Re-evaluation of classical prognostic factors in resectable ductal adenocarcinoma of the pancreas

The Nomogram predicting the overall survival of patients with pancreatic cancer treated with radiotherapy: a study based on the SEER database and a Chinese cohort

Objective

Patients with pancreatic cancer (PC) have a poor prognosis. Radiotherapy (RT) is a standard palliative treatment in clinical practice, and there is no effective clinical prediction model to predict the prognosis of PC patients receiving radiotherapy. This study aimed to analyze PC's clinical characteristics, find the factors affecting PC patients' prognosis, and construct a visual Nomogram to predict overall survival (OS).

Methods

SEER*Stat software was used to collect clinical data from the Surveillance, Epidemiology, and End Results (SEER) database of 3570 patients treated with RT. At the same time, the relevant clinical data of 115 patients were collected from the Affiliated Cancer Hospital of Zhengzhou University. The SEER database data were randomly divided into the training and internal validation cohorts in a 7:3 ratio, with all patients at The Affiliated Cancer Hospital of Zhengzhou University as the external validation cohort. The lasso regression was used to screen the relevant variables. All non-zero variables were included in the multivariate analysis. Multivariate Cox proportional risk regression analysis was used to determine the independent prognostic factors. The Kaplan-Meier(K-M) method was used to plot the survival curves for different treatments (surgery, RT, chemotherapy, and combination therapy) and calculate the median OS. The Nomogram was constructed to predict the survival rates at 1, 3, and 5 years, and the time-dependent receiver operating characteristic curves (ROC) were plotted with the calculated curves. Calculate the area under the curve (AUC), the Bootstrap method was used to plot the calibration curve, and the clinical efficacy of the prediction model was evaluated using decision curve analysis (DCA).

Results

The median OS was 25.0, 18.0, 11.0, and 4.0 months in the surgery combined with chemoradiotherapy (SCRT), surgery combined with radiotherapy, chemoradiotherapy (CRT), and RT alone cohorts, respectively. Multivariate Cox regression analysis showed that age, N stage, M stage, chemotherapy, surgery, lymph node surgery, and Grade were independent prognostic factors for patients. Nomogram models were constructed to predict patients' OS. 1-, 3-, and 5-year Time-dependent ROC curves were plotted, and AUC values were calculated. The results suggested that the AUCs were 0.77, 0.79, and 0.79 for the training cohort, 0.79, 0.82, and 0.81 for the internal validation cohort, and 0.73, 0.93, and 0.88 for the external validation cohort. The calibration curves Show that the model prediction probability is in high agreement with the actual observation probability, and the DCA curve shows a high net return.

Conclusion

SCRT significantly improves the OS of PC patients. We developed and validated a Nomogram to predict the OS of PC patients receiving RT.

A neoadjuvant therapy compatible prognostic staging for resected pancreatic ductal adenocarcinoma

OBJECTIVE

To improve prediction, the AJCC staging system was revised to be consistent with upfront surgery (UFS) and neoadjuvant therapy (NAT) for PDAC.

BACKGROUND

The AJCC staging system was designed for patients who have had UFS for PDAC, and it has limited predictive power for patients receiving NAT.

METHODS

We examined 146 PDAC patients who had resection after NAT and 1771 who had UFS at Changhai Hospital between 2012 and 2021. The clinicopathological factors were identified using Cox proportional regression analysis, and the Neoadjuvant Therapy Compatible Prognostic (NATCP) staging was developed based on these variables. Validation was carried out in the prospective NAT cohort and the SEER database. The staging approach was compared to the AJCC staging system regarding predictive accuracy.

RESULTS

The NAT cohort's multivariate analysis showed that tumor differentiation and the number of positive lymph nodes independently predicted OS. The NATCP staging simplified the AJCC stages, added tumor differentiation, and restaged the disease based on the Kaplan-Meier curve survival differences. The median OS for NATCP stages IA, IB, II, and III was 31.7 months, 25.0 months, and 15.8 months in the NAT cohort and 30.1 months, 22.8 months, 18.3 months, and 14.1 months in the UFS cohort. Compared to the AJCC staging method, the NATCP staging system performed better and was verified in the validation cohort.

CONCLUSIONS

Regardless of the use of NAT, NATCP staging demonstrated greater predictive abilities than the existing AJCC staging approach for resected PDAC and may facilitate clinical decision-making based on accurate prediction of patients' OS.

