1
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Johansen KU, Augustinus S, Wellner UF, Andersson B, Beane JD, Björnsson B, Busch OR, Davis CH, Ghadimi M, Gleeson EM, de Graaf N, Koerkamp BG, Pitt HA, van Santvoort HC, Tingstedt B, Uhl W, Werner J, Williamsson C, Besselink MG, Keck T. International differences in the selection and outcome of minimally invasive and open distal pancreatectomy: A transatlantic analysis. Surgery 2024; 176:1198-1206. [PMID: 39019733 DOI: 10.1016/j.surg.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 05/02/2024] [Accepted: 06/13/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The efficacy and safety of minimally invasive distal pancreatectomy have been confirmed by randomized trials, but current patient selection and outcome of minimally invasive distal pancreatectomy in large international cohorts is unknown. This study aimed to compare the use and outcome of minimally invasive distal pancreatectomy in North America, the Netherlands, Germany, and Sweden. METHODS All patients in the 4 Global Audits on Pancreatic Surgery Group (GAPASURG) registries who underwent minimally invasive distal pancreatectomy or open distal pancreatectomy during 2014-2020 were included. RESULTS Overall, 20,158 distal pancreatectomies were included, of which 7,316 (36%) were minimally invasive distal pancreatectomies. Use of minimally invasive distal pancreatectomy varied from 29% to 54% among registries, of which 13% to 35% were performed robotically. Both the use of minimally invasive distal pancreatectomy and robotic surgery were the highest in the Netherlands. Patients undergoing minimally invasive distal pancreatectomy tended to have a younger age (Germany and Sweden), female sex (North America, Germany), higher body mass index (North America, the Netherlands, Germany), lower comorbidity classification (North America, Germany, Sweden), lower performance status (Germany), and lower rate of pancreatic adenocarcinoma (all). The minimally invasive distal pancreatectomy group had fewer vascular resections (all) and lower rates of severe complications and mortality (North America, Germany). In the multivariable regression analysis, country was associated with severe complications but not with 30-day mortality. Minimally invasive distal pancreatectomy was associated with a lower risk of 30-day mortality compared with open distal pancreatectomy (odds ratio 1.633, 95% CI 1.159-2.300, P = .005). CONCLUSIONS Considerable disparities were seen in the use of minimally invasive distal pancreatectomy among 4 transatlantic registries of pancreatic surgery. Overall, minimally invasive distal pancreatectomy was associated with decreased mortality as compared with open distal pancreatectomy. Differences in patient selection among countries could imply that countries are in different stages of the learning curve.
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Affiliation(s)
- Karin U Johansen
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ|Pancreas Registry and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D Beane
- Department of Surgery, The Ohio State University, Columbus, USA
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | | | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Centre Göttingen, Germany
| | | | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital Bochum, Klinik der Ruhr-Universität, Bochum
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität, München
| | - Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas Registry and Clinic of Surgery, UKSH Campus Lübeck, Germany.
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2
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Uijterwijk BA, Lemmers DH, Moekotte AL, Zaniboni A, Ghidini M, Wilmink H, Milella M, Scarpa A, Luchini C, Baboeram N, Klei DS, Manzoni A, Bannone E, Oneda E, Besselink MG, Abu Hilal M. Tackling challenges in rare diseases: The ISGACA approach on non-pancreatic cancers in the periampullary region. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108601. [PMID: 39182309 DOI: 10.1016/j.ejso.2024.108601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/14/2024] [Accepted: 08/10/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE Rare but aggressive cancer types like non-pancreatic periampullary cancers pose unique challenges for cancer research due to their low incidence rates and lack of consensus on optimal treatment strategies, therefore necessitating a collaborative approach. The International Study Group on non-pancreatic peri-Ampullary CAncer (ISGACA) aimed to build a collaborative initiative to pool expertise, funding opportunities, and data from over 60 medical centers, in order to improve outcomes for underrepresented patients with rare cancers. METHODS The ISGACA approach predefined a stepwise approach including a research scope, establishing a dedicated steering committee, creating a recognizable brand, identifying research gaps, following a well-defined timeline, ensuring robust data collection, addressing legal and ethical considerations, securing financial resources, investing in research ethics training and statistical expertise, raising awareness, creating uniformity, and initiating prospective studies. RESULTS Overall, 60 medical centers joined the ISGACA consortium (41 in Europe, 15 in North-America, three in Asia, one in Australia). The database includes 4309 patients. Nine publications and several ongoing studies which in turn allowed for a successful application of research grants. Subsequently, an international consensus meeting established uniform definitions and classifications, and one prospective multicenter international clinical trial has been initiated. CONCLUSION By sharing knowledge, expertise, and clinical data, the ISGACA approach has not only gathered sufficient evidence to secure grants and ethical approvals for prospective studies, but also demonstrates options for standardizing patient care and improving outcomes for patients with rare cancers. The ISGACA approach offers a detailed methodology for initiating research on rare cancers and could serve as a replicable model for future research initiatives.
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Affiliation(s)
- Bas A Uijterwijk
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daniël H Lemmers
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Alma L Moekotte
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Alberto Zaniboni
- Department of Medical Oncology, Fondazione Poliambulanza, Brescia, Italy
| | - Michele Ghidini
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Hanneke Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Michele Milella
- Section of Innovation Biomedicine - Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and Verona University and Hospital Trust (AOUI), Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Nigel Baboeram
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Dorine S Klei
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Alberto Manzoni
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Elisa Bannone
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Ester Oneda
- Department of Medical Oncology, Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
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3
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Gehrels AM, Wagner AD, Besselink MG, Verhoeven RHA, van Eijck CHJ, van Laarhoven HWM, Wilmink JW, van der Geest LG. Gender differences in tumor characteristics, treatment allocation and survival in stage I-III pancreatic cancer: a nationwide study. Eur J Cancer 2024; 206:114117. [PMID: 38781719 DOI: 10.1016/j.ejca.2024.114117] [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: 02/12/2024] [Revised: 04/25/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Sex and gender are modulators of health and disease and may have impact on treatment allocation and survival in patients with cancer. In this study, we analyzed the impact of sex and gender on treatment allocation and overall survival in patients with stage I-III pancreatic cancer. METHODS Patients with stage I-III pancreatic cancer diagnosed between 2015 and 2020 were selected from the nationwide Netherlands Cancer Registry. Associations between sex and gender and the probability of receiving surgical and/or systemic treatment were examined with multivariable logistic regression analyses. Overall survival was assessed with log rank test and multivariable Cox proportional hazard analysis. RESULTS Among 6855 patients, 51.2 % were female. Multivariable logistic regression analyses with adjustment for known confounders (age, performance status, comorbidities, tumor location, tumor stage and previous malignancies) showed that females less often received systemic chemotherapy compared to males (OR 0.799, 95 %CI 0.703-0.909, p < .001). No difference was found in the probability for undergoing surgical resection. Furthermore, females had worse overall survival compared to males (median OS 8.5 and 9.2 months respectively, 95 %CI 8.669-9.731). CONCLUSION This nationwide study found that female patients with stage I-III pancreatic cancer significantly less often received systemic treatment and had worse overall survival as compared to males. Disparities in pancreatic cancer care can be decreased by recognizing and resolving potential obstacles or biases in treatment decision-making.
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Affiliation(s)
- A M Gehrels
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands.
| | - A D Wagner
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M G Besselink
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - R H A Verhoeven
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - H W M van Laarhoven
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - J W Wilmink
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - L G van der Geest
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands.
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4
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van Goor IWJM, Andel PCM, Buijs FS, Besselink MG, Bonsing BA, Bosscha K, Busch OR, Cirkel GA, van Dam RM, Festen S, Koerkamp BG, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, Meijer G, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Verdonk RC, van Santvoort HC, Molenaar IQ, Intven MPW, Daamen LA. Prediction of Isolated Local Recurrence After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Study. Ann Surg Oncol 2024:10.1245/s10434-024-15664-4. [PMID: 38937412 DOI: 10.1245/s10434-024-15664-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Distinguishing postoperative fibrosis from isolated local recurrence (ILR) after resection of pancreatic ductal adenocarcinoma (PDAC) is challenging. A prognostic model that helps to identify patients at risk of ILR can assist clinicians when evaluating patients' postoperative imaging. This nationwide study aimed to develop a clinically applicable prognostic model for ILR after PDAC resection. PATIENTS AND METHODS An observational cohort study was performed, including all patients who underwent PDAC resection in the Netherlands (2014-2019; NCT04605237). On the basis of recurrence location (ILR, systemic, or both), multivariable cause-specific Cox-proportional hazard analysis was conducted to identify predictors for ILR and presented as hazard ratios (HRs) with 95% confidence intervals (CIs). A predictive model was developed using Akaike's Information Criterion, and bootstrapped discrimination and calibration indices were assessed. RESULTS Among 1194/1693 patients (71%) with recurrence, 252 patients (21%) developed ILR. Independent predictors for ILR were resectability status (borderline versus resectable, HR 1.42; 95% CI 1.03-1.96; P = 0.03, and locally advanced versus resectable, HR 1.11; 95% CI 0.68-1.82; P = 0.66), tumor location (head versus body/tail, HR 1.50; 95% CI 1.00-2.25; P = 0.05), vascular resection (HR 1.86; 95% CI 1.41-2.45; P < 0.001), perineural invasion (HR 1.47; 95% CI 1.01-2.13; P = 0.02), number of positive lymph nodes (HR 1.04; 95% CI 1.01-1.08; P = 0.02), and resection margin status (R1 < 1 mm versus R0 ≥ 1 mm, HR 1.64; 95% CI 1.25-2.14; P < 0.001). Moderate performance (concordance index 0.66) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS This nationwide study identified factors predictive of ILR after PDAC resection. Our prognostic model, available through www.pancreascalculator.com , can be utilized to identify patients with a higher a priori risk of developing ILR, providing important information in patient evaluation and prognostication.
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Affiliation(s)
- I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands.
| | - P C M Andel
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - F S Buijs
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - G A Cirkel
- Department of Medical Oncology, University Medical Center Utrecht Cancer Center & Meander Medical Center Amersfoort, Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Festen
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - G Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - G Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - D Roos
- Department of Surgery, Renier de Graaf Gasthuis, Delft, The Netherlands
| | | | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - R C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Imaging Division, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
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Balzano G, Reni M, Di Bartolomeo M, Scorsetti M, Caraceni A, Rivizzigno P, Amorosi A, Scardoni A, Abu Hilal M, Ferrari G, Labianca R, Venturini M, Doglioni C, Riva L, Caccialanza R, Carrara S. Translating knowledge into policy: Organizational model and minimum requirements for the implementation of a regional pancreas unit network. Dig Liver Dis 2024:S1590-8658(24)00776-X. [PMID: 38851973 DOI: 10.1016/j.dld.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 06/10/2024]
Abstract
Pancreatic and periampullary cancers pose significant challenges in oncological care due to their complexity and diagnostic difficulties. Global experiences underscore the crucial role of multidisciplinary collaboration and centralized care in improving patient outcomes in this context. Recognizing these challenges, Lombardy, Italy's most populous region, embarked on establishing pancreas units across its territory to enhance clinical outcomes and organizational efficiency. This initiative, driven by a multistakeholder approach involving the Lombardy Welfare Directorate, clinicians, and a patient association, emphasizes the centralization of complex care in high-volume hospitals, adopting a hub-and-spoke model and a multidisciplinary approach. This article outlines the process and criteria set forth for pancreas unit implementation, aiming to provide a structured framework for enhancing pancreatic cancer care. Central to this initiative is the establishment of structured criteria and minimal requirements, not only for surgery but also for other essential components of care, ensuring a comprehensive approach to pancreatic cancer management. The Lombardy model offers a structured framework for enhancing pancreatic cancer care, with potential applicability to other regions and countries seeking to improve their cancer care infrastructure.
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Affiliation(s)
- Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Michele Reni
- Department of Medical Oncology, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
| | - Maria Di Bartolomeo
- Gastrointestinal Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano 20089, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Augusto Caraceni
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano Via della Commenda 19 20122 Milan, Italy
| | - Piero Rivizzigno
- Codice Viola, Pancreatic Cancer Advocacy Group, 20855, Lesmo (MB), Italy
| | - Alessandro Amorosi
- Welfare General Directorate, Regione Lombardia; Palazzo Lombardia, Piazza Città di Lombardia, 1, 20124 Milan, Italy
| | - Alessandro Scardoni
- Welfare General Directorate, Regione Lombardia; Palazzo Lombardia, Piazza Città di Lombardia, 1, 20124 Milan, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Via Bissolati 57, Brescia 25124, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Oncologic Surgery ASST GOM Niguarda Nigurda Hospital, Milan, Italy
| | | | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, ASST Sette Laghi, 21100, Varese, Italy; Department of Medicine and Technological Innovation (DIMIT), Insubria University, Varese, Italy
| | - Claudio Doglioni
- Department of Anatomic Pathology, University Vita-Salute San Raffaele, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Luca Riva
- Frailty Department, Local Network of Palliative Care, ASST, Lecco, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinco San Matteo, Pavia, Italy
| | - Silvia Carrara
- IRCCS Humanitas Research Hospital - Endoscopic Unit, Department of Gastroenterology, Via Manzoni 56, 20089 Rozzano (Milan), Italy
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6
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Wismans LV, Suurmeijer JA, van Dongen JC, Bonsing BA, Van Santvoort HC, Wilmink JW, van Tienhoven G, de Hingh IH, Lips DJ, van der Harst E, de Meijer VE, Patijn GA, Bosscha K, Stommel MW, Festen S, den Dulk M, Nuyttens JJ, Intven MPW, de Vos-Geelen J, Molenaar IQ, Busch OR, Koerkamp BG, Besselink MG, van Eijck CHJ. Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis. Surgery 2024; 175:1580-1586. [PMID: 38448277 DOI: 10.1016/j.surg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. METHODS All patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014-2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. RESULTS Overall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03-0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25-1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). CONCLUSION This nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.
