Standardization of surgical and pathologic variables is needed in multicenter trials of adjuvant therapy for pancreatic cancer: results from the ACOSOG Z5031 trial

Robotic Approach to Oncologic Pancreatoduodenectomy in a Case with an Aberrant Hepatic Artery Originating from the Superior Mesenteric Artery

BACKGROUND

Robotic pancreatoduodenectomy (RPD) has been increasingly performed, but maintaining oncological operative standards and safety remains challenging.1,2 An aberrant hepatic artery originating from the superior mesenteric artery (SMA), most commonly seen as a replaced right hepatic artery (rRHA), is present in approximately 16% of patients with pancreatoduodenal malignancies.3 The presence of the rRHA is a known risk factor for technically challenging RPD, and injury to this artery increases the risk of postoperative complications.4-6 Therefore, thorough preoperative review of CT images is essential. We demonstrate our approach to RPD with particular attention to oncologic proximal SMA dissection in a patient with an rRHA.

METHODS

A 77-year-old White woman with cT3N1M0 distal bile duct cancer and an rRHA originating from the SMA underwent RPD. Preoperative CT images showed lymphadenopathy in the posterior hepatic artery station and the presence of the rRHA, necessitating careful intraoperative dissection. The procedure began with identifying and encircling the distal portion of the rRHA. Following pancreatic division, the superior mesenteric vein was retracted to expose the SMA. The rRHA was identified, and a precise periadventitial dissection of the SMA was performed, completing en bloc resection.

RESULTS

The patient was discharged 8 days after surgery. Pathology revealed a 3.7-cm poorly differentiated adenocarcinoma (pT3N2) with 5 of 34 lymph nodes positive. All margins were negative.

CONCLUSIONS

Patients undergoing RPD often have an aberrant hepatic artery from the SMA. Preserving this artery while performing adequate en-bloc lymph node dissection is important for optimal outcomes.

ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer

Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well-selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.

Neoadjuvant therapy for pancreatic cancer

Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.

Minimally Invasive Pancreatectomy: Robotic and Laparoscopic Developments

Minimally invasive pancreatectomy is increasingly used. Although offering potential advantages over open approaches, minimally invasive pancreatectomy has many challenges to maintain high-quality of oncologic resection. Multiple patient and surgical factors should be considered in planning laparoscopic or robotic resection, including the learning curve required to produce proficiency. For pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections, a safe, margin-negative resection remains the goal. National and societal guidelines for the adoption of minimally invasive pancreatectomy are ongoing and will continue to be important as these techniques are further adopted.

Quality of superior mesenteric and hepatic artery dissection in robotic pancreatoduodenectomy for pancreatic cancer

This video manuscript by Ikoma and colleagues demonstrates their approach to the superior mesenteric artery and hepatic artery periadventitial dissection. The quality of superior mesenteric artery and hepatic artery dissections should be maintained in robotic pancreatoduodenectomy when performed for pancreatic cancer, to provide the best possible oncological outcomes.

Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science"

Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long-term survival outcomes, and various challenges in obtaining high-level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long-term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high-level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico-enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called "art" when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered "surgical artists," "surgical scientists," and "surgical practitioners." We look forward to more "surgical artists" educating future "surgical artists and scientists" to create a richer "spirit of innovation," leading to a more beautiful integration of art and science in the field of pancreatic surgery.

Pancreas cancer trials for early stage disease: Surgeons leading therapeutic cooperative group trials

Surgeon-led clinical trials have defined the standard of care for locoregional pancreatic cancer to date. The infrastructure and collaborative nature of cooperative oncology groups offer many advantages, such as providing an ideal mechanism through which multidisciplinary pancreatic cancer trials are performed. As key members of the treatment team, surgeons bring experience and expertise to the design of surgical and multidisciplinary trials and are uniquely poised to be leaders of future pancreatic cancer trials.

Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying

BACKGROUND

Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period.

METHODS

A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets.

RESULTS

Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042).

CONCLUSION

Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.

[Standardized diagnosis of pancreatic head carcinoma]

Most pancreatic ductal adenocarcinomas are localized in the pancreatic head. Due to the complex anatomic relationships with the surrounding organs and vascular structures in the retroperitoneal space and to the presence of numerous transection margins and dissection planes, pancreatic head resections belong to the most complex specimens concerning grossing and sampling for histopathologic analysis.Here we discuss current guidelines for standardized grossing and reporting of pancreatic cancer, with special reference to the assessment of the resection margin status. The importance of standardized reporting for the sake of completeness, comprehensibility, comparability, and quality control as well as for the integration of pathology reports in interdisciplinary digital workflows and artificial intelligence applications will be emphasized.

History of preoperative therapy for pancreatic cancer and the MD Anderson experience

Systemic chemotherapy improves the survival of patients who undergo pancreatectomy, but whether chemotherapy should be delivered before or after surgery remains debated. At The University of Texas MD Anderson Cancer Center, localized pancreatic ductal adenocarcinoma (PDAC) has been preferentially treated with preoperative therapy-a practice supported by a robust history of institutional and national trials. In the following review, we discuss the historical use of perioperative therapy, our experience with it at MD Anderson Cancer Center and internationally, and the future of treatment and trials for PDAC.

Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma

Despite tremendous gains in the molecular understanding of exocrine pancreatic cancer, the prognosis for this disease remains very poor, largely because of delayed disease detection and limited effectiveness of systemic therapies. Both incidence rates and mortality rates for pancreatic cancer have increased during the past decade, in contrast to most other solid tumor types. Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease. Finally, the substantial morbidity associated with pancreatic cancer, including wasting, fatigue, and pain, remains an under-addressed component of this disease, which powerfully affects quality of life and limits tolerance to aggressive therapies. In this article, the authors review the current multidisciplinary standards of care in pancreatic cancer with a focus on emerging concepts in pancreatic cancer detection, precision therapy, and survivorship.

Significance of Cancer Cells at the Vein Edge in Patients with Pancreatic Adenocarcinoma Following Pancreatectomy with Vein Resection

BACKGROUND

Resection of the superior mesenteric and/or portal vein (SMV-PV) is increasingly performed with pancreatectomy for adenocarcinoma. We sought to analyze the impact of cancer at the transected edge(s) of the vein wall.

METHODS

Patients who underwent pancreatectomy with vein resection between 2003 and 2015 at a single center were evaluated. R1 resection was defined per guidelines from the American Joint Commission on Cancer and the College of American Pathologists. Specimens were also evaluated for the presence (V+) or absence (V-) of cancer cells at the transected edge(s) and depth of vein invasion.

RESULTS

Among 127 evaluated patients, 114 (90%) received preoperative therapy. R-status was categorized as margin-negative (R0)/V- (n = 72, 57%), R0/V+ (n = 19, 15%), margin-positive (R1)/V- (n = 24, 19%), and R1/V+ (n = 12, 9%). Patients with V- specimens had similar median durations of recurrence-free survival (RFS) (12 vs 9 months) and overall survival (OS) (30 vs 28 months) as did patients with V+ specimens (P > 0.05). In contrast, cancer invasion into the lumen was associated with RFS and OS (P < 0.05). Among patients who underwent R0 resection, V-status had no association with OS, RFS, or local control (P > 0.05).

CONCLUSION

Cancer invasion into the superior mesenteric and/or portal vein was adversely associated with survival, but cancer at the vein edge(s) was not. Transection of the SMV-PV through macroscopically normal vein may be performed to minimize resected vein length without fear of negatively affecting oncologic outcomes.

Differentiation therapy and the mechanisms that terminate cancer cell proliferation without harming normal cells

Chemotherapeutic drugs have a common intent to activate apoptosis in tumor cells. However, master regulators of apoptosis (e.g., p53, p16/CDKN2A) are frequently genetically inactivated in cancers, resulting in multidrug resistance. An alternative, p53-independent method for terminating malignant proliferation is to engage terminal-differentiation. Normally, the exponential proliferation of lineage-committed progenitors, coordinated by the master transcription factor (TF) MYC, is self-limited by forward-differentiation to terminal lineage-fates. In cancers, however, this exponential proliferation is disengaged from terminal-differentiation. The mechanisms underlying this decoupling are mostly unknown. We performed a systematic review of published literature (January 2007-June 2018) to identify gene pathways linked to differentiation-failure in three treatment-recalcitrant cancers: hepatocellular carcinoma (HCC), ovarian cancer (OVC), and pancreatic ductal adenocarcinoma (PDAC). We analyzed key gene alterations in various apoptosis, proliferation and differentiation pathways to determine whether it is possible to predict treatment outcomes and suggest novel therapies. Poorly differentiated tumors were linked to poorer survival across histologies. Our analyses suggested loss-of-function events to master TF drivers of lineage-fates and their cofactors as being linked to differentiation-failure: genomic data in TCGA and ICGC databases demonstrated frequent haploinsufficiency of lineage master TFs (e.g., GATA4/6) in poorly differentiated tumors; the coactivators that these TFs use to activate genes (e.g. ARID1A, PBRM1) were also frequently inactivated by genetic mutation and/or deletion. By contrast, corepressor components (e.g., DNMT1, EED, UHRF1, and BAZ1A/B), that oppose coactivators to repress or turn off genes, were frequently amplified instead, and the level of amplification was highest in poorly differentiated lesions. This selection by neoplastic evolution towards unbalanced activity of transcriptional corepressors suggests these enzymes as candidate targets for inhibition aiming to re-engage forward-differentiation. This notion is supported by both pre-clinical and clinical trial literature.

