzer Vascular Plug for Preoperative Embolization Before Distal Pancreatectomy with En Bloc Celiac Axis Resection. Cardiovasc Intervent Radiol 2019; 42:1352-1357. [DOI: 10.1007/s00270-019-02233-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
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18
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Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging. AJR Am J Roentgenol 2019; 213:35-44. [PMID: 30917026 DOI: 10.2214/ajr.18.20887] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE. We describe the indications, surgical technique, outcome, and imaging findings in patients with pancreatic ductal adenocarcinoma (PDAC) treated with distal pancreatectomy and celiac artery resection (modified Appleby procedure). CONCLUSION. Distal pancreatectomy and celiac artery resection is a feasible surgery in selected patients with locally advanced PDAC. Knowledge of surgical technique and imaging features may aid radiologists in identifying patients with locally invasive PDAC who might benefit from resection and identifying characteristic distal pancreatectomy and celiac artery resection complications.
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19
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Ma J, Tian K, Du J, Wu Z, Wang L, Zhang J. High expression of survivin independently correlates with tumor progression and mortality in patients with skull base chordomas. J Neurosurg 2019; 132:140-149. [PMID: 30641849 DOI: 10.3171/2018.8.jns181580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to clarify the expression characteristics and prognostic value of survivin in skull base chordomas. METHODS In this retrospective study, the authors measured the expression of survivin at the mRNA level in 81 samples from 71 patients diagnosed with skull base chordomas at their hospital in the period from July 2005 to January 2015. Clinical data collection, follow-up, and survival analyses were performed, and correlations were analyzed. RESULTS Of the 71 patients, 50 had primary chordomas with a mean survivin expression level of 1.09; the other 21 patients had recurrent chordomas with a mean survivin expression level of 2.57, which was 2.36 times higher than the level in the primary chordoma patients (p < 0.001, Mann-Whitney U-test). In addition, an analysis of 18 paired samples derived from 9 patients showed that the expression level of survivin was 2.62 times higher in recurrent tumors than in primary tumors (p = 0.002, paired t-test). The Spearman rank correlation coefficient method showed that the expression level of survivin was positively correlated with the mean ratio of tumor signal intensity to the signal intensity of surrounding brainstem on T1-weighted sequences (RT1; rs = 0.274, p = 0.021) and was negatively correlated with the mean ratio of tumor signal intensity to the signal intensity of surrounding brainstem on T2-weighted sequences (RT2; rs = -0.389, p = 0.001). A multivariate Cox proportional-hazards model suggested that pathology (p = 0.041), survivin expression level (p = 0.018), preoperative Karnofsky Performance Status (KPS; p = 0.012), and treatment history (p = 0.009) were independent prognostic factors for tumor progression. Survivin expression level (p = 0.008), preoperative KPS (p = 0.019), tumor diameter (p = 0.027), and intraoperative blood loss (p = 0.015) were independent prognostic factors for death. CONCLUSIONS Survivin expression level and preoperative KPS were independent significant prognostic factors for tumor progression and death in skull base chordoma patients. Recurrent skull base chordomas and chordomas with high RT1 and low RT2 were likely to have high survivin expression. Other independent risk factors related to tumor progression included conventional pathology and treatment history, whereas additional mortality-related risk factors included larger tumor diameter and greater intraoperative blood loss.