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Affiliation(s)
- Leonoor V Wismans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, the Netherlands; Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/MarcBesselink
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
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7
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Mackay TM, Latenstein AEJ, Augustinus S, van der Geest LG, Bogte A, Bonsing BA, Cirkel GA, Hol L, Busch OR, den Dulk M, van Driel LMJ, Festen S, de Groot DJA, de Groot JWB, Groot Koerkamp B, Haj Mohammad N, Haver JT, van der Harst E, de Hingh IH, Homs MYV, Los M, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, Patijn GA, Quispel R, Römkens TEH, van Santvoort HC, Stommel MW, Venneman NG, Verdonk RC, van Vilsteren FGI, de Vos-Geelen J, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Implementation of Best Practices in Pancreatic Cancer Care in the Netherlands: A Stepped-Wedge Randomized Clinical Trial. JAMA Surg 2024; 159:429-437. [PMID: 38353966 PMCID: PMC10867778 DOI: 10.1001/jamasurg.2023.7872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/26/2023] [Indexed: 02/17/2024]
Abstract
Importance Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal. Objective To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival. Design, setting, and participants This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients). Intervention The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care. Main Outcomes and Measures The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score). Results Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, -1.09, 95% CI, -3.05 to 0.94). Conclusions and Relevance In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options. Trial Registration ClinicalTrials.gov Identifier: NCT03513705.
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Affiliation(s)
- Tara M. Mackay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Anouk E. J. Latenstein
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Simone Augustinus
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Lydia G. van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
- NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany, the Netherlands
| | | | | | | | | | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Joyce T. Haver
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of nutrition and dietetics, Amsterdam, the Netherlands
| | | | | | | | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
| | - Leonie Mekenkamp
- Department of Medical Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Tessa E. H. Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Niels G. Venneman
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Judith de Vos-Geelen
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Johanna W. Wilmink
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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8
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Stoop TF, Seelen LWF, van 't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, den Dulk M, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Te Riele W, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2640-2653. [PMID: 38105377 DOI: 10.1245/s10434-023-14650-6] [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: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy. PATIENTS AND METHODS A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion. RESULTS Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS. CONCLUSIONS Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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9
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Korrel M, van Hilst J, Bosscha K, Busch ORC, Daams F, van Dam R, van Eijck CHJ, Festen S, Groot Koerkamp B, van der Harst E, Lips DJ, Luyer MD, de Meijer VE, Mieog JSD, Molenaar IQ, Patijn GA, van Santvoort HC, van der Schelling GP, Stommel MWJ, Besselink MG. Nationwide use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV following a Training Program and Randomized Trial. Ann Surg 2024; 279:323-330. [PMID: 37139822 DOI: 10.1097/sla.0000000000005900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial. BACKGROUND Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking. METHODS Nationwide audit-based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014 to 2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome. RESULTS Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% ( P <0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers ( P <0.001). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. After MIDP, in-hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III-IV (24.9% vs. 35.7%, P =0.001), pancreatic cancer (24.2% vs. 45.9%, P <0.001), vascular involvement (4.6% vs. 21.9%, P <0.001), and multivisceral involvement (10.5% vs. 25.3%, P <0.001). After MIDP, shorter hospital stay (median 7 vs. 8 d, P <0.001) and less blood loss (median 150 vs. 500 mL, P <0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs. 17.2%, P =0.008) occurred as compared to ODP. CONCLUSION A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in the use of MIDP between centers and, especially, robotic MIDP.
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Affiliation(s)
- Maarten Korrel
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Jony van Hilst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Department of Surgery, OLVG Oost, Amsterdam
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch
| | - Olivier R C Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
| | - Freek Daams
- Cancer Center Amsterdam
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery, Amsterdam
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht
| | | | | | | | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Cancer Center Amsterdam
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van Goor IW, Schouten TJ, Verburg DN, Besselink MG, Bonsing BA, Bosscha K, Brosens LA, Busch OR, Cirkel GA, van Dam RM, Festen S, Koerkamp BG, van der Harst E, de Hingh IH, Intven MP, Kazemier G, Los M, Meijer GJ, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JM, Stommel MW, Verdonk RC, van Santvoort HC, Daamen LA, Molenaar IQ. Predicting Long-term Disease-free Survival After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Cohort Study. Ann Surg 2024; 279:132-137. [PMID: 37450706 PMCID: PMC10727199 DOI: 10.1097/sla.0000000000006004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To develop a prediction model for long-term (≥5 years) disease-free survival (DFS) after the resection of pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Despite high recurrence rates, ~10% of patients have long-term DFS after PDAC resection. A model to predict long-term DFS may aid individualized prognostication and shared decision-making. METHODS This nationwide cohort study included all consecutive patients who underwent PDAC resection in the Netherlands (2014-2016). The best-performing prognostic model was selected by Cox-proportional hazard analysis and Akaike's Information Criterion, presented by hazard ratios (HRs) with 95% confidence intervals (CIs). Internal validation was performed, and discrimination and calibration indices were assessed. RESULTS In all, 836 patients with a median follow-up of 67 months (interquartile range 51-79) were analyzed. Long-term DFS was seen in 118 patients (14%). Factors predictive of long-term DFS were low preoperative carbohydrate antigen 19-9 (logarithmic; HR 1.21; 95% CI 1.10-1.32), no vascular resection (HR 1.33; 95% CI 1.12-1.58), T1 or T2 tumor stage (HR 1.52; 95% CI 1.14-2.04, and HR 1.17; 95% CI 0.98-1.39, respectively), well/moderate tumor differentiation (HR 1.44; 95% CI 1.22-1.68), absence of perineural and lymphovascular invasion (HR 1.42; 95% CI 1.11-1.81 and HR 1.14; 95% CI 0.96-1.36, respectively), N0 or N1 nodal status (HR 1.92; 95% CI 1.54-2.40, and HR 1.33; 95% CI 1.11-1.60, respectively), R0 resection margin status (HR 1.25; 95% CI 1.07-1.46), no major complications (HR 1.14; 95% CI 0.97-1.35) and adjuvant chemotherapy (HR 1.74; 95% CI 1.47-2.06). Moderate performance (concordance index 0.68) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS The developed prediction model, readily available at www.pancreascalculator.com, can be used to estimate the probability of long-term DFS after resection of pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Iris W.J.M. van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Thijs J. Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Daphne N. Verburg
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Lodewijk A.A. Brosens
- Department of Pathology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & Meander Medical Center Amersfoort, Utrecht, the Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Martijn P.W. Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Vincent E. de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Daphne Roos
- Department of Surgery, Renier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Imaging Division, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
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Hopstaken JS, Daamen LA, Patijn GA, de Vos-Geelen J, Festen S, Bonsing BA, Verheij M, Hermans JJ, Bruno MJ, de Wilde RF, de Hingh IHJT, Besselink MG, Laarhoven KJHMV, Stommel MWJ. Nationwide evaluation of pancreatic cancer networks ten years after the centralization of pancreatic surgery. HPB (Oxford) 2023; 25:1513-1522. [PMID: 37580180 DOI: 10.1016/j.hpb.2023.07.904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/26/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Due to centralization of pancreatic surgery, patients with pancreatic cancer are treated in pancreatic cancer networks, composed of referring hospitals (Spokes) and an expert center (Hub). This study aimed to investigate I) how pancreatic cancer networks are organized and II) evaluated by involved clinicians. METHODS Two online surveys were sent out between January-May 2022. Part I was sent out to the surgical network directors of all hospitals of the Dutch Pancreatic Cancer Group (DPCG). Part II was sent out to all involved clinicians in the Hubs-and-Spokes networks. RESULTS There was a large variety between the 15 networks concerning number of affiliated Spokes (1-7), annual pancreatoduodenectomies (20-129), and use of a service level agreement (SLA) (40%). More Spoke clinicians considered the Spoke the best location for diagnostic workup (74% vs 36%, P < 0.001). Only 30% of Spoke clinicians attended the Hubs multidisciplinary team meeting frequently. More Hub clinicians thought that exchange of patient information should be improved (37% vs 51%, P = 0.005). CONCLUSION A large variety in Dutch pancreatic cancer networks was observed concerning number of affiliated Spokes, use of SLAs, and logistic aspects of network care. Improvement of network care concern agreements on diagnostic workup, use of SLA, Spoke participation in the MDT, and patient information exchange.
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Affiliation(s)
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht, the Netherlands; Dept. of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | - Marcel Verheij
- Department of Radiation Oncology, Radboudumc, Nijmegen, the Netherlands
| | - John J Hermans
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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Zwart MJ, van den Broek B, de Graaf N, Suurmeijer JA, Augustinus S, te Riele WW, van Santvoort HC, Hagendoorn J, Borel Rinkes IH, van Dam JL, Takagi K, Tran KT, Schreinemakers J, van der Schelling G, Wijsman JH, de Wilde RF, Festen S, Daams F, Luyer MD, de Hingh IH, Mieog JS, Bonsing BA, Lips DJ, Abu Hilal M, Busch OR, Saint-Marc O, Zeh HJ, Zureikat AH, Hogg ME, Koerkamp BG, Molenaar IQ, Besselink MG. The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants". Ann Surg 2023; 278:e1232-e1241. [PMID: 37288547 PMCID: PMC10631507 DOI: 10.1097/sla.0000000000005928] [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] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework. BACKGROUND The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program. METHODS Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned." RESULTS Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome. CONCLUSIONS The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.
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Affiliation(s)
- Maurice J.W. Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
| | - José A. Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Wouter W. te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L. van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Khé T.C. Tran
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Jan H. Wijsman
- Department of Surgery, Amphia Medical Center, Breda, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Misha D. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S.D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Twente Medical Spectrum, Enschede, the Netherlands
| | - Mohamed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Herbert J. Zeh
- Department of Surgery, University of Texas, Southwestern, Dallas, TX
| | - Amer H. Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Bas G. Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Isaac Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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Augustinus S, Mackay TM, Andersson B, Beane JD, Busch OR, Gleeson EM, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Wellner UF, Williamsson C, Besselink MG, Pitt HA. Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure. Ann Surg 2023; 278:740-747. [PMID: 37476990 PMCID: PMC10549886 DOI: 10.1097/sla.0000000000006037] [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] [Indexed: 07/22/2023]
Abstract
OBJECTIVE The aim of this study is to define and assess Ideal Outcome in the national or multicenter registries of North America, Germany, the Netherlands, and Sweden. BACKGROUND Assessing outcomes after pancreatoduodenectomy among centers and countries requires a broad evaluation that cannot be captured by a single parameter. Previously, 2 composite outcome measures (textbook outcome and optimal pancreatic surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into ideal outcome (IO). METHODS This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, The Netherlands, and Sweden. After 3 consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all 6 parameters: (1) in-hospital mortality, (2) severe complications-Clavien-Dindo ≥3, (3) postoperative pancreatic fistula-International Study Group of Pancreatic Surgery (ISGPS) grade B/C, (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative largest difference (RLD) and absolute largest difference (ALD), and multivariate regression models. RESULTS Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in The Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P <0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of chronic obstructive pulmonary disease, body mass index, performance status, American Society of Anesthesiologists (ASA) score, biliary drainage, absence of vascular resection, and histologic diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country, and neoadjuvant chemotherapy also was associated with improved IO. CONCLUSIONS The newly developed composite outcome measure "Ideal Outcome" can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve the outcomes of pancreatic surgery.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D. Beane
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas G. Koerkamp
- Department of Surgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulrich F. Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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14
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Graus MUJE, de Hingh IHJT, Besselink MG, Bruno MJ, Wilmink JW, de Meijer VE, van Velthuysen MLF, Valkenburg-van Iersel LBJ, van der Geest LGM, de Vos-Geelen J. Population-based impact of COVID-19 on incidence, treatment, and survival of patients with pancreatic cancer. HPB (Oxford) 2023; 25:1195-1202. [PMID: 37236831 PMCID: PMC10162845 DOI: 10.1016/j.hpb.2023.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The COVID-19 pandemic has put substantial strain on the healthcare system of which the effects are only partly elucidated. This study aimed to investigate the impact on pancreatic cancer care. METHODS All patients diagnosed with pancreatic cancer between 2017 and 2020 were selected from the Netherlands Cancer Registry. Patients diagnosed and/or treated in 2020 were compared to 2017-2019. Monthly incidence was calculated. Patient, tumor and treatment characteristics were analyzed and compared using Chi-squared tests. Survival data was analyzed using Kaplan-Meier and Log-rank tests. RESULTS In total, 11019 patients were assessed. The incidence in quarter (Q)2 of 2020 was comparable with that in Q2 of 2017-2019 (p = 0.804). However, the incidence increased in Q4 of 2020 (p = 0.031), mainly due to a higher incidence of metastatic disease (p = 0.010). Baseline characteristics, surgical resection (15% vs 16%; p = 0.466) and palliative systemic therapy rates (23% vs 24%; p = 0.183) were comparable. In 2020, more surgically treated patients received (neo)adjuvant treatment compared to 2017-2019 (73% vs 67%; p = 0.041). Median overall survival was comparable (3.8 vs 3.8 months; p = 0.065). CONCLUSION This nationwide study found a minor impact of the COVID-19 pandemic on pancreatic cancer care and outcome. The Dutch health care system was apparently able to maintain essential care for patients with pancreatic cancer.
