Risk factors influencing recurrence following resection of pancreatic head cancer

Recurrence and Prognostic Value of Circulating Tumor Cells in Resectable Pancreatic Head Cancer: A Single Center Retrospective Study

Background and Aim

To investigate the effect of preoperative circulation tumor cells (CTCs) on postoperative recurrence and overall survival prognosis of pancreatic head cancer after pancreaticoduodenectomy (PD).

Methods

From March 2014 to January 2018, 73 patients with pancreatic head cancer underwent radical resection (R0) in Zhongshan People's Hospital. CTCs in peripheral blood of patients with pancreatic head cancer were detected by “Cyttel” method before PD. Seventy-three patients were divided into positive and negative groups according to the positive criteria. To explore the relationship between the clinical data of CTCs and disease-free survival (DFS) and overall survival (OS). Cox proportional hazards model was used to analyzing the risk factors affecting the postoperative recurrence and the survival prognosis of patients.

Results

41 patients (56.2%) were in the CTC-positive group. Preoperative CTCs were correlated with tumor vascular invasion, CA199 level and postoperative liver metastasis (P < 0.05). Preoperative CTC-positive, lymph node metastasis, vascular invasion, and nerve invasion were independent risk factors for DFS (P < 0.05). Preoperative CTC-positive, tumor diameter > 2 cm and vascular invasion were independent risk factors for OS of patients (P < 0.05).

Conclusion

The detection of CTCs before PD is an important factor affecting the DFS and OS of pancreatic head cancer, which is significant in guiding clinical work.

Mesopancreas Excision and Triangle Operation During Robotic Pancreatoduodenectomy

BACKGROUND

The retropancreatic space between the superior mesenteric artery, celiac axis, and portal vein is called the mesopancreas. Total mesopancreas excision and skeletonization of both celiac axis and superior mesenteric artery are used to reduce R1 resection in high-risk patients and in those with locally advanced disease. The aim of this study was to present a series of video clips from several patients showing the mesopancreas excision and the triangle operation with a detailed technical description of both techniques with different approaches.

METHODS

Video clips were compiled from several robotic pancreatoduodenectomies to demonstrate the total mesopancreas excision and triangle operation technique, as follows: (1) main steps for mesopancreas excision and triangle operation, (2) anterior approach for mesopancreas excision, and (3) triangle operation.

RESULTS

A total of 87 patients underwent robotic PD at our center between March 2018 and March 2021. Of these, 22 patients underwent robotic mesopancreas excision. This technique was used for patients at high risk for R1 resection in 18 patients and triangle operation in four patients. Partial portal vein resection was necessary in 6 cases. One patient had R1 resection and was treated with adjuvant therapy. The remaining patients presented free surgical margins. The mean number of harvested lymph nodes was 40 (range: 27-77). The median interval between the operation and chemotherapy was 23 days.

CONCLUSIONS

The robotic total mesopancreas excision and the triangle operation are feasible and safe for selected patients. The indication for this radical operation is the presence of a high risk for R1 resection and for those with locally advanced disease. The presented video may help oncological surgeons to perform these techniques.

Survival in resectable pancreatic ductal adenocarcinoma with para-aortic lymph node dissection: A retrospective study in Vietnamese population

Background

Pancreatic ductal adenocarcinoma (PDAC) has a high recurrence rate and poor outcome. Lymph node (LN) metastasis, especially para-aortic LN (PALN), is an important prognostic factor. PALN assessment through sampling with frozen-section analysis is a validated method. Our aim was to evaluate the prognostic impact of PALN on overall survival (OS) in patients who underwent standard pancreaticoduodenectomy, lymphadenectomy with PALN sampling, as well as to identify other prognostic factors for survival.

Methods

Our retrospective study included 89 PDAC patients undergoing radical resection with PALN sampling. The patients were classified into PALN(+) (n = 11) and PALN(-) (n = 78). Univariate and multivariate analyses of 1-year and 3-year OS and Kaplan-Meier model were used.