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

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

Surgery for pancreatic cancer: critical radiologic findings for clinical decision making

Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States, with an estimated 53,670 new cases diagnosed and an estimated 43,090 deaths in 2017. This high mortality rate is in part due to the small percentage of patients diagnosed with local disease, as well as the biologically aggressive nature of the disease. While only 10-20% of patients will present with surgically resectable disease, this is the only possible curative therapy. Five-year survival of resected pancreatic cancer ranges from 12 to 27%. The National Comprehensive Cancer Network (NCCN) guidelines recommend specific guidelines for imaging modalities used in the diagnosis and staging of pancreatic adenocarcinoma. Indeed, high-quality imaging is not only necessary to accurately stage the disease, but is critical for the determination of key clinical decision branch points such as the determination of surgical resectability. Identification of the lesion within the pancreas, the degree of extra-pancreatic extension, and potential involvement of surrounding vascular structures with the tumor are all findings necessary to classify patients as having resectable, borderline resectable, or with unresectable primary tumors. This article reviews imaging modalities used to evaluate the pancreatic cancer patient from the surgeon's perspective, with particular emphasis on determination of resectability and preoperative planning, as well as imaging in the postoperative period.

Neoadjuvant therapy for resectable pancreatic cancer

The use of neoadjuvant therapies has played a major role for borderline resectable and locally advanced pancreatic cancers (PCs). For this group of patients, preoperative chemotherapy or chemoradiation has increased the likelihood of surgery with negative resection margins and overall survival. On the other hand, for patients with resectable PC, the main rationale for neoadjuvant therapy is that the overall survival with current strategies is unsatisfactory. There is a consensus that we need new treatments to improve the overall survival and quality of life of patients with PC. However, without strong scientific evidence supporting the theoretical advantages of neoadjuvant therapies, these potential benefits might turn out not to be worth the risk of tumors progression while waiting for surgery. The focus of this paper is to provide the readers an overview of the most recent evidence on this subject.

Redefining the Positive Margin in Pancreatic Cancer: Impact on Patterns of Failure, Long-Term Survival and Adjuvant Therapy

PURPOSE

There is debate regarding the definition and clinical significance of margin clearance in pancreatic ductal adenocarcinoma (PDA). A comprehensive archival analysis of surgical resection margins was performed to determine the effect on locoregional recurrence and survival, and the impact of adjuvant therapy in PDA.

METHODS

We identified 105 patients with resected PDA. Pancreatic, anterior, bile duct, and posterior surgical resection margins (PM; posterior surface, uncinate and vascular groove) were identified. Three pathologists reviewed all archival surgical specimens and recategorized each margin as tumor at ink/transected, <0.5, 0.5-1, >1-2, or >2 mm from the inked surface. The impact of these and other clinical variables was assessed on local control, disease-free survival (DFS), and overall survival (OS).

RESULTS

Among all margins, PM clearance up to 2 mm was prognostic of DFS (p = 0.01) and OS (p = 0.01). Dichotomizing the PM at 2 mm revealed it to be an independent predictor of local recurrence-free survival [hazard ratio HR] 0.20, 95% confidence interval [CI] 0.048-0.881, p = 0.033), DFS (HR 0.46, 95% CI 0.22-0.96, p = 0.03), and OS (HR 0.31, 95% CI 0.14-0.74, p = 0.008). A margin status of >2 mm was also prognostic of OS in patients who received adjuvant chemotherapy (HR 0.31, 95% CI 0.11-0.89, p = 0.03), however this difference was mitigated in patients receiving adjuvant chemoradiotherapy (HR 0.40, 95% CI 0.10-1.58, p = 0.19).

CONCLUSION

These data highlight the clinical significance of the PM and the lack of significance of other resection margins. Clearance in excess of 2 mm should be considered to improve long-term clinical outcomes. The use of adjuvant radiotherapy should be strongly considered in patients with PMs <2 mm.

Microscopic lymphovascular invasion is an independent predictor of survival in resected pancreatic ductal adenocarcinoma

Background and Objectives Despite routine inclusion of lymphovascular invasion (LVI) status in pathologic reports of resected pancreatic ductal adenocarcinomas (PDA), the clinical implications of LVI have not been well characterized. Methods This study is a retrospective review of 2640 patients who underwent a pancreatectomy for PDA at Thomas Jefferson University Hospital, Massachusetts General Hospital, or Johns Hopkins Hospital (2003-2014). Clinical and pathologic records were extracted from institutional databases. Results The median post-resection survival for the total cohort was 19.2 months with a 5-year survival rate of 15.2%. In a multivariate Cox proportional hazards model including conventional pathologic features, LVI was an independent predictor of survival (HR = 1.14, P = 0.017). In a stratified Kaplan-Meier survival analysis, patients with N0, LVI- PDA had a significantly improved overall survival compared to those with N0, LVI+ PDA (median 31 vs 24 mo, P = 0.020). Similarly, patients with N1, LVI- PDA had superior survival to patients with N1, LVI+ disease (18.6 vs 16.5 mo, P = 0.001). Conclusions As the first large scale study focused on the clinical impact of LVI status in PDA, these data indicate that this routinely reported pathologic feature is a bona fide and independent adverse prognostic factor.