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Affiliation(s)
- Merlijn U J E Graus
- Maastricht University Medical Center, Department of Internal Medicine, Division of Medical Oncology, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands; GROW, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Ignace H J T de Hingh
- GROW, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands; Catharina Ziekenhuis Eindhoven, Department of Surgery, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, de Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands; Cancer Center Amsterdam, de Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Marco J Bruno
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, de Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, de Boelelaan 1118, 1081 HZ, Amsterdam, the Netherlands
| | - Vincent E de Meijer
- University Medical Center Groningen, Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | | | - Liselot B J Valkenburg-van Iersel
- Maastricht University Medical Center, Department of Internal Medicine, Division of Medical Oncology, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands; GROW, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands
| | - Lydia G M van der Geest
- Netherlands Comprehensive Cancer Organisation (IKNL), Department of Research, Godebaldkwartier 419, 3511 DT, Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Maastricht University Medical Center, Department of Internal Medicine, Division of Medical Oncology, P. Debyelaan 25, 6229 HX, Maastricht, the Netherlands; GROW, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, the Netherlands.
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15
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Groen JV, Michiels N, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer: A nationwide cohort study. Surgery 2023; 174:924-933. [PMID: 37451894 DOI: 10.1016/j.surg.2023.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/19/2023] [Accepted: 06/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Practice variation exists in venous resection during pancreatoduodenectomy, but little is known about the potential causes and consequences as large studies are lacking. This study explores the potential causes and consequences of practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer in the Netherlands. METHODS This nationwide retrospective cohort study included patients undergoing pancreatoduodenectomy for pancreatic cancer in 18 centers from 2013 through 2017. RESULTS Among 1,311 patients undergoing pancreatoduodenectomy, 351 (27%) had a venous resection, and the overall median annual center volume of venous resection was 4. No association was found between the center volume of pancreatoduodenectomy and the rate of venous resections, nor between patient and tumor characteristics and the rate of venous resections per center. Female sex, lower body mass index, neoadjuvant therapy, venous involvement, and stenosis on imaging were predictive for venous resection. Adjusted for these factors, 3 centers performed significantly more, and 3 centers performed significantly fewer venous resections than expected. In patients with venous resection, significantly less major morbidity (22% vs 38%) and longer overall survival (median 16 vs 12 months) were observed in centers with an above-median annual volume of venous resections (>4). CONCLUSION Patient and tumor characteristics did not explain significant practice variation between centers in the Netherlands in venous resection during pancreatoduodenectomy for pancreatic cancer. The clinical outcomes of venous resection might be related to the volume of the procedure.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, Maastricht UMC+, The Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, The Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, The Netherlands
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16
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Ingwersen EW, Stam WT, Meijs BJV, Roor J, Besselink MG, Groot Koerkamp B, de Hingh IHJT, van Santvoort HC, Stommel MWJ, Daams F. Machine learning versus logistic regression for the prediction of complications after pancreatoduodenectomy. Surgery 2023; 174:435-440. [PMID: 37150712 DOI: 10.1016/j.surg.2023.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Machine learning is increasingly advocated to develop prediction models for postoperative complications. It is, however, unclear if machine learning is superior to logistic regression when using structured clinical data. Postoperative pancreatic fistula and delayed gastric emptying are the two most common complications with the biggest impact on patient condition and length of hospital stay after pancreatoduodenectomy. This study aimed to compare the performance of machine learning and logistic regression in predicting pancreatic fistula and delayed gastric emptying after pancreatoduodenectomy. METHODS This retrospective observational study used nationwide data from 16 centers in the Dutch Pancreatic Cancer Audit between January 2014 and January 2021. The area under the curve of a machine learning and logistic regression model for clinically relevant postoperative pancreatic fistula and delayed gastric emptying were compared. RESULTS Overall, 799 (16.3%) patients developed a postoperative pancreatic fistula, and 943 developed (19.2%) delayed gastric emptying. For postoperative pancreatic fistula, the area under the curve of the machine learning model was 0.74, and the area under the curve of the logistic regression model was 0.73. For delayed gastric emptying, the area under the curve of the machine learning model and logistic regression was 0.59. CONCLUSION Machine learning did not outperform logistic regression modeling in predicting postoperative complications after pancreatoduodenectomy.
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Affiliation(s)
- Erik W Ingwersen
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, the Netherlands
| | - Wessel T Stam
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, the Netherlands
| | - Bono J V Meijs
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, the Netherlands
| | - Joran Roor
- SAS institute B.V., Huizen, the Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, the Netherlands; Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | | | | | | | - Freek Daams
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
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Tachezy M, Gebauer F, Yekebas E, Izbicki JR. Failure of a Multi-Centric Clinical Trial Investigating Neoadjuvant Radio-Chemotherapy in Resectable Pancreatic Carcinoma (NEOPA-NCT01900327)-Which Lessons Are Learnt? Cancers (Basel) 2023; 15:4262. [PMID: 37686537 PMCID: PMC10487154 DOI: 10.3390/cancers15174262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND A significant number of clinical trials must be prematurely discontinued due to recruitment failure, and only a small fraction publish results and a failure analysis. Based on our experience on conducting the NEOPA trial on neoadjuvant radiochemotherapy for resectable and borderline resectable pancreatic carcinoma (NCT01900327-funded by the German Federal Ministry of Education and Research-BMBF), we performed an analysis of potential reasons for recruitment failure and general problems in conducting clinical trials in Germany. METHODS Systematic analysis of environmental factors, trial history, conducting and funding in the background of the published literature. RESULTS The recruitment failure was based on various study-specific conceptional and local environmental aspects and in peculiarities of the German surgical study culture. General reservations against a neo-adjuvant study concept combined with game changing scientific progresses during the long-lasting planning and funding phase have led to a reduced interest in the trial design and recruitment. CONCLUSIONS Trial planning and conducting should be focused, professionalized and financed on a national basis. Individual interests must be subordinated to reach the goal to perform more relevant and successful clinical trials in Germany. Bureaucratic processes must be further fastened between a trial idea and the start of a study.
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Affiliation(s)
- Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
| | - Florian Gebauer
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
- Department of General and Visceral Surgery, HELIOS University Hospital Wuppertal, 42283 Wuppertal, Germany
| | - Emre Yekebas
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
| | - Jakob Robert Izbicki
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
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18
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van Dongen JC, van Dam JL, Besselink MG, Bonsing BA, Bosscha K, Busch OR, van Dam RM, Festen S, van der Harst E, de Hingh IH, Kazemier G, Liem MSL, de Meijer VE, Mieog JSD, Molenaar IQ, Patijn GA, van Santvoort HC, Wijsman JH, Stommel MWJ, Wit F, De Wilde RF, van Eijck CHJ, Groot Koerkamp B. Fistula Risk Score for Auditing Pancreatoduodenectomy: The Auditing-FRS. Ann Surg 2023; 278:e272-e277. [PMID: 35837978 DOI: 10.1097/sla.0000000000005532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals. BACKGROUND For proper comparisons of outcomes in surgical audits, case-mix variation should be accounted for. METHODS This study included consecutive patients after pancreatoduodenectomy from the mandatory nationwide Dutch Pancreatic Cancer Audit. Derivation of the score was performed with the data from 2014 to 2018 and validation with 2019 to 2020 data. The primary endpoint of the study was POPF (grade B or C). Multivariable logistic regression analysis was performed for case-mix adjustment of known risk factors. RESULTS In the derivation cohort, 3271 patients were included, of whom 479 (14.6%) developed POPF. Male sex [odds ratio (OR)=1.34; 95% confidence interval (CI): 1.09-1.66], higher body mass index (OR=1.07; 95% CI: 1.05-1.10), a final diagnosis other than pancreatic ductal adenocarcinoma/pancreatitis (OR=2.41; 95% CI: 1.90-3.06), and a smaller duct diameter (OR=1.43/mm decrease; 95% CI: 1.32-1.55) were independently associated with POPF. Diabetes mellitus (OR=0.73; 95% CI: 0.55-0.98) was independently associated with a decreased risk of POPF. Model discrimination was good with a C -statistic of 0.73 in the derivation cohort and 0.75 in the validation cohort (n=913). Hospitals differed in particular in the proportion of pancreatic ductal adenocarcinoma/pancreatitis patients, ranging from 36.0% to 58.1%. The observed POPF risk per center ranged from 2.9% to 25.4%. The expected POPF rate based on the 5 risk factors ranged from 11.6% to 18.0% among hospitals. CONCLUSIONS The auditing fistula risk score was successful in case-mix adjustment and enables fair comparisons of POPF rates among hospitals.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Izaak Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
| | - Roeland F De Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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19
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Augustinus S, Latenstein AE, Bonsing BA, Busch OR, Groot Koerkamp B, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, de Vos-Geelen J, van Eijck CH, Besselink MG. Chyle Leak After Pancreatoduodenectomy: Clinical Impact and Risk Factors in a Nationwide Analysis. Ann Surg 2023; 277:e1299-e1305. [PMID: 35786606 PMCID: PMC10174101 DOI: 10.1097/sla.0000000000005449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the clinical impact and risk factors of chyle leak (CL). BACKGROUND In 2017, the International Study Group for Pancreatic Surgery (ISGPS) published the consensus definition of CL. Multicenter series validating this definition are lacking and previous studies investigating risk factors have used different definitions and showed heterogeneous results. METHODS This observational cohort study included all consecutive patients after pancreatoduodenectomy in all 19 centers in the mandatory nationwide Dutch Pancreatic Cancer Audit (2017-2019). The primary endpoint was CL (ISGPS grade B/C). Multivariable logistic regression analyses were performed. RESULTS Overall, 2159 patients after pancreatoduodenectomy were included. The rate of CL was 7.0% (n=152), including 6.9% (n=150) grade B and 0.1% (n=2) grade C. CL was independently associated with a prolonged hospital stay [odds ratio (OR)=2.84, 95% confidence interval (CI): 1.85-4.36, P <0.001] but not with mortality (OR=0.3, 95% CI: 0.0-2.3, P =0.244). In multivariable analyses, independent predictors for CL were vascular resection (OR=2.1, 95% CI: 1.4-3.2, P <0.001) and open surgery (OR=3.5, 95% CI: 1.7-7.2, P =0.001). The number of resected lymph nodes and aortocaval lymph node sampling were not identified as predictors in multivariable analysis. CONCLUSIONS In this nationwide analysis, the rate of ISGPS grade B/C CL after pancreatoduodenectomy was 7.0%. Although CL is associated with a prolonged hospital stay, the clinical impact is relatively minor in the vast majority (>98%) of patients. Vascular resection and open surgery are predictors of CL.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anouk E.J. Latenstein
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - Casper H. van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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20
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Kessels R, May AM, Koopman M, Roes KCB. The Trial within Cohorts (TwiCs) study design in oncology: experience and methodological reflections. BMC Med Res Methodol 2023; 23:117. [PMID: 37179306 PMCID: PMC10183126 DOI: 10.1186/s12874-023-01941-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 05/06/2023] [Indexed: 05/15/2023] Open
Abstract
A Trial within Cohorts (TwiCs) study design is a trial design that uses the infrastructure of an observational cohort study to initiate a randomized trial. Upon cohort enrollment, the participants provide consent for being randomized in future studies without being informed. Once a new treatment is available, eligible cohort participants are randomly assigned to the treatment or standard of care. Patients randomized to the treatment arm are offered the new treatment, which they can choose to refuse. Patients who refuse will receive standard of care instead. Patients randomized to the standard of care arm receive no information about the trial and continue receiving standard of care as part of the cohort study. Standard cohort measures are used for outcome comparisons. The TwiCs study design aims to overcome some issues encountered in standard Randomized Controlled Trials (RCTs). An example of an issue in standard RCTs is the slow patient accrual. A TwiCs study aims to improve this by selecting patients using a cohort and only offering the intervention to patients in the intervention arm. In oncology, the TwiCs study design has gained increasing interest during the last decade. Despite its potential advantages over RCTs, the TwiCs study design has several methodological challenges that need careful consideration when planning a TwiCs study. In this article, we focus on these challenges and reflect on them using experiences from TwiCs studies initiated in oncology. Important methodological challenges that are discussed are the timing of randomization, the issue of non-compliance (refusal) after randomization in the intervention arm, and the definition of the intention-to-treat effect in a TwiCs study and how this effect is related to its counterpart in standard RCTs.