Neoadjuvant therapy in resectable pancreatic cancer: A promising curative method to improve prognosis

Currently, 15 randomized controlled trials (RCTs) have been designed to investigate whether neoadjuvant therapy (NAT) benefits patients with resectable pancreatic adenocarcinoma (R-PA) compared to surgery alone. Five of them have acquired results so far; however, corresponding conclusions have not been obtained. We speculated that the reason for this phenomenon could be that some prognostic factors had proven to be adverse through upfront surgery curative patterns, but some of them were not regarded as independent baseline characteristics, which is important to obtaining comparability between the NAT and upfront surgery groups. This fact could cause bias and lead to the difference in the outcomes of RCTs. In this review, we collate data about risk factors (such as tumor size, resection margin, and lymph node status) influencing the prognoses of patients with R-PA from five RCTs and discuss the possible reasons for the varying outcomes.

Pancreatic cancer - the past, the present, and the future

BACKGROUND

Pancreatic cancer has been and still is associated with a very poor prognosis. This is due to a lack of major breakthroughs with respect to early diagnosis, prognostication, prediction, as well as novel, targeted therapies. The benefits of surgery and chemotherapy are evident, but the fact that only some 10% of all patients have early, localized disease highlights the unmet need for new early detection methods. An improved understanding of tumor biology and the development of molecular markers detectable both in the circulation and in cancer tissues may underlie the development of new tools for optimizing both diagnosis and treatment.

MATERIAL AND METHODS

Review of the literature.

RESULTS AND CONCLUSION

If we do not improve precision oncology for pancreatic ductal adenocarcinoma, the prognosis will still remain dismal and the" burden" on society will increase substantially.

Impact of radiologic splenic vessel invasion in resectable left-sided pancreatic ductal adenocarcinoma: predictor of early systemic recurrence following upfront surgery

BACKGROUND

The aim of this study is to identify prognostic factors and the best candidates for neoadjuvant therapy among patients with resectable left-sided pancreatic ductal adenocarcinoma (PDAC) by analyzing the timing and pattern of recurrence following upfront surgery.

METHODS

This single-center retrospective study included patients with resectable left-sided PDAC who underwent upfront distal pancreatectomy from 2005 to 2015. A minimum P value approach was used to evaluate the optimal cutoff of early recurrence. The predictors of recurrence were assessed with Cox regression analysis.

RESULTS

Among 311 included patients, 241 (77.5%) had a recurrence at a median follow-up of 29.3 months. Systemic recurrence occurred in 194 patients (80.5%) and isolated local recurrence in 47 patients (19.5%). A recurrence-free survival cutoff of 12 months was selected to distinguish between early and late recurrence. The patients with early recurrence had a shorter median overall survival (16.1 vs. 39.9 months, P<0.001) and post-recurrence survival (9.6 vs. 17.2 months, P<0.001) than those with late recurrence. The patients with systemic recurrence had a shorter median overall survival (19.6 vs. 29.1 months, P=0.007) and post-recurrence survival (11.0 vs. 15.3 months, P=0.024) than those with an isolated local recurrence. In multivariable analysis, preoperative CA 19-9 ≥500 U/mL [odd ratio (OR) 2.037, P=0.035], radiologic splenic vessels invasion (OR 5.014, P<0.001), positive radial resection margin (OR 2.638, P<0.001), and no adjuvant chemotherapy (OR 2.084, P=0.001) were predictors of an early systemic recurrence.

CONCLUSIONS

Radiologic splenic vessels invasion may be considered to indicate a biologically borderline status in patients with anatomically resectable left-sided PDAC. Future clinical trials of neoadjuvant therapy targeting these patients should be conducted.

Refined prognostic staging for resected pancreatic cancer by modified stage grouping and addition of tumour grade

BACKGROUND

With changes in T and N categories the 8th edition of the AJCC/UICC TNM staging system for pancreatic cancer resulted in improved prognostic staging, but inconsistencies were observed with specific stage groups. Tumour grading remains disregarded in prognostic staging. We aimed to validate the current staging system and to investigate the possibility of further optimization by integration of grading.

METHODS

1946 patients undergoing upfront surgical resection for pancreatic adenocarcinoma from 10/2001 to 12/2015 were identified from a prospective institutional database. Survival analyses based on the 8th UICC TNM edition were performed and rare TNM subgroups were reallocated based on survival. The impact of tumour grade on stage-specific survival was assessed and a TNMG staging system was developed.

