En bloc vascular resection for the treatment of borderline resectable pancreatic head carcinoma

Verification of Resectability Status for Pancreatic Cancer: Radiological and Pathological Analysis of Patients Undergoing Pancreatoduodenectomy With Combined Resection of the Superior Mesenteric Artery

OBJECTIVES

Resectability status is considered an important indicator for progression of pancreatic cancer. We verified the superior mesenteric artery (SMA) factors of resectability status by radiological and pathological analysis in patients who underwent pancreatoduodenectomy with combined resection of the SMA.

METHODS

We enrolled 22 patients who underwent pancreatoduodenectomy with combined resection of the SMA. Patients were divided into 3 groups according to the contact angle between the tumor and the SMA in preoperative computed tomography images (no contact, R-sma; contact within 180 degrees, BR-sma; contact more than 180 degrees, UR-sma). We pathologically evaluated cancer progression toward the SMA.

RESULTS

There were 3 patients with R-sma, 12 with BR-sma, and 7 with UR-sma. The median distance (mm) between the cancer and the SMA was 7.0 with R-sma, 1.0 with BR-sma, and 0 with UR-sma (P = 0.0003). Invasion to the superior mesenteric nerve plexus was positive in none with R-sma, 11 with BR-sma, and 7 with UR-sma (P < 0.0001). Invasion to the SMA was positive in none with R-sma and BR-sma, and 7 with UR-sma (P < 0.0001).

CONCLUSIONS

Superior mesenteric artery factors of resectability status are reliable indicator for cancer progression toward the SMA.

A phase I study of preoperative (neoadjuvant) chemotherapy with gemcitabine plus nab-paclitaxel for resectable pancreatic cancer

Neoadjuvant chemotherapy (NAC) has become a standard treatment for borderline resectable pancreatic ductal adenocarcinoma (PDAC). The present study examined the maximum tolerated dose of NAC with gemcitabine plus nab-paclitaxel (GnP) in patients with resectable PDAC. Between 2015 and 2019, 39 patients with resectable PDAC were enrolled in the present study. GnP was administered for two 28-day cycles on days 1, 8 and 15. The planned doses for levels 1, 2 and 3 were 75, 100 and 125 mg/m2, respectively, for nab-paclitaxel and 600, 800 and 1,000 mg/m2, respectively, for gemcitabine. Dose-limiting toxicity (neutropenia, anemia, thrombocytopenia and/or liver injury) was observed in 44.4% of patients treated at dose level 1 (21 patients) and 60.0% of those treated at dose level 2 (18 patients). Therefore, the maximum tolerated dose was set as level 1. Six patients withdrew from protocol treatment because of non-hematologic adverse events (skin rash, pancreatitis and biliary tract infection). Among the 31 patients with pathologically confirmed PDAC, partial response, stable disease and disease progression were recorded in 4 (12.9%), 24 (77.4%) and 3 (9.7%) patients, respectively. NAC significantly reduced tumor size according to computed tomography, and CA19-9 levels and the 18F-fluorodeoxyglucose maximum standardized uptake value were decreased in positron emission tomography. No postoperative complications attributable to NAC were recognized. Among the 27 patients with PDAC who underwent resection, the pathological treatment effect was judged as grades Ia, Ib and II in 21 (77.8%), 4 (14.8%) and 2 (7.4%) patients, respectively. R0 resection was performed in 24 out of 27 patients (88.9%). Adjuvant chemotherapy with oral S-1 was administered to 21 out of 27 patients (77.8%). In conclusion, NAC with GnP was safe and feasible for resectable PDAC at dose level 1. In the future, verification of the long-term results of the present study will be necessary, and a phase II clinical trial is anticipated.

Prognostic analysis of pancreatic carcinoma with portal system invasion following curative resection

Background

To analyze the related factors affecting the prognosis of pancreatic carcinoma with portal system invasion.