Definition and Management of Borderline Resectable Pancreatic Cancer

Patients with localized pancreatic ductal adenocarcinoma seek potentially curative treatment, but this group represents a spectrum of disease. Patients with borderline resectable primary tumors are a unique subset whose successful therapy requires a care team with expertise in medical care, imaging, surgery, medical oncology, and radiation oncology. This team must identify patients with borderline tumors then carefully prescribe and execute a combined treatment strategy with the highest possibility of cure. This article addresses the issues of clinical evaluation, imaging techniques, and criteria, as well as multidisciplinary treatment of patients with borderline resectable pancreatic ductal adenocarcinoma.

Intraoperative Frozen Section Analysis of the Pancreas: A Case Report and Review of the Literature

Background: Intraoperative frozen section analysis is frequently used to obtain a histological diagnosis at the time of resection and to assess resection margins. Although many surgeons perceive a clinical benefit, particularly with respect to the transected resection margins, the limitations and pitfalls of frozen section analysis have not been well documented.

Case: Here, we report a case of serous cystadenoma with background pancreatitis masquerading on frozen section as an invasive pancreatic ductal adenocarcinoma. This interpretation was a surprise in light of preoperative imaging that was highly suggestive of a benign cystic tumor, but nevertheless prompted intraoperative consideration of a more radical operation to ensure a complete resection was achieved.

Conclusions: Frozen section analysis is an imperfect test, and misdiagnoses can potentially impact patient outcomes adversely. Intraoperative decisions must carefully integrate the preliminary pathological interpretation with the overall clinical context. Further studies are warranted to more fully characterize the accuracy, utility, and cost-effectiveness of intraoperative frozen section analysis for pancreatic surgery.

Frozen section analysis of the pancreatic margin during pancreaticoduodenectomy for cancer: Does extending the resection to obtain a secondary R0 provide a survival benefit? Results of a systematic review

BACKGROUND

During pancreaticoduodenectomy, frozen section pancreatic margin analysis permits to extend the resection in case of a positive margin, to achieve R0 margin. We aim to assess if patients having an R0 margin following the extension of the pancreatectomy after a positive frozen section (secondary R0) have different survival compared to those with R1 resection or primary R0 resection.

METHODS

A systematic search was performed to identify all studies published up to March 2016 analyzing the survival of patients undergoing pancreaticoduodenectomy according to the results of frozen section pancreatic margin examination. Clinical effectiveness was synthetized through a narrative review with full tabulation of results.

RESULTS

Four studies published between 2010 and 2014 were retrieved, including 2580 patients. A primary R0 resection was obtained in a percentage of patients ranging from 36.2% to 85.5%, whereas secondary R0 in 9.4%-57.8% of cases and R1 in 5.1%-9.2%. Median survival ranged from 19 to 29 months in R0 patients, from 11.9 to 18 months in secondary R0, and from 12 to 23 months in R1 patients. None of the study demonstrated a survival benefit of extending the resection to obtain a secondary R0 pancreatic margin.

CONCLUSIONS

All the studies were concordant, and failed to demonstrate the survival benefit of additional pancreatic resection to obtain a secondary R0. However, inadequate surgery should not be advocated. This review suggests that re-resection of the pancreatic margin may have limited impact on patients' survival.

Dissection of Pancreatic Resection Specimens

Specimen grossing is a key step in the pathology examination of pancreatic resection specimens. Optimal display of pathologic changes and extensive tissue sampling are important determinants of the quality of pathology reporting. Divergence in macroscopic examination practice has led to considerable variation in the reporting of factors that are of clinical and prognostic significance. This article provides a detailed account of the macroscopic examination procedure with reference to current (inter-)national guidelines and recommendations.

Preoperative Modified FOLFIRINOX Treatment Followed by Capecitabine-Based Chemoradiation for Borderline Resectable Pancreatic Cancer: Alliance for Clinical Trials in Oncology Trial A021101

IMPORTANCE

Although consensus statements support the preoperative treatment of borderline resectable pancreatic cancer, no prospective, quality-controlled, multicenter studies of this strategy have been conducted. Existing studies are retrospective and confounded by heterogeneity in patients studied, therapeutic algorithms used, and outcomes reported.

OBJECTIVE

To determine the feasibility of conducting studies of multimodality therapy for borderline resectable pancreatic cancer in the cooperative group setting.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, multicenter, single-arm trial of a multimodality treatment regimen administered within a study framework using centralized quality control with the cooperation of 14 member institutions of the National Clinical Trials Network. Twenty-nine patients with biopsy-confirmed pancreatic cancer preregistered, and 23 patients with tumors who met centrally reviewed radiographic criteria registered. Twenty-two patients initiated therapy (median age, 64 years [range, 50-76 years]; 55% female). Patients registered between May 29, 2013, and February 7, 2014.

INTERVENTIONS

Patients received modified FOLFIRINOX treatment (85 mg/m2 of oxaliplatin, 180 mg/m2 of irinotecan hydrochloride, 400 mg/m2 of leucovorin calcium, and then 2400 mg/m2 of 5-fluorouracil for 4 cycles) followed by 5.5 weeks of external-beam radiation (50.4 Gy delivered in 28 daily fractions) with capecitabine (825 mg/m2 orally twice daily) prior to pancreatectomy.