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Affiliation(s)
- Junpeng Ma
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Kaibing Tian
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Jiang Du
- 2Department of Neuropathology, Beijing Neurosurgical Institute, Capital Medical University; and
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Zhen Wu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Liang Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Junting Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 3China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
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20
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Shi S, Yu X. Selecting chemotherapy for pancreatic cancer: Far away or so close? Semin Oncol 2018; 46:39-47. [PMID: 30611527 DOI: 10.1053/j.seminoncol.2018.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/26/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer is a lethal disease with a very poor prognosis. In contrast to treatments for many other tumor types, cytotoxic agents are still the first-line drugs for pancreatic cancer in both the palliative and adjuvant settings. Some progress has been made in recent years, but most large phase 3 studies have not shown significant improvements in survival. Because the available drugs and regimens are limited in both type and effect, the selection of chemotherapy based on clinicopathologic characteristics may be consequential for pancreatic cancer. In the present report, we focused on 7 landmark clinical trials for pancreatic cancer. We observed that FOLFIRINOX (oxaliplatin, irinotecan, fluorouracil, and leucovorin) and NG (nab-paclitaxel and gemcitabine), 2 first-line regimens, exerted opposite effects on metastatic pancreatic cancer patients with different baseline carbohydrate antigen 19-9 (CA19-9) levels. This suggested that not only the performance status but possibly also CA19-9 levels should be considered when making a therapeutic choice for patients with advanced pancreatic cancer. Moreover, we found that patients with a diagnosis of pancreatic cancer who have undergone a surgical resection with a negative margin (R0) may benefit more from fluorouracil and/or oral prodrugs of fluorouracil-based adjuvant therapy than from gemcitabine. Conversely, gemcitabine or gemcitabine-based regimens may be more effective for patients with a positive resection margin (R1). Based on these findings, we propose flowcharts for selecting chemotherapy for both advanced and resected pancreatic cancer. Furthermore, we present possible mechanisms and interpretations underlying the selection of chemotherapy for pancreatic cancer and propose the tumor burden as a key variable in this process. Regardless of the possible bias and exact treatment selection process, this study offers an opportunity to improve patient outcomes by using agents currently used in the therapy of pancreatic cancer. Although these conclusions are based on indirect evidence, we provide insights and possibilities to drive the selection of chemotherapy for pancreatic cancer.
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Affiliation(s)
- Si Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China.
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21
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Kim NH, Kim HJ. Preoperative risk factors for early recurrence in patients with resectable pancreatic ductal adenocarcinoma after curative intent surgical resection. Hepatobiliary Pancreat Dis Int 2018; 17:450-455. [PMID: 30237091 DOI: 10.1016/j.hbpd.2018.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative early recurrence (ER) in patients with pancreatic ductal adenocarcinoma (PDAC) is frequently encountered after curative intent surgery. Nonetheless, clinical significance and risk factors of ER after surgery for PDAC have not been extensively investigated. The aim of this study was to determine preoperative risk predictors for ER in patients with PDAC after upfront surgery. METHODS Eighty-one consecutive patients with PDAC who underwent curative intent surgical resection at Kangbuk Samsung Hospital between January 2004 and May 2015 were enrolled. ER was defined as tumor relapse within 6 months after surgery. RESULTS ER occurred in 26 patients (32.1%), whereas 49 patients (60.5%) had late recurrence (≥ 6 months after surgery), and 6 patients had no recurrence (7.4%). Univariate analysis showed that C-reactive protein (CRP) > 3.0 mg/dL, modified Glasgow prognostic score (mGPS) = 2, decrease of total lymphocyte count by > 50% of baseline value in the preoperative period, prognostic nutritional index (PNI) < 45, neutrophil-to-lymphocyte ratio (NLR) ≥ 3, and preoperative maximum standardized uptake value (SUVmax) were significantly associated with ER. Multivariate logistic regression analysis revealed that CRP > 3.0 mg/dL, decrease of total lymphocyte count by > 50% of baseline value, and preoperative SUVmax were significant and independent contributors of ER in patients with resectable PDAC who underwent curative intent surgery. CONCLUSIONS Postoperative ER for resectable PDAC was frequent with poor prognosis after curative intent upfront surgery. It is reasonable to suggest that there is a subgroup of resectable PDAC patients at high-risk of ER and neoadjuvant therapy should be considered in these patients in a clinical trial setting.
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Affiliation(s)
- Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea
| | - Hong Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea.