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Affiliation(s)
- Rob Kessels
- Dutch Oncology Research Platform, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, STR 6.131 , P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Radboud University Medical Center, Section Biostatistics, Nijmegen, the Netherlands
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21
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Hopstaken JS, Vissers PAJ, Quispel R, de Vos-Geelen J, Brosens LAA, de Hingh IHJT, van der Geest LG, Besselink MG, van Laarhoven KJHM, Stommel MWJ. Impact of network treatment in patients with resected pancreatic cancer on use and timing of chemotherapy and survival. BJS Open 2023; 7:7156602. [PMID: 37151083 PMCID: PMC10165062 DOI: 10.1093/bjsopen/zrad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Centralization of pancreatic cancer surgery aims to improve postoperative outcomes. Consequently, patients with pancreatic cancer may undergo pancreatic surgery in an expert centre and adjuvant chemotherapy in a local hospital (network treatment). The aim of this study was to assess whether network treatment has an impact on time to chemotherapy, failure to complete adjuvant chemotherapy, and survival. Second, whether these parameters varied between pancreatic networks was studied. METHODS This retrospective study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma who underwent pancreatic surgery and adjuvant chemotherapy, registered in the Netherlands Cancer Registry (2015-2020). Time to chemotherapy was defined as the time between surgery and the start of adjuvant chemotherapy. Completion of adjuvant chemotherapy was defined as the receipt of 12 cycles of FOLFIRINOX or six cycles of gemcitabine. Analysis was performed with linear mixed models and multilevel logistic regression models. Cox regression analyses were performed for survival. RESULTS In total, 1074 patients were included. Network treatment was observed in 468 patients (43.6 per cent) and was not associated with longer time to chemotherapy (0.77 days, standard error (s.e.) 1.14, P = 0.501), failure to complete adjuvant chemotherapy (odds ratio (OR) = 1.140, 95 per cent c.i. 0.86 to 1.52, P = 0.349), and overall survival (hazards ratio (HR) = 1.04, 95 per cent c.i. 0.88 to 1.22, P = 0.640). Significant variation between the networks was observed for time to chemotherapy (range 40.5-63 days, P < 0.0001) and completion of adjuvant chemotherapy (range 19-52 per cent, P = 0.030). Adjusted for case mix, time to chemotherapy significantly differed between networks. CONCLUSION In this nationwide analysis, network treatment in patients with resected pancreatic cancer was not associated with longer time to chemotherapy, failure to complete adjuvant chemotherapy, and worse survival. Significant variation between pancreatic cancer networks was found for time to chemotherapy.
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Affiliation(s)
- Jana S Hopstaken
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pauline A J Vissers
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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22
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Theijse RT, Stoop TF, Geerdink NJ, Daams F, Zonderhuis BM, Erdmann JI, Swijnenburg RJ, Kazemier G, Busch OR, Besselink MG. Surgical outcome of a double versus a single pancreatoduodenectomy per operating day. Surgery 2023; 173:1263-1269. [PMID: 36842911 DOI: 10.1016/j.surg.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 01/17/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND For logistical reasons, some high-volume centers have developed surgical programs wherein 1 surgical team performs 2 pancreatoduodenectomies on a single day. It is unclear whether this practice has a negative impact on surgical outcome. METHODS We conuducted a retrospective analysis including all consecutive open pancreatoduodenectomies in a single high-volume center (2014-2021). Pancreatoduodenectomies were grouped as the first (pancreatoduodenectomy-1) or second (pancreatoduodenectomy-2) pancreatoduodenectomy on a single day (ie, paired pancreatoduodenectomies) and as pancreatoduodenectomy-3 whenever 1 pancreatoduodenectomy was performed per day (ie, unpaired). Patients undergoing minimally invasive procedures were excluded. The primary outcomes were major morbidity (ie, Clavien-Dindo grade ≥IIIa) and mortality. RESULTS Among 689 patients, 151 patients had undergone minimally invasive pancreatoduodenectomy, leaving 538 patients after open pancreatoduodenectomy for inclusion. The overall rate of major morbidity was 37.4% (n = 200/538) and in-hospital/30-day mortality 1.7% (n = 9/538). Overall, 136 (25.3%) patients were operated in 68 pancreatoduodenectomy-1/ pancreatoduodenectomy-2 pairs and 402 (74.7%) patients as unpaired pancreatoduodenectomy (pancreatoduodenectomy-3). No differences were found between pancreatoduodenectomy-1 and pancreatoduodenectomy-2 regarding the rates of major morbidity (35.3% vs 26.5%; P = .265) and mortality (1.5% vs 0%; P = .999). Between the 68 pancreatoduodenectomy-1/ pancreatoduodenectomy-2 pairs and the 402 unpaired pancreatoduodenectomies, the rates of major morbidity (30.9% vs 39.6%; P = .071) and mortality (0.7% vs 2.0%; P = .461) did not differ significantly. In multivariable logistic regression analysis, pancreatoduodenectomy-1 was not associated with major morbidity (odds ratio = 0.913 [95% confidence interval 0.515-1.620]; P = .756), whereas pancreatoduodenectomy-2 was associated with less major morbidity (odds ratio = 0.522 [95% confidence interval 0.277-0.983]; P = .045). CONCLUSION In a high-volume setting, performing 2 consecutive open pancreatoduodenectomies on a single operating day appears to be safe. This approach may be an option when logistically required.
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Affiliation(s)
- Rutger T Theijse
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Thomas F Stoop
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Niek J Geerdink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Babs M Zonderhuis
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Rutger Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, location Vrije Universiteit, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands. http://www.twitter.com/MarcBesselink
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23
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Doppenberg D, Besselink MG, van Eijck CHJ, Intven MPW, Koerkamp BG, Kazemier G, van Laarhoven HWM, Meijerink M, Molenaar IQ, Nuyttens JJME, van Os R, van Santvoort HC, van Tienhoven G, Verkooijen HM, Versteijne E, Wilmink JW, Lagerwaard FJ, Bruynzeel AME. Stereotactic ablative radiotherapy or best supportive care in patients with localized pancreatic cancer not receiving chemotherapy and surgery (PANCOSAR): a nationwide multicenter randomized controlled trial according to a TwiCs design. BMC Cancer 2022; 22:1363. [PMID: 36581914 PMCID: PMC9801528 DOI: 10.1186/s12885-022-10419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant comorbidities, advanced age, and a poor performance status prevent surgery and systemic treatment for many patients with localized (non-metastatic) pancreatic ductal adenocarcinoma (PDAC). These patients are currently treated with 'best supportive care'. Therefore, it is desirable to find a treatment option which could improve both disease control and quality of life in these patients. A brief course of high-dose high-precision radiotherapy i.e. stereotactic ablative body radiotherapy (SABR) may be feasible. METHODS A nationwide multicenter trial performed within a previously established large prospective cohort (the Dutch Pancreatic cancer project; PACAP) according to the 'Trial within cohorts' (TwiCs) design. Patients enrolled in the PACAP cohort routinely provide informed consent to answer quality of life questionnaires and to be randomized according to the TwiCs design when eligible for a study. Patients with localized PDAC who are unfit for chemotherapy and surgery or those who refrain from these treatments are eligible. Patients will be randomized between SABR (5 fractions of 8 Gy) with 'best supportive care' and 'best supportive care' only. The primary endpoint is overall survival from randomization. Secondary endpoints include preservation of quality of life (EORTC-QLQ-C30 and -PAN26), NRS pain score response and WHO performance scores at baseline, and, 3, 6 and 12 months. Acute and late toxicity will be scored using CTCAE criteria version 5.0: assessed at baseline, day of last fraction, at 3 and 6 weeks, and 3, 6 and 12 months following SABR. DISCUSSION The PANCOSAR trial studies the added value of SBRT as compared to 'best supportive care' in patients with localized PDAC who are medically unfit to receive chemotherapy and surgery, or refrain from these treatments. This study will assess whether SABR, in comparison to best supportive care, can relieve or delay tumor-related symptoms, enhance quality of life, and extend survival in these patients. TRIAL REGISTRATION Clinical trials, NCT05265663 , Registered March 3 2022, Retrospectively registered.
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Affiliation(s)
- D. Doppenberg
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - C. H. J. van Eijck
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M. P. W. Intven
- grid.5477.10000000120346234Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - B. Groot Koerkamp
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - G. Kazemier
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - H. W. M. van Laarhoven
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - M. Meijerink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Intervention Radiology, Amsterdam, The Netherlands
| | - I. Q. Molenaar
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J. J. M. E. Nuyttens
- grid.508717.c0000 0004 0637 3764Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - R. van Os
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - H. C. van Santvoort
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - G. van Tienhoven
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - H. M. Verkooijen
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - E. Versteijne
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. W. Wilmink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - F. J. Lagerwaard
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - A. M. E. Bruynzeel
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
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24
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Stoop TF, van Veldhuisen E, van Rijssen LB, Klaassen R, Gurney-Champion OJ, de Hingh IH, Busch OR, van Laarhoven HWM, van Lienden KP, Stoker J, Wilmink JW, Nio CY, Nederveen AJ, Engelbrecht MRW, Besselink MG. Added value of 3T MRI and the MRI-halo sign in assessing resectability of locally advanced pancreatic cancer following induction chemotherapy (IMAGE-MRI): prospective pilot study. Langenbecks Arch Surg 2022; 407:3487-3499. [PMID: 36242618 DOI: 10.1007/s00423-022-02653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Restaging of locally advanced pancreatic cancer (LAPC) after induction chemotherapy using contrast-enhanced computed tomography (CE-CT) imaging is imprecise in evaluating local tumor response. This study explored the value of 3 Tesla (3 T) contrast-enhanced (CE) and diffusion-weighted (DWI) magnetic resonance imaging (MRI) for local tumor restaging. METHODS This is a prospective pilot study including 20 consecutive patients with LAPC with RECIST non-progressive disease on CE-CT after induction chemotherapy. Restaging CE-CT, CE-MRI, and DWI-MRI were retrospectively evaluated by two abdominal radiologists in consensus, scoring tumor size and vascular involvement. A halo sign was defined as replacement of solid perivascular (arterial and venous) tumor tissue by a zone of fatty-like signal intensity. RESULTS Adequate MRI was obtained in 19 patients with LAPC after induction chemotherapy. Tumor diameter was non-significantly smaller on CE-MRI compared to CE-CT (26 mm vs. 30 mm; p = 0.073). An MRI-halo sign was seen on CE-MRI in 52.6% (n = 10/19), whereas a CT-halo sign was seen in 10.5% (n = 2/19) of patients (p = 0.016). An MRI-halo sign was not associated with resection rate (60.0% vs. 62.5%; p = 1.000). In the resection cohort, patients with an MRI-halo sign had a non-significant increased R0 resection rate as compared to patients without an MRI-halo sign (66.7% vs. 20.0%; p = 0.242). Positive and negative predictive values of the CE-MRI-halo sign for R0 resection were 66.7% and 66.7%, respectively. CONCLUSIONS 3 T CE-MRI and the MRI-halo sign might be helpful to assess the effect of induction chemotherapy in patients with LAPC, but its diagnostic accuracy has to be evaluated in larger series.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands. .,Cancer Center, Amsterdam, The Netherlands.
| | - Eran van Veldhuisen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.,Cancer Center, Amsterdam, The Netherlands
| | - L Bengt van Rijssen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.,Cancer Center, Amsterdam, The Netherlands
| | - Remy Klaassen
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - Oliver J Gurney-Champion
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.,Cancer Center, Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands.,Department of Radiology, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Regional Academic Cancer Center Utrecht, Nieuwegein, the Netherlands
| | - Jaap Stoker
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - C Yung Nio
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Aart J Nederveen
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Marc R W Engelbrecht
- Cancer Center, Amsterdam, The Netherlands.,Amsterdam UMC, location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.,Cancer Center, Amsterdam, The Netherlands
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Hopstaken JS, Vissers PAJ, Quispel R, de Vos-Geelen J, Brosens LAA, de Hingh IHJT, van der Geest LG, Besselink MG, van Laarhoven KJHM, Stommel MWJ. Impact of multicentre diagnostic workup in patients with pancreatic cancer on repeated diagnostic investigations, time-to-diagnosis and time-to-treatment: A nationwide analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2195-2201. [PMID: 35701256 DOI: 10.1016/j.ejso.2022.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/04/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Due to the centralization of pancreatic surgery, patients with suspected pancreatic cancer may undergo diagnostic workup in both a non-pancreatic centre and a pancreatic centre, i.e. multicentre workup. This retrospective study assessed whether multicentre diagnostic workup is associated with repeated diagnostics, delayed time-to-diagnosis, delayed time-to-treatment, survival and whether variation existed among pancreatic cancer networks. METHODS This nationwide study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) in 2015, registered by the Netherlands Cancer Registry. A delayed time-to-diagnosis was defined as ≥3 weeks from initial hospital visit to final diagnosis. A delayed time-to-treatment was defined as ≥6 weeks from the first hospital visit to start of first tumour treatment. Multilevel logistic regression analyses and survival analyses were performed. RESULTS In total, 931 patients with non-metastatic PDAC were included. Overall, 175 patients (19%) underwent a multicentre diagnostic workup, which was significantly associated with repeated diagnostic investigations (OR = 6.31, 95% CI 4.13-9.64, P < 0.0001), a delayed time-to-diagnosis (OR = 2.66 95% CI 1.74-4.06, P < 0.001), and a delayed time-to-treatment (OR = 1.93 95% CI 1.12-3.31, P = 0.02), but not with decreased survival (HR = 1.09 95% CI 0.83-1.44; P = 0.532). Variation in outcomes per network was observed, especially for time-to-treatment, though the ICC was not statistically significant (P = 0.065). CONCLUSION Multicentre diagnostic workup for patients with PDAC is associated with repeated diagnostic investigations, a delayed time-to-diagnosis and delayed time-to-treatment compared to patients with monocentre workup. To reduce costs and improve treatment times, efforts should be made to improve network coordination, for example via network care pathways.