MAIN OUTCOMES AND MEASURES

Feasibility, defined by the accrual rate, the safety of the preoperative regimen, and the pancreatectomy rate.

RESULTS

The accrual rate of 2.6 patients per month was superior to the anticipated rate. Although 14 of the 22 patients (64% [95% CI, 41%-83%]) had grade 3 or higher adverse events, 15 of the 22 patients (68% [95% CI, 49%-88%]) underwent pancreatectomy. Of these 15 patients, 12 (80%) required vascular resection, 14 (93%) had microscopically negative margins, 5 (33%) had specimens that had less than 5% residual cancer cells, and 2 (13%) had specimens that had pathologic complete responses. The median overall survival of all patients was 21.7 months (95% CI, 15.7 to not reached) from registration.

CONCLUSIONS AND RELEVANCE

The successful completion of this collaborative study demonstrates the feasibility of conducting quality-controlled trials for this disease stage in the multi-institutional setting. The data generated by this study and the logistical elements that facilitated the trial's completion are currently being used to develop cooperative group trials with the goal of improving outcomes for this subset of patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01821612.

Interferon-based Adjuvant Chemoradiation for Resected Pancreatic Head Cancer: Long-term Follow-up of the Virginia Mason Protocol

OBJECTIVE

To report the long-term impact of adjuvant interferon-based chemoradiation therapy (IFN-CRT) after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC).

BACKGROUND

In 2003, we reported an actuarial 5-year overall survival (OS) of 55% (22 months median follow-up) using adjuvant IFN-CRT after PD. As the original cohort is now 10 years distant from PD, we sought to examine their actual survival, describe patterns of recurrence, and determine prognostic factors.

METHODS

From 1995 to 2002, 43 patients underwent PD for PDAC and received adjuvant IFN-CRT consisting of external-beam irradiation, continuous 5-fluorouracil infusion, weekly intravenous bolus cisplatin, and subcutaneous interferon-α. Survival was calculated by the method of Kaplan and Meier, and prognostic factors were compared using a log-rank test and a Cox proportional hazards model.

RESULTS

With all patients at least 10 years from PD, the 5-year actual survival was 42% and 10-year actual survival was 28% with median OS of 42 months (95% confidence interval: 22-110 months). Nine patients survived beyond 10 years with 7 currently alive without evidence of disease. Initial recurrence included 4 local, 17 distant, and 4 combined sites at a median of 25 months. IFN-CRT was interrupted in 70% of patients because of grade 3 or 4 toxicity, whereas 42% of patients required hospitalization. Adverse prognostic factors included lymph node ratio of 50% or more, Eastern Cooperative Oncology Group performance status of 1 or higher, and IFN-CRT treatment interruption.

CONCLUSIONS

Adjuvant IFN-CRT after PD can provide long-term survival in resected PDAC. Further studies should focus on patient and tumor factors to maximize benefit and minimize toxicity.

The importance of surgical margins in pancreatic cancer

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

Diagnosis and Management of Borderline Resectable Pancreatic Adenocarcinoma

Borderline resectable pancreatic cancer represents a subcategory of advanced cancer that is typically defined by limited involvement of the major mesenteric vasculature. Such involvement is associated with a high likelihood of microscopically incomplete resection if surgery is used as the primary therapeutic modality. Increasing data support the role of neoadjuvant therapy as part of multimodality management but there is no uniformly accepted standard of care. This review discusses, based on recent literature and the experience of the Pancreatic Tumor Study Group at The University of Texas MD Anderson Cancer Center, the classification, definition, diagnosis, and management of borderline resectable pancreatic cancer.

Pancreatic adenocarcinoma with venous involvement: is up-front synchronous portal-superior mesenteric vein resection still justified? A survey of the Association Française de Chirurgie

BACKGROUND

Venous resection (VR) during pancreatectomy has been reported to neither increase mortality nor morbidity and to provide similar survival outcomes in same stage tumors. However, controversy remains regarding the indications for up-front surgery according to the degree of venous involvement.

METHODS

From 2004 to 2009, 1,399 patients included in a French multicenter survey underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic adenocarcinoma, either without VR (997 standard resections [SR]) or with VR (402 patients; 29 %). Postoperative and long-term outcomes were compared in both groups.

RESULTS

VR was associated with the following factors: larger tumors (p < 0.001), poorly differentiated tumors (p = 0.004), higher numbers of positive lymph nodes (p = 0.042), and positive resection margins (R1; p < 0.001). Overall, VR increased neither postoperative morbidity nor postoperative mortality (5 vs. 3 % in SR patients; p = 0.16). The median and 3-year survival rates in VR patients versus SR patients were 21 months and 31 % vs. 29 months and 44 %, respectively (p = 0.0002). In the entire cohort, multivariate analysis identified VR as a significant poor prognostic factor for long-term survival (hazard ratio [HR] 1.75, 95 % confidence interval [CI] 1.28-2.40; p = 0.0005). In the VR patients, lymph node ratio, whatever the cutoff (<0.3: p = 0.093; ≥ 0.3: p = 0.0098), R1 resection (p = 0.010), and segmental resection (p = 0.016) were independent risk factors; neoadjuvant treatment (HR 0.52, 95 % CI 0.29-0.94; p = 0.031) and adjuvant treatment (HR 0.55, 95 % CI 0.35-0.85; p = 0.006) were significantly associated with improved long-term survival.