RESULTS

The 8th UICC staging system accurately stratified prognosis except for comparable survival in stages IB (pT2N0M0) and IIA (pT3N0M0). Regrouping of pT3N0M0 and pT1N1M0 to IB and of pT1N2M0 to II resulted in a modified staging system with higher consistency. High tumour grade (G3&G4 vs G1&G2) was associated with a significantly shorter survival in all new stage groups except for stage IV modified UICC. A TNMG-based prognostic stage grouping in which high tumour grade results in grouping with tumours of the next higher pTNM-stage resulted in improvement of prognostication in non-metastatic pancreatic cancer.

CONCLUSIONS

The 8th edition of the UICC TNM staging system leaves room for improvement. A TNMG staging system with adjustments in group-allocation of specific rarely occurring pTNM subgroups and integration of tumour grade results in improved prognostic stratification.

Sarcopenia: looking to muscle mass to better manage pancreatic cancer patients

PURPOSE OF REVIEW

Overall survival of patients with pancreatic cancer is strongly conditioned by tumor biology and the incidence of malnutrition and metabolic disorders. In this landscape, the assessment of body composition is crucial to properly manage the clinical implications of muscle wasting. The pathogenesis of this condition is the result of a complex interplay between cancer and the host. In particular, sarcopenia is induced by an inadequate nutritional intake, hormonal abnormalities, inflammation and imbalance between anabolic and catabolic pathways.

RECENT FINDINGS

Recent evidences have highlighted the role of sarcopenia in cancer patients, revealing a prognostic impact on morbidity, mortality and survival.

SUMMARY

The occurrence of sarcopenia could amplify chemotherapy-induced toxicities, prolong hospitalizations and reduce adherence to anticancer treatment, worsening quality of life and survival. Although considerable efforts have been made to develop treatment strategies, no effective interventions have been identified so far. Nevertheless, if promptly and adequately supported, pancreatic cancer might benefit from adopted dietary intervention to avoid further loss of lean mass.

Development and multicenter validation of a CT-based radiomics signature for discriminating histological grades of pancreatic ductal adenocarcinoma

Background

The histological grade of pancreatic cancer is an important independent predictor of outcome. However, we lack a method for safely and accurately obtaining the pathological grade before surgery. Radiomics has been used to discriminate between histological grades in tumors. We aimed to develop and validate a radiomics signature for the preoperative prediction of histological grades of pancreatic ductal adenocarcinoma (PDAC) that was based on contrast-enhanced computed tomography (CE-CT).

Methods

This study comprised 301 patients with pathologically confirmed PDAC who were randomly divided into a training (n=151) and test group (n=150). Radiomics features were selected by a support vector machine (SVM) model, and a radiomics signature was generated by the least absolute shrinkage and selection operator (LASSO) model. An additional 100 patients from 2 other medical centers were used for external validation. Receiver operating characteristic (ROC) curve analysis was used to assess the model and to identify the optimal cutoff value.

Results

The radiomics signatures between high-grade and low-grade PDACs in the training and test groups were significantly different (P<0.05). The areas under the curve (AUCs) of the training and test datasets were 0.961 and 0.910, respectively. The optimal cutoff value of the radiomics score was 0.426. In the external validation dataset, the difference between the radiomics signatures of high-grade versus low-grade PDACs was also significant (P<0.05). The radiomics signature for the external validation data had an AUC of 0.770.

Conclusions

The CE-CT-based radiomics signature showed moderate predictive accuracy for differentiating low-grade from high-grade PDAC and should become a new noninvasive method for the preoperative prediction of histological grades of PDAC.

The Prognostic Index Independently Predicts Survival in Patients with Pancreatic Ductal Adenocarcinoma Undergoing Resection

BACKGROUND

Cancer-related inflammation is associated with tumour proliferation, maintenance and dissemination. It therefore impacts pancreatic cancer survival. The goal of this study was to examine the Prognostic Index (PI) as a prognostic biomarker for survival in patients with pancreatic ductal adenocarcinoma (PDAC). In addition, we explored factors known to interact with the immune and inflammation cascade that might interfere with the PI's strength for prognostication.

METHODS

Patients with PDAC undergoing resection were analysed retrospectively. The PI was calculated from preoperatively derived C-reactive protein levels and white blood count. Data were subject to correlation and survival analysis.

