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Cobianchi L, Dal Mas F, Abu Hilal M, Adham M, Alfieri S, Balzano G, Barauskas G, Bassi C, Besselink MG, Bockhorn M, Boggi U, Conlon KC, Coppola R, Dervenis C, Dokmak S, Falconi M, Fusai GK, Gumbs AA, Ivanecz A, Memeo R, Radenković D, Ramia JM, Rangelova E, Salvia R, Sauvanet A, Serrablo A, Siriwardena AK, Stättner S, Strobel O, Zerbi A, Malleo G, Butturini G, Frigerio I. Toward a new paradigm of care: a surgical leaders' Delphi consensus on the organizational factors of the new pancreas units (E-AHPBA PUECOF study). Updates Surg 2024:10.1007/s13304-024-01839-x. [PMID: 38662309 DOI: 10.1007/s13304-024-01839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Abstract
Pancreas units represent new organizational models of care that are now at the center of the European debate. The PUECOF study, endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), aims to reach an expert consensus by enquiring surgical leaders about the Pancreas Units' most relevant organizational factors, with 30 surgical leaders from 14 countries participating in the Delphi survey. Results underline that surgeons believe in the need to organize multidisciplinary meetings, nurture team leadership, and create metrics. Clinical professionals and patients are considered the most relevant stakeholders, while the debate is open when considering different subjects like industry leaders and patient associations. Non-technical skills such as ethics, teamwork, professionalism, and leadership are highly considered, with mentoring, clinical cases, and training as the most appreciated facilitating factors. Surgeons show trust in functional leaders, key performance indicators, and the facilitating role played by nurse navigators and case managers. Pancreas units have a high potential to improve patients' outcomes. While the pancreas unit model of care will not change the technical content of pancreatic surgery, it may bring surgeons several benefits, including more cases, professional development, easier coordination, less stress, and opportunities to create fruitful connections with research institutions and industry leaders.
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Affiliation(s)
- Lorenzo Cobianchi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Via Alessandro Brambilla, 74, 27100, Pavia, Italy.
- Pancreas Unit Directorship, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
- Collegium Medicum, University of Social Sciences, Łodz, Poland.
| | - Francesca Dal Mas
- Collegium Medicum, University of Social Sciences, Łodz, Poland
- Department of Management - Venice School of Management, Ca' Foscari University, Venice, Italy
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Mustapha Adham
- Department of Hepato-Biliary and Pancreatic Surgery, Edouard Herriot Hospital, Hospices Civils De Lyon, Lyon, France
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Gianpaolo Balzano
- Pancreatic and Transplant Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, ENETS Center of Excellence, Milan, Italy
| | - Giedrius Barauskas
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Maximilian Bockhorn
- Department of General and Visceral Surgery, University Medical Centre Oldenburg, Oldenburg, Germany
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Kevin C Conlon
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland
- Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Roberto Coppola
- General Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Christos Dervenis
- Department of Hepatobiliary and Pancreatic Surgery, Metropolitan Hospital, Piraeus, Greece
| | - Safi Dokmak
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, GHU AP-HP.Nord-Université Paris Cité, Paris, France
| | - Massimo Falconi
- Pancreatic and Transplant Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, ENETS Center of Excellence, Milan, Italy
| | - Giuseppe Kito Fusai
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Andrew A Gumbs
- Advanced & Minimally Invasive Surgery Excellence Center, Department of Surgery, American Hospital Tbilisi, Tbilisi, Georgia
| | - Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva Delle Fonti, Italy
| | - Dejan Radenković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinical Center of Serbia, Clinic of Digestive Surgery, Belgrade, Serbia
| | - Jose M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Section for Upper Abdominal Surgery at Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roberto Salvia
- Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
- General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alain Sauvanet
- Université Paris Cité, Centre de Recherche Sur l'InflammationInserm, Paris, France
- Department of Hepatobiliary Surgery, APHP Nord Beaujon Hospital, Clichy, France
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Centre for Hepatobiliary Surgery, Vöcklabruck, Austria
| | | | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery Unit, Humanitas Research Hospital -IRCCS, Rozzano, Italy
| | - Giuseppe Malleo
- Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
- General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Butturini
- Department of HPB Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Isabella Frigerio
- Department of HPB Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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Piemonti L, Melzi R, Aleotti F, Capretti G, Nano R, Mercalli A, Magistretti P, Caldara R, Pecorelli N, Catarinella D, Gremizzi C, Gavazzi F, De Cobelli F, Poretti D, Falconi M, Zerbi A, Balzano G. Autologous Pancreatic Islet Cell Transplantation Following Pancreatectomy for Pancreas Diseases Other Than Chronic Pancreatitis: A 15-Y Study of the Milan Protocol. Transplantation 2024:00007890-990000000-00735. [PMID: 38637923 DOI: 10.1097/tp.0000000000005037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Pancreatogenic diabetes, a consequence of pancreatic tissue loss following pancreatectomy, poses a significant challenge for patients undergoing pancreatic surgery. Islet autotransplantation (IAT) offers a promising approach to prevent or alleviate pancreatogenic diabetes, but its application has been limited to individuals with painful chronic pancreatitis. METHODS This study presents a 15-y clinical experience with the Milan Protocol, which expands IAT after pancreatectomy to a broader spectrum of patients with malignant and nonmalignant pancreatic diseases. The analysis evaluates feasibility, efficacy, and safety of IAT. Modified Igls criteria validated through the arginine test and mixed meal tolerance tests were used to assess long-term metabolic outcomes. RESULTS Between November 2008 and June 2023, IAT procedures were performed on 114 of 147 candidates. IAT-related complications occurred in 19 of 114 patients (16.7%), with 5 being potentially serious. Patients exhibited sustained C-peptide secretion over the 10-y follow-up period, demonstrating a prevalence of optimal and good beta-cell function. Individuals who underwent partial pancreatectomy demonstrated superior metabolic outcomes, including sustained C-peptide secretion and a reduced risk of developing diabetes or insulin dependence compared with those who underwent total pancreatectomy. For patients who had total pancreatectomy, the quantity of infused islets and tissue volume were identified as critical factors influencing metabolic outcomes. An increased risk of recurrence or progression of baseline diseases was not observed in subjects with neoplasms. CONCLUSIONS These findings provide valuable insights into the benefits and applications of IAT as a therapeutic option for pancreatogenic diabetes after pancreatic surgery, expanding its potential beyond painful chronic pancreatitis.
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Affiliation(s)
- Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Aleotti
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rossana Caldara
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Davide Catarinella
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Gremizzi
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Massimo Falconi
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gianpaolo Balzano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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3
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Boggi U, Kauffmann E, Napoli N, Barreto SG, Besselink MG, Fusai GK, Hackert T, Abu Hilal M, Marchegiani G, Salvia R, Shrikhande S, Truty M, Werner J, Wolfgang C, Bannone E, Capretti G, Cattelani A, Coppola A, Cucchetti A, De Sio D, Di Dato A, Di Meo G, Fiorillo C, Gianfaldoni C, Ginesini M, Hidalgo Salinas C, Lai Q, Miccoli M, Montorsi R, Pagnanelli M, Poli A, Ricci C, Sucameli F, Tamburrino D, Viti V, Addeo PF, Alfieri S, Bachellier P, Baiocchi G, Balzano G, Barbarello L, Brolese A, Busquets J, Butturini G, Caniglia F, Caputo D, Casadei R, Chunhua X, Colangelo E, Coratti A, Costa F, Crafa F, Dalla Valle R, De Carlis L, de Wilde RF, Del Chiaro M, Di Benedetto F, Di Sebastiano P, Domak S, Hogg M, Egorov VI, Ercolani G, Ettorre GM, Falconi M, Ferrari G, Ferrero A, Filauro M, Giardino A, Grazi GL, Gruttaduaria S, Izbicki JR, Jovine E, Katz M, Keck T, Khatkov I, Kiguchi G, Kooby D, Lang H, Lombardo C, Malleo G, Massani M, Mazzaferro V, Memeo R, Miao Y, Mishima K, Molino C, Nagakawa Y, Nakamura M, Nardo B, Panaro F, Pasquali C, Perrone V, Rangelova E, Riu L, Romagnoli R, Romito R, Rosso E, Schulick R, Siriwardena A, Spampinato M, Strobel O, Testini M, Troisi R, Uzunoglo FG, Valente R, Veneroni L, Zerbi A, Vicente E, Vistoli F, Vivarelli M, Wakabayashi G, Zanus G, Zureikat A, Zyromski NJ, Coppola R, D'Andrea V, Davide J, Dervenis C, Frigerio I, Konlon KC, Michelassi F, Montorsi M, Nealon W, Portolani N, Sousa Silva D, Bozzi G, Ferrari V, Trivella MG, Cameron J, Clavien PA, Asbun HJ. REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer. Ann Surg 2024:00000658-990000000-00795. [PMID: 38407228 DOI: 10.1097/sla.0000000000006248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
OBJECTIVE The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). SUMMARY BACKGROUND DATA Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking. METHODS The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines. RESULTS Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ). CONCLUSIONS The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Emanuele Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - S George Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia, Division of Surgery and Perioperative Medicine, Flinders Medical Center, Beadfor Park, Australia
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giovanni Marchegiani
- Hepatopancreatobiliary and Liver Transplant Surgery, Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Shailesh Shrikhande
- Tata Memorial Hospital, Gastrointestinal and HPB Service, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Mark Truty
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, LMU, University of Munich, Germany
| | - Christopher Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisa Bannone
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Alice Cattelani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC; Alma Mater Studiorum Università di Bologna; Bologna, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) University of Bari, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | - Quirino Lai
- Department of General and Specialty Surgery, Sapienza University of Rome, AOU Policlinico Umberto I of Rome, Rome, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Montorsi
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Andrea Poli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy, Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna (IRCCS AOUBO)
| | - Francesco Sucameli
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Pietro F Addeo
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Philippe Bachellier
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gianluca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia and UOC General Surgery, ASST Cremona, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Linda Barbarello
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Alberto Brolese
- Department of General Surgery & HPB Unit, APSS, Trento, Italy
| | - Juli Busquets
- Division of Pancreatobiliary Surgery and Liver Transplantation, Department of Surgery, Bellvitge University Hospital, IDIBELL, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Giovanni Butturini
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Fabio Caniglia
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Damiano Caputo
- Research Unit of General Surgery, Department of Medicine and Surgery, University Campus Bio-Medico di Roma, Via Alvaro del Portillo 200,00128 Rome, Italy
- Operative Research Unit of General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy, Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna (IRCCS AOUBO)
| | - Xi Chunhua
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Institute, Nanjing Medical University
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
| | - Ettore Colangelo
- Department of General Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Andrea Coratti
- Department of General and Emergency Surgery, AUSL Toscana Sud Est, Misericordia Hospital of Grosseto, Italy
| | - Francesca Costa
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Francesco Crafa
- Division of General, Oncological and Robotic Surgery, San Giuseppe Moscati Hospital, Avellino Italy
| | | | - Luciano De Carlis
- Division of HPB Surgery and Transplantation, Niguarda Hospital , University of Milano-Bicocca, Milan, Italy
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado School of Medicine. Aurora, Colorado, USA
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Pierluigi Di Sebastiano
- Surgical Oncology, Pierangeli Clinic, Department of Innovative Technology in Medicine & Dentistry, G. D'Annunzio University Chieti-Pescara, Italy
| | - Safi Domak
- department of HPB surgery and liver transplantation, Beaujon hospital, Clichy, France. University Paris Cité, Paris, France
| | - Melissa Hogg
- Division of HPB Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Vyacheslav I Egorov
- Department for Surgical Oncology and HPB Surgery, Ilyinskaya Hospital, Moscow, Russia
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences - DIMEC; Alma Mater Studiorum Università di Bologna; Bologna, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Transplantation. San Camillo Forlanini Hospital-POIT. Rome, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, "Umberto I" Mauriziano Hospital, Turin, Italy
| | - Marco Filauro
- Department of Surgery Galliera Hospital, Genova, Italy
| | - Alessandro Giardino
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Gian Luca Grazi
- Division of HepatoBiliaryPancreatic Surgery, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Salvatore Gruttaduaria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center Italy (UPMC Italy), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Jakob R Izbicki
