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Davis CH, Augustinus S, de Graaf N, Wellner UF, Johansen K, Andersson B, Beane JD, Björnsson B, Busch OR, Gleeson EM, van Santvoort HC, Tingstedt B, Williamsson C, Keck T, Besselink MG, Koerkamp BG, Pitt HA. Impact of Neoadjuvant Therapy for Pancreatic Cancer: Transatlantic Trend and Postoperative Outcomes Analysis. J Am Coll Surg 2024; 238:613-621. [PMID: 38224148 DOI: 10.1097/xcs.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND The introduction of modern chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). A recent North American study demonstrated increased use of NAT and improved operative outcomes in patients with PDAC. The aims of this study were to compare the use of NAT and short-term outcomes in patients with PDAC undergoing pancreatoduodenectomy (PD) among registries from the US and Canada, Germany, the Netherlands, and Sweden. STUDY DESIGN Databases from 2 multicenter (voluntary) and 2 nationwide (mandatory) registries were queried from 2018 to 2020. Patients undergoing PD for PDAC were compared based on the use of upfront surgery vs NAT. Adoption of NAT was measured in each country over time. Thirty-day outcomes, including the composite measure (ideal outcomes), were compared by multivariable analyses. Sensitivity analyses of patients undergoing vascular resection were performed. RESULTS Overall, 11,402 patients underwent PD for PDAC with 33.7% of patients receiving NAT. The use of NAT increased steadily from 28.3% in 2018 to 38.5% in 2020 (p < 0.0001). However, use of NAT varied widely by country: the US (46.8%), the Netherlands (44.9%), Sweden (11.0%), and Germany (7.8%). On multivariable analysis, NAT was significantly (p < 0.01) associated with reduced rates of serious morbidity, clinically relevant pancreatic fistulae, reoperations, and increased ideal outcomes. These associations remained on sensitivity analysis of patients undergoing vascular resection. CONCLUSIONS NAT before PD for pancreatic cancer varied widely among 4 Western audits yet increased by 26% during 3 years. NAT was associated with improved short-term outcomes.
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Affiliation(s)
- Catherine H Davis
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Ulrich F Wellner
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Karin Johansen
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Bodil Andersson
- Departments of Surgery and Clinical Sciences Lund, Lund University, Lund, Sweden (Andersson)
- Skåne University Hospital, Lund, Sweden (Andersson)
| | - Joal D Beane
- Department of Surgery, The Ohio State University, Columbus, OH (Beane)
| | - Bergthor Björnsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Olivier R Busch
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Elizabeth M Gleeson
- Department of Surgery, University of North Carolina, Chapel Hill, NC (Gleeson)
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands (van Santvoort)
| | - Bobby Tingstedt
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Caroline Williamsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Tobias Keck
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Marc G Besselink
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands (Koerkamp)
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (Pitt)
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2
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Petruch N, Servin Rojas M, Lillemoe KD, Castillo CFD, Braun R, Honselmann KC, Lapshyn H, Deichmann S, Abdalla TSA, Hummel R, Klinkhammer-Schalke M, Tol KKV, Zeissig SR, Keck T, Wellner UF, Qadan M, Bolm L. The impact of surgical-oncologic textbook outcome in patients with stage I to III pancreatic ductal adenocarcinoma: A cross-validation study of two national registries. Surgery 2024; 175:1120-1127. [PMID: 38092633 DOI: 10.1016/j.surg.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/28/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Using national registries, we aimed to evaluate oncologic textbook outcomes in pancreatic ductal adenocarcinoma patients. METHODS Patients with stage I to III pancreatic ductal adenocarcinoma and surgical resection from 2010 to 2020 in the US and Germany were identified using the National Cancer Database and National Cancer Registries data. The surgical-oncologic textbook outcome was defined as complete oncologic resection with no residual tumor and ≥12 harvested lymph nodes. The composite endpoint was defined as surgical-oncologic textbook outcome and receipt of perioperative systemic and/or radiation therapy. RESULTS In total, 33,498 patients from the National Cancer Database and 14,589 patients from the National Cancer Registries were included. In the National Cancer Database, 28,931 (86%) patients had complete oncologic resection with no residual tumor, and 11,595 (79%) in the National Cancer Registries. 