A proposal of ABCD metastasectomy criteria for synchronous/metachronous metastatic pancreatic cancer in the era of multidisciplinary treatment

Technique of Circumferential Divestment of the Superior Mesenteric Artery for Locally Advanced Pancreatic Cancer

BACKGROUND

Locally advanced pancreatic cancer (LAPC) that involves more than 180° of contact with the superior mesenteric artery (SMA) is defined as unresectable. With advances in multimodal therapies, some cases with a favorable response to induction treatment have become candidates for resection.1 Although divestment of the SMA is now widely adopted,2,3 a standardized surgical technique for resecting tumors that encircle the SMA has yet to be established.

PATIENTS AND METHODS

Three patients with LAPC received a median of 8 months of chemotherapy and a total radiation dose of 50.4 gray (Gy) in 28 fractions (preoperative chemoradiotherapy, CRT) with oral S-1, followed by conversion pancreaticoduodenectomy with SMA divestment. The chemotherapy regimen and timing of radiation therapy varied by case: the first case received gemcitabine monotherapy after CRT, the second case received CRT after gemcitabine plus nab-paclitaxel (GnP), and the third case received CRT after GnP, followed by a switch to modified fluorouracil, irinotecan, and oxaliplatin (mFOLFIRINOX) before surgery.

RESULTS

All patients satisfied the ABCD criteria, which included (A) tumor shrinkage, (B) normalization of cancer antigen (CA)19-9 levels, (C) a modified Glasgow Prognostic Score of 0, and (D) a minimum of 6 months of chemotherapy.4 Each patient underwent circumferential SMA adventitia divestment and portal vein resection. Postoperative courses were favorable, with a median hospital stay of 17 days, although one patient required readmission owing to delayed pancreatic fistula. The resection margins were measured at 0.9 mm, 1.4 mm, and 4.0 mm, respectively.

CONCLUSIONS

Circumferential divestment of the SMA for LAPC can be safely performed following chemoradiotherapy, yielding favorable short-term outcomes.

Is There a Potential Oncologic Role for Local Therapy on Hepatic Metastasis in Patients Who Undergo Curative Pancreatectomy for Pancreatic Cancer?

PURPOSE

In pancreatic cancer, therapeutic investigations targeting liver metastases could improve survival. However, the use of local treatment for oligometastasis in pancreatic cancer remains controversial. This study aimed to investigate the oncological role of local therapy in patients who underwent curative pancreatectomy and subsequently developed liver metastases.

MATERIALS AND METHODS

Data concerning patients who underwent curative pancreatectomy for pancreatic cancer at Severance Hospital in Seoul, South Korea between 2006 and 2018 were retrospectively reviewed. We included patients with one or two liver metastases, as confirmed on imaging. We excluded those with metastases in other organs. The patients were divided into two groups: the NT group, receiving conventional therapy without local treatment; and the LT group, receiving local treatments for liver metastases alongside standard therapy.

RESULTS

Of the 43 included patients (NT group, n=33; LT group, n=10), no significant differences were observed in overall survival (OS) [hazard ratio (HR) 0.846; 95% confidence interval (CI) 0.397-1.804; p=0.665] or post-recurrence survival (HR 0.932; 95% CI 0.437-1.985, p=0.855) between the two groups. In multivariate analysis, early recurrence within 6 months (p<0.001) and the use of 5-fluorouracil (FU)-based adjuvant chemotherapy (CTx) (p=0.011), as well as 5-FU-based CTx after liver metastasis (p=0.008) when compared with gemcitabine-based regimens, were significant predictors of poor OS.

CONCLUSION

The oncologic role of local treatment for hepatic metastasis remains controversial in patients with hepatic metastasis after radical pancreatectomy. In the era of potent chemotherapeutic regimens, further research is needed to clarify the efficacy of such regimens.

Resectable Pancreatic Cancer with CA19-9 > 500 U/mL: A Biological Indicator for Survival Benefit with Intensive Neoadjuvant Chemotherapy

BACKGROUND

While anatomical resectability guides pancreatic cancer treatment, carbohydrate antigen (19-9 (CA19-9) serves as a biological indicator of disease burden. Current guidelines suggest considering neoadjuvant chemotherapy (NAC) for cases with markedly elevated CA19-9, but specific threshold values and treatment strategies remain undefined. This retrospective study aimed to evaluate the efficacy of intensive NAC using gemcitabine plus nab-paclitaxel or fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) for anatomically resectable pancreatic cancer with elevated CA19-9 (> 500 U/mL).

PATIENTS AND METHODS

We analyzed patients with anatomically resectable pancreatic cancer and CA19-9 > 500 U/mL treated between 2014 and 2022. Initial planned treatments were either 4-month intensive NAC followed by surgery (NAC group) or upfront surgery (UPS group). Survival outcomes were evaluated using retrospective intention-to-treat analysis.

RESULTS

Among 184 included patients, 46 received NAC and 138 underwent upfront surgery. The NAC group demonstrated significantly improved overall survival compared with the UPS group (median 52.7 vs. 22.7 months, P < 0.001). Resection rates were 89.1% and 76.1% in the NAC and UPS groups, respectively. Among resected cases, the NAC group achieved higher lymph node-negative resection rates (53.7% vs. 23.8%, P < 0.001) and better post-resection CA19-9 normalization rates (75.6% vs. 56.1%, P = 0.037). Survival benefits were maintained even in cases with CA19-9 > 2000 U/mL (median OS 52.7 vs. 18.9 months, P = 0.025).