- Department of general visceral and thoracic surgery, University Hospital Eppendorf University of Hamburg, Hamburg, Germany
| | - Elio Jovine
- Department of Surgery, Alma Mater Studiorum University of Bologna, IRCCS Azienda Ospedaliera Universitaria di Bologna
| | - Matthew Katz
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of High Technology Surgery, Moscow Clinical Scientific Center. Moscow, Russia
| | - Gozo Kiguchi
- Department of Surgery, Hirakata Kohsai Hospital, Osaka, Japan
| | - David Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hauke Lang
- University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - Carlo Lombardo
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-oncology, University of Milan HPB Surgery and Liver Transplantation Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Riccardo Memeo
- Department of HPB Surgery, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Institute, Nanjing Medical University
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Kohei Mishima
- Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Carlo Molino
- Department of General and Speciality Surgery, General and Pancreatic Surgery Team 1, AORN A. Cardarelli, Naples, Italy
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Bruno Nardo
- Division of General Surgery, Department of Surgery and Robotic, Annunziata Hub Hospital, School of Medicine Surgery and TD, University of Calabria, Cosenza, Italy
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery & Transplantation. Montpellier University Hospital School of Medicine, Montpellier, France
| | - Claudio Pasquali
- Pancreatic & Digestive Endocrine Surgery Research Group - Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Vittorio Perrone
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Elena Rangelova
- Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery at the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Long Riu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Renato Romagnoli
- Division of General Surgery 2U - Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Raffaele Romito
- Division of General Surgery II and HPB Unit, A.O.U. Maggiore della Carità di Novara, Novara, Italy
| | - Edoardo Rosso
- Service de Chirurgie Générale, Mini-Invasive et Robotique, Centre Hôspitalier de
| | - Richard Schulick
- Department of Surgery, University of Colorado School of Medicine. Aurora, Colorado, USA
| | - Ajith Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Marcello Spampinato
- Department of General and Minimally Invasive Surgery, "Vito Fazzi" Hospital, Lecce, Italy Luxembourg, Luxembourg, Luxembourg
| | - Oliver Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) University of Bari, Italy
| | - Roberto Troisi
- Division of HBP, Minimally Invasive and Robotic Surgery, Transplantation Service Federico II University Hospital - Naples, Italy
| | - Faik G Uzunoglo
- Department of general visceral and thoracic surgery, University Hospital Eppendorf University of Hamburg, Hamburg, Germany
| | | | - Luigi Veneroni
- Chirurgia Generale, Infermi Hospital Rimini, AUSL Romagna, Rimini, Italy
| | | | - Emilio Vicente
- Sanchinarro University Hospital, General Surgery Department, San Pablo University, CEU, Madrid, Spain
| | - Fabio Vistoli
- Division of General Surgery and Transplantation, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Vivarelli
- Division of Hepatobiliary, Pancreatic and Transplantation Surgery, Polytechnic University of Marche, Ospedali Riuniti delle Marche, Ancona, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Giacomo Zanus
- Second Division of Surgery-Treviso-Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Amer Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Roberto Coppola
- Research Unit of General Surgery, Department of Medicine and Surgery, University Campus Bio-Medico di Roma, Via Alvaro del Portillo 200,00128 Rome, Italy
- Operative Research Unit of General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vito D'Andrea
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - José Davide
- Department of Surgery, HEBIPA - Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - Isabella Frigerio
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Kevin C Konlon
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Fabrizio Michelassi
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital at Weill Cornell, New Yourk, NY, USA
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Italy
- Division of General and Digestive Surgery, Department of General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - William Nealon
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Zucker School of Medicine at Hofstra, New Hyde Park, NY, USA
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - Donzília Sousa Silva
- Department of Surgery, HEBIPA - Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | | | | | - John Cameron
- Department of Surgery, John Hopkins University School of Medicine, Baltimore, MD
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
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Kuemmerli C, Balzano G, Bouwense SA, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillarisetty VG, Pucci MJ, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Armstrong M, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Rozzini R, Abu Hilal M. Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis. J Hepatobiliary Pancreat Sci 2024. [PMID: 38282543 DOI: 10.1002/jhbp.1417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). METHODS Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70-79 years) and older patients (≥80 years). RESULTS IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65-1.29], p = .596 and OR 1.22 [95% CI: 0.61-2.46], p = .508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (-0.14 days [95% CI: -0.29 to 0.01], p = .071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (-0.28 days [95% CI: -0.62 to 0.05], p = .069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (-0.36 days [95% CI: -0.71 to -0.004], p = .048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. CONCLUSION ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases Basel, Basel, Switzerland
| | - Gianpaolo Balzano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sara K Daniel
- HPB Surgery, University of Washington, Seattle, Washington, USA
| | | | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Michael J Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | | | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Misha Armstrong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Athens, Greece
| | - Renzo Rozzini
- Geriatrics Operating Units, Foundation Poliambulanza, Brescia, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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5
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Pecorelli N, Guarneri G, Vallorani A, Limongi C, Licinio AW, Di Salvo F, Crippa S, Partelli S, Balzano G, Falconi M. Recovery of health-related quality of life after laparoscopic versus open distal pancreatectomy. Surg Endosc 2024; 38:327-338. [PMID: 37759144 DOI: 10.1007/s00464-023-10453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Limited data comparing recovery of health-related quality of life (HRQoL) after laparoscopic (LDP) versus open distal pancreatectomy (ODP) are available. The aim of this study was to assess the impact of laparoscopy on postoperative HRQOL after DP using the Patient-Reported Outcomes Measurement Information System (PROMIS). METHODS Data from consecutive patients who underwent DP (2020-2022) enrolled in a prospective clinical trial were reviewed. Patients completed PROMIS-29 plus 2 profile preoperatively, at postoperative day (POD) 15, 30, 90, and 180. Linear regression analysis adjusting for confounders including preoperative PROMIS scores, age, gender, ASA score, diagnosis, and multivisceral resection was used to estimate mean between-group differences (MD) in postoperative PROMIS domains T scores. RESULTS Overall, 202 patients (118 laparoscopic, 86 open) underwent DP (median age 66 years, pancreatic cancer 41%, multivisceral resection 10%, median LOS 6 days). At POD15, LDP was associated with higher physical function (MD 5.6) and participation in social roles and activities scores (MD 3.8), reduced fatigue (MD - 2.7) and sleep disturbance (MD - 3.8) compared to ODP. At POD30, LDP patients had higher physical function (MD 5.2) and participation in social roles and activities scores (MD 6.0), reduced fatigue (MD - 3.5), and anxiety (MD - 4.0) compared to ODP. No between-group differences were found in HRQoL domains at POD90 and 180. Six months after surgery, the proportions of patients who had not recovered to preoperative physical function, participation in social roles and activities, fatigue, pain interference, sleep disturbance, cognitive function, depression, and anxiety were 31%, 31%, 28%, 20%, 15%, 14%, 8%, and 7%, respectively. CONCLUSIONS According to PROMIS, LDP resulted in improved physical and social functioning and reduced anxiety and fatigue up to 30 days after surgery compared to ODP. At 6 months after surgery, recovery of physical domains is still incomplete in up to 30% of patients.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | | | | | | | - Francesca Di Salvo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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6
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Andreasi V, Partelli S, Muffatti F, Battistella A, Fermi F, Balzano G, Crippa S, Tamburrino D, Pecorelli N, De Cobelli F, Arcidiacono PG, Falconi M. Diagnostic work-up and surgical management of insulinoma: A retrospective analysis from a tertiary referral center. J Neuroendocrinol 2023; 35:e13353. [PMID: 37915303 DOI: 10.1111/jne.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/05/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Abstract
Insulinoma is a multifaceted disease that poses several challenges in terms of clinical presentation, diagnostic work-up, and surgical management. The aim of this study was to describe diagnostic work-up, surgical management, and postoperative outcomes of patients with insulinoma. All consecutive patients who underwent surgery for insulinoma at San Raffaele Hospital (Milan, Italy) between January 2008 and January 2022 were included. Overall, 98 patients were considered. The median delay between presenting symptoms and insulinoma diagnosis was 10 months (IQR, 4-21). Insulinoma diagnosis was made at our Institution in 45 patients, 20 of whom referred within 6 months from symptoms onset. In this subgroup, the median interval between symptoms presentation and insulinoma diagnosis was 4 months (IQR, 2-6), as compared to 14 months (IQR, 10-26) in patients (n = 25) who referred to our institution after 6 months from symptoms onset (p < .001). The insulinoma was localized preoperatively in all the cases. All patients underwent ≥1 high-quality imaging: computed tomography (CT: n = 87, sensitivity 84%), magnetic resonance imaging (MRI: n = 55, sensitivity 85%) and endoscopic ultrasound (EUS: n = 79, sensitivity 100%). MRI identified the tumor in eight patients with negative CT. EUS localized the insulinoma in three patients with negative CT and negative MRI. Parenchyma-sparing resections were performed in 41 patients. Contact with major vessels, lesion close to Wirsung duct and suspect of malignancy were the main reasons to perform a formal resection. An early referral to high-volume centers is important for reducing diagnostic delay in patients with insulinoma. The diagnostic work-up of insulinoma frequently requires several imaging modalities to be performed, with EUS being the most sensitive one. Parenchyma-sparing surgery for insulinoma should be performed whenever technically and oncologically feasible.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Anna Battistella
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Fermi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Radiology & Center for Experimental Imaging, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Hospital Neuroendocrine Tumor Group (ENETS Center of Excellence), IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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7
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De Monte L, Clemente F, Ruggiero E, Pini R, Ceraolo MG, Schiavo Lena M, Balestrieri C, Lazarevic D, Belfiori G, Crippa S, Balzano G, Falconi M, Doglioni C, Bonini C, Reni M, Protti MP. Pro-tumor Tfh2 cells induce detrimental IgG4 production and PGE 2-dependent IgE inhibition in pancreatic cancer. EBioMedicine 2023; 97:104819. [PMID: 37776595 PMCID: PMC10542011 DOI: 10.1016/j.ebiom.2023.104819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/12/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis and it is characterized by predominant pro-tumor Th2-type inflammation. T follicular helper (Tfh) cells are relevant immunoregulators in cancer, and often correlate with better survival. How the Th2-skewed microenvironment in PDAC modulates the differentiation of Tfh cells and their immunoregulatory function is unknown. METHODS We carried out high-dimensional flow cytometry and T-cell receptor- and RNA-sequencing, as well as bioinformatics, immunohistochemistry and in vitro mechanistic studies. FINDINGS We identified Tfh1-, Tfh2-, and Tfh17-like cell clusters in the blood, tumors and tumor-draining lymph-nodes (TDLNs) of chemo-naïve PDAC patients and showed that high percentages of Tfh2 cells within the tumor tissue and TDLNs correlated with reduced patient survival. Moreover, only Tfh2 cells were highly activated and were reduced in frequency in patients who responded to neoadjuvant chemotherapy. RNA-sequencing analysis of immunoglobulin expression showed that tumor and TDLN samples expressed all immunoglobulin (IGH) isotypes apart from IGHE. Consistent with these findings, Tfh2 cells differentiated in vitro by tumor microenvironment-conditioned dendritic cells promoted the production of anti-inflammatory IgG4 antibodies by co-cultured B cells, dependent on IL-13. Moreover, unexpectedly, Tfh2 cells inhibited the secretion of pro-inflammatory IgE, dependent on prostaglandin E2. INTERPRETATION Our results indicate that in PDAC, highly activated pro-tumor Tfh2 favor anti-inflammatory IgG4 production, while inhibit pro-inflammatory IgE. Thus, targeting the circuits that drive Tfh2 cells, in combination with chemotherapy, may re-establish beneficial anti-tumor Tfh-B cell interactions and facilitate more effective treatment. FUNDING Research grants from the Italian Association for Cancer Research (AIRC) IG-19119 to MPP and the AIRC Special Program in Metastatic disease: the key unmet need in oncology, 5 per Mille no. 22737 to CB, MF, CD, MR and MPP; the ERA-NET EuroNanoMed III (a collaborative european grant financed by the Italian Ministry of Health, Italy) project PANIPAC (JTC2018/041) to MPP; the Fondazione Valsecchi to SC.
