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Simbolo M, Silvestris N, Malleo G, Mafficini A, Maggino L, Cocomazzi A, Veghini L, Mombello A, Pezzini F, Sereni E, Martelli FM, Gkountakos A, Ciaparrone C, Piredda ML, Ingravallo G, Paolino G, Nappo F, Rapposelli IG, Frassinetti L, Saragoni L, Lonardi S, Pea A, Paiella S, Fassan M, Brunetti O, Cingarlini S, Salvia R, Milella M, Corbo V, Lawlor RT, Scarpa A, Luchini C. Clinical and Genomic Characterization of Pancreatic Ductal Adenocarcinoma with Signet-Ring/Poorly Cohesive Cells. Mod Pathol 2023; 36:100251. [PMID: 37355152 DOI: 10.1016/j.modpat.2023.100251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/12/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023]
Abstract
Signet-ring cell (SRC)/poorly cohesive cell carcinoma is an aggressive variant of pancreatic ductal adenocarcinoma (PDAC). This study aimed to clarify its clinicopathologic and molecular profiles based on a multi-institutional cohort of 20 cases. The molecular profiles were investigated using DNA and RNA sequencing. The clinicopathologic parameters and molecular alterations were analyzed based on survival indices and using a validation/comparative cohort of 480 conventional PDAC patients. The primary findings were as follows: (1) clinicopathologic features: SRC carcinomas are highly aggressive neoplasms with poor prognosis, and the lungs are elective metastatic sites; (2) survival analysis: a higher SRC component was indicative of poorer prognosis. In particular, the most clinically significant threshold of SRC was 80%, showing statistically significant differences in both disease-specific and disease-free survival; (3) genomic profiles: SRC carcinomas are similar to conventional PDAC with the most common alterations affecting the classic PDAC drivers KRAS (70% of cases), TP53 (55%), SMAD4 (25%), and CDKN2A (20%). EGFR alterations, RET::CCDC6 fusion gene, and microsatellite instability (3 different cases, 1 alteration per case) represent novel targets for precision oncology. The occurrence of SMAD4 mutations was associated with poorer prognosis; (4) pancreatic SRC carcinomas are genetically different from gastric SRC carcinomas: CDH1, the classic driver gene of gastric SRC carcinoma, is not altered in pancreatic SRC carcinoma; (5) transcriptome analysis: the cases clustered into 2 groups, one classical/exocrine-like, and the other squamous-like; and (6) SRC carcinoma-derived organoids can be successfully generated, and their cultures preserve the histologic and molecular features of parental SRC carcinoma. Although pancreatic SRC carcinoma shares similarities with conventional PDAC regarding the most important genetic drivers, it also exhibits important differences. A personalized approach for patients with this tumor type should consider the clinical relevance of histologic determination of the SRC component and the presence of potentially actionable molecular targets.
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Affiliation(s)
- Michele Simbolo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Giuseppe Malleo
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Andrea Mafficini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Laura Maggino
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | | | - Lisa Veghini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Mombello
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Francesco Pezzini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Elisabetta Sereni
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Filippo M Martelli
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | | | - Chiara Ciaparrone
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Maria L Piredda
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Ingravallo
- Department of Emergency and Transplantation, Pathology Section, University of Bari Medical School, Bari, Italy
| | - Gaetano Paolino
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Floriana Nappo
- Medical Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | | | | | - Luca Saragoni
- Department of Pathological Anatomy, AUSL Romagna, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Sara Lonardi
- Medical Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Antonio Pea
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, and Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Oronzo Brunetti
- IRCCS Istituto Tumori "Giovanni Paolo II" of Bari, Vari, Italy
| | - Sara Cingarlini
- Department of Medicine, Section of Oncology, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Michele Milella
- Department of Medicine, Section of Oncology, University and Hospital Trust of Verona, Verona, Italy
| | - Vincenzo Corbo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Rita T Lawlor
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University and Hospital Trust of Verona, Verona, Italy.
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2
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Eshmuminov D, Aminjonov B, Palm RF, Malleo G, Schmocker RK, Abdallah R, Yoo C, Shaib WL, Schneider MA, Rangelova E, Choi YJ, Kim H, Rose JB, Patel S, Wilson GC, Maloney S, Timmermann L, Sahora K, Rössler F, Lopez-Lopez V, Boyer E, Maggino L, Malinka T, Park JY, Katz MHG, Prakash L, Ahmad SA, Helton S, Jang JY, Hoffe SE, Salvia R, Taieb J, He J, Clavien PA, Held U, Lehmann K. FOLFIRINOX or Gemcitabine-based Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Cancer: A Multi-institutional, Patient-Level, Meta-analysis and Systematic Review. Ann Surg Oncol 2023; 30:4417-4428. [PMID: 37020094 PMCID: PMC10250524 DOI: 10.1245/s10434-023-13353-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/01/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Pancreatic cancer often presents as locally advanced (LAPC) or borderline resectable (BRPC). Neoadjuvant systemic therapy is recommended as initial treatment. It is currently unclear what chemotherapy should be preferred for patients with BRPC or LAPC. METHODS We performed a systematic review and multi-institutional meta-analysis of patient-level data regarding the use of initial systemic therapy for BRPC and LAPC. Outcomes were reported separately for tumor entity and by chemotherapy regimen including FOLFIRINOX (FIO) or gemcitabine-based. RESULTS A total of 23 studies comprising 2930 patients were analyzed for overall survival (OS) calculated from the beginning of systemic treatment. OS for patients with BRPC was 22.0 months with FIO, 16.9 months with gemcitabine/nab-paclitaxel (Gem/nab), 21.6 months with gemcitabine/cisplatin or oxaliplatin or docetaxel or capecitabine (GemX), and 10 months with gemcitabine monotherapy (Gem-mono) (p < 0.0001). In patients with LAPC, OS also was higher with FIO (17.1 months) compared with Gem/nab (12.5 months), GemX (12.3 months), and Gem-mono (9.4 months; p < 0.0001). This difference was driven by the patients who did not undergo surgery, where FIO was superior to other regimens. The resection rates for patients with BRPC were 0.55 for gemcitabine-based chemotherapy and 0.53 with FIO. In patients with LAPC, resection rates were 0.19 with Gemcitabine and 0.28 with FIO. In resected patients, OS for patients with BRPC was 32.9 months with FIO and not different compared to Gem/nab, (28.6 months, p = 0.285), GemX (38.8 months, p = 0.1), or Gem-mono (23.1 months, p = 0.083). A similar trend was observed in resected patients converted from LAPC. CONCLUSIONS In patients with BRPC or LAPC, primary treatment with FOLFIRINOX compared with Gemcitabine-based chemotherapy appears to provide a survival benefit for patients that are ultimately unresectable. For patients that undergo surgical resection, outcomes are similar between GEM+ and FOLFIRINOX when delivered in the neoadjuvant setting.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Botirjon Aminjonov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Ryan K Schmocker
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Raëf Abdallah
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel André Schneider
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Elena Rangelova
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology (CLINTEC) at Karolinska Institute, Stockholm, Sweden
- Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - J Bart Rose
- Division of Surgical Oncology, Pancreatobiliary Disease Center at UAB, The University of Alabama at Birmingham, Birmingham, USA
| | - Sameer Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah Maloney
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lea Timmermann
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Klaus Sahora
- Departments of Surgery and Comprehensive Cancer Center, University of Vienna, Medical University of Vienna, Vienna, Austria
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Laura Maggino
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Thomas Malinka
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Laura Prakash
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Julien Taieb
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Jin He
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
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3
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Eshmuminov D, Aminjonov B, Palm RF, Malleo G, Schmocker RK, Abdallah R, Yoo C, Shaib WL, Schneider MA, Rangelova E, Choi YJ, Kim H, Rose JB, Patel S, Wilson GC, Maloney S, Timmermann L, Sahora K, Rössler F, Lopez-Lopez V, Boyer E, Maggino L, Malinka T, Park JY, Katz MHG, Prakash L, Ahmad SA, Helton S, Jang JY, Hoffe SE, Salvia R, Taieb J, He J, Clavien PA, Held U, Lehmann K. ASO Visual Abstract: FOLFIRINOX or Gemcitabine Based Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Cancer: A Multi-Institutional, Patient-Level Meta-Analysis and Systematic Review. Ann Surg Oncol 2023; 30:4431-4432. [PMID: 37067744 DOI: 10.1245/s10434-023-13489-1] [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: 04/18/2023]
Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Botirjon Aminjonov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Ryan K Schmocker
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Raëf Abdallah
- Hepatogastroenterology and gastrointestinal oncology department, hôpitalEuropéen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel André Schneider
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Elena Rangelova
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology (CLINTEC) at Karolinska Institute, Stockholm, Sweden
- Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - J Bart Rose
- Division of Surgical Oncology, Pancreatobiliary Disease Center at UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sameer Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah Maloney
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lea Timmermann
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klaus Sahora
- Departments of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Thomas Malinka
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Laura Prakash
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Julien Taieb
- Hepatogastroenterology and gastrointestinal oncology department, hôpitalEuropéen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Jin He
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
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4
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Maggino L, Malleo G, Crippa S, Belfiori G, Bannone E, Lionetto G, Gasparini G, Nobile S, Luchini C, Mattiolo P, Schiavo-Lena M, Doglioni C, Scarpa A, Ferrone C, Bassi C, Castillo CFD, Falconi M, Salvia R. Pathological staging in postneoadjuvant pancreatectomy for pancreatic cancer: implications for adjuvant therapy. Br J Surg 2023:7187688. [PMID: 37260079 DOI: 10.1093/bjs/znad146] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 03/15/2023] [Accepted: 04/30/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND It is unclear whether pathological staging is significant prognostically and can inform the delivery of adjuvant therapy after pancreatectomy preceded by neoadjuvant therapy. METHODS This multicentre retrospective study included patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma after neoadjuvant treatment at two Italian centres between 2013 and 2017. T and N status were assigned in accordance with the seventh and eighth editions of the AJCC staging system, as well as according to a modified system with T status definition combining extrapancreatic invasion and tumour size. Patients were then stratified by receipt of adjuvant therapy. Survival analysis and multivariable interaction analysis of adjuvant therapy with pathological parameters were performed. The results were validated in an external cohort from the USA. RESULTS The developmental set consisted of 389 patients, with a median survival of 34.6 months. The modified staging system displayed the best prognostic stratification and the highest discrimination (C-index 0.763; 1-, 2- and 3-year time-dependent area under the curve (AUC) 0.746, 0.722, and 0.705; Uno's AUC 0.710). Overall, 67.0 per cent of patients received adjuvant therapy. There was no survival difference by receipt of adjuvant therapy (35.0 versus 36.0 months; P = 0.772). After multivariable adjustment, interaction analysis suggested a benefit of adjuvant therapy for patients with nodal metastases or with tumours larger than 2 cm with extrapancreatic extension, regardless of nodal status. These results were confirmed in the external cohort of 216 patients. CONCLUSION Modified staging with a T status definition combining extrapancreatic invasion and tumour size is associated with better prognostic segregation after postneoadjuvant pancreatectomy. This system allows identification of patients who might benefit from adjuvant therapy.
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Affiliation(s)
- Laura Maggino
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Crippa
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Belfiori
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Elisa Bannone
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Gabriella Lionetto
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giulia Gasparini
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Sara Nobile
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Marco Schiavo-Lena
- Division of Pathology, Pancreas Translational and Clinical Research Centre, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Division of Pathology, Pancreas Translational and Clinical Research Centre, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudio Bassi
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | | | - Massimo Falconi
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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5
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Paiella S, Azzolina D, Trestini I, Malleo G, Nappo G, Ricci C, Ingaldi C, Vacca PG, De Pastena M, Secchettin E, Zamboni G, Maggino L, Corciulo MA, Sandini M, Cereda M, Capretti G, Casadei R, Bassi C, Mansueto G, Gregori D, Milella M, Zerbi A, Gianotti L, Salvia R. Corrigendum: Body composition parameters, immunonutritional indexes, and surgical outcome of pancreatic cancer patients resected after neoadjuvant therapy: a retrospective, multicenter analysis. Front Nutr 2023; 10:1212436. [PMID: 37284653 PMCID: PMC10240154 DOI: 10.3389/fnut.2023.1212436] [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: 04/26/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
[This corrects the article DOI: 10.3389/fnut.2023.1065294.].