Results

OS after 1-year for PALN(+) and PALN(-) was 18.2 and 56.4%, after 3-year was 15.4% and 0%, respectively. Tumor differentiation, LN metastasis (LN(-), LN(+) PALN(-), LN(+) PALN(+)) were significant prognostic factors in both univariate and multivariate analyses for 1-year OS, and neural invasion (PN) was the solely significant factor for 3-year OS (p < 0.05). Kaplan-Meier estimate showed that OS of PALN(+) and PN (+) was significantly lower than the negative group, respectively (p < 0.05). No statistical difference in OS was seen between LN(-) and LN(+) PALN(-); and between LN(+) PALN(-) and PALN(+) (p = 0.107). Patients with PN (-) PALN(+) had similar OS compared to PN (+) PALN(-) (p > 0.05).

Conclusion

PDAC had a poor outcome despite treatment with radical resection. Further follow-up should be conducted to determine the role of surgery in PALN(+)and PN invasion.

The Path to Whipple Reconstruction for Pancreatic Adenocarcinoma: Trans-Mesocolon or Through Ligament of Treitz?

BACKGROUND

The path of the biliopancreatic limb for reconstruction of the pancreatic anastomosis during pancreatoduodenectomy for pancreatic ductal adenocarcinoma can be trans-mesocolon or through the ligament of Treitz. Even after curative intent pancreatoduodenectomy, incidence of recurrence in the surgical bed remains high and may lead to obstruction of the biliopancreatic limb. However, the association between path of jejunal limb and incidence of biliopancreatic limb obstruction has not been studied. Primary aim was to determine whether path of reconstruction predisposes to biliopancreatic limb obstruction in the setting of local recurrence.

METHODS

Patients who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma (2008-2018) from a single institution were identified. As disease recurrence is the predominant cause of biliopancreatic limb obstruction, analysis was limited to patients with known recurrence at date of last follow-up. Given a known median time to recurrence of 8 to 10 months after resection for pancreatic ductal adenocarcinoma, analysis was further limited to patients with at least 8 months of follow-up. Primary outcome was incidence of biliopancreatic limb obstruction.

RESULTS

Among the 517 patients identified, 182 were included. Median age was 65 years; 51% were male. Median follow-up was 22 months. Path of reconstruction was trans-mesocolon in 35% (n = 64) and through ligament of Treitz in 65% (n = 118). There was no difference between the two groups in clinicopathologic factors including age, tumor differentiation, grade, T-stage, N-stage, LVI, or PNI (all p > 0.05). Importantly, there was no difference in retroperitoneal margin positivity between groups (trans-mesocolon 8% vs ligament of Treitz 10%, p = 0.79). Both groups had similar post-operative outcomes including median length-of-stay (trans-mesocolon 6 days vs ligament of Treitz 6 days, p = 0.89) and median follow-up (trans-mesocolon 21 months vs ligament of Treitz 23 months, p = 0.68). Biliopancreatic limb obstruction was detected in 8% (n = 14) of which 14% (n = 2) were in the trans-mesocolon group and 86% (n = 12) were in the ligament of the Treitz group. Therefore, incidence of biliopancreatic limb obstruction was 3.1% in the trans-mesocolon group and 10.4% in the ligament of the Treitz group resulting in an absolute risk increase of 7.3%, risk ratio of 3.4, and relative risk increase of 2.3. There was no difference in median time to biliopancreatic limb obstruction between the groups (17.6 months vs 18.5 months, p = 1.0). Biliopancreatic limb obstruction was caused by locally recurrent pancreatic ductal adenocarcinoma in 93% (n = 13) and kinking of the duodenojejunal anastomosis in 7% (n = 1). Intervention was performed in 71% (n = 10) and included surgical bypass in 29% (n = 4), percutaneous drain in 21% (n = 3), and endoscopic/surgical decompression in 21% (n = 3).

CONCLUSION

Biliopancreatic limb obstruction is a known complication after pancreatoduodenectomy for pancreatic ductal adenocarcinoma due to local recurrence in the surgical bed. This study shows that path of jejunal limb through the ligament of Treitz may be associated with a higher incidence of biliopancreatic limb obstruction compared with trans-mesocolon as the position of the biliopancreatic limb in the surgical bed may be more predisposed to obstruction after local recurrence. Larger studies are needed; however, given this potential risk of subsequent obstruction, these data suggest that the reconstruction paths may not be equivalent when performing pancreatoduodenectomy for pancreatic ductal adenocarcinoma.