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Affiliation(s)
- Lucia De Monte
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Clemente
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eliana Ruggiero
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Pini
- Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Ceraolo
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Chiara Balestrieri
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dejan Lazarevic
- Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Chiara Bonini
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Reni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Protti
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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8
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Redegalli M, Grassini G, Magliacane G, Pecciarini L, Schiavo Lena M, Smart CE, Johnston RL, Waddell N, Maestro R, Macchini M, Orsi G, Petrone MC, Rossi G, Balzano G, Falconi M, Arcidiacono PG, Reni M, Doglioni C, Cangi MG. Routine Molecular Profiling in Both Resectable and Unresectable Pancreatic Adenocarcinoma: Relevance of Cytologic Samples. Clin Gastroenterol Hepatol 2023; 21:2825-2833. [PMID: 36280101 DOI: 10.1016/j.cgh.2022.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive disease, for which it is crucial to promptly detect actionable and prognostic alterations to drive specific therapeutic decisions, regardless of tumor resectability status. Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) is of key importance for PDAC diagnosis and can contribute significantly to tumor molecular profiling. METHODS Comprehensive genomic profile by targeted next-generation sequencing (NGS) was performed on 2 independent PDAC patient cohorts. Cohort 1 consisted of 77 patients with resectable PDAC for whom the histologic sample at the time of resection was available; for 56 patients cytologic specimens at the time of diagnosis also were obtained by EUS-FNA. Cohort 2 consisted of 20 patients with unresectable PDAC, for whom only the EUS-FNA cytologic sample was available. RESULTS In cohort 1, a complete concordant mutational profile between the cytologic sample at diagnosis and the corresponding histologic specimen after surgery was observed in 88% of the cases, proving the ability to detect potential clinically relevant alterations in cytologic samples by NGS analysis. Notably, clinically actionable mutations were identified in 20% of patients. In cohort 2, comprehensive mutational profiling was obtained successfully for all samples. Consistent with the findings of cohort 1, KRAS, TP53, CDKN2A, and SMAD4 were the most altered genes. Most importantly, 15% of the patients harbored actionable mutations. CONCLUSIONS Our findings show the feasibility of an NGS approach using both surgical specimens and cytologic samples. The model proposed in this study can be included successfully in the clinical setting for comprehensive molecular profiling of all PDAC patients irrespective of their surgical eligibility.
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Affiliation(s)
- Miriam Redegalli
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Greta Grassini
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Gilda Magliacane
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Lorenza Pecciarini
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Marco Schiavo Lena
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Chanel E Smart
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Rebecca L Johnston
- Unit of Medical Genomics, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Nicola Waddell
- Unit of Medical Genomics, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Roberta Maestro
- Unit of Oncogenetics and Functional Oncogenomics, Centro di Riferimento Oncologico Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Marina Macchini
- Department of Medical Oncology, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Orsi
- Department of Medical Oncology, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, Pancreas Translational and Clinical Research Centre, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Giulia Cangi
- Pathology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.
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9
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Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, Bratlie SO, Busch OR, Butturini G, Capretti G, Casadei R, Edwin B, Emmen AM, Esposito A, Falconi M, Groot Koerkamp B, Keck T, de Kleine RH, Kleive DB, Kokkola A, Lips DJ, Lof S, Luyer MD, Manzoni A, Marudanayagam R, de Pastena M, Pecorelli N, Primrose JN, Ricci C, Salvia R, Sandström P, Vissers FL, Wellner UF, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. Lancet Reg Health Eur 2023; 31:100673. [PMID: 37457332 PMCID: PMC10339208 DOI: 10.1016/j.lanepe.2023.100673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
Background The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking. Methods In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265). Findings Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group. Interpretation This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer. Funding Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.
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Affiliation(s)
- Maarten Korrel
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Leia R. Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Jony van Hilst
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bergthor Björnsson
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier R. Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Giovanni Capretti
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Bjørn Edwin
- The Intervention Center, Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anouk M.L.H. Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Ruben H.J. de Kleine
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dyre B. Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arto Kokkola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Sanne Lof
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Misha D.P. Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicolò Pecorelli
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - John N. Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claudio Ricci
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Per Sandström
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Frederique L.I.M. Vissers
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marcel G.W. Dijkgraaf
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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10
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Balzano G, Zerbi A, Aleotti F, Capretti G, Melzi R, Pecorelli N, Mercalli A, Nano R, Magistretti P, Gavazzi F, De Cobelli F, Poretti D, Scavini M, Molinari C, Partelli S, Crippa S, Maffi P, Falconi M, Piemonti L. Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Ann Surg 2023; 277:894-903. [PMID: 36177837 PMCID: PMC10174105 DOI: 10.1097/sla.0000000000005713] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with islet autotransplantation (IAT) in patients at high risk of postoperative pancreatic fistula (POPF). BACKGROUND Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences. METHODS Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (ie, soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery. RESULTS Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TP-IAT ( P =0.008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [odds ratio (OR)=7.64 (95% CI: 1.35-43.3), P =0.022], while the OR for grade ≥3 complications was 2.82 (95% CI: 0.86-9.24, P =0.086). After TP-IAT, the postoperative stay was shorter [median: 10.5 vs 16.0 days; P <0.001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival, and overall survival. TP-IAT was associated with a higher risk of diabetes [hazard ratio=9.1 (95% CI: 3.76-21.9), P <0.0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time. CONCLUSIONS TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.
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Affiliation(s)
- Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Francesca Aleotti
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Molinari
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Maffi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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11
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Balzano G, Guarneri G, Pecorelli N, Partelli S, Crippa S, Vico A, Falconi M, Baglio G. Geographical Disparities and Patients' Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy. Cancers (Basel) 2023; 15:cancers15092429. [PMID: 37173896 PMCID: PMC10177179 DOI: 10.3390/cancers15092429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014-2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients.
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Affiliation(s)
- Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
| | - Giovanni Guarneri
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | | | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, 20132 Milan, Italy
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giovanni Baglio
- Head of the Research and International Relations Unit, Italian National Agency for Regional Healthcare Services, 00187 Rome, Italy
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12
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Balzano G, Zerbi A, Scavini M, Piemonti L. Comment on Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-Risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Ann Surg Open 2023; 4:e262. [PMID: 37600879 PMCID: PMC10431397 DOI: 10.1097/as9.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- Gianpaolo Balzano
- From the Unit of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- General Surgery, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery Operating Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Unit of Diabetes Care, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Lorenzo Piemonti
- Vita-Salute San Raffaele University, Diabetes Research Institute, Regenerative Medicine and Transplant Unit, IRCCS Ospedale San Raffaele, Milan, Italy
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13
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Balzano G, Zerbi A, Scavini M, Piemonti L. Response to: Comment on: Pancreatectomy With Islet-Autotransplantation as Alternative for Pancreato-Duodenectomy in Patients With a High-Risk for Postoperative Pancreatic Fistula: The Jury Is Still Out. Ann Surg Open 2023; 4:e261. [PMID: 37600887 PMCID: PMC10431506 DOI: 10.1097/as9.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/31/2023] Open
Affiliation(s)
- Gianpaolo Balzano
- From the Unit of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- General Surgery, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery Operating Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Clinical Care Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Lorenzo Piemonti
- Vita-Salute San Raffaele University, Diabetes Research Institute, Regenerative Medicine and Transplant Unit, IRCCS Ospedale San Raffaele, Milan, Italy
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van Veldhuisen E, Klompmaker S, Janssen QP, Hilal MA, Alseidi A, Balduzzi A, Balzano G, Bassi C, Berrevoet F, Bonds M, Busch OR, Butturini G, Conlon KC, Frigerio IM, Fusai GK, Gagnière J, Griffin O, Hackert T, Halimi A, Keck T, Kleeff J, Klaiber U, Labori KJ, Lesurtel M, Malleo G, Marino MV, Molenaar IQ, Mortensen MB, Nikov A, Pagnanelli M, Pandé R, Pfeiffer P, Pietrasz D, Rangelova E, Roberts KJ, Cunha AS, Salvia R, Strobel O, Tarvainen T, Wilmink JW, Koerkamp BG, Besselink MG. Surgical and Oncological Outcomes After Preoperative FOLFIRINOX Chemotherapy in Resected Pancreatic Cancer: An International Multicenter Cohort Study. Ann Surg Oncol 2023; 30:1463-1473. [PMID: 36539580 PMCID: PMC9908650 DOI: 10.1245/s10434-022-12387-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Preoperative FOLFIRINOX chemotherapy is increasingly administered to patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) to improve overall survival (OS). Multicenter studies reporting on the impact from the number of preoperative cycles and the use of adjuvant chemotherapy in relation to outcomes in this setting are lacking. This study aimed to assess the outcome of pancreatectomy after preoperative FOLFIRINOX, including predictors of OS. METHODS This international multicenter retrospective cohort study included patients from 31 centers in 19 European countries and the United States undergoing pancreatectomy after preoperative FOLFIRINOX chemotherapy (2012-2016). The primary end point was OS from diagnosis. Survival was assessed using Kaplan-Meier analysis and Cox regression. RESULTS The study included 423 patients who underwent pancreatectomy after a median of six (IQR 5-8) preoperative cycles of FOLFIRINOX. Postoperative major morbidity occurred for 88 (20.8%) patients and 90-day mortality for 12 (2.8%) patients. An R0 resection was achieved for 243 (57.4%) patients, and 259 (61.2%) patients received adjuvant chemotherapy. The median OS was 38 months (95% confidence interval [CI] 34-42 months) for BRPC and 33 months (95% CI 27-45 months) for LAPC. Overall survival was significantly associated with R0 resection (hazard ratio [HR] 1.63; 95% CI 1.20-2.20) and tumor differentiation (HR 1.43; 95% CI 1.08-1.91). Neither the number of preoperative chemotherapy cycles nor the use adjuvant chemotherapy was associated with OS. CONCLUSIONS This international multicenter study found that pancreatectomy after FOLFIRINOX chemotherapy is associated with favorable outcomes for patients with BRPC and those with LAPC. Future studies should confirm that the number of neoadjuvant cycles and the use adjuvant chemotherapy have no relation to OS after resection.
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Affiliation(s)
- Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital Southampton NHS, Southampton, UK
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, USA
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gianpaolo Balzano
- Department of Surgery, Pancreas Unit, Ospedale San Raffaele, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Frederik Berrevoet
- Department of General and HPB Surgery, Gent University Hospital, Gent, Belgium
| | - Morgan Bonds
- Department of Surgery, University of California, San Francisco, USA
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Giovanni Butturini
- HPB Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin and St. Vincent's University Hospital, Dublin, Ireland
| | | | - Giuseppe K Fusai
- HPB Surgery and Liver Transplantation Unit, Royal Free Hospital, London, UK
| | - Johan Gagnière
- U1071 INSERM, Clermont-Auvergne University, Clermont-Ferrand, France
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin and St. Vincent's University Hospital, Dublin, Ireland
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Asif Halimi
- Department of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Keck
- Department of Surgery, Universitaet zu Luebeck, Luebeck, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Mickael Lesurtel
- Department of Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon, Hospices Civils de LyonLyon, France
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marco V Marino
- Department of General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
- Department of General Surgery, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael B Mortensen
- Department of Surgery, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Andrej Nikov
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Michele Pagnanelli
- Department of Surgery, Pancreas Unit, Ospedale San Raffaele, Milan, Italy
| | - Rupaly Pandé
- Department of Surgery, University Hospital Birmingham, Birmingham, UK
| | - Per Pfeiffer
- Department of Medical Oncology, Odense University Hospital, Odense, Denmark
| | - Daniel Pietrasz
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Elena Rangelova
- Department of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Keith J Roberts
- Department of Surgery, University Hospital Birmingham, Birmingham, UK
| | - Antonio Sa Cunha
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Timo Tarvainen
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Johanna W Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Digestive and Hepatobiliary Surgery-Liver Transplantation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
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Archibugi L, Ponz de Leon Pisani R, Petrone MC, Balzano G, Falconi M, Doglioni C, Capurso G, Arcidiacono PG. Needle-Tract Seeding of Pancreatic Cancer after EUS-FNA: A Systematic Review of Case Reports and Discussion of Management. Cancers (Basel) 2022; 14:cancers14246130. [PMID: 36551615 PMCID: PMC9777256 DOI: 10.3390/cancers14246130] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
Needle-tract seeding (NTS) has been sporadically reported as complication of Endoscopic Ultrasound (EUS)-guided aspiration (FNA) in pancreatic adenocarcinoma (PDAC). However, the evidence of its treatment and outcome is sparse. Adhering to PRISMA guidelines, we conducted a systematic review of EUS-FNA NTS cases of PDAC and analyzed their management and outcome. Up to September 2022, the search query retrieved forty-five cases plus an unpublished case from our center, for a total of forty-six; 43.6% were male, with a mean age of 68.6 years. Thirty-four patients (87.1%) underwent an initial surgical resection, with only 44.1% and 5.9% undergoing adjuvant and neoadjuvant chemotherapy, respectively, and 5.9% undergoing both. The NTS nodule was mostly located in the posterior gastric wall, developing at a median of 19 months after primary resection; 82.4% underwent surgical resection of the seeding, while for 17.6%, palliative chemotherapy treatment. Follow-up after NTS diagnosis and treatment was reported for only twenty-three patients: when NTS was treated with surgery, the median overall survival was 26.5 months compared to 15.5 if treated with radio/chemotherapy. NTS after EUS-FNA of PDAC occurs late and might be treated aggressively with good results. Interestingly, only a low number of patients developing NTS underwent chemotherapy for the primary cancer, suggesting its possible protective role.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Ruggero Ponz de Leon Pisani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Claudio Doglioni
- Pathology Department, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
- Correspondence:
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
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16
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Tamburrino D, Guarneri G, Provinciali L, Riggio V, Pecorelli N, Cinelli L, Partelli S, Crippa S, Falconi M, Balzano G. Effect of preoperative biliary stent on postoperative complications after pancreaticoduodenectomy for cancer: Neoadjuvant versus upfront treatment. Surgery 2022; 172:1807-1815. [PMID: 36253311 DOI: 10.1016/j.surg.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/06/2022] [Accepted: 09/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited data are available regarding the effect of preoperative biliary stent, during long-course neoadjuvant chemotherapy, on postoperative complications. The aim of the study is to analyze whether the association of neoadjuvant chemotherapy and biliary stent increases overall and infectious complications after pancreaticoduodenectomy. METHODS Data for 538 consecutive pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy between 2015 and 2020 were retrospectively analyzed. Four groups of patients were identified: neoadjuvant chemotherapy + biliary stent (171 patients), neoadjuvant chemotherapy-no biliary stent (65 patients), upfront surgery + biliary stent (184 patients), and upfront surgery-no biliary stent (118 patients). Median neoadjuvant chemotherapy duration was 6 months. The main outcome of the study was the occurrence of postoperative infections. RESULTS No differences among the 4 groups were observed for pancreaticoduodenectomy-specific complications (ie, POPF, DGE, PPH). Infectious complications, in particular surgical site infections, were more frequent in neoadjuvant chemotherapy + biliary stent group (P = 0.001). At multivariate analysis, biliary stent was significantly associated with postoperative infectious complications in the overall cohort (odds ratio 1.996, confidence interval 95% 1.29-3.09, P = .002) and in neoadjuvant chemotherapy patients (odds ratio 5.974, 95% confidence interval 2.52-14.13, P < .001). Biliary stent significantly increased the comprehensive complication index by 9.5% (95% confidence interval 0.04-0.64, P = 0.024) in the overall cohort and 18.9% (95% confidence interval 0.22-1.23, P = .005) in the neoadjuvant chemotherapy group. The presence of multidrug-resistant microorganisms in intraoperative bile culture was not influenced by long-course neoadjuvant chemotherapy. CONCLUSION In neoadjuvant chemotherapy patients, biliary stent increased the occurrence of postoperative infectious complications and surgical site infections, while the incidence of multidrug-resistant bacteria in intraoperative bile culture was similar between groups.