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Ilaria Trestini
- Dietetics Services, Hospital Medical Direction, University Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Ricci
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pier Giuseppe Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giulia Zamboni
- Radiology Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Maggino
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Maria Assunta Corciulo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marta Sandini
- General Surgery Unit, University of Siena, Siena, Italy
| | - Marco Cereda
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
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6
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Malleo G, Maggino L, Lionetto G, Patton A, Paiella S, Pea A, Esposito A, Casetti L, Luchini C, Scarpa A, Bassi C, Salvia R. A dynamic analysis of empirical survival outcomes after pancreatectomy for pancreatic ductal adenocarcinoma. Surgery 2023; 173:1030-1038. [PMID: 36585320 DOI: 10.1016/j.surg.2022.11.015] [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] [Received: 07/31/2022] [Revised: 10/18/2022] [Accepted: 11/15/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Survival outcomes after pancreatectomy for pancreatic ductal adenocarcinoma may be biased by right-censoring. We herein analyzed a large dataset with no censored events for up to 5 years and dynamically investigated the impact of known prognostic factors, accounting for unobserved tumor characteristics. METHODS Consecutive patients undergoing pancreatectomy from 2000 to July 2015 were included. The 1- to 5-year empirical survival rates were calculated, and factors associated with long-term survival (≥5 years) were analyzed using multivariable models. Dynamic analyses of survival and recurrence were conducted through landmarking, and the contribution of unobserved heterogeneity was estimated using frailty models. RESULTS The study population included 1,048 patients. The median follow-up was 30.4 months in the whole cohort and 97.2 months in survivors. The median survival was 30.4 months, with empirical 1- to 5-year rates of 85.5%, 59.6%, 43.2%, 32.1%, and 27.5%. A favorable pathological profile was associated with 5-year survival, albeit 25.7% of long-survivors received an R1 resection, and 28.8% had N2 disease. The median recurrence-free survival was 17.2 months. At landmark analyses, baseline prognostic lost strength over time, with no independent predictors of survival being identified in the sets of patients alive at 4 and 5 years. There was a significant amount of unobserved heterogeneity in the early postoperative period. CONCLUSION The 5-year post-pancreatectomy empirical survival was 27.5%. Dynamic analyses showed a time-varying structure of prognostic variables and a substantial impact of unobserved tumor characteristics that may drive the disease course under the selective pressure of surgical resection and adjuvant chemotherapy.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/gimalleo
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/LMaggino
| | | | - Alex Patton
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/Totuccio1983
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, University of Verona, Italy. https://twitter.com/peaantonio1
| | | | - Luca Casetti
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Claudio Luchini
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Italy. https://twitter.com/CLuchini10
| | - Aldo Scarpa
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University of Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University of Verona, Italy.
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7
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Paiella S, Azzolina D, Trestini I, Malleo G, Nappo G, Ricci C, Ingaldi C, Vacca PG, De Pastena M, Secchettin E, Zamboni G, Maggino L, Corciulo MA, Sandini M, Cereda M, Capretti G, Casadei R, Bassi C, Mansueto G, Gregori D, Milella M, Zerbi A, Gianotti L, Salvia R. Body composition parameters, immunonutritional indexes, and surgical outcome of pancreatic cancer patients resected after neoadjuvant therapy: A retrospective, multicenter analysis. Front Nutr 2023; 10:1065294. [PMID: 36860690 PMCID: PMC9968808 DOI: 10.3389/fnut.2023.1065294] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
Background and aims Body composition parameters and immunonutritional indexes provide useful information on the nutritional and inflammatory status of patients. We sought to investigate whether they predict the postoperative outcome in patients with pancreatic cancer (PC) who received neoadjuvant therapy (NAT) and then pancreaticoduodenectomy. Methods Data from locally advanced PC patients who underwent NAT followed by pancreaticoduodenectomy between January 2012 and December 2019 in four high-volume institutions were collected retrospectively. Only patients with two available CT scans (before and after NAT) and immunonutritional indexes (before surgery) available were included. Body composition was assessed and immunonutritional indexes collected were: VAT, SAT, SMI, SMA, PLR, NLR, LMR, and PNI. The postoperative outcomes evaluated were overall morbidity (any complication occurring), major complications (Clavien-Dindo ≥ 3), and length of stay. Results One hundred twenty-one patients met the inclusion criteria and constituted the study population. The median age at the diagnosis was 64 years (IQR16), and the median BMI was 24 kg/m2 (IQR 4.1). The median time between the two CT-scan examined was 188 days (IQR 48). Skeletal muscle index (SMI) decreased after NAT, with a median delta of -7.8 cm2/m2 (p < 0.05). Major complications occurred more frequently in patients with a lower pre-NAT SMI (p = 0.035) and in those who gained in subcutaneous adipose tissue (SAT) compartment during NAT (p = 0.043). Patients with a gain in SMI experienced fewer major postoperative complications (p = 0.002). The presence of Low muscle mass after NAT was associated with a longer hospital stay [Beta 5.1, 95%CI (1.5, 8.7), p = 0.006]. An increase in SMI from 35 to 40 cm2/m2 was a protective factor with respect to overall postoperative complications [OR 0.43, 95% (CI 0.21, 0.86), p < 0.001]. None of the immunonutritional indexes investigated predicted the postoperative outcome. Conclusion Body composition changes during NAT are associated with surgical outcome in PC patients who receive pancreaticoduodenectomy after NAT. An increase in SMI during NAT should be favored to ameliorate the postoperative outcome. Immunonutritional indexes did not show to be capable of predicting the surgical outcome.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy,*Correspondence: Salvatore Paiella ✉
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Ilaria Trestini
- Dietetics Services, Hospital Medical Direction, University Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Ricci
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pier Giuseppe Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giulia Zamboni
- Radiology Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Maggino
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Maria Assunta Corciulo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marta Sandini
- General Surgery Unit, University of Siena, Siena, Italy
| | - Marco Cereda
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy,Roberto Salvia ✉
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8
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Frigerio I, Regi P, Giardino A, Girelli R, Butturini G, Scopelliti F, Allegrini V, Maggino L. Para-aortic lymph nodes metastases in pancreatic cancer are not a too late Stage. European Journal of Surgical Oncology 2023. [DOI: 10.1016/j.ejso.2022.11.434] [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: 02/23/2023]
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9
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Karam E, Hollenbach M, Ali EA, Auriemma F, Gulla A, Heise C, Regner S, Gaujoux S, Regimbeau JM, Kähler G, Seyfried S, Vaillant JC, De Ponthaud C, Sauvanet A, Birnbaum D, Regenet N, Truant S, Pérez-Cuadrado-Robles E, Bruzzi M, Lupinacci RM, Brunel M, Belfiori G, Barbier L, Salamé E, Souche FR, Schwarz L, Maggino L, Salvia R, Gagniére J, Del Chiaro M, Leung G, Hackert T, Kleemann T, Paik WH, Caca K, Dugic A, Muehldorfer S, Schumacher B, Albers D. Outcomes of rescue procedures in the management of locally recurrent ampullary tumors: A Pancreas 2000/EPC study. Surgery 2023; 173:1254-1262. [PMID: 36642655 DOI: 10.1016/j.surg.2022.12.011] [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] [Received: 07/11/2022] [Revised: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Ampullary lesions are rare and can be locally treated either with endoscopic papillectomy or transduodenal surgical ampullectomy. Management of local recurrence after a first-line treatment has been poorly studied. METHODS Patients with a local recurrence of an ampullary lesion initially treated with endoscopic papillectomy or transduodenal surgical ampullectomy were retrospectively included from a multi-institutional database (58 centers) between 2005 and 2018. RESULTS A total of 103 patients were included, 21 (20.4%) treated with redo endoscopic papillectomy, 14 (13.6%) with transduodenal surgical ampullectomy, and 68 (66%) with pancreaticoduodenectomy. Redo endoscopic papillectomy had low morbidity with 4.8% (n = 1) severe to fatal complications and a R0 rate of 81% (n = 17). Transduodenal surgical ampullectomy and pancreaticoduodenectomy after a first procedure had a higher morbidity with Clavien III and more complications, respectively, 28.6% (n = 4) and 25% (n = 17); R0 resection rates were 85.7% (n = 12) and 92.6% (n = 63), both without statistically significant difference compared to endoscopic papillectomy (P = .1 and 0.2). Pancreaticoduodenectomy had 4.4% (n = 2) mortality. No deaths were registered after transduodenal surgical ampullectomy or endoscopic papillectomy. Recurrences treated with pancreaticoduodenectomy were more likely to be adenocarcinomas (79.4%, n = 54 vs 21.4%, n = 3 for transduodenal surgical ampullectomy and 4.8%, n = 1 for endoscopic papillectomy, P < .0001). Three-year overall survival and disease-free survival were comparable. CONCLUSION Endoscopy is appropriate for noninvasive recurrences, with resection rate and survival outcomes comparable to surgery. Surgery applies more to invasive recurrences, with transduodenal surgical ampullectomy rather for carcinoma in situ and early cancers and pancreaticoduodenectomy for more advanced tumors.
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Affiliation(s)
- Elias Karam
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France.