How to treat intestinal obstruction due to malignant recurrence after Whipple’s resection for pancreatic head cancer: Description of 2 new endoscopic techniques

The prognosis of pancreatic cancer remains poor, even after initial surgical therapy. Local recurrence after Whipple’s pancreatico-duodenectomy may lead to intestinal obstruction at the level of the afferent limb or the alimentary limb. Endoscopic insertion of a self-expandable metal stent (SEMS) into the intestinal malignant stricture is the preferred method of choice for palliation. We describe two new endoscopic techniques to treat a malignant intestinal obstruction with the insertion of a SEMS into the afferent limb and the alimentary limb. A case of malignant gastric outlet obstruction after a Whipple’s resection was treated by the creation of an endoscopic gastrojejunostomy by the insertion of a lumen apposing HotAxios stent in between the stomach and the alimentary limb under fluoroscopic and endoscopic ultrasound control. Biliary obstruction and jaundice caused by a malignant stricture of the afferent limb after a Roux-en-Y Whipple’s resection was treated by the insertion of a SEMS by means of the single-balloon overtube-assisted technique under fluoroscopic control. Feasibility and advantages of both techniques are discussed.

Epidemiologic Data, Tumor Size, Histologic Tumor Type and Grade, Pathologic Staging and Follow Up in Cancers of the Ampullary Region and Head of Pancreas in 311 Whipple Resection Specimens of Pakistani Patients

AIM

To report the histologic findings on Whipple resection specimens and thus determine the extent and spread of carcinomas of ampullary region and head of pancreas in our population.

SETTING

Section of Histopathology, Department of Pathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan.

MATERIALS AND METHODS

A case series of 311 consecutive Whipple resection specimens received between January 1,2003 and December 31, 2014. Specimens processed for histologic sections and representative sections submitted and histologically examined as per established and standard protocols. All relevant tumor parameters including histologic type, histologic grade, pathologic T and N stage and tumor size were assessed. Epidemiologic data were also recorded. All findings were analysed using SPSS 19.0 software.

RESULTS

Ampullary (periampullary) carcinomas were much more common than carcinomas of the head of the pancreas, especially in males, with an average age of 53 years. Mean tumor size was 2.5 cms, over 54% were well differentiated. A large majority were pT2 or pT3 and N0. Carcinomas of pancreatic head were also more common in males, mean age was 55 years, mean tumor size was 3.5 cms, and over 65% were moderately differentiated. The majority were T2 or T3 and pN1. Prognostically, significant statistical correlation was seen with tumor grade and pathologic T and N stage (p values statistically significant). However, tumor size was not statistically significant.

CONCLUSIONS

Ampullary carcinomas are more common compared to pancreatic carcinomas. Majority of ampullary carcinomas were well differentiated while majority of pancreatic carcinomas were moderately differentiated. Large majority of both types of cases were pT2 or T3. Histologic tumor grade and pathologic T and N stage are significantly related to prognosis in Pakistani patients with ampullary and pancreatic cancers.

Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study

BACKGROUND

This study aimed to evaluate the impact of preoperative biliary drainage (PBD) on the long-term survival of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy (PD).

METHODS

A multicenter observational study was performed using a common database of patients with resected PDAC from seven high-volume surgical institutions in Japan.

RESULTS

Of 932 patients who underwent PD for PDAC, 573 (62 %) underwent PBD, including 407 (44 %) who underwent endoscopic biliary drainage (EBD) and 166 (18 %) who underwent percutaneous transhepatic biliary drainage (PTBD). The patients who did not undergo PBD and those who underwent EBD had a significantly better overall survival than those who underwent PTBD, with median survival times of 25.7 months (P < 0.001), 22.3 months (P = 0.001), and 16.7 months, respectively. Multivariate analysis showed that seven clinicopathologic factors, including the use of PTBD but not EBD, were independently associated with poorer overall survival. Furthermore, patients who underwent PTBD more frequently experienced peritoneal recurrence (23 %) than those who underwent EBD (10 %; P < 0.001) and those who did not undergo PBD (11 %; P = 0.001). Multivariate analysis demonstrated that the independent risk factors for peritoneal recurrence included surgical margin status (P < 0.001) and use of PTBD (P = 0.004).