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Affiliation(s)
- Jana S Hopstaken
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Pauline A J Vissers
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands, Department of Pathology, UMC Utrecht, Utrecht, the Netherlands
| | | | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
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26
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Schouten TJ, Daamen LA, Dorland G, van Roessel SR, Groot VP, Besselink MG, Bonsing BA, Bosscha K, Brosens LAA, Busch OR, van Dam RM, Fariña Sarasqueta A, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Intven M, Kazemier G, de Meijer VE, Nieuwenhuijs VB, Raicu GM, Roos D, Schreinemakers JMJ, Stommel MWJ, van Velthuysen MF, Verdonk RC, Verheij J, Verkooijen HM, van Santvoort HC, Molenaar IQ. Nationwide Validation of the 8th American Joint Committee on Cancer TNM Staging System and Five Proposed Modifications for Resected Pancreatic Cancer. Ann Surg Oncol 2022; 29:5988-5999. [PMID: 35469113 PMCID: PMC9356941 DOI: 10.1245/s10434-022-11664-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The prognostic value of four proposed modifications to the 8th American Joint Committee on Cancer (AJCC) TNM staging system has yet to be evaluated. This study aimed to validate five proposed modifications. METHODS Patients who underwent pancreatic ductal adenocarcinoma resection (2014-2016), as registered in the prospective Dutch Pancreatic Cancer Audit, were included. Stratification and prognostication of TNM staging systems were assessed using Kaplan-Meier curves, Cox proportional hazard analyses, and C-indices. A new modification was composed based on overall survival (OS). RESULTS Overall, 750 patients with a median OS of 18 months (interquartile range 10-32) were included. The 8th edition had an increased discriminative ability compared with the 7th edition {C-index 0.59 (95% confidence interval [CI] 0.56-0.61) vs. 0.56 (95% CI 0.54-0.58)}. Although the 8th edition showed a stepwise decrease in OS with increasing stage, no differences could be demonstrated between all substages; stage IIA vs. IB (hazard ratio [HR] 1.30, 95% CI 0.80-2.09; p = 0.29) and stage IIB vs. IIA (HR 1.17, 95% CI 0.75-1.83; p = 0.48). The four modifications showed comparable prognostic accuracy (C-index 0.59-0.60); however, OS did not differ between all modified TNM stages (ns). The new modification, migrating T3N1 patients to stage III, showed a C-index of 0.59, but did detect significant survival differences between all TNM stages (p < 0.05). CONCLUSIONS The 8th TNM staging system still lacks prognostic value for some categories of patients, which was not clearly improved by four previously proposed modifications. The modification suggested in this study allows for better prognostication in patients with all stages of disease.
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Affiliation(s)
- Thijs J. Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Galina Dorland
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stijn R. van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent P. Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | - Olivier R. Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald M. van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - Arantza Fariña Sarasqueta
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - Ignace H. J. T. de Hingh
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Martijn Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Vincent E. de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | | | - G. Mihaela Raicu
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
| | | | | | | | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Helena M. Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - The Dutch Pancreatic Cancer Group
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
- Department of Pathology, UMC Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- GROW - School for Oncology & Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Isala, Zwolle, The Netherlands
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pathology, Erasmus MC, Rotterdam, Netherlands
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
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de Jong EJM, van der Geest LG, Besselink MG, Bouwense SAW, Buijsen J, Dejong CHC, Koerkamp BG, Heij LR, de Hingh IHJT, Hoge C, Kazemier G, van Laarhoven HWM, de Meijer VE, Stommel MWJ, Tjan-Heijnen VCG, Valkenburg-van Iersel LBJ, Wilmink JW, Geurts SME, de Vos-Geelen J. Treatment and overall survival of four types of non-metastatic periampullary cancer: nationwide population-based cohort study. HPB (Oxford) 2022; 24:1433-1442. [PMID: 35135724 DOI: 10.1016/j.hpb.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Periampullary adenocarcinoma consists of pancreatic adenocarcinoma (PDAC), distal cholangiocarcinoma (DC), ampullary cancer (AC), and duodenal adenocarcinoma (DA). The aim of this study was to assess treatment modalities and overall survival by tumor origin. METHODS Patients diagnosed with non-metastatic periampullary cancer in 2012-2018 were identified from the Netherlands Cancer Registry. OS was studied with Kaplan-Meier analysis and multivariable Cox regression analyses, stratified by origin. RESULTS Among the 8758 patients included, 68% had PDAC, 13% DC, 12% AC, and 7% DA. Resection was performed in 35% of PDAC, 56% of DC, 70% of AC, and 59% of DA. Neoadjuvant and/or adjuvant therapy was administered in 22% of PDAC, 7% of DC, 7% of AC, and 12% of DA. Three-year OS was highest for AC (37%) and DA (34%), followed by DC (21%) and PDAC (11%). Adjuvant therapy was associated with improved OS among PDAC (HR = 0.62; 95% CI 0.55-0.69) and DC (HR = 0.69; 95% CI 0.48-0.98), but not AC (HR = 0.87; 95% CI 0.62-1.22) and DA (HR = 0.85; 95% CI 0.48-1.50). CONCLUSION This retrospective study identified considerable differences in treatment modalities and OS between the four periampullary cancer origins in daily clinical practice. An improved OS after adjuvant chemotherapy could not be demonstrated in patients with AC and DA.
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Affiliation(s)
- Evelien J M de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Innovation, Netherlands Comprehensive Cancer Organization (IKNL), 3501 DB, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - C H C Dejong
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Division of Oncology, Erasmus Medical Center, 3015 GD, Rotterdam, the Netherlands
| | - Lara R Heij
- Department of Surgery, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands; Surgery Aachen: Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, 52062, Germany; Institute of Pathology, RWTH Aachen University, Aachen, 52062, Germany
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, 5623 EJ, Eindhoven, the Netherlands; GROW - School for Oncology and Developmental Biology, Maastricht University, PO Box 616, 6200 MD, Maastricht, Netherlands
| | - Chantal Hoge
- Department of Internal Medicine, Division of Gastroenterology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, 1081 HV, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, 9713 GZ, Groningen, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Nijmegen Medical Center, 6500 HB, Nijmegen, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Liselot B J Valkenburg-van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, the Netherlands
| | - Sandra M E Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, 6202 AZ, Maastricht, the Netherlands.
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28
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Pijnappel EN, Dijksterhuis WPM, Sprangers MAG, Augustinus S, de Vos-Geelen J, de Hingh IHJT, Molenaar IQ, Busch OR, Besselink MG, Wilmink JW, van Laarhoven HWM. The fear of cancer recurrence and progression in patients with pancreatic cancer. Support Care Cancer 2022; 30:4879-4887. [PMID: 35169873 PMCID: PMC9046341 DOI: 10.1007/s00520-022-06887-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE It is plausible that patients with pancreatic cancer experience fear of tumor recurrence or progression (FOP). The aim of this study was to compare FOP in patients with pancreatic cancer treated with surgical resection, palliative systemic treatment, or best supportive care (BSC) and analyze the association between quality of life (QoL) and FOP and the effect of FOP on overall survival (OS). METHODS This study included patients diagnosed with pancreatic cancer between 2015 and 2018, who participated in the Dutch Pancreatic Cancer Project (PACAP). The association between QoL and WOPS was assessed with logistic regression analyses. OS was evaluated using Kaplan-Meier curves with the log-rank tests and multivariable Cox proportional hazard analyses adjusted for clinical covariates and QoL. RESULTS Of 315 included patients, 111 patients underwent surgical resection, 138 received palliative systemic treatment, and 66 received BSC. Patients who underwent surgical resection had significantly lower WOPS scores (i.e., less FOP) at initial diagnosis compared to patients who received palliative systemic treatment or BSC only (P < 0.001). Better QoL was independently associated with the probability of having a low FOP in the BSC (OR 0.95, 95% CI 0.91-0.98) but not in the surgical resection (OR 0.97, 95% CI 0.94-1.01) and palliative systemic treatment groups (OR 0.97, 95% CI 0.94-1.00). The baseline WOPS score was not independently associated with OS in any of the subgroups. CONCLUSION Given the distress that FOP evokes, FOP should be explicitly addressed by health care providers when guiding pancreatic cancer patients through their treatment trajectory, especially those receiving palliative treatment or BSC.
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Affiliation(s)
- Esther N Pijnappel
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Willemieke P M Dijksterhuis
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Netherlands Cancer Registry, Netherlands Comprehensive Cancer Organization (IKNL), PO Box 19079, Utrecht, 3501 DB, The Netherlands
| | - Mirjam A G Sprangers
- Department of Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht UMC+, P. Debyelaan 25, Maastricht, 6229 HX, The Netherlands
| | | | - Izaak Q Molenaar
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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29
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de Jong EJM, Janssen QP, Simons TFA, Besselink MG, Bonsing BA, Bouwense SAW, Geurts SME, Homs MYV, de Meijer VE, Tjan‐Heijnen VCG, van Laarhoven HWM, Valkenburg‐van Iersel LBJ, Wilmink JW, van der Geest LG, Koerkamp BG, de Vos‐Geelen J. Real-world evidence of adjuvant gemcitabine plus capecitabine vs gemcitabine monotherapy for pancreatic ductal adenocarcinoma. Int J Cancer 2022; 150:1654-1663. [PMID: 34935139 PMCID: PMC9303436 DOI: 10.1002/ijc.33916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/12/2021] [Accepted: 12/02/2021] [Indexed: 12/30/2022]
Abstract
The added value of capecitabine to adjuvant gemcitabine monotherapy (GEM) in pancreatic ductal adenocarcinoma (PDAC) was shown by the ESPAC-4 trial. Real-world data on the effectiveness of gemcitabine plus capecitabine (GEMCAP), in patients ineligible for mFOLFIRINOX, are lacking. Our study assessed whether adjuvant GEMCAP is superior to GEM in a nationwide cohort. Patients treated with adjuvant GEMCAP or GEM after resection of PDAC without preoperative treatment were identified from The Netherlands Cancer Registry (2015-2019). The primary outcome was overall survival (OS), measured from start of chemotherapy. The treatment effect of GEMCAP vs GEM was adjusted for sex, age, performance status, tumor size, lymph node involvement, resection margin and tumor differentiation in a multivariable Cox regression analysis. Secondary outcome was the percentage of patients who completed the planned six adjuvant treatment cycles. Overall, 778 patients were included, of whom 21.1% received GEMCAP and 78.9% received GEM. The median OS was 31.4 months (95% CI 26.8-40.7) for GEMCAP and 22.1 months (95% CI 20.6-25.0) for GEM (HR: 0.71, 95% CI 0.56-0.90; logrank P = .004). After adjustment for prognostic factors, survival remained superior for patients treated with GEMCAP (HR: 0.73, 95% CI 0.57-0.92, logrank P = .009). Survival with GEMCAP was superior to GEM in most subgroups of prognostic factors. Adjuvant chemotherapy was completed in 69.5% of the patients treated with GEMCAP and 62.7% with GEM (P = .11). In this nationwide cohort of patients with PDAC, adjuvant GEMCAP was associated with superior survival as compared to GEM monotherapy and number of cycles was similar.