| | - Marcus Hollenbach
- University of Leipzig Medical Center, Medical Department II-Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, Leipzig, Germany
| | - Einas Abou Ali
- Department of Gastroenterology, Digestive Oncology, and Endoscopy, Cochin Hospital, Paris, France
| | - Francesco Auriemma
- Humanitas Clinical and Research Hospital, Rozzano, Digestive Endoscopy Unit, Division of Gastroenterology, Milan, Italy
| | - Aiste Gulla
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania; Johns Hopkins University, MedStar Georgetown University Hospital, General Surgery, Washington, DC
| | - Christian Heise
- Martin-Luther University Halle-Wittenberg Department of Medicine I-Gastroenterology, Pulmonology, Halle, Germany
| | - Sara Regner
- Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, Paris, France
| | | | - Jean M Regimbeau
- Department of Digestive Surgery, Center Hospitalo-Universitaire Amiens-Picardie, Amiens, France
| | - Georg Kähler
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany; Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Steffen Seyfried
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany; Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Jean C Vaillant
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Charles De Ponthaud
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Alain Sauvanet
- Department of Digestive Surgery, Beaujon Hospital, APHP, Clichy, France
| | - David Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Nicolas Regenet
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
| | - Stéphanie Truant
- Deparment of Digestive Surgery, Centre Hospitalo-Universitaire de Lille, France
| | | | - Matthieu Bruzzi
- Department of Digestive Surgery, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Renato M Lupinacci
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Martin Brunel
- Department of Digestive Surgery, Hôpital André Mignot, Versailles, France
| | - Giulio Belfiori
- Department of Pancreatic Surgery, Vita Salute San Raffaele University, Milan, Italy
| | - Louise Barbier
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France
| | - Ephrem Salamé
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France
| | - Francois R Souche
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles-Nicolle, Centre Hospitalier Universitaire de Rouen, France
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, The Pancreas Institute Verona, Department of Surgery, Dentistry, Paediatrics, and Gynaecology, University of Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute Verona, Department of Surgery, Dentistry, Paediatrics, and Gynaecology, University of Verona, Italy
| | - Johan Gagniére
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, Clermont-Ferrand, France; U1071 Inserm / Clermont-Auvergne University, Clermont-Ferrand, France
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, CO
| | - Galen Leung
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, PA
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Tobias Kleemann
- Department of Gastroenterology and Rheumatology, Carl-Thiem-Klinikum Cottbus, Germany
| | - Woo H Paik
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Republic of Korea
| | - Karel Caca
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes and Infectious Diseases, RKH Clinic Ludwigsburg, Germany
| | - Ana Dugic
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Steffen Muehldorfer
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | | | - David Albers
- Department of Medicine and Gastroenterology, Contilia Clinic Essen, Germany
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10
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Maggino L, Malleo G, Crippa S, Belfiori G, Nobile S, Gasparini G, Lionetto G, Luchini C, Mattiolo P, Schiavo-Lena M, Doglioni C, Scarpa A, Bassi C, Falconi M, Salvia R. CA19.9 Response and Tumor Size Predict Recurrence Following Post-neoadjuvant Pancreatectomy in Initially Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:207-219. [PMID: 36227391 PMCID: PMC9726670 DOI: 10.1245/s10434-022-12622-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on recurrence after post-neoadjuvant pancreatectomy are scant. This study investigated the incidence and pattern of recurrence in patients with initially resectable and borderline resectable pancreatic ductal adenocarcinoma who received post-neoadjuvant pancreatectomy. Furthermore, preoperative predictors of recurrence-free survival (RFS) and their interactions were determined. PATIENTS AND METHODS Patients undergoing post-neoadjuvant pancreatectomy at two academic facilities between 2013 and 2017 were analyzed using standard statistics. The possible interplay between preoperative parameters was scrutinized including interaction terms in multivariable Cox models. RESULTS Among 315 included patients, 152 (48.3%) were anatomically resectable. The median RFS was 15.7 months, with 1- and 3-year recurrence rates of 41.9% and 74.2%, respectively. Distant recurrence occurred in 83.3% of patients, with lung-only patterns exhibiting the most favorable prognostic outlook. Normal posttreatment CA19.9, ΔCA19.9 (both in patients with normal and elevated baseline levels), and posttreatment tumor size were associated with RFS. Critical thresholds for ΔCA19.9 and tumor size were set at 50% and 20 mm, respectively. Interaction between ΔCA19.9 and posttreatment CA19.9 suggested a significant risk reduction in patients with elevated values when ΔCA19.9 exceeded 50%. Moreover, posttreatment tumor size interacted with posttreatment CA19.9 and ΔCA19.9, suggesting an increased risk in the instance of elevated posttreatment CA19.9 values and a protective effect associated with CA19.9 response in patients with tumor size >20 mm. CONCLUSION Recurrence following post-neoadjuvant pancreatectomy is common. Preoperative tumor size <20 mm, normal posttreatment CA19.9 and ΔCA19.9 > 50% were associated with longer RFS. These variables should not be taken in isolation, as their interaction significantly modulates the recurrence risk.
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Affiliation(s)
- Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Stefano Crippa
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Belfiori
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Giulia Gasparini
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Gabriella Lionetto
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Marco Schiavo-Lena
- Division of Pathology, Pancreas Translational and Clinical Research Center, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Division of Pathology, Pancreas Translational and Clinical Research Center, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
| | - Massimo Falconi
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, G.B. Rossi Hospital, Verona, Italy
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11
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Maggino L, Malleo G, Crippa S, Falconi M, Salvia R. ASO Author Reflections: Recurrence Following Post-neoadjuvant Pancreatectomy: How Can We Do Better? Ann Surg Oncol 2023; 30:220-221. [PMID: 36227393 DOI: 10.1245/s10434-022-12676-w] [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: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Laura Maggino
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Crippa
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Massimo Falconi
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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12
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Maggino L, Malleo G, Crippa S, Belfiori G, Nobile S, Gasparini G, Lionetto G, Luchini C, Mattiolo P, Schiavo-Lena M, Doglioni C, Scarpa A, Bassi C, Falconi M, Salvia R. ASO Visual Abstract: Ca 19.9 Response and Tumor Size Predict Recurrence Following Post-neoadjuvant Pancreatectomy in Initially Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:222-223. [PMID: 36333571 DOI: 10.1245/s10434-022-12729-0] [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: 11/06/2022]
Affiliation(s)
- Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Crippa
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Belfiori
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giulia Gasparini
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Gabriella Lionetto
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section␣of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section␣of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Marco Schiavo-Lena
- Division of Pathology, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Claudio Doglioni
- Division of Pathology, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section␣of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Massimo Falconi
- Unit of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
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13
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Pollini T, Adsay V, Capurso G, Molin MD, Esposito I, Hruban R, Luchini C, Maggino L, Matthaei H, Marchegiani G, Scarpa A, Wood LD, Bassi C, Salvia R, Mino-Kenudson M, Maker AV. The tumour immune microenvironment and microbiome of pancreatic intraductal papillary mucinous neoplasms. Lancet Gastroenterol Hepatol 2022; 7:1141-1150. [PMID: 36057265 PMCID: PMC9844533 DOI: 10.1016/s2468-1253(22)00235-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 01/19/2023]
Abstract
Pancreatic intraductal papillary mucinous neoplasms (IPMNs) have gained substantial attention because they represent one of the only radiographically identifiable precursors of invasive pancreatic ductal adenocarcinoma. Although most of these neoplasms have low-grade dysplasia and will remain indolent, a subset of IPMNs will progress to invasive cancer. The role of the immune system in the progression of IPMNs is unclear, but understanding its role could reveal the mechanism of neoplastic progression and targets for immunotherapy to inhibit progression or treat invasive disease. The available evidence supports a shift in the immune composition of IPMNs during neoplastic progression. Although low-grade lesions contain a high proportion of effector T cells, high-grade IPMNs, and IPMNs with an associated invasive carcinoma lose the T-cell infiltrate and are characterised by a predominance of immunosuppressive elements. Several possible therapeutic strategies emerge from this analysis that are unique to IPMNs and its microbiome.
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Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA,Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Volcan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine, Istanbul, Turkey
| | - Gabriele Capurso
- Department of Pancreatobiliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele, Milan, Italy
| | - Marco Dal Molin
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Irene Esposito
- Department of Pathology, Heinrich Heine University and University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Ralph Hruban
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology University of Verona, Verona, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Hanno Matthaei
- Department of Surgery, University Hospital of Bonn, Bonn, Germany
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology University of Verona, Verona, Italy
| | - Laura D Wood
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, Section of Pathology University of Verona, Verona, Italy
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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14
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Hank T, Hinz U, Reiner T, Malleo G, König AK, Maggino L, Marchegiani G, Kaiser J, Paiella S, Binco A, Salvia R, Hackert T, Bassi C, Büchler MW, Strobel O. A Pretreatment Prognostic Score to Stratify Survival in Pancreatic Cancer. Ann Surg 2022; 276:e914-e922. [PMID: 33914468 DOI: 10.1097/sla.0000000000004845] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to develop and validate a pretreatment prognostic score in pancreatic cancer (PDAC). BACKGROUND Pretreatment prognostication in PDAC is important for treatment decisions but remains challenging. Available prognostic tools are derived from selected cohorts of patients who underwent resection, excluding up to 20% of patients with exploration only, and do not adequately reflect the pretreatment scenario. METHODS Patients undergoing surgery for PDAC in Heidelberg from July 2006 to June 2014 were identified from a prospective database. Pretreatment parameters were extracted from the database and the laboratory information system. Parameters independently associated with overall survival by uni- and multivariable analyses were used to build a prognostic score. A contemporary cohort from Verona was used for external validation. RESULTS In 1197 patients, multiple pretreatment parameters were associated with overall survival by univariable analyses. American Society of Anesthesiology classification, carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen, C-reactive protein, albumin, and platelet count were independently associated with survival and were used to create the Heidelberg Prognostic Pancreatic Cancer (HELPP)-score. The HELPP-score was closely associated with overall survival (median survival between 31.3 and 4.8 months; 5-year survival rates between 35% and 0%) and was able to stratify survival in subgroups with or without resection as well as in CA19-9 nonsecretors. In the resected subgroup the HELPP-score stratified survival independently of pathological prognostic factors. The HELPP-score was externally validated and was superior to CA19-9 in both the development and validation cohorts. CONCLUSION The HELPP-score is a readily available prognostic tool based on pretreatment routine parameters to stratify survival in PDAC independently of resection status and pathological tumor stage.
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Affiliation(s)
- Thomas Hank
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Thomas Reiner
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Giuseppe Malleo
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Anna-Katharina König
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Laura Maggino
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Jörg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Salvatore Paiella
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Alessandra Binco
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Claudio Bassi
- Department of General, and Pancreatic Surgery, The Verona Pancreas Institute, University of Verona, Hospital Trust, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg, University Hospital, Heidelberg, Germany
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15
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Malleo G, Maggino L, Qadan M, Marchegiani G, Ferrone CR, Paiella S, Luchini C, Mino-Kenudson M, Capelli P, Scarpa A, Lillemoe KD, Bassi C, Castillo CFD, Salvia R. Reassessment of the Optimal Number of Examined Lymph Nodes in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma. Ann Surg 2022; 276:e518-e526. [PMID: 33177357 DOI: 10.1097/sla.0000000000004552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to reappraise the optimal number of examined lymph nodes (ELNs) in pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). SUMMARY BACKGROUND DATA The well-established threshold of 15 ELNs in PD for PDAC is optimized for detecting 1 positive node (PLN) per the previous 7th edition of the American Joint Committee on Cancer (AJCC) staging manual. In the framework of the 8th edition, where at least 4 PLN are needed for an N2 diagnosis, this threshold may be inadequate for accurate staging. METHODS Patients who underwent upfront PD at 2 academic institutions between 2000 and 2016 were analyzed. The optimal ELN threshold was defined as the cut-point associated with a 95% probability of identifying at least 4 PLNs in N2 patients. The results were validated addressing the N-status distribution and stage migration. RESULTS Overall, 1218 patients were included. The median number of ELN was 26 (IQR 17-37). ELN was independently associated with N2-status (OR 1.27, P < 0.001). The estimated optimal threshold of ELN was 28. This cut-point enabled improved detection of N2 patients and stage III disease (58% vs 37%, P = 0.001). The median survival was 28.6 months. There was an improved survival in N0/N1 patients when ELN exceeded 28, suggesting a stage migration effect (47 vs 29 months, adjusted HR 0.649, P < 0.001). In N2 patients, this threshold was not associated with survival on multivariable analysis. CONCLUSION Examining at least 28 LN in PD for PDAC ensures optimal staging through improved detection of N2/stage III disease. This may have relevant implications for benchmarking processes and quality implementation.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | | | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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16
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Malleo G, Maggino L, Casciani F, Lionetto G, Nobile S, Lazzarin G, Paiella S, Esposito A, Capelli P, Luchini C, Scarpa A, Bassi C, Salvia R. Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective, Lymphadenectomy Protocol. Ann Surg Oncol 2022; 29:3477-3488. [PMID: 35192154 PMCID: PMC9072462 DOI: 10.1245/s10434-022-11417-3] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Implementing a prospective lymphadenectomy protocol, we investigated the nodal yields and metastases per anatomical stations and nodal echelon following upfront pancreatoduodenectomy (PD) for cancer. Next, the relationship between the extension of nodal dissection, the number of examined and positive nodes (ELN/PLN), disease staging and prognosis was assessed. METHODS Lymphadenectomy included stations 5, 6, 8a-p, 12a-b-p, 13, 14a-b, 17, and jejunal mesentery nodes. Data were stratified by N-status, anatomical stations, and nodal echelons. First echelon was defined as stations embedded in the main specimen and second echelon as stations sampled as separate specimens. Recurrence and survival analyses were performed by using standard statistics. RESULTS Overall, 424 patients were enrolled from June 2013 through December 2018. The median number of ELN and PLN was 42 (interquartile range [IQR] 34-50) and 4 (IQR 2-8). Node-positive patients were 88.2%. The commonest metastatic sites were stations 13 (77.8%) and 14 (57.5%). The median number of ELN and PLN in the first echelon was 28 (IQR 23-34) and 4 (IQR 1-7). While first-echelon dissection provided enough ELN for optimal nodal staging, the aggregate rate of second-echelon metastases approached 30%. Nodal-related factors associated with recurrence and survival were N-status, multiple metastatic stations, metastases to station 14, and jejunal mesentery nodes. CONCLUSIONS First-echelon dissection provides adequate number of ELN for optimal staging. Nodal metastases occur mostly at stations 13/14, although second-echelon involvement is frequent. Only station 14 and jejunal mesentery nodes involvement was prognostically relevant. This latter station should be included in the standard nodal map and analyzed pathologically.