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Affiliation(s)
- Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy. https://twitter.com/MimmoTamburrino
| | - Giovanni Guarneri
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy. https://twitter.com/GuarneriG88
| | - Lorenzo Provinciali
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Valentina Riggio
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/nicpecorelli
| | - Lorenzo Cinelli
- Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/spartelli
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy. https://twitter.com/StefanoCrippa6
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Department of General Surgery, Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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17
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Testoni SGG, Petrone MC, Reni M, Di Serio C, Rancoita PM, Rossi G, Balzano G, Linzenbold W, Enderle M, Della-Torre E, De Cobelli F, Falconi M, Capurso G, Arcidiacono PG. EUS-guided ablation with the HybridTherm Probe as second-line treatment in patients with locally advanced pancreatic ductal adenocarcinoma: A case-control study. Endosc Ultrasound 2022; 11:383-392. [PMID: 36255026 PMCID: PMC9688129 DOI: 10.4103/eus-d-21-00200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives Data on the clinical efficacy of EUS-guided ablation using the HybridTherm-Probe (EUS-HTP) in locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) are lacking. The aim of the study was to assess the impact of EUS-HTP added to chemotherapy (CT) on overall survival (OS) and progression-free survival (PFS) of LA-PDAC patients with local disease progression (DP) after first-line therapy, compared to CT alone in controls. Methods LA-PDAC cases, prospectively treated by EUS-HTP, were retrospectively compared to matched controls (1:2) receiving standard treatment. Study endpoints were the OS and PFS from local DP after first-line therapy, compared through log-rank test calculating hazard ratios and differences in restricted mean OS/PFS time (RMOST/RMPFST) within prespecified time points (4, 6, and 12 months). Results Thirteen cases and 26 controls were included. Clinical, tumor, and therapy features before and after first-line therapy were case-control balanced. The median OS and PFS were not significantly improved in cases over controls (months: 7 vs. 5 and 5 vs. 3, respectively). At 4 and 6 months, the RMPFST difference was in favor of cases (P = 0.0001 and P = 0.003, respectively). In cases and controls not candidate to further CT (N = 5 and N = 9), the median OS and PFS were not significantly improved in cases over controls (months: 6 vs. 3 and 4 vs. 2, respectively), but the RMPFST difference was in favor of cases at 4 months (P = 0.002). Conclusions In locally progressive PDAC patients experiencing failure of first-line therapy, EUS-HTP achieves a significantly better RMPFST up to 6 months compared to standard treatment, although without a significant impact on OS.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Michele Reni
- Department of Oncology, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Clelia Di Serio
- Vita-Salute San Raffaele University, CUSSB, University Centre for Statistics in the Biomedical Sciences, Milan, Italy
| | - Paola Maria Rancoita
- Vita-Salute San Raffaele University, CUSSB, University Centre for Statistics in the Biomedical Sciences, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | | | | | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology and Center for Experimental Imaging, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy,Address for correspondence Prof. Paolo Giorgio Arcidiacono, Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy. E-mail:
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18
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Redegalli M, Schiavo Lena M, Cangi MG, Smart CE, Mori M, Fiorino C, Arcidiacono PG, Balzano G, Falconi M, Reni M, Doglioni C. Proposal for a New Pathologic Prognostic Index After Neoadjuvant Chemotherapy in Pancreatic Ductal Adenocarcinoma (PINC). Ann Surg Oncol 2022; 29:3492-3502. [PMID: 35230580 PMCID: PMC9072515 DOI: 10.1245/s10434-022-11413-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/16/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Limited information is available on the relevant prognostic variables after surgery for patients with pancreatic ductal adenocarcinoma (PDAC) subjected to neoadjuvant chemotherapy (NACT). NACT is known to induce a spectrum of histological changes in PDAC. Different grading regression systems are currently available; unfortunately, they lack precision and accuracy. We aimed to identify a new quantitative prognostic index based on tumor morphology. PATIENTS AND METHODS The study population was composed of 69 patients with resectable or borderline resectable PDAC treated with preoperative NACT (neoadjuvant group) and 36 patients submitted to upfront surgery (upfront-surgery group). A comprehensive histological assessment on hematoxylin and eosin (H&E) stained sections evaluated 20 morphological parameters. The association between patient survival and morphological variables was evaluated to generate a prognostic index. RESULTS The distribution of morphological parameters evaluated was significantly different between upfront-surgery and neoadjuvant groups, demonstrating the effect of NACT on tumor morphology. On multivariate analysis for patients that received NACT, the predictors of shorter overall survival (OS) and disease-free survival (DFS) were perineural invasion and lymph node ratio. Conversely, high stroma to neoplasia ratio predicted longer OS and DFS. These variables were combined to generate a semiquantitative prognostic index based on both OS and DFS, which significantly distinguished patients with poor outcomes from those with a good outcome. Bootstrap analysis confirmed the reproducibility of the model. CONCLUSIONS The pathologic prognostic index proposed is mostly quantitative in nature, easy to use, and may represent a reliable tumor regression grading system to predict patient outcomes after NACT followed by surgery for PDAC.
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Affiliation(s)
- M Redegalli
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - M Schiavo Lena
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - M G Cangi
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - C E Smart
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - M Mori
- Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - C Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - P G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - G Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - M Reni
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, Pancreas Translational and Clinical Research Centre, Milan, Italy.
| | - C Doglioni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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19
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Redegalli M, Schiavo Lena M, Cangi MG, Smart CE, Mori M, Fiorino C, Arcidiacono PG, Balzano G, Falconi M, Reni M, Doglioni C. ASO Visual Abstract: Proposal for a New Pathologic Prognostic Index After Neoadjuvant Chemotherapy in Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-022-11451-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Pecorelli N, Licinio AW, Guarneri G, Aleotti F, Crippa S, Reni M, Falconi M, Balzano G. Prognosis of Upfront Surgery for Pancreatic Cancer: A Systematic Review and Meta-Analysis of Prospective Studies. Front Oncol 2022; 11:812102. [PMID: 35083158 PMCID: PMC8784375 DOI: 10.3389/fonc.2021.812102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The rate of patients with pancreatic ductal adenocarcinoma (PDAC) receiving neoadjuvant chemotherapy is increasing, but upfront resection is still offered to most patients with resectable or borderline resectable disease. Encouraging data reported in adjuvant chemotherapy trials prompts surgeons towards upfront surgery, but such trials are subject to a significant selection bias. This systematic review aims to summarize available high-quality evidence regarding survival of patients treated with upfront surgery for PDAC. METHODS Pubmed, Cochrane, and Web of Science Databases were interrogated for prospective studies published between 2000 and 2021 that included at least a cohort of patients treated with upfront surgery for resectable or borderline resectable PDAC. The Cochrane Collaboration's risk-of-bias tool for randomized trials (RoB-2) was used to assess risk of bias in all randomized studies. Patient weighted median overall survival (OS) and disease-free survival (DFS) were calculated. RESULTS Overall, 8,341 abstracts were screened, 17 reports were reviewed in full text, and finally 5 articles and 1 conference abstract underwent data extraction. Included studies were published between 2014 and 2021. All studies were RCTs comparing different neoadjuvant treatment strategies to upfront surgery. Three studies included only resectable PDAC patients, two studies recruited patients with resectable and borderline resectable disease, and one study selected only borderline resectable patients. A total of 439 patients were included in the upfront resection cohorts of the 6 studies, ranging between 20 to 180 patients per study. The weighted median OS after upfront surgery was 18.8 (95% CI 12.4 - 20.6) months. Median DFS was 9 (95% CI 1.6 - 12.5) months. Resection rate was 74.5% (range 65-90%). Adjuvant treatment was initiated in 68% (range 43-77%) of resected patients. CONCLUSIONS High-quality data for PDAC patients undergoing upfront surgery is scarce. Meta-analysis from the included studies showed a significantly shorter OS and DFS compared to recently published studies focusing on adjuvant combination chemotherapy, suggesting that the latter may overestimate survival due to the exclusion of most patients scheduled for upfront surgery.
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Affiliation(s)
- Nicolò Pecorelli
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Alice W Licinio
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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Kuemmerli C, Tschuor C, Kasai M, Alseidi AA, Balzano G, Bouwense S, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Liang T, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillai SA, Pillarisetty VG, Pucci MJ, Su W, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Abu Hilal M. Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis. Br J Surg 2022; 109:256-266. [PMID: 35037019 DOI: 10.1093/bjs/znab436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. METHODS The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. RESULTS Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate. CONCLUSION ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis-University Centre for Gastrointestinal and Liver Diseases Basle, Basle, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Adnan A Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sara K Daniel
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Michael J Passeri
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - Sastha Ahanatha Pillai
- Department of Surgery, Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, India
| | - Venu G Pillarisetty
- Hepatopancreatobiliary Surgery, University of Washington, Seattle, Washington, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wei Su
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, Zhejiang, China
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Department of Surgery, Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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22
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Pecorelli N, Mazza M, Guarneri G, Delpini R, Partelli S, Balzano G, Turi S, Meani R, Beretta L, Falconi M. Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program. HPB (Oxford) 2021; 23:1815-1823. [PMID: 33975798 DOI: 10.1016/j.hpb.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). METHODS Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. RESULTS Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to -2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p < 0.001). CONCLUSION Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Meani
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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23
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Testoni SGG, Petrone MC, Reni M, Rossi G, Barbera M, Nicoletti V, Gusmini S, Balzano G, Linzenbold W, Enderle M, Della-Torre E, De Cobelli F, Doglioni C, Falconi M, Capurso G, Arcidiacono PG. Efficacy of Endoscopic Ultrasound-Guided Ablation with the HybridTherm Probe in Locally Advanced or Borderline Resectable Pancreatic Cancer: A Phase II Randomized Controlled Trial. Cancers (Basel) 2021; 13:4512. [PMID: 34572743 PMCID: PMC8464946 DOI: 10.3390/cancers13184512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 11/30/2022] Open
Abstract
Endoscopic ultrasound-ablation with HybridTherm-Probe (EUS-HTP) significantly reduces tumour volume (TV) in locally-advanced pancreatic ductal adenocarcinoma (LA-PDAC). We aimed at investigating the clinical efficacy of EUS-HTP plus chemotherapy versus chemotherapy (HTP-CT and CT arms) in LA- and borderline-resectable (BR) PDAC, with 6-months progression-free survival (6-PFS) rate as primary endpoint. In a phase-II randomized-controlled-trial, 33 LA/BR-PDAC patients per-arm were planned to verify 20% improved 6-PFS rate. Radiological response (Choi criteria), TV and serum CA19.9 were assessed up to 6-months. Seventeen and 20 LA/BR-PDAC patients were randomized to HTP-CT or CT. Baseline and CT-related features were balanced. At 6-months, 6-PFS rate was 41.2% and 30% in HTP-CT and CT arms (p = 0.48), respectively. A decrease ≥50% of serum CA19.9 was achieved in 75% and 64.3% of HTP-CT and CT patients (p = 0.53), respectively. TV reduced up to 6-months in 64.3% and 47.1% of HTP-CT and CT patients (p = 0.35), respectively. Resection rate, PFS-time and overall survival (OS-time) were similar. HTP-CT achieves a non-significant 11.2%, 10.7% and 17.2% improved 6-PFS, CA19.9 decrease ≥50% and TV reduction rates over CT, without any impact on resection rate, PFS-time and OS-time. As the study was underpowered, these results suggest further investigation of EUS-local ablation in selected patients with localized disease after induction CT.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Maria Chiara Petrone
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Michele Reni
- Pancreas Translational & Clinical Research Center, Oncology Department, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy;
| | - Gemma Rossi
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Maurizio Barbera
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Valeria Nicoletti
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Simone Gusmini
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Gianpaolo Balzano
- Pancreas Translational & Clinical Research Center, Pancreatic Surgery Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.B.); (M.F.)