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Affiliation(s)
- Evelien J. M. de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Tessa F. A. Simons
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMCUniversity of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Bert A. Bonsing
- Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | | | - Sandra M. E. Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Vincent E. de Meijer
- Department of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Vivianne C. G. Tjan‐Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, University of AmsterdamCancer Center AmsterdamAmsterdamThe Netherlands
| | - Liselot B. J. Valkenburg‐van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of AmsterdamCancer Center AmsterdamAmsterdamThe Netherlands
| | - Lydia G. van der Geest
- Department of ResearchNetherlands Comprehensive Cancer Organization (IKNL)UtrechtThe Netherlands
| | - Bas Groot Koerkamp
- Department of SurgeryErasmus MC Cancer InstituteRotterdamThe Netherlands
| | - Judith de Vos‐Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW ‐ School for Oncology and Developmental BiologyMaastricht University Medical Center+MaastrichtThe Netherlands
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30
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Mackay TM, Dijksterhuis WPM, Latenstein AEJ, van der Geest LG, Sprangers MAG, van Eijck CHJ, Homs MYV, Luelmo SAC, Molenaar IQ, van Santvoort H, Schreinemakers JMJ, Wilmink JW, Besselink MG, van Laarhoven HW, van Oijen MGH. The impact of cancer treatment on quality of life in patients with pancreatic and periampullary cancer: a propensity score matched analysis. HPB (Oxford) 2022; 24:443-451. [PMID: 34635432 DOI: 10.1016/j.hpb.2021.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/24/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact of pancreatic and periampullary cancer treatment on health-related quality of life (HRQoL) is unclear. METHODS This study merged data from the Netherlands Cancer Registry with EORTC QLQ-C30 and -PAN26 questionnaires at baseline and three-months follow-up of pancreatic and periampullary cancer patients (2015-2018). Propensity score matching (1:3) of group without to group with treatment was performed. Linear mixed model regression analyses were performed to investigate the association between cancer treatment and HRQoL at follow-up. RESULTS After matching, 247 of 629 available patients remained (68 (27.5%) no treatment, 179 (72.5%) treatment). Treatment consisted of resection (n = 68 (27.5%)), chemotherapy only (n = 111 (44.9%)), or both (n = 40 (16.2%)). At follow-up, cancer treatment was associated with better global health status (Beta-coefficient 4.8, 95% confidence-interval 0.0-9.5) and less constipation (Beta-coefficient -7.6, 95% confidence-interval -13.8-1.4) compared to no cancer treatment. Median overall survival was longer for the cancer treatment group compared to the no treatment group (15.4 vs. 6.2 months, p < 0.001). CONCLUSION Patients undergoing treatment for pancreatic and periampullary cancer reported slight improvement in global HRQoL and less constipation at three months-follow up compared to patients without cancer treatment, while overall survival was also improved.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Willemieke P M Dijksterhuis
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | | | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital, Utrecht, the Netherlands
| | - Hjalmar van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital, Utrecht, the Netherlands
| | | | - Johanna W Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Martijn G H van Oijen
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands.
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Pijnappel EN, Schuurman M, Wagner AD, de Vos-Geelen J, van der Geest LGM, de Groot JWB, Koerkamp BG, de Hingh IHJT, Homs MYV, Creemers GJ, Cirkel GA, van Santvoort HC, Busch OR, Besselink MG, van Eijck CH, Wilmink JW, van Laarhoven HWM. Sex, Gender and Age Differences in Treatment Allocation and Survival of Patients With Metastatic Pancreatic Cancer: A Nationwide Study. Front Oncol 2022; 12:839779. [PMID: 35402271 PMCID: PMC8987273 DOI: 10.3389/fonc.2022.839779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/24/2022] [Indexed: 12/17/2022] Open
Abstract
Background Biological sex, gender and age have an impact on the incidence and outcome in patients with metastatic pancreatic cancer. The aim of this study is to investigate whether biological sex, gender and age are associated with treatment allocation and overall survival (OS) of patients with metastatic pancreatic cancer in a nationwide cohort. Methods Patients with synchronous metastatic pancreatic cancer diagnosed between 2015 and 2019 were selected from the Netherlands Cancer Registry (NCR). The association between biological sex and the probability of receiving systemic treatment were examined with multivariable logistic regression analyses. Kaplan Meier analyses with log-rank test were used to describe OS. Results A total of 7470 patients with metastatic pancreatic cancer were included in this study. Fourty-eight percent of patients were women. Women received less often systemic treatment (26% vs. 28%, P=0.03), as compared to men. Multivariable logistic regression analyses with adjustment for confounders showed that women ≤55 years of age, received more often systemic treatment (OR 1.82, 95% CI 1.24-2.68) compared to men of the same age group. In contrast, women at >55 years of age had a comparable probability to receive systemic treatment compared to men of the same age groups. After adjustment for confounders, women had longer OS compared to men (HR 0.89, 95% CI 0.84-0.93). Conclusion This study found that women in general had a lower probability of receiving systemic treatment compared to men, but this can mainly be explained by age differences. Women had better OS compared to men after adjustment for confounders.
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Affiliation(s)
- Esther N. Pijnappel
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Melinda Schuurman
- Netherlands Cancer Registry, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Anna D. Wagner
- Department of Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW–School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, Netherlands
| | - Lydia G. M. van der Geest
- Netherlands Cancer Registry, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | | | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Medical Oncology, Meander Medical Center, Amersfoort, Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, Netherlands
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olivier R. Busch
- Department of surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Marc G. Besselink
- Department of surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | | | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
- *Correspondence: Hanneke W. M. van Laarhoven,
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van Dongen JC, van der Geest LGM, de Meijer VE, van Santvoort HC, de Vos-Geelen J, Besselink MG, Groot Koerkamp B, Wilmink JW, van Eijck CHJ. Age and prognosis in patients with pancreatic cancer: a population-based study. Acta Oncol 2022; 61:286-293. [PMID: 34935577 DOI: 10.1080/0284186x.2021.2016949] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The diagnosis of pancreatic ductal adenocarcinoma (PDAC) has an enormous impact on patients, and even more so if they are of younger age. It is unclear how their treatment and outcome compare to older patients. This study compares clinicopathological characteristics and overall survival (OS) of PDAC patients aged <60 years to older PDAC patients. METHOD This is a retrospective, population-based cohort study using Netherlands Cancer Registry data of patients diagnosed with PDAC (1 January 2015-31 December 2018). Kaplan-Meier curves and Cox proportional hazards models were used to assess OS. RESULTS Overall, 10,298 patients were included, of whom 1551 (15%) were <60 years. Patients <60 years were more often male, had better performance status, less comorbidities and less stage I disease, and more often received anticancer treatment (67 vs. 33%, p < 0.001) than older patients. Patients <60 years underwent resection of the tumour more often (22 vs. 14%p < 0.001), more often received chemotherapy, and had a better median OS (6.9 vs. 3.3 months, p < 0.001) compared to older patients. No differences in median OS were demonstrated between both age groups of patients who underwent resection (19.7 vs. 19.4 months, p = 0.123), received chemotherapy alone (7.8 vs. 8.5 months, p = 0.191), or received no anticancer treatment (1.8 vs. 1.9 months, p = 0.600). Patients <60 years with stage-IV disease receiving chemotherapy had a somewhat better OS (7.5 vs. 6.3 months, p = 0.026). CONCLUSION Patients with PDAC <60 years more often underwent resection despite less stage I disease and had superior OS. Stratified for treatment, however, survival was largely similar.
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Affiliation(s)
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Judith de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Groen JV, Michiels N, van Roessel S, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Venous wedge and segment resection during pancreatoduodenectomy for pancreatic cancer: impact on short- and long-term outcomes in a nationwide cohort analysis. Br J Surg 2021; 109:96-104. [PMID: 34791069 PMCID: PMC10364765 DOI: 10.1093/bjs/znab345] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 09/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Venous resection of the superior mesenteric or portal vein is increasingly performed in pancreatic cancer surgery, whereas results of studies on short- and long-term outcomes are contradictory. The aim of this study was to evaluate the impact of the type of venous resection in pancreatoduodenectomy for pancreatic cancer on postoperative morbidity and overall survival. METHODS This nationwide retrospective cohort study included all patients who underwent pancreatoduodenectomy for pancreatic cancer in 18 centres (2013-2017). RESULTS A total of 1311 patients were included, of whom 17 per cent underwent wedge resection and 10 per cent segmental resection. Patients with segmental resection had higher rates of major morbidity (39 versus 20 versus 23 per cent, respectively; P < 0.001) and portal or superior mesenteric vein thrombosis (18 versus 5 versus 1 per cent, respectively; P < 0.001) and worse overall survival (median 12 versus 16 versus 20 months, respectively; P < 0.001), compared to patients with wedge resection and those without venous resection. Multivariable analysis showed patients with segmental resection, but not those who had wedge resection, had higher rates of major morbidity (odds ratio = 1.93, 95 per cent c.i. 1.20 to 3.11) and worse overall survival (hazard ratio = 1.40, 95 per cent c.i. 1.10 to 1.78), compared to patients without venous resection. Among patients who received neoadjuvant therapy, there was no difference in overall survival among patients with segmental and wedge resection and those without venous resection (median 32 versus 25 versus 33 months, respectively; P = 0.470), although there was a difference in major morbidity rates (52 versus 19 versus 21 per cent, respectively; P = 0.012). CONCLUSION In pancreatic surgery, the short- and long-term outcomes are worse in patients with venous segmental resection, compared to patients with wedge resection and those without venous resection.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Stijn van Roessel
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Epidemiology, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht, the Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Centre, St Antonius Hospital Nieuwegein; Regional Academic Cancer Centre Utrecht, Utrecht, the Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - Babs M Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Strijker M, van der Sijde F, Suker M, Boermeester MA, Bonsing BA, Bruno MJ, Busch OR, Doukas M, van Eijck CH, Gerritsen A, Groot Koerkamp B, Haj Mohammad N, van Hilst J, de Hingh IH, van Hooft JE, Luyer MD, Quintus Molenaar I, Verheij J, Waasdorp C, Wilmink JW, Besselink MG, van Laarhoven HW, Bijlsma MF. Preoperative serum ADAM12 levels as a stromal marker for overall survival and benefit of adjuvant therapy in patients with resected pancreatic and periampullary cancer. HPB (Oxford) 2021; 23:1886-1896. [PMID: 34103247 DOI: 10.1016/j.hpb.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND We evaluated the stroma marker A Disintegrin And Metalloprotease 12 (ADAM12) as a preoperative prognostic and treatment-predictive marker for overall survival (OS) in pancreatic ductal adenocarcinoma (PDAC) and periampullary cancers. METHODS Materials were derived from the prospective nationwide Dutch Pancreas Biobank (2015-2017). We included patients who underwent resection because of PDAC/periampullary cancer or non-invasive IPMN (control group) and had a preoperative serum sample available. ADAM12 levels were dichotomized using a pre-defined cut-off (316 pg/mL). Univariable and multivariable Cox regression analyses (backward selection) were performed. RESULTS Median ADAM12 levels were 161 (IQR 79-352) pg/mL in 215 PDAC and periampullary adenocarcinomas. High ADAM12 levels (>316 pg/mL) predicted poor OS in the total group of pancreatic and periampullary adenocarcinomas (P = 0.04), but not after adjustment. In distal cholangiocarcinoma (n = 33), high ADAM12 levels predicted poor OS in univariable analysis (P = 0.02), but not in PDAC (P = 0.63). PDAC patients (n = 135) with high ADAM12 levels benefited from adjuvant treatment (median OS 27 vs 14 months, P = 0.02), whereas those with low levels did not (21 vs 21 months, P = 0.87). CONCLUSION High circulating ADAM12 levels, as a proxy for activated stroma, predict survival benefit from adjuvant chemotherapy in PDAC, requiring validation in future studies.
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Affiliation(s)
- Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Fleur van der Sijde
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Cynthia Waasdorp
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam, University of Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Maarten F Bijlsma
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Cancer Center Amsterdam, University of Amsterdam, the Netherlands.
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Groen JV, Smits FJ, Koole D, Besselink MG, Busch OR, den Dulk M, van Eijck CHJ, Groot Koerkamp B, van der Harst E, de Hingh IH, Karsten TM, de Meijer VE, Pranger BK, Molenaar IQ, Bonsing BA, van Santvoort HC, Mieog JSD. Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis. Br J Surg 2021; 108:1371-1379. [PMID: 34608941 PMCID: PMC10364904 DOI: 10.1093/bjs/znab273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy. METHODS This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines. RESULTS From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84). CONCLUSION Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- J V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - D Koole
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - T M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - B K Pranger
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits. Surgery 2021; 170:1799-1806. [PMID: 34373107 DOI: 10.1016/j.surg.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence on the optimal pancreatic anastomosis during pancreatoduodenectomy is inconclusive. Large multicenter and nationwide registries may provide additional insights. The study compared the practice and outcome of different pancreatic anastomoses during pancreatoduodenectomy, focusing on the rate of postoperative pancreatic fistula, in two large audits of pancreatic surgery. METHODS Posthoc analysis of patients after pancreatoduodenectomy in the Dutch Pancreatic Cancer Audit and the German DGAV StuDoQ|Pancreas registries (January 2014 to December 2017). Postoperative pancreatic fistula (International Study Group of Pancreatic Surgery B/C), postpancreatectomy hemorrhage (International Study Group of Pancreatic Surgery B/C) and Clavien-Dindo ≥3 complications rates were compared for the three most common anastomoses: duct-to-mucosa pancreatojejunostomy, non-duct-to-mucosa pancreatojejunostomy, and non-duct-to-mucosa pancreatogastrostomy. Multivariable adjustment for potential confounders was performed. RESULTS Overall, 6,149 patients were included. The most common anastomosis was duct-to-mucosa pancreatojejunostomy (duct-to-mucosa pancreatojejunostomy 59.8%, non-duct-to-mucosa pancreatojejunostomy 21.1%, non-duct-to-mucosa pancreatogastrostomy 12.4%). The overall postoperative pancreatic fistula rate was 14%: duct-to-mucosa pancreatojejunostomy 12.9%, non-duct-to-mucosa pancreatojejunostomy 14.4% (P = .162), non-duct-to-mucosa pancreatogastrostomy 18.3% (P < .001). The rate of postpancreatectomy hemorrhage was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 6.9%, non-duct-to-mucosa pancreatojejunostomy 10% (P < .001), non-duct-to-mucosa pancreatogastrostomy 17.9% (P < .001). The rate of Clavien-Dindo ≥3 complications was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 28%, non-duct-to-mucosa pancreatojejunostomy 32.7% (P = .002), non-duct-to-mucosa pancreatogastrostomy 43.1% (P < .001). In the multivariable analysis, the risk of postoperative pancreatic fistula did not differ significantly between the three anastomoses. The risk of hemorrhage (odds ratio 2.4, 95% confidence interval 1.6-3.5, P < .001) and Clavien-Dindo ≥3 (odds ratio 1.6, 95% confidence interval 1.2-2.1, P = .001) remained significantly higher only for non-duct-to-mucosa pancreatogastrostomy. CONCLUSION Data from two national audits showed no difference in the risk-adjusted postoperative pancreatic fistula rate among the three most used pancreatic anastomoses during pancreatoduodenectomy. Pancreatogastrostomy was inferior to pancreatojejunostomy regarding bleeding and overall major complications.