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Affiliation(s)
- Giuseppe Malleo
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Laura Maggino
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Fabio Casciani
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Gabriella Lionetto
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Sara Nobile
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Gianni Lazzarin
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Alessandro Esposito
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Paola Capelli
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Luchini
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Aldo Scarpa
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy.
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17
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Malleo G, Maggino L, Casciani F, Lionetto G, Nobile S, Lazzarin G, Paiella S, Esposito A, Capelli P, Luchini C, Scarpa A, Bassi C, Salvia R. ASO Visual Abstract: Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective Lymphadenectomy Protocol. Ann Surg Oncol 2022. [PMID: 35235085 DOI: 10.1245/s10434-022-11458-8] [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: 11/18/2022]
Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Gabriella Lionetto
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Gianni Lazzarin
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Paola Capelli
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Luchini
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Aldo Scarpa
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, G.B. Rossi Hospital, University of Verona, Verona, Italy.
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18
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Malleo G, Maggino L, Luchini C, Salvia R. ASO Author Reflection: Location of Nodal Metastases in Pancreatoduodenectomy for Cancer: Which Station Matters? Ann Surg Oncol 2022; 29:3489-3490. [PMID: 35217974 DOI: 10.1245/s10434-022-11469-5] [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: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. .,Unit of Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy.
| | - Laura Maggino
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Unit of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy.,Unit of Pancreatic Surgery, Department of Surgery, Dentistry, Gynecology, and Pediatrics, University of Verona, Verona, Italy
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19
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Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, McMillan MT, Miller B, Pratt WB, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Castillo CFD, Christein JD, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Salem RR, Wolfgang CL, Zureikat AH, Vollmer CM. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg 2022; 275:e463-e472. [PMID: 32541227 DOI: 10.1097/sla.0000000000004068] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. BACKGROUND The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. METHODS FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. RESULTS The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). CONCLUSION Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.
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Affiliation(s)
- Maxwell T Trudeau
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Fabio Casciani
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Brett L Ecker
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laura Maggino
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Thomas F Seykora
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Priya Puri
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Matthew T McMillan
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Benjamin Miller
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wande B Pratt
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | - Adam C Berger
- Jefferson Medical College, Philadelphia, Pennsylvania
| | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | - Michael G House
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven J Hughes
- University of Florida College of Medicine, Jacksonville, Florida
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charles M Vollmer
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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20
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Zhang B, Lee GC, Qadan M, Fong ZV, Mino-Kenudson M, Desphande V, Malleo G, Maggino L, Marchegiani G, Salvia R, Scarpa A, Luchini C, De Gregorio L, Ferrone CR, Warshaw AL, Lillemoe KD, Bassi C, Castillo CFD. Revision of Pancreatic Neck Margins Based on Intraoperative Frozen Section Analysis Is Associated With Improved Survival in Patients Undergoing Pancreatectomy for Ductal Adenocarcinoma. Ann Surg 2021; 274:e134-e142. [PMID: 31851002 DOI: 10.1097/sla.0000000000003503] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To test the hypothesis that complete, tumor-free resection at the pancreatic neck, achieved either en-bloc or non-en-bloc (ie, revision based on intraoperative frozen section [FS] analysis), is associated with improved survival as compared with incomplete resection (IR) in pancreatic ductal adenocarcinoma. SUMMARY BACKGROUND DATA Given the likely systemic nature of pancreatic ductal adenocarcinoma, the oncologic benefit of achieving a histologically complete local resection, particularly through revision of a positive intraoperative FS at the pancreatic neck, remains controversial. METHODS Clinicopathologic and treatment data were reviewed for 986 consecutive patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas who underwent open pancreatectomy as well as intraoperative FS analysis between 1998 and 2012 at Massachusetts General Hospital and between 1998 and 2013 at the University of Verona. Overall survival (OS) and perioperative morbidity and mortality were compared across 3 groups: complete resection achieved en-bloc (CR-EB), complete resection achieved non-en-bloc (CR-NEB), and IR. RESULTS The CR-EB cohort comprised 749 (76%) patients, CR-NEB 159 patients (16%), and IR 78 patients (8%). Other than a higher incidence of vascular resection among CR-NEB and IR patients, no demographic, pathologic (eg, tumor grade, lymph node positivity, superior mesenteric artery involvement), or treatment factors (eg, neoadjuvant and adjuvant therapy use) differed between the groups. Median OS was significantly higher in patients with CR-EB (28 mo, P = 0.01) and CR-NEB resections (24 mo, P = 0.02) as compared with patients with IR resections (19 mo). After adjusting for clinicopathologic and treatment characteristics, CR-EB and CR-NEB margin status were found to be independent predictors of improved OS (relative to IR, CR-EB hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.86; CR-NEB HR 0.69, 95% CI 0.50-0.96). There were no intergroup differences in perioperative morbidity and mortality, including rates of pancreatic fistula. CONCLUSIONS For patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas undergoing pancreatectomy, complete tumor extirpation via either en-bloc or non-en-bloc complete resection based on FS analysis is associated with improved OS, without an associated increased perioperative morbidity or mortality.
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Affiliation(s)
- Biqi Zhang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vikram Desphande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Applied Research on Cancer Centre (ARC-Net), University and Hospital Trust of Verona, Verona, Italy
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Lucia De Gregorio
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital of Verona Hospital Trust, Verona, Italy
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21
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Malleo G, Salvia R, Maggino L, Marchegiani G, D'Angelica M, DeMatteo R, Kingham P, Pulvirenti A, Sereni E, Jarnagin WR, Bassi C, Allen PJ, Butturini G. Long-term Outcomes After Surgical Resection of Pancreatic Metastases from Renal Clear-Cell Carcinoma. Ann Surg Oncol 2021; 28:3100-3108. [PMID: 33575870 PMCID: PMC8119267 DOI: 10.1245/s10434-021-09649-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 08/31/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic metastases (PM) from renal cell carcinoma (RCC) are uncommon. We herein describe the long-term outcomes associated with pancreatectomy at two academic institutions, with a specific focus on 10-year survival. METHODS This investigation was limited to patients undergoing pancreatectomy for PM between 2000 and 2008 at the University of Verona and Memorial Sloan Kettering Cancer Center, allowing a potential for 10 years of surveillance. The probabilities of further RCC recurrence and RCC-related death were estimated using a competing risk analysis (method of Fine and Gray) to account for patients who died of other causes during follow-up. RESULTS The study population consisted of 69 patients, mostly with isolated metachronous PM (77%). The median interval from nephrectomy to pancreatic metastasectomy was 109 months, whereas the median post-pancreatectomy follow-up was 141 months. The 10-year cumulative incidence of new RCC recurrence was 62.7%. In the adjusted analysis, the relative risk of repeated recurrence was significantly higher in PM synchronous to the primary RCC (sHR = 1.27) and in patients receiving extended pancreatectomy (sHR = 3.05). The 10-year cumulative incidence of disease-specific death was 25.5%. The only variable with an influence on disease-specific death was the recurrence-free interval following metastasectomy (sHR = 0.98). In patients with repeated recurrence, the 10-year cumulative incidence of RCC-related death was 35.4%. CONCLUSION In a selected group of patients followed for a median of 141 months and mostly with isolated metachronous PM, resection was associated with a high possibility of long-term disease control in surgically fit patients with metastases confined to the pancreas.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery-DSCOMI University of Verona, Verona, Italy.
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery-DSCOMI University of Verona, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Michael D'Angelica
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald DeMatteo
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter Kingham
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessandra Pulvirenti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elisabetta Sereni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - William R Jarnagin
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Peter J Allen
- The Hepato-Biliary and Pancreatic Unit, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Duke University, Durham, NC, USA
| | - Giovanni Butturini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
- Unit of Pancreatic Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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22
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Casciani F, De Luca R, Maggino L, Nobile S, Paiella S, Marchegiani G, Salvia R, Bassi C, Malleo G. Early onset predicts neither better surgical outcomes nor improved survival following resection for pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2021. [DOI: 10.1016/j.ejso.2020.11.167] [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: 11/29/2022] Open
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23
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Trudeau MT, Casciani F, Gershuni VM, Maggino L, Ecker BL, Lee MK, Roses RE, DeMatteo RP, Fraker DL, Drebin JA, Vollmer CM. Defining postoperative weight change after pancreatectomy: Factors associated with distinct and dynamic weight trajectories. Surgery 2020; 168:1041-1047. [PMID: 32943201 DOI: 10.1016/j.surg.2020.07.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/10/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Weight change offers the simplest indication of a patient's recovery after an operation. There have been no studies that have thoroughly investigated postoperative weight dynamics after pancreatectomy. The aim of this study was to define postoperative weight change after a pancreatectomy and determine factors associated with optimal and poor weight trajectories. METHODS From 2004 to 2019, 1,090 proximal (65%) and distal (35%) pancreatectomies were performed in patients with adequate data in the medical records. Patient weights were acquired preoperatively and at postoperative months 1, 3, and 12. Optimal (top quartile, weight restoration) and poor (bottom quartile, persistent weight loss) postoperative weight cohorts were identified at 1 year postoperatively. RESULTS The median percentage weight change 1 year postpancreatectomy was -6.6% (interquartile range: -1.4% to -12.5%), -7.8% for proximal pancreatectomy, and -4.2% for distal pancreatectomy. For most patients (interquartile range cohort), the median percentage weight change at 1, 3, and 12 months was -6.2%, -7.2%, and -6.6%. The independent factors associated with weight restoration were age <65, nonobesity (body mass index <30kg/m2), receiving total parenteral nutrition/total enteral nutrition preoperatively, experiencing preoperative weight loss >10%, distal pancreatectomy, not undergoing vascular resection, and no readmission within 30 days. Conversely, persistent weight loss was associated with American Society of Anesthesiologists classes III to IV, obesity, malignancy, proximal pancreatectomy, blood loss ≥350mL, and experiencing readmission within 30 days. Focusing on pancreatic ductal adenocarcinoma (n = 372) patients, the factors associated with persistent weight loss were obesity, proximal pancreatectomy, and experiencing recurrence within 1 year; however, weight cohorts were not associated with overall survival for pancreatic ductal adenocarcinoma patients. CONCLUSION These data define weight kinetics after pancreatectomy. Ultimately, postoperative weight trajectories appear to be largely predetermined but may be mitigated by limiting readmissions and complications. Clinicians should use these data to identify patients who continue to lose weight between the first and third month postoperatively with a high suspicion for the requirement of nutritional monitoring or other interventions.