| | - Walter Linzenbold
- ERBE Research Elektromedizin GmbH, 72072 Tübingen, Germany; (W.L.); (M.E.)
| | - Markus Enderle
- ERBE Research Elektromedizin GmbH, 72072 Tübingen, Germany; (W.L.); (M.E.)
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Francesco De Cobelli
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Claudio Doglioni
- Pancreas Translational & Clinical Research Center, Pathology Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, Pancreatic Surgery Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.B.); (M.F.)
| | - Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Paolo Giorgio Arcidiacono
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
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24
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Giannone F, Capretti G, Abu Hilal M, Boggi U, Campra D, Cappelli C, Casadei R, De Luca R, Falconi M, Giannotti G, Gianotti L, Girelli R, Gollini P, Ippolito D, Limerutti G, Maganuco L, Malagnino V, Malleo G, Morone M, Mosconi C, Mrakic F, Palumbo D, Salvia R, Sgroi S, Zerbi A, Balzano G. Resectability of Pancreatic Cancer Is in the Eye of the Observer: A Multicenter, Blinded, Prospective Assessment of Interobserver Agreement on NCCN Resectability Status Criteria. Ann Surg Open 2021; 2:e087. [PMID: 37635813 PMCID: PMC10455302 DOI: 10.1097/as9.0000000000000087] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives To determine the reproducibility of the National Comprehensive Cancer Network (NCCN) resectability status classification for pancreatic cancer. Background The NCCN classification defines 3 resectability classes (resectable, borderline resectable, locally advanced), according to vascular invasion. It is used to recommend different approaches and stratify patients during clinical trials. Methods Prospective, multicenter, observational study (trial ID: NCT03673423). Main outcome measure was the interobserver agreement of tumor assignment to different resectability classes and quantification of vascular invasion degrees. Agreement was measured by Fleiss' k (k = 1 perfect agreement; k = 0 agreement by chance). Sixty-nine computed tomography (CT) scans of pathologically confirmed pancreatic adenocarcinoma were independently reviewed in a blinded fashion by 22 observers from 11 hospitals (11 surgeons and 11 radiologists). Rating differences between surgeons or radiologists and between hospitals with different volumes (≥60 or <60 resections/year) were assessed. Results Complete agreement among 22 observers was recorded in 5 CT scans (7.2%), whereas 25 CT scans (36.2%) were variously assigned to all 3 resectability classes. Interobserver agreement varied from fair to moderate (Fleiss' k range: 0.282-0.555), with the lowest agreement for borderline resectable tumors. Assessing vascular contact ≤180° had the lowest agreement for all vessels (k range: 0.196-0.362). The highest concordance was recorded for venous invasion >180° (k range: 0.619-0.756). Neither reviewers' specialty nor hospital volume influenced the agreement. Conclusions There is high variability in the assignment to resectability categories, which may compromise the reliability of treatments recommendations and the evidence of trials stratifying patients in resectability classes. Criteria should be revised to allow a reproducible classification.
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Affiliation(s)
- Fabio Giannone
- From the Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Hepato-pancreato-biliary Unit, Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, HPB Unit, Southampton University Hospital, Southampton, United Kingdom
| | - Ugo Boggi
- Department of Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Donata Campra
- General Surgery and Emergency Department, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carla Cappelli
- Department of Radiology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna and Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori “Giovanni Paolo II,” Bari, Italy
| | - Massimo Falconi
- From the Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Giannotti
- Department of Radiology, University of Verona Hospital Trust, Verona, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Roberto Girelli
- Pancreatic Surgery Unit, “P. Pederzoli” Hospital, Peschiera del Garda, Verona, Italy
| | - Paola Gollini
- Radiology and Neuroradiology Unit, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Giorgio Limerutti
- Department of Radiology 2, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lorenzo Maganuco
- General Surgery Unit 2 and Pancreas Group, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Valeria Malagnino
- Department of Radiology, IRCCS Istituto Tumori “Giovanni Paolo II,” Bari, Italy
| | - Giuseppe Malleo
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Mario Morone
- Department of Radiology, Fondazione Poliambulanza, Brescia, Italy
| | - Cristina Mosconi
- Department of Radiology, Policlinico “S. Orsola Malpighi,” Bologna, Italy
| | - Federica Mrakic
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Diego Palumbo
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Salvia
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Sgroi
- Department of Radiology, “P.Pederzoli” Hospital, Peschiera del Garda, Verona, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Gianpaolo Balzano
- From the Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
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25
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Aleotti F, Nano R, Piemonti L, Falconi M, Balzano G. Correction to: Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy. Updates Surg 2021; 73:2403. [PMID: 34406617 DOI: 10.1007/s13304-021-01151-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesca Aleotti
- Chirurgia del Pancreas, Pancreas Translational and Clinical Center, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Massimo Falconi
- Chirurgia del Pancreas, Pancreas Translational and Clinical Center, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Gianpaolo Balzano
- Chirurgia del Pancreas, Pancreas Translational and Clinical Center, IRCCS Ospedale San Raffaele, Milano, Italy.
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26
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Archibugi L, Mariani A, Ciambriello B, Petrone MC, Rossi G, Testoni SGG, Carlucci M, Aldrighetti L, Falconi M, Balzano G, Doglioni C, Capurso G, Arcidiacono PG. High sensitivity of ROSE-supported ERCP-guided brushing for biliary strictures. Endosc Int Open 2021; 9:E363-E370. [PMID: 33655035 PMCID: PMC7895655 DOI: 10.1055/a-1322-2638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in biliary strictures, with brushing being a cheap and fast method to acquire a cytological specimen, despite a sensitivity around 45 %. Rapid on-site evaluation (ROSE) is widely used for endoscopic ultrasound-acquired cytological specimen adequacy, improving its sensitivity and specificity. Nevertheless, no study has evaluated its role for ERCP-guided brushing. Our aim was to assess the diagnostic yield of ERCP-guided brushing of biliary strictures when supported by ROSE. Patients and methods This was a retrospective single-center study that included patients undergoing ERCP-guided brush cytology supported by ROSE for biliary strictures. Recorded data included patient clinical-radiological and ERCP features. Final diagnosis was determined after surgery, intraductal biopsy or adequate follow-up. The diagnostic yield was calculated and a subgroup analysis for factors associated with false-negative or true-positive results was performed. Results Two hundred six patients were included, 57.3 % males, median age 72 years, 77.2 % having extrahepatic biliary strictures. Of the patients, 99 % had an adequate sample at ROSE after a mean of 2.6 passages. The diagnostic yield was accuracy 83 %, sensitivity 74.6 %, and specificity 98 %, positive and negative predictive values 98 % and 71 % respectively, with an area under the curve of 0.86. A diagnosis of cholangiocarcinoma was significantly more frequent among true-positive cases (68 % vs 46.8 %; P = 0.04). Conclusions This is the first study evaluating the use of ROSE as support for ERCP-guided brushing of biliary strictures, with a sensitivity far higher than those reported for brushing alone and at least comparable to those of more expensive and invasive techniques.
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Affiliation(s)
- Livia Archibugi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Carlucci
- Department of General and Emergency Surgery, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Pathology Unit, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, Milan, Italy, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Crippa S, Giannone F, Schiavo Lena M, Belfiori G, Partelli S, Tamburrino D, Delpini R, Pagnanelli M, Pecorelli N, Balzano G, Doglioni C, Falconi M. R Status is a Relevant Prognostic Factor for Recurrence and Survival After Pancreatic Head Resection for Ductal Adenocarcinoma. Ann Surg Oncol 2021; 28:4602-4612. [PMID: 33393031 DOI: 10.1245/s10434-020-09467-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prognostic role of resection margins in pancreatic ductal adenocarcinoma (PDAC) is debated. This study aimed to investigate the impact that global and individual resection margin status after pancreatic head resection for PDAC has on disease-free survival (DFS) and disease-specific survival (DSS). METHODS Surgical specimens of pancreaticoduodenectomy/total pancreatectomy performed for PDAC were examined with a standardized protocol. Surgical margin status (biliary, pancreatic neck, duodenal, anterior and posterior pancreatic, superior mesenteric vein groove and superior mesenteric artery margins) was classified as the presence of malignant cells (1) directly at the inked surface (R1 direct), (2) within less than 1 mm (R1 ≤ 1 mm), or (3) with a distance greater than 1 mm (R0). Patients with a positive neck margin at the final histology were excluded from the study. RESULTS Of the 362 patients included in the study, 179 patients (49.4 %) had an R0 resection, 123 patients (34 %) had an R1 ≤ 1 mm resection, and 60 patients (16.6 %) had an R1 direct resection. The independent predictors of DFS were R1 direct resection (hazard ratio [HR], 1.49), R1 ≤ 1 mm resection (HR, 1.38), involvement of one margin (HR, 1.36), and involvement of two margins or more (HR, 1.55). When surgical margins were analyzed separately, only R1 ≤ 1 mm superior mesenteric vein margin (HR, 1.58) and R1 direct posterior margin (HR, 1.69) were independently associated with DFS. CONCLUSIONS Positive R status is an independent predictor of DFS (R1 direct and R1 ≤ 1 mm definitions) and of DSS (R1 direct). The presence of multiple positive margins is a risk factor for cancer recurrence and poor survival. Different surgical margins could have different prognostic roles.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Fabio Giannone
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Roberto Delpini
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Michele Pagnanelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita Salute San Raffaele University, Milan, Italy
| | - Nicolo Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Claudio Doglioni
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Department of Pathology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milano, Italy. .,Vita Salute San Raffaele University, Milan, Italy.