CONCLUSIONS

Use of PTBD, but not EBD, was associated with a poorer prognosis, with an increased rate of peritoneal recurrence among patients who underwent PD for PDAC.

Surgical technique and results of total mesopancreas excision (TMpE) in pancreatic tumors

BACKGROUND AND OBJECTIVES

Retro pancreatic invasion is a major concern in pancreatic head carcinoma. Posterior clearance has been recognized as an independent risk factor for disease recurrence and hence patient survival. The aim of this study was to report a standardized method that ensures posterior clearance with Total Mesopancreas Excision (TMpE).

METHODS

Our procedure consisted in a posterior approach with cranio-caudal dissection at the origin of the superior mesenteric artery and the celiac trunk all along their right semi-circumference. This allowed a complete clearance of retro pancreatic tissues with safe control of pancreaticoduodenal arteries at their origin.

RESULTS

Fifty-two consecutive pancreatic resections with TMpE were performed. Sixteen cases were associated to vascular resection. Pathology revealed an adenocarcinoma of the pancreatic duct, distal bile duct, periampullary and neuroendocrine carcinoma. Mesopancreas was invaded by cancer in 12 cases, of these, 3 had invaded margins and 7 had a margin less than 1 mm. Mesopancreas was the only site of tumour infiltration. Applying the International Union Against Cancer criteria, an R0 resection was thus achieved in 42 patients.

CONCLUSION

Our procedure is feasible and safe in experienced hand. It is a description of a standardized method for TMpE that clearly shows an advantage in improving posterior clearance and R0 resection.

Current and emerging therapies for the treatment of pancreatic cancer

Pancreatic adenocarcinoma carries a dismal prognosis and remains a significant cause of cancer morbidity and mortality. Most patients survive less than 1 year; chemotherapeutic options prolong life minimally. The best chance for long-term survival is complete resection, which offers a 3-year survival of only 15%. Most patients who do undergo resection will go on to die of their disease. Research in chemotherapy for metastatic disease has made only modest progress and the standard of care remains the purine analog gemcitabine. For resectable pancreatic cancer, presumed micrometastases provide the rationale for adjuvant chemotherapy and chemoradiation (CRT) to supplement surgical management. Numerous randomized control trials, none definitive, of adjuvant chemotherapy and CRT have been conducted and are summarized in this review, along with recent developments in how unresectable disease can be subcategorized according to the potential for eventual curative resection. This review will also emphasize palliative care and discuss some avenues of research that show early promise.

Intraoperative assessment of the Whipple resection specimen

Intraoperative consultation for the Whipple resection procedure has evolved due to the increasing influence of imaging techniques in surgical planning and decision-making. The indications and utilisation of this service vary, at least to some degree, from one institution to the other. The following discussion is a single institutional approach, which is hoped to provide assistance to the practising pathologists in this field. Special emphasis is given to the relevant anatomical considerations and the most common indications for an intraoperative consultation.

Hematemesis as the initial complication of pancreatic adenocarcinoma directly invading the duodenum: A case report

Pancreatic carcinoma is a debilitating disease and carries a poor prognosis. It is a rare cause of upper gastrointestinal bleeding, even though pancreas, stomach, duodenum and jejunum are adjacent organs. The incidence of pancreatic adenocarcinoma directly invading the gastrointestinal tract leading to gastrointestinal hemorrhage is very low, and most of them present with melena and hematochezia. Here, we describe one unique case manifesting characteristically severe and unremitting hematemesis as an initial presentation of pancreatic adenocarcinoma. This tumor directly invaded the duodenal mucosa as a bleeding protruding tumor mass. Our MEDLINE search has confirmed that this is the first reported case with an initial manifestation of hematemesis from pancreatic adenocarcinoma in Asians. Pancreatic adenocarcinoma directly invading duodenum complicated by hemorrhage can be a rare cause of hematemesis, and clinicians should be reminded of it while they are making differential diagnosis.