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Affiliation(s)
- Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Victoria M Gershuni
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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24
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Weniger M, Moir J, Damm M, Maggino L, Kordes M, Rosendahl J, Ceyhan GO, Schorn S, D'Haese JG, Werner J, Boeck S, Kruger S, Haas M, Roeder F, Friess H, Chiaro MD, Löhr M, Tamburrino D, Falconi M, Masini G, Maisonneuve P, Malleo G, Salvia R, Bassi C, Charnley R, Algül H, Schmidt M, Lange S, Michl P. Respect - A multicenter retrospective study on preoperative chemotherapy in locally advanced and borderline resectable pancreatic cancer. Pancreatology 2020; 20:1131-1138. [PMID: 32739267 DOI: 10.1016/j.pan.2020.06.012] [Citation(s) in RCA: 12] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy has become a powerful tool to convert borderline resectable (BRPC) and locally advanced pancreatic cancers (LAPC) into a resectable scenario. However, data analyzing the optimal type of therapy are scarce. In the present multicenter retrospective study, we evaluated the influence of FOLFIRINOX (FFX) and gemcitabine (GEM)-based neoadjuvant therapy on patient prognosis. METHODS Data on 239 patients from 7 centers across Europe was gathered using an online database. Patients having received their first cycle of chemotherapy for BRPC/LAPC before 06/2017, with a minimum follow-up of 12 months, were included in the intention-to-treat analysis. RESULTS Patients treated with neoadjuvant FFX (n = 135) or gemcitabine + nab-paclitaxel (GNP) (n = 38) had significantly improved radiological response according to RECIST criteria as compared to single-agent GEM (n = 16), with a partial/complete response of 59.3%, 55.3% and 6.25% respectively (p = 0.001). Treatment with FFX (n = 135) and GNP (n = 38) resulted in higher resection rates compared to GEM (73.3%, 81.6% and 43.8%; p = 0.01 and p = 0.005). Regardless of regimen, patients who were resected had significantly prolonged overall survival compared to non-resected patients (p < 0.01). Complete pathological responses (ypT0 ypN0) were predominantly observed with FFX (p = 0.01). Adjuvant GNP in addition to successful neoadjuvant therapy and surgery resulted in a trend towards improved median survival as compared to postoperative observation (47.0 vs. 30.1 months, p = 0.06). CONCLUSIONS Representing one of the largest studies published so far, our results reveal that patients with BRPC/LAPC should be offered either FFX or GNP to improve chances of resection and with this also survival.
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Affiliation(s)
- Maximilian Weniger
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians University, Munich, Germany
| | - John Moir
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Marko Damm
- Department of Gastroenterology, University Hospital Halle/Saale, Halle, Germany
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Maximilian Kordes
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Rosendahl
- Department of Gastroenterology, University Hospital Halle/Saale, Halle, Germany
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany; Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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25
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Malleo G, Casciani F, Maggino L, Marchegiani G, Paiella S, Salvia R, Bassi C. Analysis and proceeding to full publication of abstracts presented at the Pancreas Club annual meeting. Pancreatology 2020; 20:1008-1010. [PMID: 32622758 DOI: 10.1016/j.pan.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy.
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
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26
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Affiliation(s)
- Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona Hospital Trust, P.Le L.A, Scuro 10, 37134, Verona, Italy.
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona Hospital Trust, P.Le L.A, Scuro 10, 37134, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona Hospital Trust, P.Le L.A, Scuro 10, 37134, Verona, Italy
| | - Michele Milella
- Department of Medicine, Section of Medical Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona Hospital Trust, P.Le L.A, Scuro 10, 37134, Verona, Italy
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Malleo G, Maggino L, Fernàndez-Del Castillo C, Salvia R. ASO Author Reflections: Does Site Matter? Impact of Tumor Location on Pathologic Characteristics, Recurrence, and Survival of Resected Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2020; 27:3913-3914. [PMID: 32399766 DOI: 10.1245/s10434-020-08572-w] [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: 04/30/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | | | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy.
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28
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Trudeau MT, Maggino L, Chen B, McMillan MT, Lee MK, Roses R, DeMatteo R, Drebin JA, Vollmer CM. Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice. J Am Coll Surg 2020; 230:809-818.e1. [DOI: 10.1016/j.jamcollsurg.2020.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 01/08/2023]
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Malleo G, Maggino L, Ferrone CR, Marchegiani G, Luchini C, Mino-Kenudson M, Paiella S, Qadan M, Scarpa A, Lillemoe KD, Bassi C, Fernàndez-Del Castillo C, Salvia R. Does Site Matter? Impact of Tumor Location on Pathologic Characteristics, Recurrence, and Survival of Resected Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2020; 27:3898-3912. [PMID: 32307617 DOI: 10.1245/s10434-020-08354-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The authors hypothesized that in resected pancreatic adenocarcinoma (PDAC), pathologic characteristics, oncologic outcomes, prognostic factors, and the accuracy of the American Joint Committee on Cancer (AJCC) staging system might differ based on tumor location. METHODS Patients undergoing pancreatectomy for PDAC at two academic institutions from 2000 to 2015 were retrieved. A comparative analysis between head (H-PDAC) and body-tail (BT-PDAC) tumors was performed using uni- and multivariable models. The accuracy of the eighth AJCC staging system was analyzed using C-statistics. RESULTS Among 1466 patients, 264 (18%) had BT-PDAC, which displayed greater tumor size but significantly lower rates of perineural invasion and G3/4 grading. Furthermore, BT-PDAC was associated with a lower frequency of nodal involvement and a greater representation of earlier stages. The recurrence-free survival and disease-specific survival times were longer for BT-PDAC (16 vs 14 months [p = 0.020] and 33 vs 26 months [p = 0.026], respectively), but tumor location was not an independent predictor of recurrence or survival in the multivariable analyses. The recurrence patterns did not differ. Certain prognostic factors (i.e., CA 19.9, grading, R-status, and adjuvant treatment) were common, whereas others were site-specific (i.e., preoperative pain, diabetes, and multivisceral resection). The performances of the AJCC staging system were similar (C-statistics of 0.573 for H-PDAC and 0.597 for BT-PDAC, respectively). CONCLUSIONS Despite differences in pathologic profile found to be in favor of BT-PDAC, tumor location was not an independent predictor of recurrence or survival after pancreatectomy. An array of site-specific prognostic factors was identified, but the AJCC staging system displayed similar prognostic power regardless of primary tumor location.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | | | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy.
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30
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Malleo G, Maggino L, Nobile S, Casciani F, Cacciatori N, Paiella S, Luchini C, Rusev B, Capelli P, Marchegiani G, Bassi C, Salvia R. Reappraisal of nodal staging and study of lymph node station involvement in distal pancreatectomy for body-tail pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2020; 46:1734-1741. [PMID: 32327367 DOI: 10.1016/j.ejso.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/27/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The pattern of nodal spread in body-tail pancreatic ductal adenocarcinoma (PDAC) has been poorly investigated. This study analyzed the characteristics of lymph node (LN) involvement and the prognostic role of nodal metastases stratified by LN stations. METHODS All upfront distal pancreatectomies (DPs) for PDAC (2000-2017) with complete information on station 8,10,11, and 18 were included. Clinico-pathological correlates and survival were investigated using uni- and multivariable analyses. RESULTS Among 100 included patients, 28 were N0, 42 N1 and 30 N2. The median number of examined LN was 32 (IQR 26-44). Tumor size at preoperative imaging increased across N-classes. Preoperative size >27.5 mm was associated with N2 status. The frequency of nodal metastases at stations 8, 9, 10, 11, and 18 was 12.0%, 10.9%, 3.0%, 71.0%, and 19%, respectively. The pattern of LN spread was independent from primary tumor location (with tail tumors metastasizing to station 8/9 and body tumors to station 10), while it was highly associated with N-class. At multivariable analysis, tumor grading, adjuvant treatment, station 9 and 10 metastases were independent prognostic factors in node-positive patients. CONCLUSIONS In patients undergoing upfront DP for PDAC preoperative tumor size is associated with the degree of nodal spread. While station 11 was the most frequently involved, only station-9 and 10 metastases were independent prognostic factors. The site of nodal metastases was somewhat unpredictable based on tumor location. This data has potential implications for allocating patients to neoadjuvant treatment and supports the performance of routine splenectomy during DP for PDAC.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Sara Nobile
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicolò Cacciatori
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Borislav Rusev
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Perri G, Prakash L, Malleo G, Caravati A, Varadhachary GR, Fogelman D, Pant S, Koay EJ, Herman J, Maggino L, Milella M, Kim M, Ikoma N, Tzeng CW, Salvia R, Lee JE, Bassi C, Katz MHG. The Sequential Radiographic Effects of Preoperative Chemotherapy and (Chemo)Radiation on Tumor Anatomy in Patients with Localized Pancreatic Cancer. Ann Surg Oncol 2020; 27:3939-3947. [PMID: 32266574 PMCID: PMC7471157 DOI: 10.1245/s10434-020-08427-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence and magnitude of indicators of radiographic response of pancreatic cancer to systemic chemotherapy and (chemo)radiation administered prior to anticipated pancreatectomy are unclear. METHODS Sequential computed tomography scans of 226 patients with localized pancreatic cancer who received chemotherapy consisting of 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) or gemcitabine and nanoparticle albumin-bound paclitaxel (GA) with or without (chemo)radiation and who subsequently underwent surgery with curative intent from January 2010 to December 2018 at The University of Texas MD Anderson Cancer Center and Verona University Hospital were re-reviewed and compared. RESULTS Overall, 141 patients (62%) received FOLFIRINOX, 70 (31%) received GA, and 15 (7%) received both; 164 patients (73%) received preoperative (chemo)radiation following chemotherapy and prior to surgery; and 151 (67%), 70 (31%), and 5 (2%) patients had Response Evaluation Criteria in Solid Tumors (RECIST) stable disease, partial response, and progressive disease, respectively. The tumors of 29% of patients with borderline resectable or locally advanced cancer were downstaged after preoperative therapy. Radiographic downstaging was more common with chemotherapy than with (chemo)radiation (24% vs. 6%; p = 0.04), and the median tumor volume loss after chemotherapy was significantly greater than that after (chemo)radiation (28% vs. 17%; p < 0.01). CONCLUSIONS Less than one-third of patients treated with FOLFIRINOX or GA with or without (chemo)radiation experienced either RECIST partial response or radiographic downstaging prior to surgery. The incidence of tumor downstaging was higher and the magnitude of tumor volume loss was greater following chemotherapy than after (chemo)radiation.