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Survival Benefit Associated With Resection of Locally Advanced Pancreatic Cancer Following Upfront FOLFIRINOX versus FOLFIRINOX Only: Multicenter Propensity Score-Matched Analysis. Ann Surg 2021; 274:729-735. [PMID: 34334641 DOI: 10.1097/sla.0000000000005120] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study compared median overall survival (OS) after resection of locally advanced pancreatic cancer (LAPC) following upfront FOLFIRINOX versus a propensity-score matched cohort of LAPC patients treated with FOLFIRINOX-only (i.e. without resection). BACKGROUND Since the introduction of FOLFIRINOX chemotherapy, increased resection rates in LAPC patients have been reported, with improved OS. Some studies have also reported promising OS with FOLFIRINOX-only treatment in LAPC. Multicenter studies assessing the survival benefit associated with resection of LAPC versus patients treated with FOLFIRINOX-only are lacking. METHODS Patients with non-progressive LAPC after 4 cycles of FOLFIRINOX treatment, both with and without resection, were included from a prospective multicenter cohort in 16 centers (April 2015-December 2019). Cox regression analysis identified predictors for OS. One-to-one propensity score matching (PSM) was used to obtain a matched cohort of patients with and without resection. These patients were compared for OS. RESULTS Overall, 293 patients with LAPC were included, of whom 89 underwent a resection. Resection was associated with improved OS (24 vs 15 months, p<0.01), as compared to patients without resection. Before PSM, resection, Charlson Comorbidity Index, and RECIST response were predictors for OS. After PSM, resection remained associated with improved OS (HR 0.344, 95% CI [0.222-0.534], p<0.01), with an OS of 24 vs 15 months, as compared to patients without resection. Resection of LAPC was associated with improved 3-year OS (31% vs 11%, p<0.01). CONCLUSION Resection of LAPC following FOLFIRINOX was associated with increased OS and 3-year survival, as compared to propensity-score matched patients treated with FOLFIRINOX-only.
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van den Boorn HG, Dijksterhuis WPM, van der Geest LGM, de Vos-Geelen J, Besselink MG, Wilmink JW, van Oijen MGH, van Laarhoven HWM. SOURCE-PANC: A Prediction Model for Patients With Metastatic Pancreatic Ductal Adenocarcinoma Based on Nationwide Population-Based Data. J Natl Compr Canc Netw 2021; 19:1045-1053. [PMID: 34293719 DOI: 10.6004/jnccn.2020.7669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A prediction model for overall survival (OS) in metastatic pancreatic ductal adenocarcinoma (PDAC) including patient and treatment characteristics is currently not available, but it could be valuable for supporting clinicians in patient communication about expectations and prognosis. We aimed to develop a prediction model for OS in metastatic PDAC, called SOURCE-PANC, based on nationwide population-based data. MATERIALS AND METHODS Data on patients diagnosed with synchronous metastatic PDAC in 2015 through 2018 were retrieved from the Netherlands Cancer Registry. A multivariate Cox regression model was created to predict OS for various treatment strategies. Available patient, tumor, and treatment characteristics were used to compose the model. Treatment strategies were categorized as systemic treatment (subdivided into FOLFIRINOX, gemcitabine/nab-paclitaxel, and gemcitabine monotherapy), biliary drainage, and best supportive care only. Validation was performed according to a temporal internal-external cross-validation scheme. The predictive quality was assessed with the C-index and calibration. RESULTS Data for 4,739 patients were included in the model. Sixteen predictors were included: age, sex, performance status, laboratory values (albumin, bilirubin, CA19-9, lactate dehydrogenase), clinical tumor and nodal stage, tumor sublocation, presence of distant lymph node metastases, liver or peritoneal metastases, number of metastatic sites, and treatment strategy. The model demonstrated a C-index of 0.72 in the internal-external cross-validation and showed good calibration, with the intercept and slope 95% confidence intervals including the ideal values of 0 and 1, respectively. CONCLUSIONS A population-based prediction model for OS was developed for patients with metastatic PDAC and showed good performance. The predictors that were included in the model comprised both baseline patient and tumor characteristics and type of treatment. SOURCE-PANC will be incorporated in an electronic decision support tool to support shared decision-making in clinical practice.
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Affiliation(s)
- Héctor G van den Boorn
- 1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Willemieke P M Dijksterhuis
- 1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam.,2Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht
| | - Lydia G M van der Geest
- 2Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht
| | - Judith de Vos-Geelen
- 4Division of Medical Oncology, Department of Internal Medicine, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marc G Besselink
- 3Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam; and
| | - Johanna W Wilmink
- 1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Martijn G H van Oijen
- 1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam.,2Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht
| | - Hanneke W M van Laarhoven
- 1Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam
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Brada LJH, Walma MS, Daamen LA, van Roessel S, van Dam RM, de Hingh IH, Liem MLS, de Meijer VE, Patijn GA, Festen S, Stommel MWJ, Bosscha K, Polée MB, Yung Nio C, Wessels FJ, de Vries JJJ, van Lienden KP, Bruijnen RC, Los M, Mohammad NH, Wilmink HW, Busch OR, Besselink MG, Quintus Molenaar I, van Santvoort HC. Predicting overall survival and resection in patients with locally advanced pancreatic cancer treated with FOLFIRINOX: Development and internal validation of two nomograms. J Surg Oncol 2021; 124:589-597. [PMID: 34115379 DOI: 10.1002/jso.26567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/07/2021] [Accepted: 05/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with locally advanced pancreatic cancer (LAPC) are increasingly treated with FOLFIRINOX, resulting in improved survival and resection of tumors that were initially unresectable. It remains unclear, however, which specific patients benefit from FOLFIRINOX. Two nomograms were developed predicting overall survival (OS) and resection at the start of FOLFIRINOX for LAPC. METHODS From our multicenter, prospective LAPC registry in 14 Dutch hospitals, LAPC patients starting first-line FOLFIRINOX (April 2015-December 2017) were included. Stepwise backward selection according to the Akaike Information Criterion was used to identify independent baseline predictors for OS and resection. Two prognostic nomograms were generated. RESULTS A total of 252 patients were included, with a median OS of 14 months. Thirty-two patients (13%) underwent resection, with a median OS of 23 months. Older age, female sex, Charlson Comorbidity Index ≤1, and CA 19.9 < 274 were independent factors predicting a better OS (c-index: 0.61). WHO ps >1, involvement of the superior mesenteric artery, celiac trunk, and superior mesenteric vein ≥ 270° were independent factors decreasing the probability of resection (c-index: 0.79). CONCLUSIONS Two nomograms were developed to predict OS and resection in patients with LAPC before starting treatment with FOLFIRINOX. These nomograms could be beneficial in the shared decision-making process and counseling of these patients.
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Affiliation(s)
- Lilly J H Brada
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke S Walma
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Mike L S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Marco B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - C Yung Nio
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank J Wessels
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan J J de Vries
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rutger C Bruijnen
- Department of Radiology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein and Meander Medical Center, Utrecht, The Netherlands
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Walma MS, Rombouts SJ, Brada LJH, Borel Rinkes IH, Bosscha K, Bruijnen RC, Busch OR, Creemers GJ, Daams F, van Dam RM, van Delden OM, Festen S, Ghorbani P, de Groot DJ, de Groot JWB, Haj Mohammad N, van Hillegersberg R, de Hingh IH, D'Hondt M, Kerver ED, van Leeuwen MS, Liem MS, van Lienden KP, Los M, de Meijer VE, Meijerink MR, Mekenkamp LJ, Nio CY, Oulad Abdennabi I, Pando E, Patijn GA, Polée MB, Pruijt JF, Roeyen G, Ropela JA, Stommel MWJ, de Vos-Geelen J, de Vries JJ, van der Waal EM, Wessels FJ, Wilmink JW, van Santvoort HC, Besselink MG, Molenaar IQ. Radiofrequency ablation and chemotherapy versus chemotherapy alone for locally advanced pancreatic cancer (PELICAN): study protocol for a randomized controlled trial. Trials 2021; 22:313. [PMID: 33926539 PMCID: PMC8082784 DOI: 10.1186/s13063-021-05248-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/03/2021] [Indexed: 12/18/2022] Open
Abstract
Background Approximately 80% of patients with locally advanced pancreatic cancer (LAPC) are treated with chemotherapy, of whom approximately 10% undergo a resection. Cohort studies investigating local tumor ablation with radiofrequency ablation (RFA) have reported a promising overall survival of 26–34 months when given in a multimodal setting. However, randomized controlled trials (RCTs) investigating the effect of RFA in combination with chemotherapy in patients with LAPC are lacking. Methods The “Pancreatic Locally Advanced Unresectable Cancer Ablation” (PELICAN) trial is an international multicenter superiority RCT, initiated by the Dutch Pancreatic Cancer Group (DPCG). All patients with LAPC according to DPCG criteria, who start with FOLFIRINOX or (nab-paclitaxel/)gemcitabine, are screened for eligibility. Restaging is performed after completion of four cycles of FOLFIRINOX or two cycles of (nab-paclitaxel/)gemcitabine (i.e., 2 months of treatment), and the results are assessed within a nationwide online expert panel. Eligible patients with RECIST stable disease or objective response, in whom resection is not feasible, are randomized to RFA followed by chemotherapy or chemotherapy alone. In total, 228 patients will be included in 16 centers in The Netherlands and four other European centers. The primary endpoint is overall survival. Secondary endpoints include progression-free survival, RECIST response, CA 19.9 and CEA response, toxicity, quality of life, pain, costs, and immunomodulatory effects of RFA. Discussion The PELICAN RCT aims to assess whether the combination of chemotherapy and RFA improves the overall survival when compared to chemotherapy alone, in patients with LAPC with no progression of disease following 2 months of systemic treatment. Trial registration Dutch Trial RegistryNL4997. Registered on December 29, 2015. ClinicalTrials.govNCT03690323. Retrospectively registered on October 1, 2018
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Affiliation(s)
- M S Walma
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - S J Rombouts
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - L J H Brada
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I H Borel Rinkes
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - K Bosscha
- Departments of Surgery and Medical Oncology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - R C Bruijnen
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - O R Busch
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - G J Creemers
- Departments of Surgery and Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - F Daams
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R M van Dam
- Departments of Surgery and Medical Oncology GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - O M van Delden
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Festen
- Departments of Surgery and Medical Oncology, OLVG, Amsterdam, The Netherlands
| | - P Ghorbani
- Pancreatic Surgery Unit, Division of Surgery, CLINTEC, Karolinska Institute at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - D J de Groot
- Departments of Surgery and Medical Oncology, UMC Groningen, Groningen, The Netherlands
| | - J W B de Groot
- Departments of Surgery and Medical Oncology, Isala, Zwolle, The Netherlands
| | - N Haj Mohammad
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - R van Hillegersberg
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - I H de Hingh
- Departments of Surgery and Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - M D'Hondt
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - E D Kerver
- Departments of Surgery and Medical Oncology, OLVG, Amsterdam, The Netherlands
| | - M S van Leeuwen
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M S Liem
- Departments of Surgery and Medical Oncology, Medical Spectrum Twente, Enschede, The Netherlands
| | - K P van Lienden
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Los
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - V E de Meijer
- Departments of Surgery and Medical Oncology, UMC Groningen, Groningen, The Netherlands
| | - M R Meijerink
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - L J Mekenkamp
- Departments of Surgery and Medical Oncology, Medical Spectrum Twente, Enschede, The Netherlands
| | - C Y Nio
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Oulad Abdennabi
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Pando
- HBP Surgery and Transplant Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - G A Patijn
- Departments of Surgery and Medical Oncology, Isala, Zwolle, The Netherlands
| | - M B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - J F Pruijt
- Departments of Surgery and Medical Oncology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - G Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - J A Ropela
- Department of Medical Oncology, St Jansdal Hospital, Harderwijk, The Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J de Vos-Geelen
- Departments of Surgery and Medical Oncology GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - J J de Vries
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E M van der Waal
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - F J Wessels
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - J W Wilmink
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H C van Santvoort
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M G Besselink
- Departments of Surgery, Radiology and Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Q Molenaar
- Departments of Surgery, Radiology and Medical Oncology, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Latenstein AEJ, Mackay TM, van der Geest LGM, van Eijck CHJ, de Meijer VE, Stommel MWJ, Vissers PAJ, Besselink MG, de Hingh IHJT. Effect of centralization and regionalization of pancreatic surgery on resection rates and survival. Br J Surg 2021; 108:826-833. [PMID: 33738473 DOI: 10.1093/bjs/znaa146] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/20/2020] [Accepted: 11/25/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Centralization of pancreatic surgery in the Netherlands has been ongoing since 2011. The aim of this study was to assess how centralization has affected the likelihood of resection and survival of patients with non-metastatic pancreatic head and periampullary cancer, diagnosed in hospitals with and without pancreatic surgery services. METHODS An observational cohort study was performed on nationwide data from the Netherlands Cancer Registry (2009-2017), including patients diagnosed with non-metastatic pancreatic head or periampullary cancer. The period of diagnosis was divided into three time intervals: 2009-2011, 2012-2014 and 2015-2017. Hospital of diagnosis was classified as a pancreatic or non-pancreatic surgery centre. Analyses were performed using multivariable logistic and Cox regression models. RESULTS In total, 10 079 patients were included, of whom 3114 (30.9 per cent) were diagnosed in pancreatic surgery centres. Between 2009-2011 and 2015-2017, the number of patients undergoing resection increased from 1267 of 3169 (40.0 per cent) to 1705 of 3566 (47.8 per cent) (P for trend < 0.001). In multivariable analysis, in 2015-2017, unlike the previous periods, patients diagnosed in pancreatic and non-pancreatic surgery centres had a similar likelihood of resection (odds ratio 1.08, 95 per cent c.i. 0.90 to 1.28; P = 0.422). In this period, however, overall survival was higher in patients diagnosed in pancreatic surgery than in those diagnosed in non-pancreatic surgery centres (hazard ratio 0.92, 95 per cent c.i. 0.85 to 0.99; P = 0.047). CONCLUSION After centralization of pancreatic surgery, the resection rate for patients with pancreatic head and periampullary cancer diagnosed in non-pancreatic surgery centres increased and became similar to that in pancreatic surgery centres. Overall survival remained higher in patients diagnosed in pancreatic surgery centres.