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22
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Chen S, Na N, Jian Z. Pretreatment platelet count as a prognostic factor in patients with pancreatic cancer: a systematic review and meta-analysis. Onco Targets Ther 2017; 11:59-65. [PMID: 29317834 PMCID: PMC5743191 DOI: 10.2147/ott.s147715] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background The relationship between platelet counts and pancreatic cancer as a prognostic factor has been reported in many studies. We aimed to evaluate the prognostic value of platelet counts in predicting the prognosis of pancreatic cancer patients. Methods We searched PubMed, Medline, EMBASE, and Google Scholar for eligible studies up to May 2017. Information about the characteristics of the study and relevant outcomes was extracted. A meta-analysis was performed to analyze the prognostic value of platelet counts using the hazard ratio (HR) and 95% confidence intervals (CIs). Results A total of 1,756 patients in 13 retrospective studies were included. The pooled HR of 1.51 (95% CI: 1.20–1.90, P<0.001) showed that patients with elevated platelet counts were expected to have poor overall survival after treatment. Subgroup analysis showed that prognostic value of platelet levels was stronger in patients who received surgical resection (HR =1.60, 95% CI: 1.09–2.34, P=0.02), followed by patients who received palliative therapy (HR =1.46, 95% CI: 1.03–2.06, P=0.03). Conclusion Platelet counts could be a useful prognostic marker for pancreatic cancer. Patients with high platelet counts are expected to have poor survival.
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Affiliation(s)
- Sheng Chen
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences
| | - Ning Na
- Department of Kidney Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zhixiang Jian
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences
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Walczak S, Velanovich V. An Evaluation of Artificial Neural Networks in Predicting Pancreatic Cancer Survival. J Gastrointest Surg 2017; 21:1606-1612. [PMID: 28776157 DOI: 10.1007/s11605-017-3518-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/20/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to evaluate the development of an artificial neural network (ANN) method for predicting the survival likelihood of pancreatic adenocarcinoma patients. The ANN predictive model should produce results with a 90% sensitivity. METHODS A prospective examination of the records for 283 consecutive pancreatic adenocarcinoma patients is used to identify 219 records with complete data. These records are then used to create two unique samples which are then used to train and validate an ANN predictive model. Numerous network architectures are evaluated, following recommended ANN development protocols. RESULTS Several backpropagation-trained ANNs were produced that satisfied the 90% sensitivity requirement. An ANN model with over a 91% sensitivity is selected because even though it did not have the highest sensitivity, it was able to achieve over 38% specificity. CONCLUSIONS ANN models can accurately predict the 7-month survival of pancreatic adenocarcinoma patients, both with and without resection, at a 91% sensitivity and 38% specificity. This implies that ANN models may be useful objective decision tools in complex treatment decisions. This information may be used by patients and surgeons in determining optimal treatment plans that minimize regret and improve the quality of life for these patients.
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Affiliation(s)
- Steven Walczak
- School of Information and Florida Center for Cybersecurity, University of South Florida, 4202 E. Fowler Ave., CIS 1040, Tampa, FL, 33620, USA.
| | - Vic Velanovich
- Division of General Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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24
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Prediction of Postoperative Early Recurrence and Prognosis in Pancreatic Cancer Patients. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00072.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:Stratification of pancreatic cancer patients based on early recurrence and prognosis is essential for selecting optimal therapeutic strategies. The aim of this study was to investigate whether serum carbohydrate antigen (CA) 19-9 levels can be better used to predict early recurrence and prognosis.Methods:Patients whose CA 19-9 levels obtained in association with total bilirubin >2.0 mg/dL and whose CA 19-9 levels <5.0 U/mL were excluded to avoid the influence of obstructive jaundice and Lewis phenotype Lea−b−, respectively. A total of 125 pancreatic cancer patients who underwent surgical resection were enrolled.Results:Larger tumor size, higher serum CA 19-9 level, higher C-reactive protein (CRP) level, more advanced T status, and lymph node metastasis were significantly associated with recurrence within 1 year after surgery (early recurrence). The rate of early recurrence in patients with CA 19-9 levels >100 U/mL (76.9%) was significantly higher than that of patients with CA 19-9 levels ≤100 U/mL (27.9%). We performed combination analysis of 2 additional risk factors, CRP level (cutoff: 1.0 mg/dL) and tumor size (cutoff: 3.0 cm), with serum CA 19-9 level (cutoff: 100 U/mL). Patients were divided into 3 groups according to their number of risk factors. Rates of early recurrence in patients with 0, 1, and 2 or 3 risk factors were 22.0%, 45.2%, and 91.7%, respectively. Moreover, overall survival was significantly different in each group.Conclusion:Serum CA 19-9 level, in addition to CRP level and tumor size, improve patient stratification in early recurrence as well as prognosis.