Methods

We retrospectively analyzed the clinical data of 118 patients with portal venous system invasion in Beijing Chaoyang Hospital between January 2011 and December 2018. Only patients with borderline resectable pancreatic cancer were included in this study. Borderline pancreatic cancer was defined according to NCCN (The National Comprehensive Cancer Network) guidelines. All patients underwent surgical treatment combined with vascular resection and reconstruction. The prognosis was evaluated according to the follow-up results, and the related risk factors for prognosis were analyzed. The survival curve was drawn by Kaplan-Meier method, and the survival rate was compared by log-rank test. Multivariate Cox regression was used to analyze the prognostic factors.

Results

In our research, all of 126 patients were successfully completed the operations. Complications occurred in 29.7% of patients and perioperative death in 4.0%. A total of 118 patients were followed up and the followed-up rate was 97.5% (118/121). The overall 1-year, 2-year and 3-year survival rates were 49.2%, 27.1% and 19.8%, And the median survival time was 20 months. Multivariate analysis showed that preoperative CA19-9 (RR 1.449, 95% CI: 1.053-1.994), N status (RR 2.533, 95% CI: 1.337-4.798), degree of tumor differentiation (RR 1.592, 95% CI: 1.064-2.381) and venous invasion depth (RR 2.03, 95% CI: 1.504-2.758) were independent risk factors for the prognosis.

Conclusions

The long-term prognosis of pancreatic carcinoma patients with portal system invasion is poor. The venous invasion depth is an independent risk factor for the prognosis of pancreatic carcinoma with portal system invasion, the deeper of venous invasion, the worse the prognosis, and poorly differentiated tumors have the worst prognosis. Other independent risk factors included N status and the preoperative CA19-9. Those may help with patients' selection for different treatment protocols.

Neoadjuvant chemotherapy with gemcitabine-based regimens improves the prognosis of node positive resectable pancreatic head cancer

The effectiveness of preoperative (neoadjuvant) chemotherapy (NAC) for resectable pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study retrospectively evaluated the efficacy of NAC with gemcitabine (GEM)-based regimens or GEM monotherapy for resectable PDAC. Between 2006 and 2015, NAC with GEM was performed in 52 cases (head 31, and body and tail 21) and compared with 34 resection-only cases serving as controls (head 20, and body and tail 14). According to the Response Evaluation Criteria In Solid Tumors guidelines, the treatment effect was a partial response in 5 cases, stable disease in 45 cases, and progressive disease in 2 cases. Maximum standardized uptake values and carbohydrate antigen (CA19-9) values were significantly reduced after preoperative chemotherapy. Using the Evans grading system, the treatment effect was grade I in 31 patients, grade IIa in 8, and grade IIb in 3 cases. There were significant differences in the overall survival rate between the NAC and control groups, only in the patients with node-positive pancreatic head cancer. Significantly higher CA19-9 values in peripheral blood and higher lymph node metastasis and plexus invasion rates were observed in early-recurring cases within a year. The preoperative CA 19-9 cutoff value as an early recurrence risk factor was calculated as 30 U/ml in the NAC group and 88 U/ml in the control group. NAC with GEM prolonged survival in patients with node-positive pancreatic head cancer. High CA19-9 values before operation, lymph node metastases and plexus invasion were risk factors for early tumor recurrence after surgery. Preoperative chemotherapy would be necessary for resectable pancreatic head cancer as lymph node metastasis was observed in >60% with resectable PDAC. Moreover, if normalization of CA19-9 values is not achieved with NAC, extension of preoperative chemotherapy should be considered as for borderline resectable PDAC cases.

Systematic review of the mesopancreas: concept and clinical implications

BACKGROUND

In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP.

METHODS

An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian).

RESULTS

The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series.

CONCLUSION

MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.