CONCLUSIONS

CA19-9 > 500 U/mL serves as an effective indicator for implementing intensive NAC in anatomically resectable pancreatic cancer. This biomarker-based strategy effectively extracts the beneficial group from NAC, prolonging survival outcomes through better systemic disease control.

Clinical implications of disappearing pancreatic cancer liver metastases: Lessons from colorectal liver metastases

BACKGROUND

The efficacy of local control for pancreatic cancer liver metastases (PCLM), including surgical treatment, remains controversial, with no consensus on the management and clinical significance of disappearing liver metastases (DLMs). This study aimed to evaluate the clinical implications of DLMs in treating PCLM after multi-agent chemotherapy, utilizing contrast-enhanced imaging modalities.

METHODS

A retrospective analysis was conducted on patients who underwent curative resection for pancreatic cancer with synchronous or metachronous liver metastases between 2014 and 2023. Surgical indications were based on our recently reported ABCD criteria (Anatomical/Biological/Conditional/Duration). Both contrast-enhanced computed tomography (CE-CT) and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) were used to monitor metastatic lesions in the liver. DLMs were defined as tumors undetected on CE-CT post-chemotherapy.

RESULTS

A total of 58 lesions in 29 patients with PCLM who underwent surgical resection were evaluated. Of the 13 lesions evident on CE-CT, 76.9 % (10/13) contained clinically/pathologically residual tumors. Of the 45 DLMs, 16 (35.6 %) had residual tumors. Twenty-six DLMs (57.8 %) were detected on EOB-MRI or intraoperative screening (contrast-enhanced ultrasonography and palpation), with 42.3 % (11/26) being residual tumors. Nineteen DLMs were undetectable by any modality, of which 26.3 % (5/19) were confirmed to be residual tumors with a median follow-up of 32 months. The median overall survival from initiating treatment for PCLM was 48.5 months.

CONCLUSION

Integrating EOB-MRI into preoperative evaluations for PCLM enhances the detection of clinically relevant DLMs. Our findings highlight the potential benefits of considering an image-guided surgical approach in selected patients.

Survival Analysis of Conversion Surgery in Borderline Resectable and Locally Advanced Unresectable Pancreatic Ductal Adenocarcinoma Addressing Selection and Immortal Time Bias: A Retrospective Single-Center Study

BACKGROUND

The purpose of this study was to provide a detailed evaluation of the oncological advantages of surgery following neoadjuvant chemotherapy (NAC) for patients with borderline resectable (BR) or unresectable (UR) pancreatic ductal adenocarcinoma (PDAC), with a focus on minimizing biases. Recently, NAC has become the standard care for BR or UR locally advanced (UR-LA) PDAC, however, many studies have assessed survival benefits and favorable variables without consideration for biases, particularly immortal time bias.

PATIENTS AND METHODS

This study included patients diagnosed with BR or UR-LA PDAC at Juntendo University Hospital from 2019 to 2022. To mitigate bias, we applied methods such as propensity score matching (PSM), time-dependent covariate Cox proportional hazard regression analysis (TDC), landmark analysis, and multivariable Cox proportional hazards regression model.

RESULTS

The study analyzed 124 patients, dividing them into a surgery group (n = 57) and a chemotherapy-only group (n = 67). After PSM, there were 21 matched pairs. Survival analysis using TDC analysis showed that the surgery group had significantly better overall survival compared with the chemotherapy-only group in both the entire cohort and the matched pairs. Cox regression analysis of the entire cohort also revealed a similar superiority of surgery, while the landmark analysis showed varying results depending on the landmark setting.

CONCLUSIONS

After careful adjustment for selection and immortal time biases, surgery following NAC appears to significantly extend survival in patients with BR or UR PDAC.

Surveillance after surgery for pancreatic cancer: a global scoping review of guidelines and a nordic Survey of contemporary practice

OBJECTIVES

Most patients with pancreatic cancer who have undergone surgical resection eventually develop disease recurrence. ‍This study aimed to investigate whether there is evidence to support routine surveillance after pancreatic cancer surgery, with a secondary aim of analyzing the implementation of surveillance strategies in the Nordic countries.

MATERIALS AND METHODS

A scoping review was conducted to identify clinical practice guidelines globally and research studies relating to surveillance after pancreatic cancer resection. This was followed by a survey among 20 pancreatic units from four Nordic countries to assess their current practice of follow-up for operated patients.

RESULTS

Altogether 16 clinical practice guidelines and 17 research studies were included. The guidelines provided inconsistent recommendations regarding postoperative surveillance of pancreatic cancer. The clinical research data were mainly based on retrospective cohort studies with low level of evidence and lead-time bias was not addressed. Active surveillance was recommended in Sweden and Denmark, but not in Norway beyond the post-operative/adjuvant period. Finland had no national recommendations for surveillance. The Nordic survey revealed a wide variation in reported practice among the different units. About 75% (15 of 20 units) performed routine postoperative surveillance. Routine CA 19-9 testing was used by 80% and routine CT by 67% as part of surveillance. About 73% of centers continued follow-up until 5 years postoperatively.

CONCLUSION

Evidence for routine long-term (i.e. 5 years) surveillance after pancreatic cancer surgery remains limited. Most pancreatic units in the Nordic countries conduct regular follow-up, but protocols vary.