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Klompmaker S, de Rooij T, Korteweg JJ, van Dieren S, van Lienden KP, van Gulik TM, Busch OR, Besselink MG. Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer. Br J Surg 2017; 103:941-9. [PMID: 27304847 DOI: 10.1002/bjs.10148] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic cancer involving the coeliac axis is considered unresectable by most guidelines, with a median survival of 6-11 months. A subgroup of these patients can undergo distal pancreatectomy with coeliac axis resection, but consensus on the value of this procedure is lacking. The evidence for this procedure, including the impact of preoperative hepatic artery embolization and (neo)adjuvant therapy, was evaluated. METHODS A systematic review was performed according to the PRISMA guidelines until 27 May 2015. The primary endpoint was overall survival; secondary endpoints included morbidity and radical resection rates. RESULTS A total of 19 retrospective studies, involving 240 patients, were included. The methodological quality of the studies ranged from poor to moderate. A radical resection was reported in 74·5 per cent (152 of 204), major morbidity in 27 per cent (26 of 96), ischaemic morbidity in 9·0 per cent (21 of 223) and 90-day mortality in 3·5 per cent (4 of 113). Overall, 35·5 per cent of patients (55 of 155) underwent preoperative hepatic artery embolization without an apparent beneficial impact on ischaemic morbidity. Overall, 15·7 per cent (29 of 185) had neoadjuvant and 51·0 per cent (75 of 147) had adjuvant therapy. There was a difference in survival between patient series where less than half of patients had (neo)adjuvant chemotherapy and series where more than half were receiving this treatment: case-weighted median overall survival was 16 (range 9-48) versus 18 (10-26) months respectively (P = 0·002). Overall median survival for the whole study population was 14·4 (range 9-48) months. CONCLUSION Distal pancreatectomy with coeliac axis resection seems a valuable option for selected patients with pancreatic cancer involving the coeliac axis with acceptable morbidity and mortality, and a median survival of 18 months when combined with (neo)adjuvant therapy.
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Affiliation(s)
- S Klompmaker
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - T de Rooij
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J J Korteweg
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - K P van Lienden
- Departments of Interventional Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R Busch
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Platelet × CRP Multiplier Value as an Indicator of Poor Prognosis in Patients With Resectable Pancreatic Cancer. Pancreas 2017; 46:35-41. [PMID: 27984485 DOI: 10.1097/mpa.0000000000000697] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Thrombocytosis in patients with various cancers has been considered a parameter for poor prognosis; however, its contribution to pancreatic cancer remains controversial. METHODS Potential preoperative prognostic parameters (platelets, neutrophils, lymphocytes, the platelet-lymphocyte ratio, the neutrophil-lymphocyte ratio, the serum C-reactive protein [CRP], and carbohydrate antigen 19-9) were retrospectively analyzed in 95 patients with pancreatic cancer. Cutoff values were defined according to receiver operating characteristic curve analysis, and median survival times (MSTs) were compared. RESULTS Median survival times (days) significantly differed according to platelet count (high [552] vs low [735], P = 0.017), CRP (high [471] vs low [750], P = 0.001), and carbohydrate antigen 19-9 level (high [639] vs low [765], P = 0.021), whereas there was no difference in the platelet-lymphocyte ratio and the neutrophil-lymphocyte ratio. Multivariate analysis identified thrombocytosis (hazard ratio, 2.015) and CRP level (hazard ratio, 1.771) as independent prognostic factors. The combinatory effects of platelets and the inflammatory response using a platelet × CRP multiplier value could effectively distinguished the MSTs (days) of patients with pancreatic cancer (high [482] vs low [812], P < 0.001). CONCLUSIONS Thrombocytosis and CRP influenced pancreatic cancer patient prognosis. Platelet × CRP multiplier is assumed as a useful parameter that reflects the contribution of activated platelets to cancer progression.