8,723 (26%) patients in the National Cancer Database and 556 (4%) in the National Cancer Registries had <12 lymph nodes harvested. The National Cancer Database shows 26,135 (78%) underwent perioperative therapy and 8,333 (57%) in the National Cancer Registries. Surgical-oncologic textbook outcome was achieved in 21,198 (63%) patients in the National Cancer Database and in 11,234 (77%) patients from the National Cancer Registries. 16,967 (50%) patients in the National Cancer Database and 7,878 (54%) patients in the National Cancer Registries had composite textbook outcome. Median overall survival in patients with composite textbook outcomes was 32 months in the National Cancer Database and 27 months in the National Cancer Registries (P < .001). In contrast, those with non-textbook outcomes had a median overall survival of 23 months in the National Cancer Database and 20 months in the National Cancer Registries (P < .001). CONCLUSION Surgical-oncologic textbook outcomes were achieved in > 50% of stage I to III pancreatic ductal adenocarcinoma for both the National Cancer Database and the National Cancer Registries. Failure to achieve textbook outcomes was associated with impaired survival across both registries.
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Affiliation(s)
- Natalie Petruch
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Thaer S A Abdalla
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Richard Hummel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Monika Klinkhammer-Schalke
- German Cancer Registry Group of the Society of German Tumor Centers - Network for Care, Quality, and Research in Oncology, Berlin, Germany
| | - Kees Kleihues-van Tol
- German Cancer Registry Group of the Society of German Tumor Centers - Network for Care, Quality, and Research in Oncology, Berlin, Germany
| | - Sylke R Zeissig
- German Cancer Registry Group of the Society of German Tumor Centers - Network for Care, Quality, and Research in Oncology, Berlin, Germany; Institute for Clinical Epidemiology and Biometry, University of Wuerzburg, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Louisa Bolm
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
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Ten Winkel M, Salama H, Timrott K, Kleine M, Kleine-Doepke D, Raehder-Johnson S, Meisel H, Rahberi NN, Abdelhadi S, Rückert F, Reissfelder C, Honselmann KC, Braun R, Faerber B, Lapshyn H, Keck T, Uhl W, Belyaev O, Wellner UF, Bolm L. Patient-reported outcomes at three months after pancreatic surgery for benign and malignant diseases - A prospective observational study. Pancreatology 2024; 24:314-322. [PMID: 38310036 DOI: 10.1016/j.pan.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND/OBJECTIVES Pancreatic surgery may have a long-lasting effect on patients' health status and quality of life (QoL). We aim to evaluate patient-reported outcomes (PRO) 3 months after pancreatic surgery. METHODS Patients scheduled for pancreatic surgery were enrolled in a prospective trial at five German centers. Patients completed PRO questionnaires (EQ-5D-5L, EORTC QLQ-PAN26, patient-reported happiness, and HADS-D), we report the first follow-up 3 months after surgery as an interim analysis. Statistical testing was performed using R software. RESULTS From 2019 to 2022 203 patients were enrolled, a three-month follow-up questionnaire was available in 135 (65.5 %). 77 (57.9 %) underwent surgery for malignant disease. Patient-reported health status (EQ-5D-5L) was impaired in 4/5 dimensions (mobility, self-care, usual activities, pain, discomfort) for patients with malignant and 3/5 dimensions (mobility, self-care, usual activities) for patients with benign disease 3 months after surgery (p < 0.05). Patients with malignant disease reported an increase in depressive symptoms, patients with benign disease had a decrease in anxiety symptoms (HADS-D; depression: 5.00 vs 6.51, p = 0.002; anxiety: 8.04 vs. 6.34, p = 0.030). Regarding pancreatic-disease-specific symptoms (EORTC-QLQ-PAN26), patients with malignant disease reported increased problems with taste, weight loss, weakness in arms and legs, dry mouth, body image and troubling side effects at three months. Patients with benign disease indicated more weakness in arms and legs, troubling side effects but less future worries at three months. CONCLUSION Patient-reported outcomes of patients undergoing pancreatic surgery for benign vs. malignant disease show important differences. Patients with malignant tumors report more severely decreased quality of life 3 months postoperatively than patients with benign tumors.