RESULTS

Of 357 patients, 235 (65.8%) patients had a PI 0, 108 (30.3%) PI 1, and 14 (3.9%) PI 2. Median (quartiles) survival with a high PI (group 1 + 2) was 13.2 months (7.7-27.0), compared with 18.7 months (10.2-35.4) with a low PI (group 0; p = 0.012). The PI proved to be an independent prognostic factor for cancer-specific survival (p = 0.003) adjusted for conventional prognostic factors. Prognostic strength was influenced by the presence of a bile stent (p = 0.032).

CONCLUSIONS

The PI is a strong and solid independent prognostic tool for survival in patients with PDAC undergoing resection. Preoperative survey of inflammatory activity as provided by the use of a biomarker like the PI may help to identify those patients at risk of a poor prognosis.

Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma?

INTRODUCTION

The aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA).

METHODS

A single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN- (peripancreatic lymph node)/HALN-, PPLN+/HALN- and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses.

RESULTS

Out of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12patients (PPLN-/HALN-, 19%), PPLN was positive and HALN negative in 40patients (PPLN+/HALN-, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN-/HALN- group (82%, 72%, 54%) than in the PPLN+/HALN- group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P=.001 vs P=.007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN-/HALN- group (18%, 46%, 55%) than in the PPLN+/HALN- group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P=.006 vs P=.021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status.

CONCLUSIONS

In pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status.

Comparison of Radical Antegrade Modular Pancreatosplenectomy with Standard Retrograde Pancreatosplenectomy for Left-Sided Pancreatic Cancer: A Meta-Analysis and Experience of a Single Center

BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported as a modified surgical technique used to achieve better margin resection and to retrieve more lymph nodes compared with standard retrograde pancreatosplenectomy (SRPS). MATERIAL AND METHODS A systematic literature review was performed to identify studies published in PubMed, EmBase, and Web of Science. Hazard ratio (HR), risk ratio (RR), weighted mean difference (WMD), and their 95% confidence intervals (95% CIs) were used as effect measures. In addition, the clinical data of 27 patients in our center were collected and retrospectively analyzed. RESULTS Seven studies containing 474 patients were finally enrolled in this meta-analysis. The pooled results showed that the RAMPS group had a better overall survival (OS) compared with the SRPS group (HR=0.65, 95% CI: 0.43-0.99, P=0.046; I²=41.8%, P=0.143). Significantly more lymph nodes were harvested in the RAMPS group compared with in the SRPS group (WMD=4.74, 95% CI: 0.36-9.12, P=0.034). Recurrence rate (RR=0.8, 95% CI: 0.66-0.98, P=0.028) and blood loss (WMD=-153.19 ml, 95% CI: -303.95 to -2.42, P=0.046) were both significantly reduced in the RAMPS group. Retrospective analysis results showed that only significantly more harvested lymph nodes were noted in the RAMPS group compared with the SRPS group (7.55±0.91 vs. 2.81±0.73, P=0.001). CONCLUSIONS Our study suggests that RAMPS has better prognosis and surgical outcomes than SRPS for left-sided pancreatic cancer. Nevertheless, more high-quality clinical trials are required to validate the result.

Sarcopenia and sarcopenic obesity are independent adverse prognostic factors in resectable pancreatic ductal adenocarcinoma

Background

Incidence and mortality of pancreatic ductal adenocarcinoma (PDAC) are on the rise. Sarcopenia and sarcopenic obesity have proven to be prognostic factors in different types of cancers. In the context of previous findings, we evaluated the impact of body composition in patients undergoing surgery in a national pancreatic center.

Methods

Patient’s body composition (n = 133) was analyzed on diagnostic CT scans and defined as follows: Skeletal muscle index ≤38.5 cm²/m² (women), ≤52.4 cm²/m² (men); obesity was classified as BMI ≥25kg/m².

Results

Sarcopenia showed a negative impact on overall survival (OS; 14 vs. 20 months, p = 0.016). Sarcopenic patients suffering from obesity showed poorer OS compared to non-sarcopenic obese patients (14 vs. 23 months, p = 0.007). Both sarcopenia and sarcopenic obesity were associated with sex (p<0.001 and p = 0.006; males vs. females 20% vs. 38% and 12% vs. 38%, respectively); sarcopenia was further associated with neoadjuvant treatment (p = 0.025), tumor grade (p = 0.023), weight loss (p = 0.02) and nutritional depletion (albumin, p = 0.011) as well as low BMI (<25 kg/m², p = 0.038). Sarcopenic obese patients showed higher incidence of major postoperative complications (p<0.001). In addition, sarcopenia proved as an independent prognostic factor for OS (p = 0.031) in the multivariable Cox Regression model.