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Nakamura T, Hirano S, Noji T, Asano T, Okamura K, Tsuchikawa T, Murakami S, Kurashima Y, Ebihara Y, Nakanishi Y, Tanaka K, Shichinohe T. Distal Pancreatectomy with en Bloc Celiac Axis Resection (Modified Appleby Procedure) for Locally Advanced Pancreatic Body Cancer: A Single-Center Review of 80 Consecutive Patients. Ann Surg Oncol 2016; 23:969-975. [PMID: 27495282 DOI: 10.1245/s10434-016-5493-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Recently, distal pancreatectomy with en bloc celiac axis resection (DP-CAR) or modified Appleby procedure for locally advanced pancreatic body cancer is increasingly reported. However, actual long-term survival data are still unknown. METHODS This study retrospectively reviewed 80 consecutive patients with pancreatic body cancer who underwent DP-CAR at a single institution. RESULTS The study included 40 men and 40 women with a median age of 65 years (range, 44-85 years). A pancreatic fistula was the most common complication, occurring in 47 patients (57.5 %). Other complications with a high incidence were ischemic gastropathy (23 patients, 28.8 %) and delayed gastric emptying (20 patients, 25 %). According to the Clavien-Dindo classification, the major complications, defined as complications of grade 3 or higher, were observed in 33 patients (41.3 %), and the in-hospital mortality involved four patients (5 %). For all 80 patients, the 1-, 2-, and 5-year overall survivals (OSs) were respectively 81.1, 56.9, and 32.7 %, and the median survival time was 30.9 months. The actual 5-year survival for the 61 patients whose surgery was performed five or more years earlier was 27.9 % (17 of 61). The 1-, 2-, and 5-year OSs for the patients who underwent preoperative therapy (100, 90, and 78.8 %) were significantly better than for those who underwent upfront surgery (77.9, 51.5, and 26.7 %; P < 0.0001). CONCLUSIONS The findings show DP-CAR to be a valid procedure for treating locally advanced pancreatic body cancer, which might contribute more to patients' survival when performed as part of multidisciplinary treatment.
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Affiliation(s)
- Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Hackert T, Ulrich A, Büchler MW. Borderline resectable pancreatic cancer. Cancer Lett 2016; 375:231-237. [PMID: 26970276 DOI: 10.1016/j.canlet.2016.02.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023]
Abstract
Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20-25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications. The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.
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Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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Cesaretti M, Abdel-Rehim M, Barbier L, Dokmak S, Hammel P, Sauvanet A. Modified Appleby procedure for borderline resectable/locally advanced distal pancreatic adenocarcinoma: A major procedure for selected patients. J Visc Surg 2016; 153:173-81. [PMID: 26775202 DOI: 10.1016/j.jviscsurg.2015.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND In distal pancreatic ductal adenocarcinoma (PDAC), distal pancreatectomy with en bloc splenectomy and celiac axis resection (DP-CAR) can allow curative resection in case of tumor extension to celiac axis. METHODS From 2008 to 2013, of 102 patients with localized distal PDAC, 7 patients with celiac axis involvement were planned to undergo DP-CAR with curative intent. All patients received neoadjuvant treatment followed by preoperative coil embolization to enlarge collateral arterial pathways, except if a replaced right hepatic artery arising from superior mesenteric artery was present and sufficient for the blood supply. We herein analyzed indications, technique and outcomes of DP-CAR. RESULTS After neoadjuvant treatment and arterial embolization, two patients experienced tumor progression and were not operated while five underwent DP-CAR. No patient required arterial reconstruction. Postoperative mortality was nil, but morbidity was 100%, mainly represented by pancreatic fistula. Postoperatively, there was a complete pain relief but chronic diarrhea was observed in all patients. Resections were R0 in three patients. One operated patient was alive and disease free at 60 months whereas median overall survival of patients who underwent resection was 24 months. CONCLUSIONS DP-CAR for borderline resectable/locally advanced distal PDAC is associated with high morbidity and mixed long-term functional results. Neoadjuvant treatment may prevent from unnecessary surgery for patients with progressive disease and may facilitate resection with acceptable long-term survival.