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Affiliation(s)
- Meike Ten Winkel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Hussein Salama
- Department of Surgery, St. Joseph-Hospital, Ruhr University Bochum, Germany
| | - Kai Timrott
- Department of Surgery, University Hospital, Medical School Hannover, Germany
| | - Moritz Kleine
- Department of Surgery, University Hospital, Medical School Hannover, Germany; Department of Surgery, Vinzenz Hospital Hannover, Germany
| | | | | | | | - Nuh N Rahberi
- Department of Surgery, University Medical Center Mannheim, Germany
| | | | - Felix Rückert
- Department of Surgery, University Medical Center Mannheim, Germany; Department of Surgery, Diakonissen Hospital Speyer, Germany
| | | | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Benedikt Faerber
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany.
| | - Waldemar Uhl
- Department of Surgery, St. Joseph-Hospital, Ruhr University Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Joseph-Hospital, Ruhr University Bochum, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
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Ungefroren H, Reimann J, Konukiewitz B, Braun R, Wellner UF, Lehnert H, Marquardt JU. RAC1b Collaborates with TAp73α-SMAD4 Signaling to Induce Biglycan Expression and Inhibit Basal and TGF-β-Driven Cell Motility in Human Pancreatic Cancer. Biomedicines 2024; 12:199. [PMID: 38255305 PMCID: PMC10813112 DOI: 10.3390/biomedicines12010199] [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: 11/21/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer type characterized by a marked desmoplastic tumor stroma that is formed under the influence of transforming growth factor (TGF)-β. Data from mouse models of pancreatic cancer have revealed that transcriptionally active p73 (TAp73) impacts the TGF-β pathway through activation of Smad4 and secretion of biglycan (Bgn). However, whether this pathway also functions in human PDAC cells has not yet been studied. Here, we show that RNA interference-mediated silencing of TAp73 in PANC-1 cells strongly reduced the stimulatory effect of TGF-β1 on BGN. TAp73-mediated regulation of BGN, and inhibition of TGF-β signaling through a (Smad-independent) ERK pathway, are reminiscent of what we previously observed for the small GTPase, RAC1b, prompting us to hypothesize that in human PDAC cells TAp73 and RAC1b are part of the same tumor-suppressive pathway. Like TAp73, RAC1b induced SMAD4 protein and mRNA expression. Moreover, siRNA-mediated knockdown of RAC1b reduced TAp73 mRNA levels, while ectopic expression of RAC1b increased them. Inhibition of BGN synthesis or depletion of secreted BGN from the culture medium reproduced the promigratory effect of RAC1b or TAp73 silencing and was associated with increased basal and TGF-β1-dependent ERK activation. BGN also phenocopied the effects of RAC1b or TAp73 on the expression of downstream effectors, like the EMT markers E-cadherin, Vimentin and SNAIL, as well as on negative regulation of the ALK2-SMAD1/5 arm of TGF-β signaling. Collectively, we showed that tumor-suppressive TAp73-Smad4-Bgn signaling also operates in human cells and that RAC1b likely acts as an upstream activator of this pathway.