CONCLUSIONS

Long-term survival after pancreatectomy was significantly altered when up-front VR was performed. Neoadjuvant treatment may be a better strategy than up-front resection in patients with preoperative suspicion of venous involvement.

Diagnostic evaluation and staging of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) frequently presents at an advanced and incurable stage of the disease. Common signs and symptoms of PDA include abdominal or back pain, jaundice, weight loss, pruritus, and nausea/vomiting. Diagnostic workup includes serum chemistries and CA19-9, primarily to monitor disease status and response to treatment. Imaging studies are performed to assess resectability and stage disease, and pancreatic protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) are the preferred imaging studies for this purpose. Conventional staging is based on the American Joint Cancer Committee (AJCC) Staging System, 7th Edition and informs prognosis, while surgical staging systems focus specifically on assessing the likelihood of a complete (negative margins) resection with operative management. Herein, we review the presenting signs and symptoms, the diagnostic evaluation, and staging of PDA.

Neoadjuvant vs adjuvant therapy for resectable pancreatic cancer: the evolving role of radiation

A major challenge with pancreatic cancer management is in the discrimination of clearly resectable tumors from those that would likely be accompanied by a positive resection margin if upfront surgery was attempted. The standard of care for clearly resectable pancreatic cancer remains surgery followed by adjuvant therapy, but there is considerable controversy over whether such therapeutic adjuvant strategies should include radiotherapy. Furthermore, in a malignancy with such high rates of distant metastasis, investigators are now exploring the feasibility and outcomes of delivering therapy in the neoadjuvant setting, both for clearly resectable as well as borderline resectable tumors. In this review, we explore the current standard of care of upfront surgery for clearly resectable cancers followed by adjuvant therapy, focusing on the role of radiotherapy. We highlight the difficulties in interpreting a literature fraught with inconsistencies in how resectable vs borderline resectable cancers are defined and treated. Finally, we explore the role of neoadjuvant strategies in the modern era.

Pathology of pancreatic ductal adenocarcinoma: Facts, challenges and future developments

Despite major improvements concerning its diagnosis and treatment, pancreatic ductal adenocarcinoma (PDAC) remains an aggressive disease with an extremely poor prognosis. Pathology, as interface discipline between basic and clinical medicine, has substantially contributed to the recent developments and has laid the basis for further progress. The definition and classification of precursor lesions of PDAC and their molecular characterization is a fundamental step for the potential identification of biomarkers and the development of imaging methods for early detection. In addition, by integrating findings in humans with the knowledge acquired through the investigation of transgenic mouse models for PDAC, a new model for pancreatic carcinogenesis has been proposed and partially validated in individuals with genetic predisposition for PDAC. The introduction and validation of a standardized system for pathology reporting based on the axial slicing technique has shown that most pancreatic cancer resections are R1 resections and that this is due to inherent anatomical and biological properties of PDAC. This standardized assessment of prognostic relevant parameters represents the basis for the successful conduction of multicentric studies and for the interpretation of their results. Finally, recent studies have shown that distinct molecular subtypes of PDAC exist and are associated with different prognosis and therapy response. The prospective validation of these results and the integration of molecular analyses in a comprehensive pathology report in the context of individualised cancer therapy represent a major challenge for the future.

Value of intraoperative neck margin analysis during Whipple for pancreatic adenocarcinoma: a multicenter analysis of 1399 patients

INTRODUCTION

During pancreaticoduodenectomy (PD) for ductal adenocarcinoma, a frozen section (FS) neck margin is typically assessed, and if positive, additional pancreas is removed to achieve an R0 margin. We analyzed the association of this practice with improved overall survival (OS).

METHODS

Patients who underwent PD for pancreatic ductal adenocarcinoma from January 2000 to August 2012 at 8 academic centers were classified by neck margin status as negative (R0) or microscopically positive (R1) on the basis of FS and permanent section (PS). Impact on OS of converting an FS-R1-neck margin to a PS-R0-neck margin by additional resection was assessed.

RESULTS

A total of 1399 patients had FS neck margins analyzed. Median OS was 19.7 months. On FS, 152 patients (10.9%) were R1, and an additional 51 patients (3.6%) had false-negative FS-R0 margins. PS-R0-neck was achieved in 1196 patients (85.5%), 131 patients (9.3%) remained PS-R1, and 72 patients (5.1%) were converted from FS-R1-to-PS-R0 by additional resection. Median OS for PS-R0-neck patients was 21.1 months versus 13.7 months for PS-R1-neck patients (P < 0.001) and 11.9 months for FS-R1-to-PS-R0 patients (P < 0.001). Both FS-R1-to-PS-R0 and PS-R1-neck patients had larger tumors (P = 0.001), more perineural invasion (P = 0.02), and more node positivity (P = 0.08) than PS-R0-neck patients. On multivariate analysis controlling for adverse pathologic factors, FS-R1-to-PS-R0 conversion remained associated with significantly worse OS compared with PS-R0-neck patients (hazard ratio: 1.55; P = 0.009).