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Affiliation(s)
- M Cesaretti
- Service de chirurgie hépatobiliaire et pancréatique, pôle des maladies de l'appareil digestif, hôpital Beaujon, AP-HP, université Paris VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - M Abdel-Rehim
- Service de radiologie, hôpital Beaujon, AP-HP, université Paris 7, 92110 Clichy, France
| | - L Barbier
- Service de chirurgie hépatobiliaire et pancréatique, pôle des maladies de l'appareil digestif, hôpital Beaujon, AP-HP, université Paris VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - S Dokmak
- Service de chirurgie hépatobiliaire et pancréatique, pôle des maladies de l'appareil digestif, hôpital Beaujon, AP-HP, université Paris VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - P Hammel
- Service d'oncologie digestive, hôpital Beaujon, AP-HP, université Paris 7, 92110 Clichy, France
| | - A Sauvanet
- Service de chirurgie hépatobiliaire et pancréatique, pôle des maladies de l'appareil digestif, hôpital Beaujon, AP-HP, université Paris VII, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
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Egorov VI, Petrov RV, Starostina NS, Zhurina YA, Grigorievsky MV. [Results of the modified Appleby procedure]. Khirurgiia (Mosk) 2016:9-17. [PMID: 27070870 DOI: 10.17116/hirurgia201639-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
AIM To evaluate safety and efficacy of distal pancreatectomy with en bloc celiac artery resection (DP-CAR) for pancreatic malignancy. MATERIAL AND METHODS Medical reports of 17 patients who underwent DP-CAR procedure (15 of them with pancreatic malignancy) were retrospectively analyzed. Also we studied 27 publications describing more than 2 cases of DP-CAR. RESULTS R0- and R1-resection was performed in 14 (82%) and 3 (18%) patients respectively. Postoperative complications ware observed in 11 (65%) cases. Nine of them were successfully treated. Full pain control was achieved in all patients. There were no any ischemic complications. 16 patients received chemotherapy. 2 (11%) patients died in early postoperative period due to aortic dissection in 10 days and fungal sepsis in 44 days after surgery. Median survival was 20 months. Literature review included 27 articles describing 311 operations. Herewith postoperative complications developed in 43% of cases and 90-day postoperative mortality was 4%. Median survival ranged from 9.3 to 26 months. CONCLUSION DP-CAR is effective and safe procedure in certain patients with locally advanced pancreatic cancer.
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Affiliation(s)
- V I Egorov
- City Clinical Hospital #5, Moscow Department of Health
| | - R V Petrov
- City Clinical Hospital #5, Moscow Department of Health
| | | | - Yu A Zhurina
- City Clinical Hospital #5, Moscow Department of Health
| | - M V Grigorievsky
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of the Russian Federation, Moscow
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De Rosa A, Cameron IC, Gomez D. Indications for staging laparoscopy in pancreatic cancer. HPB (Oxford) 2016; 18:13-20. [PMID: 26776846 PMCID: PMC4750228 DOI: 10.1016/j.hpb.2015.10.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients. METHODS Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords 'pancreatic cancer', 'resectability', 'staging', 'laparoscopy', and 'Whipple's procedure'. RESULTS Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL. CONCLUSION The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.
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Affiliation(s)
- Antonella De Rosa
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Iain C Cameron
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Dhanwant Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
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Gall TMH, Tsakok M, Wasan H, Jiao LR. Pancreatic cancer: current management and treatment strategies. Postgrad Med J 2015; 91:601-7. [PMID: 26243882 DOI: 10.1136/postgradmedj-2014-133222] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 07/14/2015] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Tamara M H Gall
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Maria Tsakok
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Harpreet Wasan
- Department of Oncology, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Long R Jiao
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
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Gluth A, Werner J, Hartwig W. Surgical resection strategies for locally advanced pancreatic cancer. Langenbecks Arch Surg 2015; 400:757-65. [DOI: 10.1007/s00423-015-1318-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 02/07/2023]
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Liu P, Zhu Y, Liu L. Elevated pretreatment plasma D-dimer levels and platelet counts predict poor prognosis in pancreatic adenocarcinoma. Onco Targets Ther 2015; 8:1335-40. [PMID: 26082650 PMCID: PMC4461118 DOI: 10.2147/ott.s82329] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
This retrospective study was conducted to evaluate the prognostic significance of the preoperative plasma D-dimer levels and platelet counts in patients with pancreatic adenocarcinoma. A total of 168 consecutive locally advanced pancreatic adenocarcinoma patients who underwent intensity modulated radiation therapy with or without chemotherapy were enrolled in this study. Plasma D-dimer levels were measured by a latex-enhanced immunoturbidimetric assay. Of the 168 patients enrolled, 106 patients were males and 62 patients were females. There was significant difference between plasma D-dimer levels and clinical responses (P=0.001). The 1-year, 2-year, and 3-year cumulative overall survival rates were 50.6%, 15.0%, and 4.9%, respectively. Plasma D-dimer levels (P<0.001) and platelet counts (P=0.010) were significantly related with overall survival in univariate analysis. The Cox proportional hazards regression indicated that plasma D-dimer levels (P=0.028), platelet counts (P=0.004), and treatment response (P<0.001) were independent prognostic factors for overall survival. Elevated pretreatment plasma D-dimer levels and platelet counts predict poor prognosis in pancreatic adenocarcinoma.