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Affiliation(s)
- Hendrik Ungefroren
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, 23538 Lübeck, Germany
- Institute of Pathology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany
| | - Julissa Reimann
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, 23538 Lübeck, Germany
| | - Björn Konukiewitz
- Institute of Pathology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany
| | - Rüdiger Braun
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, 23538 Lübeck, Germany
| | - Ulrich F. Wellner
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, 23538 Lübeck, Germany
| | | | - Jens-Uwe Marquardt
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, 23538 Lübeck, Germany
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Augustinus S, Mackay TM, Andersson B, Beane JD, Busch OR, Gleeson EM, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Wellner UF, Williamsson C, Besselink MG, Pitt HA. Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure. Ann Surg 2023; 278:740-747. [PMID: 37476990 PMCID: PMC10549886 DOI: 10.1097/sla.0000000000006037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE The aim of this study is to define and assess Ideal Outcome in the national or multicenter registries of North America, Germany, the Netherlands, and Sweden. BACKGROUND Assessing outcomes after pancreatoduodenectomy among centers and countries requires a broad evaluation that cannot be captured by a single parameter. Previously, 2 composite outcome measures (textbook outcome and optimal pancreatic surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into ideal outcome (IO). METHODS This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, The Netherlands, and Sweden. After 3 consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all 6 parameters: (1) in-hospital mortality, (2) severe complications-Clavien-Dindo ≥3, (3) postoperative pancreatic fistula-International Study Group of Pancreatic Surgery (ISGPS) grade B/C, (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative largest difference (RLD) and absolute largest difference (ALD), and multivariate regression models. RESULTS Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in The Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P <0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of chronic obstructive pulmonary disease, body mass index, performance status, American Society of Anesthesiologists (ASA) score, biliary drainage, absence of vascular resection, and histologic diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country, and neoadjuvant chemotherapy also was associated with improved IO. CONCLUSIONS The newly developed composite outcome measure "Ideal Outcome" can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve the outcomes of pancreatic surgery.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D. Beane
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas G. Koerkamp
- Department of Surgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulrich F. Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Finton S, Bolm L, Nebbia M, Petruch N, Férnandez-Del Castillo C, Qadan M, Lillemoe KD, Wellner UF, Distler M, Zimmermann C, Weitz J, Rückert F, Rahbari NN, Reissfelder C, Nappo G, Keck T, Zerbi A, Ferrone CR. The Role of Adjuvant Therapy in Duodenal Adenocarcinoma and Intestinal Subtype Ampullary Carcinoma after Curative Resection. Ann Surg 2023:00000658-990000000-00672. [PMID: 37830246 DOI: 10.1097/sla.0000000000006129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Defining the role of adjuvant therapy in duodenal adenocarcinoma (DAC) and intestinal subtype ampullary carcinoma (iAC). SUMMARY BACKGROUND DATA DAC and iAC share a similar histological differentiation but the benefit of adjuvant therapy remains unclear. METHODS Patients undergoing curative-intent surgical resection for DAC and iAC between 2010 and 2021 at five high-volume centers were included. Patient baseline, perioperative and long-term oncological outcomes were evaluated. Statistical testing was performed with SPSS 25 (IBM). RESULTS A total of 136 patients with DAC and 171 with iAC were identified. Patients with DAC had more advanced tumors than those with iAC. Median overall survival (OS) in DAC patients was 101 months versus 155 months for iAC patients (P=0.098). DAC had a higher rate of local (14.1% vs. 1.2%, P<0.001) and systemic recurrence (30.4% vs. 3.5%, P<0.001). Adjuvant therapy failed to improve overall survival in all patients with DAC and iAC. For DAC, patients with perineural invasion, but not other negative prognostic factors had improved OS rates with adjuvant therapy (72 m vs. 44 m, P=0.044). IAC patients with N+ (190 m vs. 57 m, P=0.003), T3-4 (177 m vs. 59 m, P=0.050) and perineural invasion (150 m vs. 59 m, P=0.019) had improved OS rates with adjuvant therapy. CONCLUSION While adjuvant therapy fails to improve OS in all patients with DAC and iAC in the current study, it improved overall survival in DAC patients with perineural invasion and in iAC patients with T3-4 tumors, positive lymph nodes, and perineural invasion.