Conclusion

Patients with sarcopenia and sarcopenic obesity undergoing resection for PDAC have a significantly shorter overall survival and a higher complication rate. The assessment of body composition in these patients may provide a broader understanding of patients’ individual condition and guide specific supportive strategies in patients at risk.

A Preoperative Prognostic Scoring System to Predict Prognosis for Resectable Pancreatic Cancer: Who Will Benefit from Upfront Surgery?

BACKGROUND

Upfront surgery is recommended in patients with potentially resectable pancreatic ductal adenocarcinoma (R-PDAC) by National Comprehensive Center Network (NCCN) guidelines. However, even among R-PDACs, there is a subset that demonstrates extremely poor prognosis. The purpose of this study was to identify preoperative prognostic factors for upfront surgical resection of R-PDACs.

METHODS

The records of 278 consecutive patients with PDAC who underwent curative resection between 2001 and 2015 in a single institution were retrospectively reviewed. Preoperative factors to predict prognosis in patients with R-PDAC according to the NCCN guidelines were analyzed.

RESULTS

Of the 278 patients who underwent resection, 153 R-PDACs received upfront surgery with a median survival time (MST) of 26.4 months. Tumor location (pancreatic head) (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14-3.40; P = 0.015), preoperative cancer antigen 19-9 (CA19-9) > 100 U/mL (OR 1.92, 1.31-2.80; P = 0.0009), and tumor size > 20 mm (OR 1.50, 1.02-2.19; P = 0.038) were identified as preoperative independent predictive risk factors for poor prognosis in patients with R-PDACs. In the patients with R-PDAC, 5-year survival was 60.7%, 21.5%, and 0% in patients with 0, 1 or 2, and 3 risk factors, respectively. There were significant differences in overall survival between the three groups (P < .0001).

CONCLUSIONS

A preoperative prognostic scoring system using preoperative tumor location, tumor size, and CA19-9 enables preoperative prediction of prognosis and facilitates selection of appropriate treatment for resectable pancreatic cancer.

A Single-Institution Validation Study of Lymph Node Staging By the AJCC 8th Edition for Patients with Pancreatic Head Cancer: A Proposal to Subdivide the N2 Category

BACKGROUND

According to the revised staging of the American Joint Committee on Cancer, 8th edition (AJCC8), the N category in pancreatic ductal adenocarcinoma is classified as N0 (0), N1 (1-3), and N2 (≥ 4) based on the number of metastatic lymph nodes (LNs). This study aimed to validate this classification and analyze cutoff values of metastatic LN numbers.

METHODS

Patients with pancreatic head ductal adenocarcinoma who underwent pancreaticoduodenectomy at our institution between 2005 and 2016 without preoperative therapy were retrospectively analyzed. The patients were staged by AJCC8, and prognostic analyses were performed. The best cutoff value for the metastatic LN number was determined by the minimum P value approach.

RESULTS

In 228 of 309 patients, LN metastases were found (median number of examined LNs, 41). The median survival time (MST) was 56 months in the N0 group, 34 months in the N1 group, and 20 months in the N2 group (N0 vs N1: P = 0.023; N1 vs N2: P < 0.001). The best cutoff number of metastatic LNs was 4 for patients with LN metastases and 7 for patients with N2 disease. The MST for patients with four to six positive nodes (N2a) was significantly longer than for those with seven or more positive nodes (N2b) (24.0 vs 19.1 months: P = 0.012). For N2b patients, conventional adjuvant chemotherapy did not show survival benefits (P = 0.133), and overall survival did not differ significantly from that for patients with para-aortic LN metastasis (P = 0.562).

CONCLUSION

The N staging of AJCC8 was valid. Clinicians should regard N2b as similar to distant LN metastasis, and more intensive adjuvant therapy may be indicated for this group.

Natural History and Treatment Trends in Pancreatic Cancer Subtypes

BACKGROUND

While pancreatic ductal adenocarcinoma is the most common form of pancreatic cancer, many other histologic forms of pancreatic cancer are also recognized. These histologic variants portray unique characteristics in terms of patient demographics, tumor behavior, survival, and responsiveness to treatments.