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28
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Pecorelli N, Pagnanelli M, Belfiori G, Delpini R, Cinelli L, Tamburrino D, Crippa S, Partelli S, Castoldi R, Reni M, Falconi M, Balzano G. Postoperative outcomes and functional recovery after neoadjuvant chemotherapy for pancreatic cancer: A propensity score-matched study. European Journal of Surgical Oncology 2020. [DOI: 10.1016/j.ejso.2020.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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29
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van Roessel S, van Veldhuisen E, Klompmaker S, Janssen QP, Abu Hilal M, Alseidi A, Balduzzi A, Balzano G, Bassi C, Berrevoet F, Bonds M, Busch OR, Butturini G, Del Chiaro M, Conlon KC, Falconi M, Frigerio I, Fusai GK, Gagnière J, Griffin O, Hackert T, Halimi A, Klaiber U, Labori KJ, Malleo G, Marino MV, Mortensen MB, Nikov A, Lesurtel M, Keck T, Kleeff J, Pandé R, Pfeiffer P, Pietrasz D, Roberts KJ, Sa Cunha A, Salvia R, Strobel O, Tarvainen T, Bossuyt PM, van Laarhoven HWM, Wilmink JW, Groot Koerkamp B, Besselink MG. Evaluation of Adjuvant Chemotherapy in Patients With Resected Pancreatic Cancer After Neoadjuvant FOLFIRINOX Treatment. JAMA Oncol 2020; 6:1733-1740. [PMID: 32910170 DOI: 10.1001/jamaoncol.2020.3537] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance The benefit of adjuvant chemotherapy after resection of pancreatic cancer following neoadjuvant combination treatment with folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) is unclear. Objective To assess the association of adjuvant chemotherapy with overall survival (OS) in patients after pancreatic cancer resection and neoadjuvant FOLFIRINOX treatment. Design, Setting, and Participants This international, multicenter, retrospective cohort study was conducted from January 1, 2012, to December 31, 2018. An existing cohort of patients undergoing resection of pancreatic cancer after FOLFIRINOX was updated and expanded for the purpose of this study. All consecutive patients who underwent pancreatic surgery after at least 2 cycles of neoadjuvant FOLFIRINOX chemotherapy for nonmetastatic pancreatic cancer were retrospectively identified from institutional databases. Patients with resectable pancreatic cancer, borderline resectable pancreatic cancer, and locally advanced pancreatic cancer were eligible for this study. Patients with in-hospital mortality or who died within 3 months after surgery were excluded. Exposures The association of adjuvant chemotherapy with OS was evaluated in different subgroups including interaction terms for clinicopathological parameters with adjuvant treatment in a multivariable Cox model. Overall survival was defined as the time starting from surgery plus 3 months (moment eligible for adjuvant therapy), unless mentioned otherwise. Results We included 520 patients (median [interquartile range] age, 61 [53-66] years; 279 [53.7%] men) from 31 centers in 19 countries. The median number of neoadjuvant cycles of FOLFIRINOX was 6 (interquartile range, 5-8). Overall, 343 patients (66.0%) received adjuvant chemotherapy, of whom 68 (19.8%) received FOLFIRINOX, 201 (58.6%) received gemcitabine-based chemotherapy, 14 (4.1%) received capecitabine, 45 (13.1%) received a combination or other agents, and 15 (4.4%) received an unknown type of adjuvant chemotherapy. Median OS was 38 months (95% CI, 36-46 months) after diagnosis and 31 months (95% CI, 29-37 months) after surgery. No survival difference was found for patients who received adjuvant chemotherapy vs those who did not (median OS, 29 vs 29 months, univariable hazard ratio [HR], 0.99; 95% CI, 0.77-1.28; P = .93). In multivariable analysis, only the interaction term for lymph node stage with adjuvant therapy was statistically significant: In patients with pathology-proven node-positive disease, adjuvant chemotherapy was associated with improved survival (median OS, 26 vs 13 months; multivariable HR, 0.41 [95% CI, 0.22-0.75]; P = .004). In patients with node-negative disease, adjuvant chemotherapy was not associated with improved survival (median OS, 38 vs 54 months; multivariable HR, 0.85; 95% CI, 0.35-2.10; P = .73). Conclusions and Relevance These results suggest that adjuvant chemotherapy after neoadjuvant FOLFIRINOX and resection of pancreatic cancer was associated with improved survival only in patients with pathology-proven node-positive disease. Future randomized studies should be conducted to confirm this finding.
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Affiliation(s)
- Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands.,Department of Radiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Quisette P Janssen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital Southampton National Health Service, Southampton, Hampshire, United Kingdom.,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington.,Department of Surgery, University of California at San Francisco, San Francisco
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery, Gent University Hospital, Gent, Belgium
| | - Morgan Bonds
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | | | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin, Trinity Centre for Health Sciences, Dublin, Ireland
| | - Massimo Falconi
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | | | - Giuseppe K Fusai
- Hepatobiliary Surgery and Liver Transplantation Unit, Royal Free Hospital, London, United Kingdom
| | - Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery-Liver Transplantation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.,Department of Surgery, Clermont-Auvergne University, Clermont-Ferrand, France
| | - Oonagh Griffin
- Department of Digestive and Hepatobiliary Surgery-Liver Transplantation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Asif Halimi
- Department of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marco V Marino
- General Surgery Department, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.,Department of General Surgery, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Michael B Mortensen
- Department of Surgery, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - Andrej Nikov
- Department of Surgery, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Tobias Keck
- Department of Surgery, Universitaet zu Luebeck, Luebeck, Germany
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Rupaly Pandé
- Department of Surgery, University Hospital Birmingham, Birmingham, United Kingdom
| | - Per Pfeiffer
- Department of Medical Oncology, Odense University Hospital, Odense, Denmark
| | - D Pietrasz
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Keith J Roberts
- Department of Surgery, University Hospital Birmingham, Birmingham, United Kingdom
| | - Antonio Sa Cunha
- Department of Hepato-Biliary-Pancreatic Surgery, Liver Transplant Center, Paul Brousse Hospital, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Timo Tarvainen
- Department of Gastroenterological Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
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30
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Partelli S, Tamburrino D, Andreasi V, Mazzocato S, Crippa S, Perretti E, Belfiori G, Marmorale C, Balzano G, Falconi M. Implications of increased serum amylase after pancreaticoduodenectomy: toward a better definition of clinically relevant postoperative acute pancreatitis. HPB (Oxford) 2020; 22:1645-1653. [PMID: 32291175 DOI: 10.1016/j.hpb.2020.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/07/2020] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative acute pancreatitis (POAP) can be a possible cause of postoperative pancreatic fistula (POPF). The present study aimed to evaluate the role of clinically-relevant POAP (CR-POAP), defined according to different cut-offs of postoperative amylase (AMS) values and C-reactive protein (CRP), in the development of clinically relevant POPF (CR-POPF) after pancreaticoduodenectomy (PD). METHODS Data from 610 patients who underwent PD (2015-2018) were analyzed. Patients were divided according to the upper limit (100 U/l) and 3-fold the upper limit (300 U/l) of serum POD1 AMS. Univariate and multivariable analysis of possible predictors of CR-POPF were performed. RESULTS Overall, 360 patients (59%) had POD1 serum AMS ≤100 U/l, 142 patients (23%) had POD1 serum AMS >100 U/l and ≤300 U/l, and 108 patients (18%) had POD1 serum AMS >300 U/l. Patients with POD1 serum AMS >300 had a higher frequency of soft pancreatic texture, complications, main pancreatic duct diameter ≤3 mm, and CR-POPF. POD1 serum AMS >100 U/l associated to POD2 CRP ≥180 mg/l (OR: 4.3, p < 0.001) was an independent predictor of CR-POPF. CONCLUSION These results confirm that CR-POAP, defined as POD1 serum AMS >100 U/l and POD2 CRP ≥ 180 mg/l, is associated with an increased risk of CR-POPF.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; PhD Candidate in Digestive Oncology, La Sapienza University, Rome, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Susanna Mazzocato
- Department of Experimental and Clinical Medicine, Section of Surgical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giulio Belfiori
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Marmorale
- Department of Experimental and Clinical Medicine, Section of Surgical Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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31
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Balzano G, Falconi M. Author response to: Modelling centralization of pancreatic surgery: some additional considerations. Br J Surg 2020; 107:e671. [PMID: 33047831 DOI: 10.1002/bjs.12056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/18/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Gianpaolo Balzano
- Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
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32
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Pecorelli N, Guarneri G, Alagol K, Mazza M, Quattromani R, Partelli S, Crippa S, Castoldi R, Balzano G, Falconi M. The impact of minimally invasive surgery on hospital readmissions, emergency department visits and functional recovery after distal pancreatectomy. Surg Endosc 2020; 35:5740-5751. [DOI: 10.1007/s00464-020-08051-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/26/2020] [Indexed: 12/19/2022]
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Belfiori G, Fiorentini G, Tamburrino D, Partelli S, Pagnanelli M, Gasparini G, Castoldi R, Balzano G, Rubini C, Zamboni G, Crippa S, Falconi M. Vascular resection during pancreatectomy for pancreatic head cancer: A technical issue or a prognostic sign? Surgery 2020; 169:403-410. [PMID: 32912782 DOI: 10.1016/j.surg.2020.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/11/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is an increased interest in venous vascular resection associated with pancreatic resection for pancreatic ductal adenocarcinoma as an upfront procedure or after neoadjuvant treatment. The aim of this study was to evaluate the impact of venous vascular resection for pancreatic ductal adenocarcinoma on postoperative and long-term outcomes. METHODS The study is a retrospective analysis of patients who underwent pancreatectomy for pancreatic head pancreatic ductal adenocarcinoma with and without venous vascular resection between January 2010 and April 2018. The impact of venous vascular resection on postoperative and pathologic data was analyzed. Univariate and multivariate analyses of predictors of disease-free and disease-specific survival were analyzed for the entire cohort. A propensity-score matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. RESULTS Four hundred and eighty-one patients were included, and 126 (26%) underwent a venous vascular resection. Patients undergoing venous vascular resection had higher morbidity (64% vs 54%; P = .026) with no differences in 90-day postoperative mortality (3.1 vs 2.8%; P = .5). Venous vascular resections were also significantly associated with R1 resections (52% vs 37%; P = .002) and perineural invasion (87% vs 77%; P = .017). Five-year disease-free survival in patients with and without venous vascular resection were 7% and 20% (P = .018), respectively. Independent predictors of worse disease-free survival included venous vascular resection, positive lymph node status, and perineural invasion. Independent predictors of worse disease-specific survival were perineural invasion and positive nodal status, while adjuvant treatment was a protective factor. Five-year disease-specific survival in patients with and without venous vascular resection were 19% and 35% (P = .42). CONCLUSION Pancreatectomy with venous vascular resection can be accomplished safely. Venous vascular resections are associated with poor prognostic factors and with a worse clinical outcome, being a significant predictor of cancer recurrence.
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Affiliation(s)
- Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guido Fiorentini
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Pagnanelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Renato Castoldi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Rubini
- Department of Pathology, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Giuseppe Zamboni
- Department of Pathology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Andreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, Belfiori G, Cirocchi R, Falconi M. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB (Oxford) 2020; 22:1227-1239. [PMID: 32631806 DOI: 10.1016/j.hpb.2020.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD. METHODS Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals. RESULTS Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620). DISCUSSION Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Cirocchi
- Department of General Surgery and Surgical Oncology, University of Perugia, Hospital of Terni, Terni, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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35
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Crippa S, Guarneri G, Belfiori G, Partelli S, Pagnanelli M, Gasparini G, Balzano G, Lena MS, Rubini C, Doglioni C, Zamboni G, Falconi M. Positive neck margin at frozen section analysis is a significant predictor of tumour recurrence and poor survival after pancreatodudenectomy for pancreatic cancer. Eur J Surg Oncol 2020; 46:1524-1531. [DOI: 10.1016/j.ejso.2020.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 01/09/2020] [Accepted: 02/12/2020] [Indexed: 01/04/2023] Open
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Balzano G, Guarneri G, Pecorelli N, Paiella S, Rancoita PMV, Bassi C, Falconi M. Modelling centralization of pancreatic surgery in a nationwide analysis. Br J Surg 2020; 107:1510-1519. [DOI: 10.1002/bjs.11716] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/26/2020] [Accepted: 04/29/2020] [Indexed: 12/31/2022]
Abstract
Abstract
Background
The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort.
Methods
Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds.
Results
A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively).
Conclusion
The best performance model for centralization involved a threshold for volume combined with a mortality threshold.
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Affiliation(s)
- G Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - G Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - N Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - S Paiella
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - P M V Rancoita
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - C Bassi
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - M Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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37
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Reni M, Peretti U, Zanon S, Macchini M, Balzano G, Mazza E, Tamburrino D, Orsi G, Arcidiacono PG, Falconi M, Gianni L. Time to CA19-9 nadir: a clue for defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma. Cancer Chemother Pharmacol 2020; 85:641-650. [PMID: 32157412 DOI: 10.1007/s00280-020-04047-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma (PDAC) receiving primary chemotherapy is an unmet need. The role of time to CA19-9 nadir and of nadir magnitude was explored in this study. PATIENTS AND METHODS The databases of our institution's prospective trials were queried to speculate on the time to maximum chemotherapy response. Patients with pathologically proven, metastatic (N = 356) or non-metastatic non-resected (N = 163) PDAC and elevated baseline (> 34 UI/mL) CA19-9 were analyzed. Survival curves were estimated using the Kaplan-Meier method and compared by means of the log-rank test for analyses including at least 45 patients. Multivariable Cox proportional hazards model was used to estimate clinical features for their association with OS. All probability values were from two-sided tests. RESULTS Time to CA19-9 nadir was ≥ 4 months in 184 of 346 (53%) metastatic and 121 of 163 (74%) non-metastatic patients (p = 0.002). The likelihood of a later nadir was higher with taxane-based chemotherapy as compared to taxane-free combinations (73% versus 56%; p = 0.02). Both metastatic and non-metastatic patients had significantly longer survival when nadir occurred later. Patients with a larger CA19-9 nadir magnitude had significantly longer survival. Metastatic patients with CA19-9 reduced by < 50%, 50-89%, or > 89% and had a median survival of 7.4, 9.8, and 14.7 months, respectively (p ≤ 0.001 for all comparisons). The corresponding figures for non-metastatic patients were 10.6; 17.0; and 18.7 months, respectively (p ≤ 0.02 for < 50% versus 50-89% or > 89%; p = 0.14 for 50-89% versus > 89%). Multivariable analyses showed that time to CA19-9 nadir but not CA19-9 nadir magnitude was independently predictive of survival. CONCLUSION The present study suggests that a 4-6 months program might be a more suitable candidate for prospective assessment in comparison to shorter pre-defined period in patients who are candidates to surgery after primary chemotherapy.