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Affiliation(s)
- Giampaolo Perri
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Prakash
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Maggino
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Michele Milella
- Department of Gastrointestinal Medical Oncology, Verona University Hospital, Verona, Italy
| | - Michael Kim
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jeffrey E Lee
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Matthew H G Katz
- Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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32
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Maggino L, Liu JB, Thompson VM, Pitt HA, Ko CY, Vollmer CM. Assessing the influence of experience in pancreatic surgery: a risk-adjusted analysis using the American College of Surgeons NSQIP database. HPB (Oxford) 2019; 21:1773-1783. [PMID: 31153836 DOI: 10.1016/j.hpb.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 10/07/2018] [Revised: 03/07/2019] [Accepted: 04/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association between higher surgical volume and better perioperative outcomes after pancreatectomy has been extensively demonstrated. However, how different notions of experience impact outcomes of surgeons operating within high-quality scenarios remains unclear. METHODS Self-reported experience parameters from ACS-NSQIP HPB-Collaborative surgeons were merged with 2014-2016 ACS-NSQIP clinical data. The association of various experience parameters with outcomes was investigated through uni- and multivariable analyses. Hierarchical regression assessed surgeon performance. RESULTS 111/151 HPB-Collaborative surgeons provided responses (73.5%). Compared to the other 532 ACS-NSQIP surgeons performing pancreatectomy, HPB-Collaborative surgeons performed 7692/16,239 of the overall pancreatectomies (47.3%), with improved outcomes of serious morbidity, pancreatic fistula, reoperation, duration of stay and readmissions. Median age of respondents was 49 years and 92.8% were fellowship-trained. Median career and annual pancreatectomy volume were 400 and 35, respectively; median annual institutional volume was 100 resections. On unadjusted analyses, several aspects of experience were associated with the outcomes studied, especially for pancreatoduodenectomy; however, none remained significant after multivariable adjustment. Surgeons' profiling showed substantial homogeneity in performance for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS Contemporary data shows that for surgeons operating in high quality settings clinical outcomes are largely independent of indicators of greater experience.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Jason B Liu
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Chen B, Trudeau MT, Maggino L, Ecker BL, Keele LJ, DeMatteo RP, Drebin JA, Fraker DL, Lee MK, Roses RE, Vollmer CM. Defining the Safety Profile for Performing Pancreatoduodenectomy in the Setting of Hyperbilirubinemia. Ann Surg Oncol 2019; 27:1595-1605. [PMID: 31691110 DOI: 10.1245/s10434-019-08044-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hyperbilirubinemia is commonly observed in patients requiring pancreatoduodenectomy (PD). Thus far, literature regarding the danger of operating in the setting of hyperbilirubinemia is equivocal. What remains undefined is at what specific level of bilirubin there is an adverse safety profile for undergoing PD. The aim of this study is to identify the optimal safety profile of patients with hyperbilirubinemia undergoing PD. PATIENTS AND METHODS The present work analyzed 803 PDs from 2004 to 2018. A generalized additive model was used to determine cutoff values of total serum bilirubin (TB) that were associated with increases in adverse outcomes, including 90-day mortality. Subgroup comparisons and biliary stent-specific analyses were performed for patients with TB below and above the cutoff. RESULTS TB of 13 mg/dL was associated with an increase in 90-day mortality (P = 0.043) and was the dominant risk factor on multivariate logistic regression [odds ratio (OR) 8.193, P = 0.001]. Increased TB levels were also associated with reoperations, number of complications per patient, and length of stay. Patients with TB greater than or equal to 13 mg/dL (TB ≥ 13) who received successful biliary decompression through stenting had less combined death and serious morbidity (P = 0.048). CONCLUSIONS Preoperative TB ≥ 13 mg/dL was associated with increased 90-day mortality after PD. Reducing a TB ≥ 13 is generally recommended before proceeding to surgery.
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Affiliation(s)
- Bofeng Chen
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, University of Verona, The Pancreas Institute, Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Luke J Keele
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Maggino L, Malleo G, Salvia R, Bassi C, Vollmer CM. Defining the practice of distal pancreatectomy around the world. HPB (Oxford) 2019; 21:1277-1287. [PMID: 30910318 DOI: 10.1016/j.hpb.2019.02.016] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Best management practices for distal pancreatectomy (DP) have not been conclusively defined. The aim of this study was to analyze the practice of DP worldwide and to compare surgeons' behavior with the best available evidence. METHODS A survey assessing management approaches for DP was distributed worldwide, in eight native-language translations. Regions were clustered: North-America, South/Central America, Asia/Australia, and Europe/Africa/Middle East. RESULTS Overall, 721/797 (91%) responding surgeons (median age = 48; years of experience = 14) indicated their region, representing six continents and 68 nations. Use of minimally-invasive (MI) techniques is diverse-highest in North-America (p < 0.001). Laparoscopy is the most common MI approach, while robotic techniques are rarely performed outside North-America. The preferred means of pancreatic remnant closure is via stapler - more commonly applied in North-America than in Europe/Africa/Middle East. Management techniques for the remnant and other fistula mitigation strategies display significant regional variability. The use of drains is also diverse, with the biggest disparity between North-American and Asian/Australian surgeons (selective and routine drainers, respectively). CONCLUSION There is wide heterogeneity in practices for DP worldwide, which is influenced by the surgeon's region of practice. Variability in practice reflects the lack of solid evidence on the benefit of any given strategy, underlining areas for improvement.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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35
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Maggino L, Malleo G, Marchegiani G, Viviani E, Nessi C, Ciprani D, Esposito A, Landoni L, Casetti L, Tuveri M, Paiella S, Casciani F, Sereni E, Binco A, Bonamini D, Secchettin E, Auriemma A, Merz V, Simionato F, Zecchetto C, D’Onofrio M, Melisi D, Bassi C, Salvia R. Outcomes of Primary Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma. JAMA Surg 2019; 154:932-942. [PMID: 31339530 PMCID: PMC6659151 DOI: 10.1001/jamasurg.2019.2277] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [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: 02/23/2019] [Accepted: 05/17/2019] [Indexed: 12/21/2022]
Abstract
Importance Chemotherapy is the recommended induction strategy in borderline resectable and locally advanced pancreatic ductal adenocarcinoma. However, the associated results on an intention-to-treat basis are poorly understood. Objective To investigate pragmatically the treatment compliance, conversion to surgery, and survival outcomes of patients with borderline resectable and locally advanced pancreatic ductal adenocarcinoma undergoing primary chemotherapy. Design, Setting, and Participants This prospective study took place in a national referral center for pancreatic diseases in Italy. Consecutive patients with borderline resectable and locally advanced pancreatic ductal adenocarcinoma were enrolled at the time of diagnosis (January 2013 through December 2015) and followed up to June 2018. Exposures The chemotherapy regimen, assigned based on multidisciplinary evaluation, was delivered either at a hub center or at spoke centers. By convention, primary chemotherapy was considered completed after 6 months. After restaging, surgical candidates were selected based on radiologic and biochemical response. All surgeries were carried out at the hub center. Main Outcomes and Measures Rates of receipt and completion of chemotherapy, rates of conversion to surgery, and disease-specific survival. Results Of 680 patients, 267 (39.3%) had borderline resectable and 413 (60.7%) had locally advanced pancreatic ductal adenocarcinoma. Overall, 66 patients (9.7%) were lost to follow-up. The rate of chemotherapy receipt was 92.9% (n = 570). The chemotherapeutic regimens most commonly used included FOLFIRINOX (fluorouracil, leucovorin, oxaliplatin, and irinotecan) (260 [45.6%]) and gemcitabine plus nanoparticle albumin-bound-paclitaxel (123 [21.6%]). Nineteen patients (3.3%) receiving chemotherapy died within 6 months, mainly for disease progression. The treatment completion rate was 71.6% (408 of 570). The overall rate of resection was 15.1% (93 of 614) (borderline resectable, 60 of 249 [24.1%]; locally advanced, 33 of 365 [9%]; resection:exploration ratio, 63.3%). Independent predictors of resection were age, borderline resectable disease, chemotherapy completion, radiologic response, and biochemical response. The median survival for the whole cohort was 12.8 (95% CI, 11.7-13.9) months. Factors independently associated with survival were completion of chemotherapy, receipt of complementary radiation therapy, and resection. In patients who underwent resection, the median survival was 35.4 (95% CI, 27.0-43.7) months for initially borderline resectable and 41.8 (95% CI, 27.5-56.1) months for initially locally advanced disease. No pretreatment and posttreatment factors were associated with survival after pancreatectomy. Conclusions and Relevance This pragmatic observational cohort study with an intention-to-treat design provides real-world evidence of outcomes associated with the most current primary chemotherapy regimens used for borderline resectable and locally advanced pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Elena Viviani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Nessi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Debora Ciprani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Elisabetta Sereni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Binco
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Valeria Merz
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Francesca Simionato
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Camilla Zecchetto
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Mirko D’Onofrio
- Unit of Radiology, Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Davide Melisi
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Seykora TF, Maggino L, Malleo G, Lee MK, Roses R, Salvia R, Bassi C, Vollmer CM. Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy. J Gastrointest Surg 2019; 23:135-144. [PMID: 30406578 DOI: 10.1007/s11605-018-3959-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 06/11/2018] [Accepted: 08/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent data illustrates improved outcomes when adhering to early drain removal following pancreatoduodenectomy (PD). This study aims to explore the potential benefits of expanding the timeframe for early drain removal. METHODS Six hundred forty PDs were originally managed by selective drain placement and early removal. Outcomes were reappraised in the framework of a novel proposal; intraoperative drains were omitted based on a low-risk profile (Fistula Risk Score 0-2), followed by drain removal at PODs 1, 3, and 5 if drain fluid amylase (DFA) fell below specific cutoffs based on optimized negative predictive values (NPV) for clinically relevant postoperative pancreatic fistula (CR-POPF). Characteristics of the remaining cohort with drains in situ on POD5 were examined using multivariable analysis (MVA). RESULTS Intraoperative FRS would preclude drains from 230 (35.9%) negligible/low-risk cases with a cohort CR-POPF rate of 1.7%. Of the remaining patients, 30.5% would have drains removed on POD1 based on a DFA threshold of 300 IU/L (NPV = 98.4%), demonstrating a 1.6% CR-POPF rate. On POD3, drains could be removed in the residual cohort from 21.1% of patients with DFA ≤ 150 IU/L (NPV = 96.6%), reflecting a 3.4% CR-POPF rate. On POD5, a DFA threshold of 50 IU/L (NPV = 84%) identified 16.3% more patients whose drains could be removed. The remaining cohort (POD5 DFA > 50 IU/L), "enriched" for fistula development and reflecting just 18.4% of the original patients, displays a 61% CR-POPF rate. Among these patients on POD5, a DFA threshold > 2000 IU/L best predicted subsequent CR-POPF (PPV = 89.5%), and MVA revealed a positive association between pancreatic cancer/pancreatitis (OR = 4.37, p = 0.022) and longer operations (OR = 3.74, p = 0.014) with CR-POPF development. CONCLUSION Early drain removal is a dynamic concept and can be employed throughout the postoperative time course using conditional thresholds to better identify patients at risk for CR-POPF.
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Affiliation(s)
- Thomas F Seykora
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Major K Lee
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Robert Roses
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA.
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37
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Uzunoglu FG, Welte MN, Gavazzi F, Maggino L, Perinel J, Salvia R, Janot M, Reeh M, Perez D, Montorsi M, Zerbi A, Adham M, Uhl W, Bassi C, Izbicki JR, Malleo G, Bockhorn M. Evaluation of the MDACC clinical classification system for pancreatic cancer patients in an European multicenter cohort. Eur J Surg Oncol 2018; 45:793-799. [PMID: 30585172 DOI: 10.1016/j.ejso.2018.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 09/06/2018] [Revised: 12/06/2018] [Accepted: 12/18/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The MDACC group recommends to extend the current borderline classification for pancreatic cancer into three groups: type A patients with resectable/borderline tumor anatomy, type B with resectable/borderline resectable tumor anatomy and clinical findings suspicious for extrapancreatic disease and type C with borderline resectable and marginal performance status/severe pre-existing comorbidity profile or age>80. This study intents to evaluate the proposed borderline classification system in a multicenter patient cohort without neoadjuvant treatment. METHODS Evaluation was based on a multicenter database of pancreatic cancer patients undergoing surgery from 2005 to 2016 (n = 1020). Complications were classified based on the Clavien-Dindo classification. χ2-test, Kaplan-Meier estimator and Cox regression hazard model were used for statistical analysis. RESULTS Most patients (55.1%) were assigned as type A patients, followed by type C (35.8%) and type B patients (9.1%). Neither the complication rate, nor the mortality rate revealed a correlation to any subgroup. Type B patients had a significant worse progression free (p < 0.001) and overall survival (p = 0.005). Type B classification was identified as an independent prognostic marker for progression free survival (p = 0.005, HR 1.47). CONCLUSION The evaluation of the proposed classification in a cohort without neoadjuvant treatment did not justify an additional medical borderline subgroup. A new subgroup based on prognostic borderline patients might be the main target group for neoadjuvant protocols in future.
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Affiliation(s)
- F G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - M-N Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - F Gavazzi
- Department of General Surgery, Humanitas Research Hosptital and University, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - L Maggino
- Department of Surgery and Oncology, Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - J Perinel
- Hospices Civils de Lyon & Lyon Sud Faculty of Medicine, UCBL1, E. Herriot Hospital, Department of Digestive Surgery, Lyon, France
| | - R Salvia
- Department of Surgery and Oncology, Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - M Janot
- Department of Surgery, St. Josef-Hospital Bochum, Hospital of the Ruhr- University, Bochum, Germany
| | - M Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - D Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - M Montorsi
- Department of General Surgery, Humanitas Research Hosptital and University, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - A Zerbi
- Department of General Surgery, Humanitas Research Hosptital and University, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - M Adham
- Hospices Civils de Lyon & Lyon Sud Faculty of Medicine, UCBL1, E. Herriot Hospital, Department of Digestive Surgery, Lyon, France
| | - W Uhl
- Department of Surgery, St. Josef-Hospital Bochum, Hospital of the Ruhr- University, Bochum, Germany
| | - C Bassi
- Department of Surgery and Oncology, Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - J R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - G Malleo
- Department of Surgery and Oncology, Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - M Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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38
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van Roessel S, Kasumova GG, Verheij J, Najarian RM, Maggino L, de Pastena M, Malleo G, Marchegiani G, Salvia R, Ng SC, de Geus SW, Lof S, Giovinazzo F, van Dam JL, Kent TS, Busch OR, van Eijck CH, Koerkamp BG, Abu Hilal M, Bassi C, Tseng JF, Besselink MG. International Validation of the Eighth Edition of the American Joint Committee on Cancer (AJCC) TNM Staging System in Patients With Resected Pancreatic Cancer. JAMA Surg 2018; 153:e183617. [PMID: 30285076 DOI: 10.1001/jamasurg.2018.3617] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance The recently released eighth edition of the American Joint Committee on Cancer TNM staging system for pancreatic cancer seeks to improve prognostic accuracy but lacks international validation. Objective To validate the eighth edition of the American Joint Committee on Cancer TNM staging system in an international cohort of patients with resected pancreatic ductal adenocarcinoma. Design, Setting, and Participants This international multicenter cohort study took place in 5 tertiary centers in Europe and the United States from 2000 to 2015. Patients who underwent pancreatoduodenectomy for nonmetastatic pancreatic ductal adenocarcinoma were eligible. Data analysis took place from December 2017 to April 2018. Exposures Patients were retrospectively staged according to the seventh and eighth editions of the TNM staging system. Main Outcomes and Measures Prognostic accuracy on survival rates, assessed by Kaplan-Meier and multivariate Cox proportional hazards analyses and concordance statistics. Results A total of 1525 consecutive patients were included (median [IQR] age, 66 (58-72) years; 802 (52.6%) male). Distribution among stages via the seventh edition was stage IA in 41 patients (2.7%), stage IB in 42 (2.8%), stage IIA in 200 (13.1%), stage IIB in 1229 (80.6%), and stage III in 12 (0.8%); this changed with use of the eighth edition to stage IA in 118 patients (7.7%), stage IB in 144 (9.4%), stage IIA in 22 (1.4%), stage IIB in 643 (42.2%), and stage III in 598 (39.2%). With the eighth edition, 774 patients (50.8%) migrated to a different stage; 183 (12.0%) were reclassified to a lower stage and 591 (38.8%) to a higher stage. Median overall survival for the entire cohort was 24.4 months (95% CI, 23.4-26.2 months). On Kaplan-Meier analysis, 5-year survival rates changed from 38.2% for patients in stage IA, 34.7% in IB, 35.3% in IIA, 16.5% in IIB, and 0% in stage III (log-rank P < .001) via classification with the seventh edition to 39.2% for patients in stage IA, 33.9% in IB, 27.6% in IIA, 21.0% in IIB, and 10.8% in stage III (log-rank P < .001) with the eighth edition. For patients who were node negative, the T stage was not associated with prognostication of survival in either edition. In the eighth edition, the N stage was associated with 5-year survival rates of 35.6% in N0, 20.8% in N1, and 10.9% in N2 (log-rank P < .001). The C statistic improved from 0.55 (95% CI, 0.53-0.57) for the seventh edition to 0.57 (95% CI, 0.55-0.60) for the eighth edition. Conclusions and Relevance The eighth edition of the TNM staging system demonstrated a more equal distribution among stages and a modestly increased prognostic accuracy in patients with resected pancreatic ductal adenocarcinoma compared with the seventh edition. The revised T stage remains poorly associated with survival, whereas the revised N stage is highly prognostic.
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Affiliation(s)
- Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert M Najarian
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Laura Maggino
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Susanna W de Geus
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sanne Lof
- Department of Surgery, Southampton University Hospital National Health Service Foundation Trust, Southampton, United Kingdom
| | - Francesco Giovinazzo
- Department of Surgery, Southampton University Hospital National Health Service Foundation Trust, Southampton, United Kingdom
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Tara S Kent
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital National Health Service Foundation Trust, Southampton, United Kingdom
| | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Jennifer F Tseng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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39
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Amato E, Mafficini A, Hirabayashi K, Lawlor RT, Fassan M, Vicentini C, Barbi S, Delfino P, Sikora K, Rusev B, Simbolo M, Esposito I, Antonello D, Pea A, Sereni E, Ballotta M, Maggino L, Marchegiani G, Ohike N, Wood LD, Salvia R, Klöppel G, Zamboni G, Scarpa A, Corbo V. Molecular alterations associated with metastases of solid pseudopapillary neoplasms of the pancreas. J Pathol 2018; 247:123-134. [PMID: 30306561 PMCID: PMC6588017 DOI: 10.1002/path.5180] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/20/2018] [Revised: 09/13/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022]
Abstract
Solid pseudopapillary neoplasms (SPN) of the pancreas are rare, low‐grade malignant neoplasms that metastasise to the liver or peritoneum in 10–15% of cases. They almost invariably present somatic activating mutations of CTNNB1. No comprehensive molecular characterisation of metastatic disease has been conducted to date. We performed whole‐exome sequencing and copy‐number variation (CNV) analysis of 10 primary SPN and comparative sequencing of five matched primary/metastatic tumour specimens by high‐coverage targeted sequencing of 409 genes. In addition to CTNNB1‐activating mutations, we found inactivating mutations of epigenetic regulators (KDM6A, TET1, BAP1) associated with metastatic disease. Most of these alterations were shared between primary and metastatic lesions, suggesting that they occurred before dissemination. Differently from mutations, the majority of CNVs were not shared among lesions from the same patients and affected genes involved in metabolic and pro‐proliferative pathways. Immunostaining of 27 SPNs showed that loss or reduction of KDM6A and BAP1 expression was significantly enriched in metastatic SPNs. Consistent with an increased transcriptional response to hypoxia in pancreatic adenocarcinomas bearing KDM6A inactivation, we showed that mutation or reduced KDM6A expression in SPNs is associated with increased expression of the HIF1α‐regulated protein GLUT1 at both primary and metastatic sites. Our results suggest that BAP1 and KDM6A function is a barrier to the development of metastasis in a subset of SPNs, which might open novel avenues for the treatment of this disease. © 2018 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Eliana Amato
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Andrea Mafficini
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Kenichi Hirabayashi
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy.,Department of Pathology, Tokai University School of Medicine, Isehara, Japan
| | - Rita T Lawlor
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Matteo Fassan
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy
| | - Caterina Vicentini
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Stefano Barbi
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Pietro Delfino
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Katarzyna Sikora
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy
| | - Borislav Rusev
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy
| | - Michele Simbolo
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy
| | - Irene Esposito
- Institute of Pathology, Heinrich-Heine-University and University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Davide Antonello
- Department of Surgery, General Surgery B, University of Verona, Verona, Italy
| | - Antonio Pea
- Department of Surgery, General Surgery B, University of Verona, Verona, Italy
| | - Elisabetta Sereni
- Department of Surgery, General Surgery B, University of Verona, Verona, Italy
| | - Maria Ballotta
- Section of Anatomic Pathology, Azienda Ospedaliera Rovigo, Rovigo, Italy
| | - Laura Maggino
- Department of Surgery, General Surgery B, University of Verona, Verona, Italy
| | | | - Nobuyuki Ohike
- Department of Pathology and Laboratory Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Laura D Wood
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Roberto Salvia
- Department of Surgery, General Surgery B, University of Verona, Verona, Italy
| | - Günter Klöppel
- Department of Pathology, Technical University Munich, Munich, Germany
| | - Giuseppe Zamboni
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy.,Division of Pathology, Sacro Cuore-Don Calabria Hospital, Negrar, Italy
| | - Aldo Scarpa
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Vincenzo Corbo
- ARC-Net Research Centre, University and Hospital Trust of Verona, Verona, Italy.,Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
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40
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Ecker BL, McMillan MT, Maggino L, Vollmer CM. Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score. J Am Coll Surg 2018; 227:430-438.e1. [DOI: 10.1016/j.jamcollsurg.2018.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
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41
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Marchegiani G, Andrianello S, Perri G, Secchettin E, Maggino L, Malleo G, Bassi C, Salvia R. Does the surgical waiting list affect pathological and survival outcome in resectable pancreatic ductal adenocarcinoma? HPB (Oxford) 2018; 20:411-417. [PMID: 29191689 DOI: 10.1016/j.hpb.2017.10.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/07/2017] [Revised: 10/04/2017] [Accepted: 10/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND High-volume centers have to deal with long surgical waiting-lists leading to a potential delay in treatment. This study assessed whether a longer time from diagnosis to surgery worsened pathological and survival outcomes in resectable pancreatic ductal adenocarcinoma (PDAC). METHODS A retrospective analysis of patients treated for resectable PDAC. Difference in size between preoperative CT-scan and specimen, pathological features, the rate of vascular and R1 resections as well as recurrence and survival were analyzed depending on the waiting time using a 30-day cut-off. RESULTS Waiting more than 30 days for surgery was associated with an increase in tumor size on specimen when compared with CT-scan (+3 vs. +1 mm, p = 0.04). T and N status, rate of vascular resection, grading, perineural and lymphovascular infiltration, and R1 rates did not differ between groups, as well as tumor recurrence (48.8% vs. 48.9%, p = 0.5) and survival (31 vs. 29 months, p = 0.7). For PDAC < 20 mm, waiting less than 30 days improved overall survival (p = 0.02). CONCLUSION The duration of the surgical waiting-list did not affect pathological features and survival. Delayed surgery was associated with increased cancer size on the specimen. However, surgery should not be delayed for PDACs < 20 mm as this may negatively affect the prognosis.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Erica Secchettin
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy.
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
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42
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Marchegiani G, Andrianello S, Nessi C, Sandini M, Maggino L, Malleo G, Paiella S, Polati E, Bassi C, Salvia R. Neoadjuvant Therapy Versus Upfront Resection for Pancreatic Cancer: The Actual Spectrum and Clinical Burden of Postoperative Complications. Ann Surg Oncol 2017; 25:626-637. [PMID: 29214453 DOI: 10.1245/s10434-017-6281-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [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: 08/22/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used for borderline-resectable or locally advanced pancreatic cancer (PDAC) and exhibits promising results in terms of pathological outcomes. However, little is known about its effect on surgical complications. METHODS We analyzed 445 pancreatic resections for PDAC from 2014 to 2016 at The Pancreas Institute, Verona University Hospital. The Modified Accordion Severity Grading System and average complication burden (ACB) were used to compare patients treated with NAT with patients who underwent upfront surgery (UFS). RESULTS Of 305 pancreaticoduodenectomies (PD), patients treated with NAT (n = 99) had less pancreatic fistula (POPF, 9.1% vs. 15.6%, p = 0.05) without grade C cases, but grade B ACB was increased (0.28 for NAT vs. 0.24 for UFS, p = 0.05). The postpancreatectomy hemorrhage (PPH) rate was lower in the NAT group (9.1% vs. 14.6%, p = 0.02), but ACB grades B (0.37 for NAT vs. 0.26 for UFS, p = 0.03) and C (0.43 for NAT vs. 0.29 for UFS, p = 0.05) were increased. Delayed gastric emptying (DGE) was increased in NAT cases (15.2% vs. 8.3%, p = 0.04), with higher grade C ACB (0.43 for NAT vs. 0.29 for UFS, p = 0.03). Of 94 distal pancreatectomies (DP), NAT patients (n = 26) developed more grade C POPF (11.5% vs. 1.5%, p = 0.04) and DGE (11.5% vs. 2.9%, p = 0.01) without differences in ACB. CONCLUSIONS Patients undergoing PD for PDAC after NAT exhibited reduced incidence of POPF and PPH but increased incidence of DGE compared with patients treated with UFS. Among patients developing postoperative complications after PD, those receiving NAT were associated with increased clinical burden.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Nessi
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marta Sandini
- Department of Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Laura Maggino
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Enrico Polati
- Department of Anesthesia and Intensive Care Unit, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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43
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Kennedy GT, McMillan MT, Maggino L, Sprys MH, Vollmer CM. Surgical experience and the practice of pancreatoduodenectomy. Surgery 2017; 162:812-822. [DOI: 10.1016/j.surg.2017.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/13/2017] [Accepted: 06/25/2017] [Indexed: 01/10/2023]
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44
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Ecker BL, Vining CC, Roses RE, Maggino L, Lee MK, Drebin JA, Fraker DL, Vollmer CM, Datta J. Identification of Patients for Adjuvant Therapy After Resection of Carcinoma of the Extrahepatic Bile Ducts: A Propensity Score-Matched Analysis. Ann Surg Oncol 2017; 24:3926-3933. [PMID: 28952140 DOI: 10.1245/s10434-017-6095-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Resectability rates for extrahepatic cholangiocarcinoma have increased over time, but long-term survival after resection alone with curative intent remains poor. Recent series suggest improved survival with adjuvant therapy. Patient subsets benefiting most from adjuvant therapy have not been clearly defined. METHODS Patients with extrahepatic cholangiocarcinoma who underwent resection with curative intent and received adjuvant therapy (chemotherapy ± radiotherapy) or surgery alone (SA) were identified in the U.S. National Cancer Data Base (2004-2014). Cox regression identified covariates associated with overall survival (OS). Adjuvant therapy and SA cohorts were matched (1:1) by propensity scores based on the survival hazard in Cox modeling. Overall survival was compared by Kaplan-Meier estimates. RESULTS Of 4872 patients, adjuvant chemotherapy was used frequently for 2416 (49.6%), often in conjunction with radiotherapy (RT) (n = 1555, 64.4%). Adjuvant chemotherapy with or without RT was used increasingly for cases with higher T classification [reference: T1-2; T3: 1.36; 95% confidence interval (CI), 1.19-1.55; T4: 1.77; 95% CI 1.38-2.26], nodal positivity [odds ratio (OR), 1.26; 95% CI 1.01-1.56], lymphovascular invasion (OR 1.21; 95% CI 1.01-1.46), or margin-positive resection (OR 1.85; 95% CI 1.61-2.12), and was associated with significant improvements in OS for each high-risk subset in the propensity score-matched cohort. Adjuvant therapy was associated with improved median OS for hilar tumors (40.0 vs 30.6 months; p = 0.025) but not distal tumors (33.0 vs 30.3 months; p = 0.123). Chemoradiotherapy was associated with superior outcomes compared with chemotherapy alone in the subset of margin-positive resection [hazard ratio (HR), 0.63; 95% CI 0.42-0.94]. CONCLUSIONS Adjuvant multimodality therapy is associated with improved survival for patients with resected extrahepatic cholangiocarcinoma and high-risk features.
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Affiliation(s)
- Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles C Vining
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Surgery, Pancreas Institute, University of Verona, Verona, Italy
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jashodeep Datta
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Malleo G, Maggino L, Marchegiani G, Feriani G, Esposito A, Landoni L, Casetti L, Paiella S, Baggio E, Lipari G, Capelli P, Scarpa A, Bassi C, Salvia R. Pancreatectomy with venous resection for pT3 head adenocarcinoma: Perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration. Pancreatology 2017; 17:847-857. [PMID: 28843714 DOI: 10.1016/j.pan.2017.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 02/10/2017] [Revised: 07/20/2017] [Accepted: 08/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The outcomes of pancreatectomy with superior mesenteric vein (SMV) or portal vein (PV) resection have been mixed. This study investigated the morbidity and mortality profile after SMV-PV resection in comparison with standard pancreatectomy. Furthermore, we assessed whether tumors with histologically proven SMV-PV infiltration differ from other pT3 neoplasms in terms of recurrence pattern and survival. METHODS All patients with a pT3 head adenocarcinoma resected from 2000 to 2013 were analyzed retrospectively. In the SMV-PV resection group, information on venous wall status was obtained through pathologic reports. Standard statistical methods were used for data analysis. RESULTS The study population consisted of 651 patients, of whom 81 (12.4%) underwent synchronous SMV-PV resection. Venous resection was not associated with a higher rate of postoperative complications (60.5% versus 50.2%) and mortality (1.2% versus 1.1%) in comparison with standard pancreatectomy. Vascular infiltration was confirmed pathologically in 56/81 patients (69.1%). The median disease-specific survival of the entire population was 27 months (95% CI 24.6-29.3), with a 5-year survival rate of 20.5%. The median recurrence-free survival was 18 months (95% CI 15.0-20.9). On multivariate analysis, ASA score, preoperative pain, Ca 19-9 levels, tumor grade, R-status, lymph-vascular invasion, N-status, and adjuvant therapy resulted to be survival predictors. Similarly, Ca 19.9 levels, R-status, and N-status were predictors of recurrence. SMV-PV infiltration was not a significant prognostic factor. CONCLUSION Morbidity and mortality rates of pancreatectomy with SMV-PV resection are comparable with standard pancreatectomy. Pancreatic head adenocarcinoma with histologically confirmed SMV-PV infiltration does not segregate prognostically from other pT3 tumors.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy.
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Feriani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elda Baggio
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Giovanni Lipari
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy; ARC-NET Research Center, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
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46
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Affiliation(s)
- Laura Maggino
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Francesco Crinò
- Unit of Digestive Endoscopy, Department of Medicine, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Laura Bernardoni
- Unit of Digestive Endoscopy, Department of Medicine, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of Surgery B, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Armando Gabbrielli
- Unit of Digestive Endoscopy, Department of Medicine, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Abstract
OPINION STATEMENT Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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Frigerio I, Regi P, Giardino A, Scopelliti F, Girelli R, Bassi C, Gobbo S, Martini PT, Capelli P, D'Onofrio M, Malleo G, Maggino L, Viviani E, Butturini G. Downstaging in Stage IV Pancreatic Cancer: A New Population Eligible for Surgery? Ann Surg Oncol 2017; 24:2397-2403. [PMID: 28516291 DOI: 10.1245/s10434-017-5885-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recent papers consider surgery as an option for synchronous liver oligometastatic patients [metastatic pancreatic ductal adenocarcinoma (mPDAC)]. In this study, we present our series of resected mPDACs after neoadjuvant chemotherapy (nCT). PATIENTS AND METHODS All patients resected after downstaging of mPDAC were included in this study. Downstaging criteria were disappearance of liver metastasis and a decrease in cancer antigen (CA) 19-9. The type and duration of nCT, last nCT surgery interval, histology, morbidity, and mortality were recorded, and overall survival (OS) and disease-free survival (DFS) were analyzed. RESULTS Overall, 24 of 535 patients (4.5%) observed with mPDAC were included. These patients received gemcitabine alone (5/24), gemcitabine + nanoparticle albumin-bound (nab)-paclitaxel (3/24), and FOLFIRINOX (16/24). Primary tumor size decreased from 31 to 19 mm (p < 0.001), and serum CA19-9 decreased from 596 to 18 U/mL (p < 0.001). In 14/24 patients, the tumor was located in the head. Median interval nCT surgery was 2 months, there were no mortalities, and the postoperative course was uneventful in 34% of cases. Grade B/C pancreatic fistula, postoperative bleeding, and sepsis occurred in 17/4, 4, and 12% of cases, respectively, and reoperation rate was 4%. R0 resection was achieved in 88% of cases, with 17% complete pathological response. Positive nodes were found in 9/24 patients with a median node ratio of 0.37, and OS and DFS was 56 and 27 months, respectively. CONCLUSIONS Patients with mPDAC who were fully responsive to nCT may be cautiously considered for surgery, with potential benefit in survival compared with palliative chemotherapy alone. This is supported by results of our retrospective study, which is the largest ever reported.
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Affiliation(s)
| | - Paolo Regi
- HPB Surgical Unit, Pederzoli Hospital, Verona, Italy
| | | | | | | | - Claudio Bassi
- General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Gobbo
- Department of Pathology, Pederzoli Hospital, Verona, Italy
| | | | - Paola Capelli
- Department of Pathology, Pederzoli Hospital, Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, G.B. Rossi Hospital, University of Verona, Verona, Italy
| | - Giuseppe Malleo
- General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Elena Viviani
- General Surgery B, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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49
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Paiella S, De Pastena M, Pollini T, Zancan G, Ciprani D, De Marchi G, Landoni L, Esposito A, Casetti L, Malleo G, Marchegiani G, Tuveri M, Marrano E, Maggino L, Secchettin E, Bonamini D, Bassi C, Salvia R. Pancreaticoduodenectomy in patients ≥ 75 years of age: Are there any differences with other age ranges in oncological and surgical outcomes? Results from a tertiary referral center. World J Gastroenterol 2017; 23:3077-3083. [PMID: 28533664 PMCID: PMC5423044 DOI: 10.3748/wjg.v23.i17.3077] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/20/2017] [Accepted: 03/31/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To compare surgical and oncological outcomes after pancreaticoduodenectomy (PD) in patients ≥ 75 years of age with two younger cohorts of patients.
METHODS The prospectively maintained Institutional database of pancreatic resection was queried for patients aged ≥ 75 years (late elderly, LE) submitted to PD for any disease from January 2010 to June 2015. We compared clinical, demographic and pathological features and survival outcomes of LE patients with 2 exact matched cohorts of younger patients [≥ 40 to 64 years of age (adults, A) and ≥ 65 to 74 years of age (young elderly, YE)] submitted to PD, according to selected variables.
RESULTS The final LE population, as well as the control groups, were made of 96 subjects. Up to 71% of patients was operated on for a periampullary malignancy and pancreatic cancer (PDAC) accounted for 79% of them. Intraoperative data (estimated blood loss and duration of surgery) did not differ among the groups. The overall complication rate was 65.6%, 61.5% and 58.3% for LE, YE and A patients, respectively, P = NS). Reoperation and cardiovascular complications were significantly more frequent in LE than in YE and A groups (P = 0.003 and P = 0.019, respectively). When considering either all malignancies and PDAC only, the three groups did not differ in survival. Considering all benign diseases, the estimated mean survival was 58 and 78 mo for ≥ and < 75 years of age (YE + A groups), respectively (P = 0.012).
CONCLUSION Age is not a contraindication for PD. A careful selection of LE patients allows to obtain good surgical and oncological results.
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50
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McMillan MT, Maggino L, Ecker BL, Vollmer CM. Response to: "Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation". Ann Surg 2017; 268:e6-e7. [PMID: 28296660 DOI: 10.1097/sla.0000000000002218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Matthew T McMillan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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