CONCLUSIONS

For patients who undergo pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, additional resection to achieve a negative neck margin after positive frozen section is not associated with improved OS.

Pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma

Traditionally, pancreatic ductal adenocarcinoma with regional vascular involvement was thought to represent unresectable disease and was associated with disease progression and death within 1 year of diagnosis. Recent evidence demonstrates that pancreaticoduodenectomy with vascular resection and reconstruction can be safely performed in select patients with 5-year survival rates as high as 20%. In order to safely treat and to optimize survival in these complex patients, it is essential to accurately identify vascular involvement preoperatively, to utilize a multidisciplinary treatment approach, and to emphasize meticulous surgical technique with awareness of the critical margins of resection.

Treatment of borderline resectable pancreatic cancer

OPINION STATEMENT

Borderline resectable pancreatic adenocarcinoma represents a subset of localized cancers that are at high risk for a margin-positive resection and early treatment failure when resected de novo. Although several different anatomic definitions for this disease stage exist, there is agreement that some degree of reconstructible mesenteric vessel involvement by the tumor is the critical anatomic feature that positions borderline resectable between anatomically resectable and unresectable (locally advanced) tumors in the spectrum of localized disease. Consensus also exists that such cancers should be treated with neoadjuvant chemotherapy and/or chemoradiation before resection; although the optimal algorithm is unknown, systemic chemotherapy followed by chemoradiation is a rational approach. Although gemcitabine-based systemic chemotherapy with either 5-FU or gemcitabine-based chemoradiation regimens has been used to date, newer regimens, including FOLFIRINOX, should be evaluated on protocol. Delivery of neoadjuvant therapy necessitates durable biliary decompression for as many as 6 months in many patients with cancers of the pancreatic head. Patients with no evidence of metastatic disease following neoadjuvant therapy should be brought to the operating room for pancreatectomy, at which time resection of the superior mesenteric/portal vein and/or hepatic artery should be performed when necessary to achieve a margin-negative resection. Following completion of multimodality therapy, patients with borderline resectable pancreatic cancer can expect a duration of survival as favorable as that of patients who initially present with resectable tumors. Coordination among a multidisciplinary team of physicians is necessary to maximize these complex patients' short- and long-term oncologic outcomes.

Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens

OBJECTIVES

This study aimed to determine the impact of a standardized pathological protocol on resection margin status after pancreaticoduodenectomy (PD) for ductal adenocarcinoma.

METHODS

A total of 150 patients operated during 2008-2010 were included in a prospective multicentre study using a 'quality protocol'. Multicolour inking by the surgeon identified three resection margins: the portal vein-superior mesenteric vein margin (PV-SMVm) or mesenterico-portal vein groove; the superior mesenteric artery margin (SMAm), and the posterior margin. Resection margins were stratified by 0.5-mm increments (range: 0-2.0 mm). Pancreatic neck, bile duct and intestinal margins were also analysed. Correlations between histopathological factors and survival in the 0-mm resection margin group were analysed.

RESULTS

Thirty-six patients (24%) had a PV-SMV resection (PV-SMVR). An analysis of resections categorized according to margin distances of 0 mm, <1.0 mm, <1.5 mm and <2.0 mm confirmed R1 resections in 35 (23%), 91 (61%), 94 (63%) and 107 (71%) patients, respectively. The most frequently invaded resection margin was the PV-SMVm (35% of all patients) and PV-SMVR was the only factor correlated with a higher risk for at least one 0-mm positive resection margin on multivariate analysis (P < 0.001). Two-year progression-free survival (PFS) and median PFS time in patients with R0 and R1 resections (at 0 mm), respectively, were 42.0% and 26.5%, and 19.5 months and 10.5 months, respectively (P = 0.02). A positive PV-SMVm and SMAm had significant impact on PFS, whereas a positive posterior margin had no impact.

CONCLUSIONS

Pancreaticoduodenectomy requiring PV-SMVR was associated with a higher risk for R1 resection. The standardization of histopathological analysis has a clinically relevant impact on PFS data.

[Is the surgeon still the main prognosis factor?]

Assessment of surgeon's influence on the results of cancer surgery is complex. Investigation field is extremely large and should differentiate surgeon's impact from the one of surgery. This can result in major differences in the rate of postoperative complications and deaths, in the indication and use of technically difficult surgeries, and also in long-term results. The surgeon's impact is correlated with his activity volume for each type of major procedures and is independent from hospital activity volume. It persists independently of major progresses in hospital organization and process standardization. Data from the literature confirm the prognosis importance of the surgeon in cancer outcome. In the future, the timely implementation of established, evidence-based guidelines and checklists programs could prevent large number of deaths and complications and reduce the surgeon specific impact.