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Affiliation(s)
- Sarah Finton
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Louisa Bolm
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Martina Nebbia
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Unit of Pancreatic Surgery, Humanitas Research Hospital, Milan, Italy
| | - Natalie Petruch
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Carlos Férnandez-Del Castillo
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Motaz Qadan
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Keith D Lillemoe
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Marius Distler
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Dresden, Germany
| | - Carolin Zimmermann
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Dresden, Germany
| | - Felix Rückert
- Department of Surgery, Diakonissen Hospital Speyer, Speyer, Germany
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gennaro Nappo
- Department of Surgery, Unit of Pancreatic Surgery, Humanitas Research Hospital, Milan, Italy
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Alessandro Zerbi
- Department of Surgery, Unit of Pancreatic Surgery, Humanitas Research Hospital, Milan, Italy
| | - Cristina R Ferrone
- Department of Gastrointestinal Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Cedars' Sinai Medical Center, Los Angeles, CA, United States
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7
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Honselmann KC, Elser Y, Boeckmann T, Bolm L, Winkel MT, Deichmann S, Braun R, Wellner UF, Keck T, Lapshyn H. Recent onset diabetes is associated with better survival in pancreatic ductal adenocarcinoma-An analysis of preoperative symptoms within the DGAV StuDoQ|Pancreas Registry. Surgery 2023; 174:674-683. [PMID: 37349251 DOI: 10.1016/j.surg.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND This multicenter study analyzed the relationship between preoperative symptoms and postsurgical outcomes utilizing the German national DGAV StuDoQ|Pancreas database. METHODS This retrospective study included 2,643 pancreatic ductal adenocarcinoma patients undergoing pancreatic head resection from 2013-2017 within the German pancreatic surgery registry (DGAV StuDoQ|Pancreas). The association of preoperative symptoms with overall survival was analyzed using Kaplan-Meier and Cox regression analysis. RESULTS Preoperative symptoms were common, with 2,380 of 2,643 (90%) patients presenting with any one or more of the following symptoms: jaundice (40%), biliary obstruction treated with biliary stent (41%), pain (37%), weight loss (29%), nausea (18%), diabetes (31%), emesis (6%), and recent onset diabetes (5%). Patients were separated into 3 groups: no symptoms (n = 293), symptoms (n = 2,229), and recent onset diabetes (n = 121). The 3 groups differed in body mass index and nodal staging, where patients with recent onset diabetes had the highest values (body mass index: no symptoms: 24.5 kg/m2, symptoms: 25.1 kg/m2; recent-onset diabetes: 26.3 kg/m2, P = .007), (no symptoms: N1: 55%, N2: 10%; symptoms: N1: 53%, N2: 17%; recent-onset diabetes: N1: 56%, N2: 16%, P = .023). Other pathological characteristics, carbohydrate antigen 19-9 levels, and adjuvant chemotherapy receival did not differ between the groups. Interestingly, recent-onset diabetes was associated with better survival compared with the other groups (Median overall survival: 28 months [no symptoms at all], 22 months [symptoms] versus not reached [recent onset diabetes group], and 5-year overall survival rates of 28%, 11%, and 57%, respectively [log rank, P = .013]). Multivariable analysis revealed that recent-onset diabetes and preoperative symptoms were independently associated with overall survival (recent-onset diabetes, relative risk 0.052 P = .027, >5 symptoms relative risk 3.66, P < .001). CONCLUSION Pancreatic ductal adenocarcinoma symptoms occured in up to 90% of patients with resectable pancreatic ductal adenocarcinoma. In addition, PDAC symptoms were associated with overall survival and might identify unique pancreatic ductal adenocarcinoma subtypes.