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Affiliation(s)
- Peng Liu
- Department of Radiotherapy, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - Yuan Zhu
- Department of Radiotherapy, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - Luying Liu
- Department of Radiotherapy, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, People's Republic of China
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Tsuchikawa T, Hirano S, Nakamura T, Okamura K, Tamoto E, Shichinohe T. Concomitant major vessel resection in pancreatic adenocarcinoma. Postgrad Med 2015; 127:273-6. [PMID: 25823640 DOI: 10.1080/00325481.2015.1032180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Increasing evidence has contraindicated extended radical dissection of pancreatic adenocarcinoma (PC). With the recent improvement of perioperative management techniques and multimodal treatment strategy for PC, concomitant major vessel resection and reconstruction has thus been aggressively attempted in association with comparatively better pathologically negative surgical margins and postoperative survival. We have discussed the clinical relevance of concomitant major vessel resection mainly focusing on indications for such resection with borderline resectable tumor associated with chemoradiotherapy, distal pancreatectomy with en bloc celiac axis resection for pancreatic body and tail cancer, and adjuvant surgery for initially unresectable pancreatic cancer.
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Affiliation(s)
- Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine , Sapporo , Japan
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Mittal A, de Reuver PR, Shanbhag S, Staerkle RF, Neale M, Thoo C, Hugh TJ, Gill AJ, Samra JS. Distal pancreatectomy, splenectomy, and celiac axis resection (DPS-CAR): Common hepatic arterial stump pressure should determine the need for arterial reconstruction. Surgery 2015; 157:811-7. [DOI: 10.1016/j.surg.2014.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/17/2014] [Accepted: 10/02/2014] [Indexed: 12/25/2022]
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Prognostic significance of WNT signaling in pancreatic ductal adenocarcinoma. Virchows Arch 2014; 465:401-8. [PMID: 25146168 DOI: 10.1007/s00428-014-1642-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/08/2014] [Accepted: 08/08/2014] [Indexed: 01/05/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is one of the most lethal human malignancies and is associated with a variety of molecular abnormalities. Although WNT signaling through its canonical/non-canonical pathways is one of the major factors involved in oncogenesis or progression of PDA, the prognostic significance of WNT signaling still remains poorly investigated. In this study, the status of the WNT signaling pathways was immunohistochemically analyzed in 101 PDAs, and its potential association with patient postoperative survival was assessed. Nuclear expression of beta-catenin, a hallmark of the activated canonical pathway, was identified in 59 cases, and was associated with reduced survival compared to the patients lacking nuclear beta-catenin expression (P = 0.002). In contrast, activation of the non-canonical pathway (25 cases), as indicated by co-expression of WNT2/5a and nuclear NFATc1, was not correlated with reduced survival (P = 0.268). Co-activation of both pathways (16 cases) was associated with worse prognosis in comparison with cases with an activated non-canonical pathway (P = 0.034). In addition, nuclear beta-catenin expression was an independent unfavorable prognostic factor (P = 0.006). Our data indicate that activated WNT signaling through its canonical pathway has a significantly negative effect on the clinical course of PDA, and the canonical WNT pathway should be considered as a future therapeutic target for PDA.
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