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Affiliation(s)
- Michele Reni
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - Umberto Peretti
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Silvia Zanon
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Marina Macchini
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Elena Mazza
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Giulia Orsi
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Università "Vita E Salute", Via Olgettina 58, 20132, Milan, Italy
| | - Luca Gianni
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
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38
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Partelli S, Andreasi V, Rancoita PMV, Perez-Sanchez E, Muffatti F, Balzano G, Crippa S, Di Serio C, Falconi M. Outcomes after distal pancreatectomy for neuroendocrine neoplasms: a retrospective comparison between minimally invasive and open approach using propensity score weighting. Surg Endosc 2020; 35:165-173. [PMID: 31953734 DOI: 10.1007/s00464-020-07375-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic neuroendocrine neoplasms (PanNEN) are ideal entities for minimally invasive surgery. The advantage of the laparoscopic approach in terms of complications, length of stay (LOS) and cosmetic results has been previously demonstrated. However, scarce data are available on long-term oncological outcomes. Aim of this study was to compare short-term postoperative outcomes, pathological findings and long-term oncological results of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) for PanNEN. METHODS Patients who underwent ODP or MIDP for nonfunctioning PanNEN (NF-PanNEN) were retrospectively analyzed. Inverse probability of treatment weighting using propensity score was performed to compare the outcomes of MIDP and ODP. RESULTS Overall, 124 patients were included in the study: 84 underwent OPD, whereas 40 were submitted to MIDP. The rate of high-grade postoperative complications was significantly lower in the MIDP group (p = 0.005, grade of complication with highest estimated probability 0 vs 2) and the postoperative LOS was significantly shorter after MIDP (p < 0.001, estimated days 8 versus 10). The number of examined lymph nodes (ELN) in the ODP group was significantly higher (p = 0.0036, estimated number of ELN 13 vs 10). Similar disease-free survival and overall survival were reported for the two groups (p = 0.234 and p = 0.666, respectively). CONCLUSIONS Although MIDP for PanNEN seems to be associated with a lower number of ELN, long-term survival is not influenced by the type of surgical approach. MIDP is advantageous in terms of postoperative complications and LOS, but prospective studies are needed to confirm the overall oncological quality of resection in this group of neoplasms.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Maria Vittoria Rancoita
- Vita-Salute San Raffaele University, Milan, Italy
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - Eduardo Perez-Sanchez
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Clelia Di Serio
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, ENETS Center of Excellence, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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39
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Lof S, Korrel M, van Hilst J, Alseidi A, Balzano G, Boggi U, Butturini G, Casadei R, Dokmak S, Edwin B, Falconi M, Keck T, Malleo G, de Pastena M, Tomazic A, Wilmink H, Zerbi A, Besselink MG, Abu Hilal M. Impact of Neoadjuvant Therapy in Resected Pancreatic Ductal Adenocarcinoma of the Pancreatic Body or Tail on Surgical and Oncological Outcome: A Propensity-Score Matched Multicenter Study. Ann Surg Oncol 2019; 27:1986-1996. [PMID: 31848815 PMCID: PMC7210228 DOI: 10.1245/s10434-019-08137-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several studies have suggested a survival benefit of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head. Data concerning NAT for PDAC located in pancreatic body or tail are lacking. METHODS Post hoc analysis of an international multicenter retrospective cohort of distal pancreatectomy for PDAC in 34 centers from 11 countries (2007-2015). Patients who underwent resection after NAT were matched (1:1 ratio), using propensity scores based on baseline characteristics, to patients who underwent upfront resection. Median overall survival was compared using the stratified log-rank test. RESULTS Among 1236 patients, 136 (11.0%) received NAT, most frequently FOLFIRINOX (25.7%). In total, 94 patients receiving NAT were matched to 94 patients undergoing upfront resection. NAT was associated with less postoperative major morbidity (Clavien-Dindo ≥ 3a, 10.6% vs. 23.4%, P = 0.020) and pancreatic fistula grade B/C (9.6% vs. 21.3%, P = 0.026). NAT did not improve overall survival [27 (95% CI 14-39) versus 31 months (95% CI 19-42), P = 0.277], as compared with upfront resection. In a sensitivity analysis of 251 patients with radiographic tumor involvement of splenic vessels, NAT (n = 37, 14.7%) was associated with prolonged overall survival [36 (95% CI 18-53) versus 20 months (95% CI 15-24), P = 0.049], as compared with upfront resection. CONCLUSION In this international multicenter cohort study, NAT for resected PDAC in pancreatic body or tail was associated with less morbidity and pancreatic fistula but similar overall survival in comparison with upfront resection. Prospective studies should confirm a survival benefit of NAT in patients with PDAC and splenic vessel involvement.
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Affiliation(s)
- Sanne Lof
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK.,Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Gianpaolo Balzano
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | | | - Riccardo Casadei
- Department of Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Safi Dokmak
- Department of Surgery, Hospital of Beaujon, Clichy, France
| | - Bjørn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Massimo Falconi
- Pancreatic Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Tobias Keck
- Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Hanneke Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas University Hospital, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK. .,Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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40
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Pecorelli N, Pagnanelli M, Cinelli L, Di Salvo F, Partelli S, Crippa S, Tamburrino D, Castoldi R, Belfiori G, Reni M, Falconi M, Balzano G. Postoperative Outcomes and Functional Recovery After Preoperative Combination Chemotherapy for Pancreatic Cancer: A Propensity Score-Matched Study. Front Oncol 2019; 9:1299. [PMID: 31850203 PMCID: PMC6901953 DOI: 10.3389/fonc.2019.01299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction: Previous studies show encouraging oncologic outcomes for neoadjuvant chemotherapy (NACT) in the setting of pancreatic ductal adenocarcinoma (PDAC). However, recent literature reported an increased clinical burden in patients undergoing pancreaticoduodenectomy (PD) following NACT. Therefore, the aim of our study was to assess the impact of NACT on postoperative outcomes and recovery after PD. Methods: A retrospective propensity score-matched study was performed including all patients who underwent PD for PDAC in a single center between 2015 and 2018. Patients treated with NACT for resectable, borderline resectable or locally advanced PDAC were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients who underwent upfront resection. Propensity scores were calculated using 7 perioperative variables, including gender, age, BMI, ASA score, Charlson-Deyo comorbidity score, fistula risk score (FRS), vascular resection. Primary outcome was the number and severity of complications at 90-days after surgery measured by the comprehensive complication index (CCI). Data are reported as median (IQR) or number of patients (%). Results: Of 283 resected patients, 95 (34%) were treated with NACT. Before matching, NACT patients were younger, had less comorbidities (Charlson-Deyo score 0 vs. 1, p = 0.04), similar FRS [2 (0–3) for both groups], and more vascular resections performed [n = 28 (30%) vs. n = 26 (14%), p < 0.01]. After propensity-score matching, preoperative and intraoperative characteristics were comparable. Postoperatively, CCI was similar between groups [8.7 (0–29.6) for both groups, p = 0.59]. NACT patients had a non-statistically significant increase in superficial incisional surgical site infections [n = 12 (13%) vs. 6 (6%), p = 0.14], while no difference was found for overall infectious complications and organ-space SSI. The occurrence of clinically-relevant pancreatic fistula was similar between groups [10 (11%) vs. 13 (14%), p = 0.51]. No difference was found between groups for length of hospital stay [8 (7–15) vs. 8 (7–14) days, p = 0.62], and functional recovery outcomes. Conclusion: After propensity score adjustment for perioperative risk factors, NACT did not worsen postoperative outcomes and functional recovery following PD for PDAC compared to upfront resection.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Francesca Di Salvo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Castoldi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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41
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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42
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Peretti U, Reni M, Zanon S, Macchini M, Mazza E, Balzano G, Tamburrino D, Arcidiacono P, Massimo F, Gianni L. Time to CA19.9 nadir: a clue for defining treatment duration of primary chemotherapy in resectable PDAC. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz156.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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43
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Nigri G, Petrucciani N, Pinna AD, Ravaioli M, Jovine E, Minni F, Grazi GL, Chirletti P, Balzano G, Ferla F, De Carlis L, Tisone G, Napoli N, Boggi U, Ramacciato G. Corrigendum to "Evolution of pancreatectomy with en bloc venous resection for pancreatic cancer in Italy. Retrospective cohort study on 425 cases in 10 pancreatic referral units" [Int. J. Surg. 55 (2018) 103-109]. Int J Surg 2019; 67:129. [PMID: 31227366 DOI: 10.1016/j.ijsu.2019.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Giuseppe Nigri
- General Surgery and Hepato-pancreato-biliary Unit, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy.
| | - Niccolò Petrucciani
- General Surgery and Hepato-pancreato-biliary Unit, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Antonio Daniele Pinna
- General Surgery and Transpantation Unit, University of Bologna, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Matteo Ravaioli
- General Surgery and Transpantation Unit, University of Bologna, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Elio Jovine
- General Surgery Unit, Ospedale Maggiore di Bologna, Italy
| | - Francesco Minni
- General Surgery Unit, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Gian Luca Grazi
- Hepato-pancreato-biliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Piero Chirletti
- General Surgery Unit, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ferla
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Giuseppe Tisone
- Transplantation Unit, University of Tor Vergata, Policlinico Tor Vergata, Roma, Italy
| | - Niccolò Napoli
- General Surgery and Transplantation Unit, University of Pisa, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- General Surgery and Transplantation Unit, University of Pisa, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giovanni Ramacciato
- General Surgery and Hepato-pancreato-biliary Unit, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
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Balzano G, Maffi P, Nano R, Mercalli A, Melzi R, Aleotti F, De Cobelli F, Magistretti P, Scavini M, Secchi A, Falconi M, Piemonti L. Diabetes-free survival after extended distal pancreatectomy and islet auto transplantation for benign or borderline/malignant lesions of the pancreas. Am J Transplant 2019; 19:920-928. [PMID: 30549450 DOI: 10.1111/ajt.15219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/07/2018] [Accepted: 11/27/2018] [Indexed: 01/25/2023]
Abstract
Islet autotransplant is particularly attractive to prevent diabetes after extended pancreatectomy for benign or borderline/malignant pancreas disease. Between 2008 and 2018, 25 patients underwent left extended pancreatectomy (>60%) and islet autotransplant for a neoplasm located in the pancreatic neck or proximal body. Overall, disease-free and diabetes-free survivals were estimated and compared with those observed in 68 nondiabetic patients who underwent distal pancreatectomy for pancreatic neoplasms without islet autotransplant. Median follow-up was 4 years. We observed no deaths and a low morbidity (nonserious procedure-related complications in 2 of 25 patients). Patient and insulin-independent survival rates at 4 years were 100% and 96%, respectively. Glucose homeostasis remained within a nondiabetic range at all times for 19 (73%) of 25 patients. Preoperative glycemic level and insulin resistance were major predictors of diabetes development in these patients. Patients undergoing islet autotransplant had a longer diabetes-free survival than did patients without islet autotransplant (P = .04). In conclusion, islet autotransplant after extended pancreatic resection for neoplasms is a safe and successful procedure for preventing diabetes.