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Affiliation(s)
- Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. http://www.twitter.com/KimCHonselmann
| | - Yannic Elser
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tabea Boeckmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Meike Ten Winkel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Färber B, Lapshyna O, Künstner A, Kohl M, Sauer T, Bichmann K, Heckelmann B, Watzelt J, Honselmann K, Bolm L, ten Winkel M, Busch H, Ungefroren H, Keck T, Gemoll T, Wellner UF, Braun R. Molecular profiling and specific targeting of gemcitabine-resistant subclones in heterogeneous pancreatic cancer cell populations. Front Oncol 2023; 13:1230382. [PMID: 37719017 PMCID: PMC10502231 DOI: 10.3389/fonc.2023.1230382] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023] Open
Abstract
Purpose Chemotherapy is pivotal in the multimodal treatment of pancreatic ductal adenocarcinoma (PDAC). Technical advances unveiled a high degree of inter- and intratumoral heterogeneity. We hypothesized that intratumoral heterogeneity (ITH) impacts response to gemcitabine treatment and demands specific targeting of resistant subclones. Methods Using single cell-derived cell lines (SCDCLs) from the classical cell line BxPC3 and the basal-like cell line Panc-1, we addressed the effect of ITH on response to gemcitabine treatment. Results Individual SCDCLs of both parental tumor cell populations showed considerable heterogeneity in response to gemcitabine. Unsupervised PCA including the 1,000 most variably expressed genes showed a clustering of the SCDCLs according to their respective sensitivity to gemcitabine treatment for BxPC3, while this was less clear for Panc-1. In BxPC3 SCDCLs, enriched signaling pathways EMT, TNF signaling via NfKB, and IL2STAT5 signaling correlated with more resistant behavior to gemcitabine. In Panc-1 SCDCLs MYC targets V1 and V2 as well as E2F targets were associated with stronger resistance. We used recursive feature elimination for Feature Selection in order to compute sets of proteins that showed strong association with the response to gemcitabine. The optimal protein set calculated for Panc-1 comprised fewer proteins in comparison to the protein set determined for BxPC3. Based on molecular profiles, we could show that the gemcitabine-resistant SCDCLs of both BxPC3 and Panc-1 are more sensitive to the BET inhibitor JQ1 compared to the respective gemcitabine-sensitive SCDCLs. Conclusion Our model system of SCDCLs identified gemcitabine-resistant subclones and provides evidence for the critical role of ITH for treatment response in PDAC. We exploited molecular differences as the basis for differential response and used these for more targeted therapy of resistant subclones.
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Affiliation(s)
- Benedikt Färber
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Olga Lapshyna
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Axel Künstner
- Medical Systems Biology Group, Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute for Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Michael Kohl
- Medical Systems Biology Group, Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Section for Translational Surgical Oncology & Biobanking, Department of Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Lübeck, Germany
| | - Thorben Sauer
- Section for Translational Surgical Oncology & Biobanking, Department of Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Lübeck, Germany
| | - Kira Bichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Benjamin Heckelmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Jessica Watzelt
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Kim Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Meike ten Winkel
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Hauke Busch
- Medical Systems Biology Group, Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
- Institute for Cardiogenetics, University of Lübeck, Lübeck, Germany
| | - Hendrik Ungefroren
- First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
- Institute of Pathology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Timo Gemoll
- Section for Translational Surgical Oncology & Biobanking, Department of Surgery, University Hospital Schleswig-Holstein, University of Lübeck, Lübeck, Germany
| | - Ulrich F. Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
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9
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Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, Bratlie SO, Busch OR, Butturini G, Capretti G, Casadei R, Edwin B, Emmen AM, Esposito A, Falconi M, Groot Koerkamp B, Keck T, de Kleine RH, Kleive DB, Kokkola A, Lips DJ, Lof S, Luyer MD, Manzoni A, Marudanayagam R, de Pastena M, Pecorelli N, Primrose JN, Ricci C, Salvia R, Sandström P, Vissers FL, Wellner UF, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. Lancet Reg Health Eur 2023; 31:100673. [PMID: 37457332 PMCID: PMC10339208 DOI: 10.1016/j.lanepe.2023.100673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
Background The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking. Methods In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265). Findings Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group. Interpretation This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer. Funding Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.