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Affiliation(s)
- A E J Latenstein
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - T M Mackay
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - L G M van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - V E de Meijer
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - P A J Vissers
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - M G Besselink
- Department of surgery, Cancer Centre Amsterdam, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
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van Roessel S, Soer EC, Daamen LA, van Dalen D, Fariña Sarasqueta A, Stommel MWJ, Molenaar IQ, van Santvoort HC, van de Vlasakker VCJ, de Hingh IHJT, Groen JV, Mieog JSD, van Dam JL, van Eijck CHJ, van Tienhoven G, Klümpen HJ, Wilmink JW, Busch OR, Brosens LAA, Groot Koerkamp B, Verheij J, Besselink MG. Preoperative misdiagnosis of pancreatic and periampullary cancer in patients undergoing pancreatoduodenectomy: A multicentre retrospective cohort study. Eur J Surg Oncol 2021; 47:2525-2532. [PMID: 33745791 DOI: 10.1016/j.ejso.2021.03.228] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Whereas neoadjuvant chemo(radio)therapy is increasingly used in pancreatic cancer, it is currently not recommended for other periampullary (non-pancreatic) cancers. This has important implications for the relevance of the preoperative diagnosis for pancreatoduodenectomy. This retrospective multicentre cohort study aimed to determine the frequency of clinically relevant misdiagnoses in patients undergoing pancreatoduodenectomy for pancreatic or other periampullary cancer. METHODS Data from all consecutive patients who underwent a pancreatoduodenectomy between 2014 and 2018 were obtained from the prospective Dutch Pancreatic Cancer Audit. The preoperative diagnosis as concluded by the multidisciplinary team (MDT) meeting was compared with the final postoperative diagnosis at pathology to determine the rate of clinically relevant misdiagnosis (defined as missed pancreatic cancer or incorrect diagnosis of pancreatic cancer). RESULTS In total, 1244 patients underwent pancreatoduodenectomy of whom 203 (16%) had a clinically relevant misdiagnosis preoperatively. Of all patients with a final diagnosis of pancreatic cancer, 13% (87/679) were preoperatively misdiagnosed as distal cholangiocarcinoma (n = 41, 6.0%), ampullary cancer (n = 27, 4.0%) duodenal cancer (n = 16, 2.4%), or other (n = 3, 0.4%). Of all patients with a final diagnosis of periampullary (non-pancreatic) cancer, 21% (116/565) were preoperatively incorrectly diagnosed as pancreatic cancer. Accuracy of preoperative diagnosis was 84% for pancreatic cancer, 71% for distal cholangiocarcinoma, 73% for ampullary cancer and 73% for duodenal cancer. A prediction model for the preoperative likelihood of pancreatic cancer (versus other periampullary cancer) prior to pancreatoduodenectomy demonstrated an AUC of 0.88. DISCUSSION This retrospective multicentre cohort study showed that 16% of patients have a clinically relevant misdiagnosis that could result in either missing the opportunity of neoadjuvant chemotherapy in patients with pancreatic cancer or inappropriate administration of neoadjuvant chemotherapy in patients with non-pancreatic periampullary cancer. A preoperative prediction model is available on www.pancreascalculator.com.
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Affiliation(s)
- Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Eline C Soer
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Demi van Dalen
- Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
| | - Arantza Fariña Sarasqueta
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | | | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Pathology, Radboud UMC, Nijmegen, the Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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de Jong EJM, Geurts SME, van der Geest LG, Besselink MG, Bouwense SAW, Buijsen J, Dejong CHC, Heij LR, Koerkamp BG, de Hingh IHJT, Hoge C, Kazemier G, van Laarhoven HWM, de Meijer VE, Mohammad NH, Strijker M, Timmermans KCAA, Valkenburg-van Iersel LBJ, Wilmink JW, Tjan-Heijnen VCG, de Vos-Geelen J. A population-based study on incidence, treatment, and survival in ampullary cancer in the Netherlands. Eur J Surg Oncol 2021; 47:1742-1749. [PMID: 33712346 DOI: 10.1016/j.ejso.2021.02.028] [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: 12/23/2020] [Revised: 02/11/2021] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Ampullary cancer is rare and as a result epidemiological data are scarce. The aim of this population-based study was to determine the trends in incidence, treatment and overall survival (OS) in patients with ampullary adenocarcinoma in the Netherlands between 1989 and 2016. METHODS Patients diagnosed with ampullary adenocarcinoma were identified from the Netherlands Cancer Registry. Incidence rates were age-adjusted to the European standard population. Trends in treatment and OS were studied over (7 years) period of diagnosis, using Kaplan-Meier and Cox regression analyses for OS and stratified by the presence of metastatic disease. RESULTS In total, 3840 patients with ampullary adenocarcinoma were diagnosed of whom, 55.0% were male and 87.1% had non-metastatic disease. The incidence increased from 0.59 per 100,000 in 1989-1995 to 0.68 per 100,000in 2010-2016. In non-metastatic disease, the resection rate increased from 49.5% in 1989-1995 to 63.9% in 2010-2016 (p < 0.001). The rate of adjuvant therapy increased from 3.1% to 7.9%. In non-metastatic disease, five-year OS (95% CI) increased from 19.8% (16.9-22.8) in 1989-1995 to 29.1% (26.0-31.2) in 2010-2016 (logrank p < 0.001). In patients with metastatic disease, median OS did not significantly improve (from 4.4 months (3.6-5.0) to 5.9 months (4.7-7.1); logrank p = 0.06). Cancer treatment was an independent prognostic factor for OS among all patients. CONCLUSION Both incidence and OS of ampullary cancer increased from 1989 to 2016 which is most likely related to the observed increased resection rates and use of adjuvant therapy.
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Affiliation(s)
- Evelien J M de Jong
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Sandra M E Geurts
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Lydia G van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, 5612 HZ, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Lara R Heij
- Department of Surgery, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands; Surgery Aachen: Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, 52062, Germany; Institute of Pathology, RWTH Aachen University, Aachen, 52062, Germany
| | - Bas Groot Koerkamp
- Department of Surgery, Division of Oncology, Erasmus Medical Center, Rotterdam, 3015 GD, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, 5623 EJ, the Netherlands
| | - Chantal Hoge
- Department of Internal Medicine, Division of Gastroenterology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Amsterdam, Amsterdam UMC, VU Amsterdam, Amsterdam, 1081 HV, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, 9713 GZ, the Netherlands
| | - Nadia Haj Mohammad
- Department Medical Oncology Medicine, Division of Radiology and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, 3584 CX, the Netherlands
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, the Netherlands
| | - Karin C A A Timmermans
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, 5612 HZ, the Netherlands
| | - Liselot B J Valkenburg-van Iersel
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, the Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6202 AZ, the Netherlands.
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Mackay TM, Smits FJ, Latenstein AEJ, Bogte A, Bonsing BA, Bos H, Bosscha K, Brosens LAA, Hol L, Busch ORC, Creemers GJ, Curvers WL, den Dulk M, van Dieren S, van Driel LMJW, Festen S, van Geenen EJM, van der Geest LG, de Groot DJA, de Groot JWB, Haj Mohammad N, Haberkorn BCM, Haver JT, van der Harst E, Hemmink GJM, de Hingh IH, Hoge C, Homs MYV, van Huijgevoort NC, Jacobs MAJM, Kerver ED, Liem MSL, Los M, Lubbinge H, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, van Oijen MGH, Patijn GA, Quispel R, van Rijssen LB, Römkens TEH, van Santvoort HC, Schreinemakers JMJ, Schut H, Seerden T, Stommel MWJ, Ten Tije AJ, Venneman NG, Verdonk RC, Verheij J, van Vilsteren FGI, de Vos-Geelen J, Vulink A, Wientjes C, Wit F, Wessels FJ, Zonderhuis B, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Impact of nationwide enhanced implementation of best practices in pancreatic cancer care (PACAP-1): a multicenter stepped-wedge cluster randomized controlled trial. Trials 2020; 21:334. [PMID: 32299515 PMCID: PMC7161112 DOI: 10.1186/s13063-020-4180-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/18/2020] [Indexed: 01/05/2023] Open
Abstract
Background Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life. Methods/design PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide. Discussion The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life. Trial registration ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.
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Affiliation(s)
- T M Mackay
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - F J Smits
- Department of surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A E J Latenstein
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - A Bogte
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B A Bonsing
- Department of surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - H Bos
- Department of medical oncology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - K Bosscha
- Department of surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - L A A Brosens
- Department of pathology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of pathology, Radboud University, Nijmegen, the Netherlands
| | - L Hol
- Department of gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - O R C Busch
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - G J Creemers
- Department of medical oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - W L Curvers
- Department of gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | - M den Dulk
- Department of surgery, Maastricht UMC+, Maastricht, the Netherlands
| | - S van Dieren
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - L M J W van Driel
- Department of gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Festen
- Department of surgery, OLVG, Amsterdam, the Netherlands
| | - E J M van Geenen
- Department of gastroenterology, Radboud UMC, Nijmegen, the Netherlands
| | - L G van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - D J A de Groot
- Department of medical oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - J W B de Groot
- Department of medical oncology, Oncology Center Isala, Zwolle, the Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B C M Haberkorn
- Department of medical oncology, Maasstad Hospital, Rotterdam, the Netherlands
| | - J T Haver
- Department of nutrition and dietetics, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - E van der Harst
- Department of surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - G J M Hemmink
- Department of gastroenterology, Oncology Center Isala, Zwolle, the Netherlands
| | - I H de Hingh
- Department of surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Hoge
- Department of gastroenterology, Maastricht UMC+, Maastricht, the Netherlands
| | - M Y V Homs
- Department of medical oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N C van Huijgevoort
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M A J M Jacobs
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - E D Kerver
- Department of medical oncology, OLVG, Amsterdam, the Netherlands
| | - M S L Liem
- Department of surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - H Lubbinge
- Department of gastroenterology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - S A C Luelmo
- Department of medical oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - V E de Meijer
- Department of surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - L Mekenkamp
- Department of medical oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I Q Molenaar
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - M G H van Oijen
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G A Patijn
- Department of surgery, Oncology Center Isala, Zwolle, the Netherlands
| | - R Quispel
- Department of gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - L B van Rijssen
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - T E H Römkens
- Department of gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - H C van Santvoort
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - H Schut
- Department of medical oncology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - T Seerden
- Department of gastroenterology, Amphia Hospital, Breda, the Netherlands
| | - M W J Stommel
- Department of surgery, Radboud UMC, Nijmegen, the Netherlands
| | - A J Ten Tije
- Department of medical oncology, Amphia Hospital, Breda, the Netherlands
| | - N G Venneman
- Department of gastroenterology and hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - R C Verdonk
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Verheij
- Department of pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - F G I van Vilsteren
- Department of gastroenterology, University Medical Center Groningen, Groningen, the Netherlands
| | - J de Vos-Geelen
- Department of medical oncology, Maastricht UMC+, Maastricht, the Netherlands
| | - A Vulink
- Department of medical oncology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - C Wientjes
- Department of gastroenterology, OLVG, Amsterdam, the Netherlands
| | - F Wit
- Department of surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - F J Wessels
- Department of radiology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B Zonderhuis
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J E van Hooft
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C H J van Eijck
- Department of surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J W Wilmink
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H W M van Laarhoven
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands.
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