MATERIALS AND METHODS

Patients who underwent surgical resection of the pancreas for non-metastatic, invasive pancreatic cancer between 2004 and 2014 were selected from the National Cancer Data Base and categorized by histologic variant according to WHO classification guidelines. Patient demographics, tumor variables, treatment characteristics, and survival were compared between histologic groups and subgroups.

RESULTS

A total of 57,804 patients met inclusion and exclusion criteria and were grouped into eight major histologic categories. Survival analysis by the histologic group showed median overall survival of 20.2 months for ductal adenocarcinoma, 20.5 months for squamous cell carcinoma, 26.8 months for mixed acinar-neuroendocrine carcinomas, 52.6 months for cystic mucinous neoplasms with an associated invasive carcinoma, 67.5 months for acinar cell carcinoma, and 69.3 months for mesenchymal tumors. Median survival was not reached for neuroendocrine tumors and solid-pseudopapillary neoplasms, with 5-year overall survival rates of 84% and 97% respectively.

CONCLUSIONS

Rare subtypes of pancreatic cancer present unique clinicopathologic characteristics and display distinct tumor biologies. This study presents data on demographic, prognostic, treatment, and survival outcomes between rare forms of pancreatic neoplasms in order to aid understanding of the natural history and behavior of these neoplasms, with the hope of serving as a reference in clinical decision-making and ability to provide accurate prognostic information to patients.

Surgical Margin Status of Patients with Pancreatic Ductal Adenocarcinoma Undergoing Surgery with Radical Intent: Risk Factors for the Survival Impact of Positive Margins

BACKGROUND

For pancreatic ductal adenocarcinoma (PDAC), surgical margin status is an important pathological factor for evaluating surgical adequacy. In this study, we attempted to investigate predictive factors for the survival impact of positive surgical margins.

MATERIALS AND METHODS

From February 2004 to December 2013, 204 patients were diagnosed with PDAC and underwent surgery with radical intent; 189 patients fulfilled our selection criteria and were enrolled for analysis.

RESULTS

For the 189 enrolled patients with PDAC, we found male predominance (112/189, 59%) and a median age of 64 years; most patients were diagnosed with stage IIB disease (n=115, 61%). The positive surgical margin rate was 21% (n=40). Carbohydrate antigen 19-9 (CA19-9) level higher than 246 U/ml (odds ratio (OR)=2.318; 95% confidence interval (CI)=1.037-5.181 p=0.040) and lesion location in the uncinate process (OR=2.996; 95% CI=1.232-7.284 p=0.015) were the only two independent risk factors for positive surgical margins. Positive retroperitoneal soft-tissue margins were the most frequently observed (24/40, 60%). Overall, positive surgical margins had no survival impact in the 189 patients with PDAC who underwent surgery; however, positive surgical margins had an unfavorable survival impact on patients with stage IIA PDAC who underwent surgery.

CONCLUSION

Retroperitoneal soft-tissue was the most common site for positive surgical margins. Additionally, surgical margin positivity was more likely for tumors located in the uncinate process than for other tumors. Positive surgical margins had an unfavorable survival impact on patients with stage IIA PDAC who underwent surgery.

Selecting chemotherapy for pancreatic cancer: Far away or so close?

Pancreatic cancer is a lethal disease with a very poor prognosis. In contrast to treatments for many other tumor types, cytotoxic agents are still the first-line drugs for pancreatic cancer in both the palliative and adjuvant settings. Some progress has been made in recent years, but most large phase 3 studies have not shown significant improvements in survival. Because the available drugs and regimens are limited in both type and effect, the selection of chemotherapy based on clinicopathologic characteristics may be consequential for pancreatic cancer. In the present report, we focused on 7 landmark clinical trials for pancreatic cancer. We observed that FOLFIRINOX (oxaliplatin, irinotecan, fluorouracil, and leucovorin) and NG (nab-paclitaxel and gemcitabine), 2 first-line regimens, exerted opposite effects on metastatic pancreatic cancer patients with different baseline carbohydrate antigen 19-9 (CA19-9) levels. This suggested that not only the performance status but possibly also CA19-9 levels should be considered when making a therapeutic choice for patients with advanced pancreatic cancer. Moreover, we found that patients with a diagnosis of pancreatic cancer who have undergone a surgical resection with a negative margin (R0) may benefit more from fluorouracil and/or oral prodrugs of fluorouracil-based adjuvant therapy than from gemcitabine. Conversely, gemcitabine or gemcitabine-based regimens may be more effective for patients with a positive resection margin (R1). Based on these findings, we propose flowcharts for selecting chemotherapy for both advanced and resected pancreatic cancer. Furthermore, we present possible mechanisms and interpretations underlying the selection of chemotherapy for pancreatic cancer and propose the tumor burden as a key variable in this process. Regardless of the possible bias and exact treatment selection process, this study offers an opportunity to improve patient outcomes by using agents currently used in the therapy of pancreatic cancer. Although these conclusions are based on indirect evidence, we provide insights and possibilities to drive the selection of chemotherapy for pancreatic cancer.