Location of the meso-pancreatoduodenum as a regional lymphatic basin for pancreatic head carcinoma

The meso-pancreatoduodenum is the primary site of tumor infiltration in patients with pancreatic head cancer, with numerous patients exhibiting lymph node metastases. Effective dissection of the regional lymphatic basin requires knowledge of the patterns of the arterial branches. The present study examined the patterns of the arteries feeding the pancreatic head and the distribution of the meso-pancreatoduodenum. The present study included 123 patients with pancreatic cancer who underwent contrast-enhanced preoperative 64-multidetector-computed tomography to determine the routes of the inferior pancreaticoduodenal and first jejunal arteries. Surgical specimens and cadavers were also evaluated histologically to clarify the distribution of the meso-pancreatoduodenum. The feeding arteries were divided into three types, with 64.2% of patients having type A, 28.4% having type B and 7.3% having type C branches. The branches emerged from the back or left side of the superior mesenteric artery and ran to the far side of the pancreatic head in an arc. Consequently, the meso-pancreatoduodenum had a roll-shaped appearance, surrounding the trunk arteries and extending to the left side of the superior mesenteric artery. Dissecting the right and left sides of the superior mesenteric artery during lymphadenectomy could improve the effectiveness of resection.

Neoadjuvant chemotherapy for pancreatic cancer: Effects on cancer tissue and novel perspectives

Chemotherapy for pancreatic cancer has diversified following the addition of more treatment regimens; however, in spite of this, pancreatic cancer remains a fatal disease. Preoperative (neoadjuvant) chemotherapy (NAC) or neoadjuvant chemoradiation therapy (NACRT) has been developed and implemented. For patients with borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), a number of clinical trials have been conducted; NACRT was demonstrated to improve resectability, R0 resection rate, overall survival rate, disease-free survival rate and even an LAPC and BRPC survival advantage over NAC. However, from the knowledge obtained from resected specimens following preoperative treatment, residual pancreatic cancer tissues following NAC are rich in chemoresistant cancer stem-like cells and epithelial-mesenchymal transition (EMT) markers. Conversely, metformin, angiotensin receptor blocker, statins and low-dose paclitaxel are well-known as drugs that inhibit EMT, which is associated with cancer stem cell-like characteristics. Although clinical effectiveness is unlikely to be achieved using one of these as an anticancer agent, it is reasonable to use these drugs for patients with comorbidities in the treatment of pancreatic cancer. Furthermore, gemcitabine (GEM) affects antitumor immunity by stimulating the expression of major histocompatibility complex class I-related chain A on the surface of cancer cells to enhance the cytotoxicity of natural killer cells. Considering EMT and antitumor immunity, there is a possibility that GEM and nanoparticle albumin-bound paclitaxel therapy is the most suitable regimen for treating pancreatic cancer. However, even as preoperative treatment progresses, R0 resection is the most important factor for the long-term survival of pancreatic cancer patients.

Hind right approach pancreaticoduodenectomy: from skill to indications

Background. Pancreaticoduodenectomy is the potentially curative treatment for malignant and several benign conditions of the pancreatic head and periampullary region. While performing pancreaticoduodenectomy, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels, intraductal papillary mucinous neoplasm, and pancreatic head bleeding pseudoaneurysm. Our work aims to highlight a particular hind right approach pancreaticoduodenectomy in selected indications and assess the preliminary results. Methods. We describe our early hind right approach to the retropancreatic vasculature during pancreaticoduodenectomy by mesopancreas dissection before any pancreatic or digestive transection. Results. We used this approach in 52 patients. Thirty-two had hepatic artery anatomic variant and 2 had bleeding pancreatic head pseudoaneurysm. The hepatic artery variant was preserved in all cases out of 2 in which arterial reconstruction was performed. In nine patients with intraductal papillary mucinous neoplasms the pancreaticoduodenectomy was extended to the body in 6 and totalized in 3 patients. Seven patients with adenocarcinoma involving the portomesenteric axis required venous resection and reconstruction. Conclusions. Early hind right approach is advocated in selected cases of pancreaticoduodenectomy to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement.