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Safi SA, Rehders A, Haeberle L, Fung S, Lehwald N, Esposito I, Ziayee F, Krieg A, Knoefel WT, Fluegen G. Para-aortic lymph nodes and ductal adenocarcinoma of the pancreas: Distant neighbors? Surgery 2021; 170:1807-1814. [PMID: 34392977 DOI: 10.1016/j.surg.2021.06.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Para-aortic lymph nodes in the ductal adenocarcinoma of the pancreatic head are regarded as distant metastases. Chemotherapy is considered the only treatment option if para-aortic lymph nodes metastases are detected preoperatively or intraoperatively. The role of standardized para-aortic lymph node lymphadenectomy during pancreaticoduodenectomy remains controversial. The aim of this study was to evaluate complication profiles and survival. METHODS All cases of ductal adenocarcinoma of the pancreatic head were evaluated from a prospectively maintained database (n = 289). Para-aortic lymph node lymphadenectomy was routinely performed in all patients with suspected ductal adenocarcinoma of the pancreatic head. Subgroup analysis was performed between patients with histologically positive (+) and negative (-) para-aortic lymph nodes. Patients receiving pancreaticoduodenectomy without para-aortic lymph node lymphadenectomy for other causes served as a control group. RESULTS A total of 192 patients received para-aortic lymph node lymphadenectomy, of which 41 were positive for para-aortic lymph node metastases. In 97 patients with ductal adenocarcinoma of the pancreatic head, no para-aortic lymph node lymphadenectomy was performed owing to postoperative pancreatic ductal adenocarcinoma diagnosis. Clinicopathologic data were homogenously distributed. Hospital stay and postoperative morbidity demonstrated no significant difference between the 3 subgroups. The median overall survival of 19.63 months (95% confidence interval: 14.57-24.79 months) in para-aortic lymph node- patients was not statistically different when compared with the median overall survival of 18.22 months (95% confidence interval: 12.68-23.75 months) in para-aortic lymph node + patients (log-rank test P = .223). Preoperative computed tomography was a poor predictor for para-aortic lymph node status (sensitivity = 10.3%, specificity = 97.8%). CONCLUSION This study represents the largest cohort receiving routine para-aortic lymph node lymphadenectomy. Extended lymphadenectomy can be performed safely and, although disease-free survival of para-aortic lymph node+ patients was significantly shorter, overall survival and postrelapse survival were on par with that of para-aortic lymph node- patients. Preoperative computed tomography indicating para-aortic lymph node metastasis should not preclude curative resection.
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Affiliation(s)
- Sami A Safi
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Lena Haeberle
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Stephen Fung
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Nadja Lehwald
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Irene Esposito
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Farid Ziayee
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - Wolfram T Knoefel
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany.
| | - Georg Fluegen
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
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Safi SA, Fluegen G, Rehders A, Haeberle L, Fung S, Keitel V, Krieg A, Knoefel WT, Lehwald-Tywuschik N. Surgical margin clearance and extended chemotherapy defines survival for synchronous oligometastatic liver lesions of the ductal adenocarcinoma of the pancreas. Int J Clin Oncol 2021; 26:1911-1921. [PMID: 34132929 PMCID: PMC8449759 DOI: 10.1007/s10147-021-01961-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/03/2021] [Indexed: 11/28/2022]
Abstract
Background The role of surgery for circumscribed synchronous hepatic lesions of the pancreatic ductal adenocarcinoma (PDAC) remains controversial. Thus, the aim of our study was to compare survival outcome (OS) after surgery of patients with hepatic metastases (M1surg) to patients with only localized disease. Methods Correlation analysis of clinicopathological data and OS after resection of M1surg patients and patients with localized PDACs (M0) was performed. Patients were included for survival analysis only if a complete staging including perineural, venous and lymphatic invasion was available. Results Out of the study collective, 35 patients received extended surgery (M1surg), whereas 131 patients received standardized surgery for localized disease (M0). Length of hospitalization and mortality was similar in both groups. FOLFIRNOX as an adjuvant treatment regime was administered in ~ 23 and ~ 8% of M1surg and M0 patients, respectively. In subgroup analysis of R0 resected patients and in multivariate analysis of the total cohort, there was no difference in overall survival between both groups. Only the resection status (R1 vs R0) and venous invasion (V1) were identified as independent prognostic factors. Site of recurrence in R0 resected M1surg patients and in M0 patients were homogenously distributed. Conclusion This is the first study demonstrating a survival benefit after extended surgery for synchronously hepatic-metastasized PDACs. We found no difference in survival outcome of metastasized patients when compared to patients with localized disease. FOLFIRINOX as an adjuvant treatment regime for resected M1surg presumably is worthwhile. Larger multicenter studies are still needed to validate our results. Supplementary Information The online version contains supplementary material available at 10.1007/s10147-021-01961-5.
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Affiliation(s)
- S A Safi
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - G Fluegen
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - A Rehders
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - L Haeberle
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Dusseldorf, Germany
| | - S Fung
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - V Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Dusseldorf, Germany
| | - A Krieg
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - W T Knoefel
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - N Lehwald-Tywuschik
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital Dusseldorf, Moorenstr. 5, 40225, Dusseldorf, Germany
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Safi SA, Lehwald-Tywuschik N, Rehders A, Fluegen G, Haeberle L, Keitel V, Knoefel WT. Site of relapse of ductal adenocarcinoma of the pancreas affects survival after multimodal therapy. BMC Surg 2021; 21:110. [PMID: 33658016 PMCID: PMC7931536 DOI: 10.1186/s12893-021-01082-w] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 02/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ductal adenocarcinoma of the pancreas (PDAC) remains one of the most lethal malignancies. To date, no guidelines exists for isolated resectable metachronous disease. It is still unknown, which patients may benefit from relapse surgery. The aim of our study was to compare disease free survival (DFS) and post relapse survival (PRS) in patients with isolated local recurrence, metachronous hepatic or pulmonary metastases. METHODS Patients with isolated resectable local recurrence, metachronous hepatic or pulmonary metastases were included for survival analyses. PRS of surgically treated patients (local (n = 11), hepatic (n = 6) and pulmonary metastases (n = 9)) was compared to conservatively treated patients (local (n = 17), hepatic (n = 37) and pulmonary metastases (n = 8)). RESULTS Resected PDAC patients suffering from isolated metachronous hepatic metastases initially had a higher T-stage and venous invasion (V1) compared to the other patients. DFS in the metachronous pulmonary metastases group was longer compared to DFS of the hepatic metastases and local recurrence groups. Surgical resection significantly improved PRS in patients with local recurrence and pulmonary metastases, when compared to patients receiving chemotherapy alone. Very-long term survivors (> 5 years) were detected following secondary resection of local recurrence and 45% of these patients were still alive at the end of our study period. CONCLUSION Although DFS in PDAC patients suffering from isolated local recurrence was dismal and comparable to that of patients with isolated hepatic metastases, very-long term survivors were present only in this group. These results indicate that a surgical approach for isolated local recurrence, if anatomically possible, should be considered.
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Affiliation(s)
- S A Safi
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - N Lehwald-Tywuschik
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - A Rehders
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - G Fluegen
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - L Haeberle
- Institute of Pathology, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - V Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany
| | - W T Knoefel
- Department of Surgery (A), Medical Faculty, Heinrich-Heine-University and University Hospital, Duesseldorf, Germany.
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Dizdar L, Tomczak M, Werner TA, Safi SA, Riemer JC, Verde PE, Stoecklein NH, Knoefel WT, Krieg A. Survivin and XIAP expression in distinct tumor compartments of surgically resected gastric cancer: XIAP as a prognostic marker in diffuse and mixed type adenocarcinomas. Oncol Lett 2017; 14:6847-6856. [PMID: 29109763 DOI: 10.3892/ol.2017.6999] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 08/03/2017] [Indexed: 02/06/2023] Open
Abstract
There is considerable evidence that the inhibitor of apoptosis protein (IAP) family serves a role in tumorigenesis. The most studied IAP family members, survivin and X-linked inhibitor of apoptosis (XIAP), have been demonstrated to serve as biomarkers in distinct tumor entities. Thus, the present study aimed to investigate the expression levels of both IAPs in the tumor center, invasion front and lymph node metastases of surgically resected gastric cancer (GC) specimens. Tissue microarrays containing samples from 201 primary GCs were analyzed. IAP expression was detected using immunohistochemistry in different tumor compartments, normal mucosa and lymph node metastases. In addition, the association between the expression levels of these proteins, and clinicopathological parameters and overall survival was investigated. High levels of survivin and XIAP were evident in GC, when compared with normal mucosa, and were correlated with intestinal-type and well-differentiated GC, as well as low International Union Against Cancer stages. Increased XIAP expression was detected in lymph node metastases as compared with corresponding primary tumors. XIAP overexpression was identified to be an independent negative prognostic marker in diffuse and mixed type GC. These results suggest a potential role of survivin and XIAP in the early phase of gastric carcinogenesis. In addition, increased XIAP expression in lymph node metastases supports the observation that IAPs serve an essential role in metastatic tumor disease. Since XIAP expression was identified to be associated with poor survival in diffuse and mixed type GC, XIAP may serve as a novel therapeutic target in these types of GC.
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Affiliation(s)
- Levent Dizdar
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Monika Tomczak
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Thomas A Werner
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Sami A Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Jasmin C Riemer
- Institute of Pathology, Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Pablo E Verde
- Coordination Centre for Clinical Trials, Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Nikolas H Stoecklein
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Wolfram T Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, D-40225 Duesseldorf, Germany
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