Neoadjuvant therapy offers longer survival than upfront surgery for poorly differentiated and higher stage pancreatic cancer

BACKGROUND

Neoadjuvant therapy for pancreatic cancer remains controversial. Our aim was to assess differences in survival, disease recurrence and histopathological tumor characteristics between patients treated with neoadjuvant therapy followed by subsequent surgery and patients undergoing upfront surgery.

MATERIAL AND METHODS

Out of 399 consecutive pancreatic ductal adenocarcinoma (PDAC) patients operated at Helsinki University Hospital in 2000-2015, 75 borderline resectable patients were treated with neoadjuvant therapy. Resectable propensity scored patients (n = 150) underwent upfront surgery. Neoadjuvant therapy consisted of folfirinox, single gemcitabine or combined with cisplatin, nab-paclitaxel or capecitabine with or without radiation. Survival was calculated with Kaplan-Meier and compared with the Breslow test. Survival was determined from the start of treatment, being the first day of treatment for patients treated with neoadjuvant therapy and the date of surgery for others.

RESULTS

Between 2000 and 2015 median disease-specific survival (DSS) [34 vs. 26 months, p = .016] and disease-free survival (DFS) [22 vs. 13 months, p = .001] were longer in patients treated with neoadjuvant therapy than in those undergoing upfront surgery. Survival differences were not significant in the 2000s but were, in turn, among patients treated in the 2010s with better survival for patients treated with neoadjuvant therapy [DSS 35 vs. 26 months, p = .008 and DFS 25 vs. 13 months, p = .001]. Especially patients with poorly differentiated G3 tumors [DSS 30 vs. 11 months, p = .004 and DFS 21 vs. 7 months, p = .001] and higher stage IIB-III [DSS 34 vs. 20 months, p = .006 and DFS 21 vs. 10 months, p = .001] had longer survival when treated with neoadjuvant therapy.

CONCLUSIONS

PDAC patients treated with neoadjuvant therapy had longer DSS and DFS than those undergoing upfront surgery. Neoadjuvant therapy benefits especially borderline resectable patients with higher stage and poorly differentiated tumors.

Lymph node 8a as a prognostic marker for poorer prognosis in pancreatic and periampullary carcinoma

OBJECTIVES

An investigation of patients with pancreatic carcinoma aims to identify those who will benefit from surgery. Physical examination, radiology and laboratory findings are helpful. Most prognostic markers, such as lymph node status, micro metastasis and tumour differentiation, are not preoperatively accessible. Metastatic disease in lymph node 8a (Ln8a) in patients operated for pancreatic carcinoma has been reported to be a predictor of shorter overall survival (OS). This lymph node can be assessed preoperatively through resection (possibly even with laparoscopy) and subsequent histopathology. The value of the procedure is disputed. The aim of this study is to investigate whether metastatic disease in Ln8a is a predictor of decreased OS.

MATERIALS AND METHODS

In patients with suspected pancreatic or periampullary carcinoma, who were operated with pancreatoduodenectomy (PD), Ln8a was separately resected and analysed with standard and immuno-histochemical methods. Patients with or without metastasis in Ln8a were compared regarding OS.

RESULTS

Between 2008 and 2011, 122 consecutive patients were eligible and 87 were resected and had LN8a analysed separately. Sixteen patients were Ln8a + and 71 were Ln8a-. Patients with Ln8a + had a significantly reduced median OS as compared to patients with Ln8a- (0.74 (95% CI 0.26-1.26) versus 5.91 years (95% CI 2.91-), p < .001).

CONCLUSION

Ln8a + was associated with a marked reduction of OS, indicating a possible role in the future preoperative workup in patients with a suspicion of pancreatic cancer.

Prognostic significance of hepatocyte growth factor activator inhibitor type 1 (HAI-1) immunoreactivity in pancreatic ductal adenocarcinoma

Objective

Hepatocyte growth factor activator inhibitor type 1 (HAI-1) is a membrane-bound serine protease inhibitor that is expressed on the surface of epithelial cells. Evidence has suggested that decreased cell surface HAI-1 in carcinoma cells results in enhanced invasiveness. However, little is known regarding the expression of HAI-1 in pancreatic ductal adenocarcinoma (PDAC). This study aimed to analyze HAI-1 expression in PDAC and its impact on patient prognosis.

Results

HAI-1 immunohistochemistry was performed on samples from 67 PDAC cases. HAI-1 expression was increased in intraepithelial neoplasia compared to the adjacent non-neoplastic ductal epithelium. Of the 67 samples tested, 58% (39/67) of PDAC cases showed diffuse (> 75%) immunoreactivity in PDAC cells. The remaining cases showed reduced HAI-1 immunoreactivity in a substantial number of cancer cells. Although there was no correlation between HAI-1 status and tumor size, histologic grade or lymph node metastasis, diffuse HAI-1 positive cases showed longer disease-free survival (DFS; p = 0.006, log-rank test). In conclusion, HAI-1 is upregulated in pancreatic intraepithelial neoplasia and broadly expressed in PDAC cells. However, PDAC cases having areas of reduced HAI-1 immunoreactivity may show shorter DFS.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3014-x) contains supplementary material, which is available to authorized users.

Relationship between autophagy and perineural invasion, clinicopathological features, and prognosis in pancreatic cancer

AIM

To investigate the relationship between autophagy and perineural invasion (PNI), clinical features, and prognosis in patients with pancreatic cancer.

METHODS

Clinical and pathological data were retrospectively collected from 109 patients with pancreatic ductal adenocarcinoma who underwent radical resection at the First Affiliated Hospital of Zhengzhou University from January 2011 to August 2016. Expression levels of the autophagy-related protein microtubule-associated protein 1A/1B-light chain 3 (LC3) and PNI marker ubiquitin carboxy-terminal hydrolase (UCH) in pancreatic cancer tissues were detected by immunohistochemistry. The correlations among LC3 expression, PNI, and clinical pathological features in pancreatic cancer were analyzed. The patients were followed for further survival analysis.

RESULTS

In 109 cases of pancreatic cancer, 68.8% (75/109) had evidence of PNI and 61.5% (67/109) had high LC3 expression. PNI was associated with lymph node metastasis, pancreatitis, and CA19-9 levels (P < 0.05). LC3 expression was related to lymph node metastasis (P < 0.05) and was positively correlated with neural invasion (P < 0.05, r = 0.227). Multivariate logistic regression analysis indicated that LC3 expression, lymph node metastasis, pancreatitis, and CA19-9 level were factors that influenced neural invasion, whereas only neural invasion itself was an independent factor for high LC3 expression. Univariate analysis showed that LC3 expression, neural invasion, and CA19-9 level were related to the overall survival of pancreatic cancer patients (P < 0.05). Multivariate COX regression analysis indicated that PNI and LC3 expression were independent risk factors for poor prognosis in pancreatic cancer (P < 0.05).

CONCLUSION

PNI in patients with pancreatic cancer is positively related to autophagy. Neural invasion and LC3 expression are independent risk factors for pancreatic cancer with a poor prognosis.

神经营养因子和趋化因子与胰腺癌神经浸润的研究进展

胰腺癌癌细胞浸润神经组织, 沿神经或进入神经束膜内沿束膜间隙浸润生长, 即发生神经浸润(perineural invasion, PNI). PNI是特殊的肿瘤转移通路, 在胰腺癌中的发生率极高, 为胰腺癌的重要生物学特性之一, 被认为是导致胰腺癌手术后高复发率和胰腺癌相关疼痛的最主要原因之一, 与患者不良预后和低存活率密切相关. PNI发生的机制十分复杂, 涉及多种生物分子和信号途径. 神经营养因子和趋化因子参与相关信号通路, 促进癌细胞神经交互作用, 导致胰腺癌PNI发生, 在胰腺癌PNI中扮演重要角色. 本文将神经营养因子家族和趋化因子与胰腺癌PNI的研究进展作一综述.