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings

BACKGROUND

High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown.

METHODS

We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated.

RESULTS

There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6).

DISCUSSION

While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

Controversial issues of neoadjuvant treatment in borderline resectable pancreatic cancer

Pancreatic ductal adenocarcinoma is known as one of the most fatal malignant diseases in gastrointestinal system. Approximately 20% of patients are deemed resectable at the time of diagnosis. Preoperative neoadjuvant therapy to the borderline resectable pancreatic cancer (BRPC) has been challenged to achieve down-staging of cancer, to avoid unnecessary major operation if the pancreatic cancer progresses and distant metastasis develops during preoperative treatment, and to avoid delayed adjuvant treatment after major operation due to postoperative complications and poor general condition after major surgery. However, there are some controversial issues influencing the clinical interpretation of surgical and oncologic outcomes of pancreatectomy following neoadjuvant treatment in managing BRPC. This manuscript reviews the current controversial issues in managing BRPC in order to enhance proper understanding the current status and potential role of neoadjuvant treatment in managing BRPC.

An anatomical-based mapping analysis of the pancreaticoduodenectomy retroperitoneal margin highlights the urgent need for standardized assessment

OBJECTIVES

Assessment of a pancreaticoduodenectomy specimen by pathologists requires specialized knowledge of anatomy. Standardized assessment, description and documentation of the retroperitoneal margin are crucial for the accurate interpretation of studies evaluating adjuvant therapy for pancreatic cancer patients.

METHODS

Twenty-five patients who underwent a pancreaticoduodenectomy for pancreatic adenocarcinomas had their pathological specimens examined prospectively, using an anatomical-based mapping approach. All margins, including the bile duct, pancreatic neck, superior mesenteric artery, superior mesenteric vein and posterior surface of the uncinate process, were microscopically examined in their entirety. The assessment of an R1 margin in terms of distance was assessed in two ways: first defining it as a tumour at the margin or secondary as tumour within 1 mm (1 mm rule).

RESULTS

If the existing College of American Pathologists recommendations were applied (assessing only the bile duct, pancreatic neck and superior mesenteric artery margins), a R1 status would be achieved in only 9 of 25 patients. Extending the examination by assessment and reporting of the entire retroperitoneal resection margin, including the Superior Mesenteric Vein margin and the Posterior surface of the uncinate process margin, increased the number of patients with a R1 resection to 14 out of 25. Applying the 1-mm rule further increased the number of patient with a R1 resection to 20 of 25 patients.

CONCLUSIONS

The above findings illustrate that different approaches to the assessment and reporting of the retroperitoneal margin can change the results and adversely affect the final statistics used in pancreatic cancer studies and clinical trials.

Borderline resectable pancreatic cancer: need for standardization and methods for optimal clinical trial design

BACKGROUND

Methodological limitations of prior studies have prevented progress in the treatment of patients with borderline resectable pancreatic adenocarcinoma. Shortcomings have included an absence of staging and treatment standards and pre-existing biases with regard to the use of neoadjuvant therapy and the role of vascular resection at pancreatectomy.

METHODS

In this manuscript, we review limitations of studies of borderline resectable PDAC reported to date, highlight important controversies related to this disease stage, emphasize the research infrastructure necessary for its future study, and present a recently-approved Intergroup pilot study (Alliance A021101) that will provide a foundation upon which subsequent well-designed clinical trials can be performed.

RESULTS

We identified twenty-three studies published since 2001 which report outcomes of patients with tumors labeled as borderline resectable and who were treated with neoadjuvant therapy prior to planned pancreatectomy. These studies were heterogeneous in terms of the populations studied, the metrics used to characterize therapeutic response, and the indications used to select patients for surgery. Mechanisms used to standardize these and other issues that are incorporated into Alliance A021101 are reviewed.

CONCLUSIONS

Rigorous standards of clinical trial design incorporated into trials of other disease stages must be adopted in all future studies of borderline resectable pancreatic cancer. The Intergroup trial should serve as a paradigm for such investigations.

Adequacy of pathology reports of specimens from patients with differentiated thyroid cancer

This study aims to investigate the adequacy of pathology reports of specimens from patients with differentiated thyroid cancer (DTC) operated in our institution. Retrospective analysis of the pathology reports of all patients diagnosed with DTC in our area, from 1 January 2006 through 30 June 2011, was done. Sixty-eight patients were diagnosed with DTC. All reports were descriptive. In all the reports, but one, one or more core data items (according to the Royal College of Pathologists) were missing. Information about 1 and 2 items was lacking in 7.4 and 42.6 % of the reports, respectively. The rest were missing three or more data. Lymphovascular invasion, histology subtype, and completeness of excision were, in this order, the three most frequently omitted data. Sometimes, the information in question was not explicitly expressed but could be extrapolated from the data available. The pathology reports of DTC specimens frequently miss some of the information considered necessary to provide a comprehensive patient care.