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Affiliation(s)
- Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Maffi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Melzi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Aleotti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Paola Magistretti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Secchi
- Clinical Transplant Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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45
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Brunetto E, De Monte L, Balzano G, Camisa B, Laino V, Riba M, Heltai S, Bianchi M, Bordignon C, Falconi M, Bondanza A, Doglioni C, Protti MP. The IL-1/IL-1 receptor axis and tumor cell released inflammasome adaptor ASC are key regulators of TSLP secretion by cancer associated fibroblasts in pancreatic cancer. J Immunother Cancer 2019; 7:45. [PMID: 30760333 PMCID: PMC6373075 DOI: 10.1186/s40425-019-0521-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/30/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The thymic stromal lymphopoietin (TSLP), a key cytokine for development of Th2 immunity, is produced by cancer associated fibroblasts (CAFs) in pancreatic cancer where predominant tumor infiltrating Th2 over Th1 cells correlates with reduced patients' survival. Which cells and molecules are mostly relevant in driving TSLP secretion by CAFs in pancreatic cancer is not defined. METHODS We performed in vitro, in vivo and ex-vivo analyses. For in vitro studies we used pancreatic cancer cell lines, primary CAFs cultures, and THP1 cells. TSLP secretion by CAFs was used as a read-out system to identify in vitro relevant tumor-derived inflammatory cytokines and molecules. For in vivo studies human pancreatic cancer cells and CAFs were orthotopically injected in immunodeficient mice. For ex-vivo studies immunohistochemistry was performed to detect ASC (apoptosis-associated speck-like protein containing a caspase recruitment domain) expression in surgical samples. Bioinformatics was applied to interrogate published data sets. RESULTS We show in vitro that IL-1α and IL-1β released by pancreatic cancer cells and tumor cell-conditioned macrophages are crucial for TSLP secretion by CAFs. Treatment of immunodeficient mice orthotopically injected with human IL-1 positive pancreatic cancer cells plus CAFs using the IL-1R antagonist anakinra significantly reduced TSLP expression in the tumor. Importantly, we found that pancreatic cancer cells release alarmins, among which ASC, able to induce IL-1β secretion in macrophages. The relevance of ASC was confirmed ex-vivo by its expression in both tumor cells and tumor associated macrophages in pancreatic cancer surgical samples and survival data analyses showing statistically significant inverse correlation between ASC expression and survival in pancreatic cancer patients. CONCLUSIONS Our findings indicate that tumor released IL-1α and IL-1β and ASC are key regulators of TSLP secretion by CAFs and their targeting should ultimately dampen Th2 inflammation and improve overall survival in pancreatic cancer.
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Affiliation(s)
- Emanuela Brunetto
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia De Monte
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Camisa
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Innovative Immunotherapies Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vincenzo Laino
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy
| | - Michela Riba
- Center for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Heltai
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy
| | - Marco Bianchi
- Chromatin Dynamics Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Bordignon
- MolMed SpA, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit and Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Attilio Bondanza
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.,Innovative Immunotherapies Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Doglioni
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Pia Protti
- Tumor Immunology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy. .,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Via Olgettina 58, 20132, Milan, Italy.
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46
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Dugnani E, Sordi V, Pellegrini S, Chimienti R, Marzinotto I, Pasquale V, Liberati D, Balzano G, Doglioni C, Reni M, Gandolfi A, Falconi M, Lampasona V, Piemonti L. Gene expression analysis of embryonic pancreas development master regulators and terminal cell fate markers in resected pancreatic cancer: A correlation with clinical outcome. Pancreatology 2018; 18:945-953. [PMID: 30293872 DOI: 10.1016/j.pan.2018.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 09/03/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the recent introduction of new drugs and the development of innovative multi-target treatments, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains very poor. Even when PDAC is resectable, the rate of local or widespread disease recurrence remains particularly high. Currently, reliable prognostic biomarkers of recurrence are lacking. We decided to explore the potential usefulness of pancreatic developmental regulators as biomarkers of PDAC relapse. METHODS We analyzed by quantitative real-time PCR the mRNA of selected factors involved either in pancreatic organogenesis (ISL1, NEUROD1, NGN3, NKX2.2, NKX6.1, PAX4, PAX6, PDX1 and PTF1α) or associated with terminally committed pancreatic cells (CHGA, CHGB, GAD2, GCG, HNF6α, INS, KRT19, SYP) in 17 PDAC cell lines and in frozen tumor samples from 41 PDAC patients. RESULTS High baseline levels of the ISL1, KRT19, PAX6 and PDX1 mRNAs in PDAC cell lines, were risk factors for time-dependent xenograft appearance after subcutaneous injection in CD1-Nude mice. Consistently, in human PDAC samples, high levels of KRT19 mRNA were associated with reduced overall survival and earlier recurrence. Higher levels of PDX1 or PAX6 mRNAs were instead associated with a higher frequency of local recurrence. CONCLUSIONS Our findings suggest that selected factors associated with pancreas development or its terminal differentiation might be implicated in mechanisms of PDAC progression and/or metastatic spread and that the measurement of their mRNA in tumors might be potentially used to improve patient prognostic stratification and prediction of the relapse site.
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Affiliation(s)
- Erica Dugnani
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Valeria Sordi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Silvia Pellegrini
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Raniero Chimienti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Ilaria Marzinotto
- Division of Genetics and Cell Biology, Genomic Unit for the Diagnosis of Human Pathologies, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Valentina Pasquale
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Daniela Liberati
- Division of Genetics and Cell Biology, Genomic Unit for the Diagnosis of Human Pathologies, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Claudio Doglioni
- Department of Pathology, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Alessandra Gandolfi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vito Lampasona
- Division of Genetics and Cell Biology, Genomic Unit for the Diagnosis of Human Pathologies, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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47
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Reni M, Zanon S, Peretti U, Chiaravalli M, Barone D, Pircher C, Balzano G, Macchini M, Romi S, Gritti E, Mazza E, Nicoletti R, Doglioni C, Falconi M, Gianni L. Nab-paclitaxel plus gemcitabine with or without capecitabine and cisplatin in metastatic pancreatic adenocarcinoma (PACT-19): a randomised phase 2 trial. Lancet Gastroenterol Hepatol 2018; 3:691-697. [DOI: 10.1016/s2468-1253(18)30196-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/28/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022]
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48
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Reni M, Zanon S, Balzano G, Passoni P, Pircher C, Chiaravalli M, Fugazza C, Ceraulo D, Nicoletti R, Arcidiacono PG, Macchini M, Peretti U, Castoldi R, Doglioni C, Falconi M, Partelli S, Gianni L. A randomised phase 2 trial of nab-paclitaxel plus gemcitabine with or without capecitabine and cisplatin in locally advanced or borderline resectable pancreatic adenocarcinoma. Eur J Cancer 2018; 102:95-102. [DOI: 10.1016/j.ejca.2018.07.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/29/2018] [Accepted: 07/08/2018] [Indexed: 01/29/2023]
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49
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Della-Torre E, Bozzalla-Cassione E, Sciorati C, Ruggiero E, Lanzillotta M, Bonfiglio S, Mattoo H, Perugino CA, Bozzolo E, Rovati L, Arcidiacono PG, Balzano G, Lazarevic D, Bonini C, Falconi M, Stone JH, Dagna L, Pillai S, Manfredi AA. A CD8α- Subset of CD4+SLAMF7+ Cytotoxic T Cells Is Expanded in Patients With IgG4-Related Disease and Decreases Following Glucocorticoid Treatment. Arthritis Rheumatol 2018; 70:1133-1143. [PMID: 29499100 PMCID: PMC6019645 DOI: 10.1002/art.40469] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/22/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE An unconventional population of CD4+ signaling lymphocytic activation molecule family member 7-positive (SLAMF7+) cytotoxic effector memory T (TEM ) cells (CD4+ cytotoxic T lymphocytes [CTLs]) has been linked causally to IgG4-related disease (IgG4-RD). Glucocorticoids represent the first-line therapeutic approach in patients with IgG4-RD, but their mechanism of action in this specific condition remains unknown. We undertook this study to determine the impact of glucocorticoids on CD4+ CTLs in IgG4-RD. METHODS Expression of CD8α, granzyme A, perforin, and SLAMF7 within the effector memory compartment of CD45RO+ (TEM ) and CD45RA+ effector memory T (TEMRA ) CD4+ cells was quantified by flow cytometry in 18 patients with active IgG4-RD, both at baseline and after 6 months of glucocorticoid treatment. Eighteen healthy subjects were studied as controls. Next-generation sequencing of the T cell receptor α- and β-chain gene was performed on circulating CD4+ CTLs from patients with IgG4-RD before and after treatment and in affected tissues. RESULTS Circulating CD4+ TEM and TEMRA cells were not expanded in IgG4-RD patients compared to healthy controls. CD4+SLAMF7+ TEM cells (but not TEMRA cells) were significantly increased among IgG4-RD patients. Within CD4+SLAMF7+ TEM cells, CD8α- cells but not CD8αlow cells were elevated in IgG4-RD patients. The same dominant clones of CD8α-CD4+SLAMF7+ TEM cells found in peripheral blood were also identified in affected tissue. CD8α- and CD8αlow CD4+SLAMF7+ TEM cells both expressed cytolytic molecules. Clonally expanded CD8α- but not CD8αlow CD4+SLAMF7+ TEM cells decreased following glucocorticoid-induced disease remission. CONCLUSION A subset of CD8α-CD4+SLAMF7+ cytotoxic TEM cells is oligoclonally expanded in patients with active IgG4-RD. This TEM cell population contracts following glucocorticoid-induced remission. Further characterization of this cell population may provide prognostic information and targets for therapeutic intervention.
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Affiliation(s)
- Emanuel Della-Torre
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Massachusetts General Hospital, Boston and Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Emanuele Bozzalla-Cassione
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Clara Sciorati
- Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eliana Ruggiero
- Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Experimental Hematology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Lanzillotta
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Bonfiglio
- Centre for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Hamid Mattoo
- Massachusetts General Hospital, Boston and Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Cory A. Perugino
- Massachusetts General Hospital, Boston and Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Enrica Bozzolo
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucrezia Rovati
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dejan Lazarevic
- Centre for Translational Genomics and Bioinformatics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Bonini
- Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Experimental Hematology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - John H. Stone
- Massachusetts General Hospital, Boston and Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Lorenzo Dagna
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Shiv Pillai
- Massachusetts General Hospital, Boston and Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Angelo A. Manfredi
- Università Vita-Salute San Raffaele, and Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Division of Immunology, Transplantation and Infectious Disease, IRCCS San Raffaele Scientific Institute, Milan, Italy
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50
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Venturini M, Sallemi C, Marra P, Palmisano A, Agostini G, Lanza C, Balzano G, Falconi M, Secchi A, Fiorina P, Piemonti L, Maffi P, Esposito A, De Cobelli F, Del Maschio A. Allo- and auto-percutaneous intra-portal pancreatic islet transplantation (PIPIT) for diabetes cure and prevention: the role of imaging and interventional radiology. Gland Surg 2018; 7:117-131. [PMID: 29770308 DOI: 10.21037/gs.2017.11.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although the life expectancy of patients with type 1 diabetes mellitus (T1DM) has improved since the introduction of insulin therapy, the acute life-threatening and long-term complications from diabetes mellitus are significant causes of both mortality and morbidity. Percutaneous intra-portal pancreatic islet transplantation (PIPIT) is a minimally invasive, repeatable procedure which allows a β-cell replacement therapy through a liver islet engraftment, leading to insulin release and glycaemic control restoration in patients with diabetes. Allo-PIPIT, in which isolated and purified islets from cadaveric donor are used, does not require major surgery, and is potentially less expensive for the recipient. In case of long-term T1DM, islet-after-kidney (IAK) transplantation can simultaneously cure diabetes and chronic renal failure, while islet-transplant-alone (ITA) is performed in brittle, short-term T1DM, based on the infusion of an adequate islet mass and on a steroid-free immunosuppressive regimen according to the Edmonton protocol. Results of the Collaborative Islet Transplant Registry (CITR) demonstrate that allo-PIPIT reduces episodes of hypoglycemia and diabetic complications, and improves quality of life of diabetic patients. Auto-PIPIT, in which the own patient's islets are used, has been investigated as a preventive treatment for pancreatogenic diabetes in patients who undergo extensive pancreatectomy for malignant and non-malignant disease. This Review outlines the role of imaging and interventional radiology in allo- and auto-PIPIT.
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Affiliation(s)
- Massimo Venturini
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Sallemi
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Marra
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Palmisano
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Agostini
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Carolina Lanza
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Department of Pancreatic Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Antonio Secchi
- Vita-Salute San Raffaele University, Milan, Italy.,Department of Internal Medicine, Transplant Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Fiorina
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorenzo Piemonti
- Vita-Salute San Raffaele University, Milan, Italy.,Diabetes Research Institute, San Raffaele Scientific Institute, Milan, Italy
| | - Paola Maffi
- Department of Internal Medicine, Transplant Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Del Maschio
- Department of Radiology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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