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Affiliation(s)
- Maarten Korrel
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Leia R. Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Jony van Hilst
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bergthor Björnsson
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier R. Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Giovanni Capretti
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Bjørn Edwin
- The Intervention Center, Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anouk M.L.H. Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Ruben H.J. de Kleine
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dyre B. Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arto Kokkola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Sanne Lof
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Misha D.P. Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicolò Pecorelli
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - John N. Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claudio Ricci
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Per Sandström
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Frederique L.I.M. Vissers
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marcel G.W. Dijkgraaf
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Vladimirov M, Wellner UF, Klinger C, Buhr HJ, Seyfried F. [Impact of the COVID pandemic on treatment of bariatric patients in Germany-An analysis of the national StuDoQ/MBE register]. Chirurgie (Heidelb) 2023; 94:487-496. [PMID: 36894648 PMCID: PMC9998013 DOI: 10.1007/s00104-023-01838-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND During the coronavirus disease 2019 (COVID-19) pandemic the standard inpatient care of patients was restricted to increase overall and intensive care capacity reserves for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons. OBJECTIVE This article presents the impact of the COVID-19 pandemic on the surgical and postoperative care of bariatric patients in Germany. MATERIAL AND METHODS A statistical analysis of the national StuDoQ/MBE register data for the period from 1 May 2018 until 31 May 2022 was performed. RESULTS Throughout the entire study period there was a continuous increase in documented operations, which continued even during the COVID-19 pandemic. A significant intermittent decline in surgery performed was observed only during the imposition of first lockdown in the months of March to May 2020, with a minimum number of 194 cases performed monthly in April 2020. The pandemic had no measurable effect on the surgically treated patient population, the type of surgical procedure, the perioperative and postoperative outcomes and follow-up care. CONCLUSION Based on the results of the StuDoQ data and the current literature, it can be deduced that bariatric surgery can be carried out with no increased risk during the COVID-19 pandemic and the quality of postoperative care is not impaired.
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Affiliation(s)
- M Vladimirov
- Metabolische und bariatrische Chirurgie, Klinik für Allgemein, Viszeral- und Thoraxchirurgie, PMU Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
| | - U F Wellner
- Klinik für Chirurgie, UKSH Campus Lübeck, Lübeck, Deutschland
| | - C Klinger
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - H J Buhr
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - F Seyfried
- Klinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, 97080, Würzburg, Deutschland
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11
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Henn J, Wyzlic PK, Esposito I, Semaan A, Branchi V, Klinger C, Buhr HJ, Wellner UF, Keck T, Lingohr P, Glowka TR, Manekeller S, Kalff JC, Matthaei H. Surgical treatment for pancreatic cystic lesions-implications from the multi-center and prospective German StuDoQ|Pancreas registry. Langenbecks Arch Surg 2023; 408:28. [PMID: 36640188 PMCID: PMC9840584 DOI: 10.1007/s00423-022-02740-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/20/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE The detection of pancreatic cystic lesions (PCL) causes uncertainty for physicians and patients, and international guidelines are based on low evidence. The extent and perioperative risk of resections of PCL in Germany needs comparison with these guidelines to highlight controversies and derive recommendations. METHODS Clinical data of 1137 patients who underwent surgery for PCL between 2014 and 2019 were retrieved from the German StuDoQ|Pancreas registry. Relevant features for preoperative evaluation and predictive factors for adverse outcomes were statistically identified. RESULTS Patients with intraductal papillary mucinous neoplasms (IPMN) represented the largest PCL subgroup (N = 689; 60.6%) while other entities (mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), neuroendocrine tumors, pseudocysts) were less frequently resected. Symptoms of pancreatitis were associated with IPMN (OR, 1.8; P = 0.012) and pseudocysts (OR, 4.78; P < 0.001), but likewise lowered the likelihood of MCN (OR, 0.49; P = 0.046) and SCN (OR, 0.15, P = 0.002). A total of 639 (57.2%) patients received endoscopic ultrasound before resection, as recommended by guidelines. Malignancy was histologically confirmed in 137 patients (12.0%), while jaundice (OR, 5.1; P < 0.001) and weight loss (OR, 2.0; P = 0.002) were independent predictors. Most resections were performed by open surgery (N = 847, 74.5%), while distal lesions were in majority treated using minimally invasive approaches (P < 0.001). Severe morbidity was 28.4% (N = 323) and 30d mortality was 2.6% (N = 29). Increased age (P = 0.004), higher BMI (P = 0.002), liver cirrhosis (P < 0.001), and esophageal varices (P = 0.002) were independent risk factors for 30d mortality. CONCLUSION With respect to unclear findings frequently present in PCL, diagnostic means recommended in guidelines should always be considered in the preoperative phase. The therapy of PCL should be decided upon in the light of patient-specific factors, and the surgical strategy needs to be adapted accordingly.
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Affiliation(s)
- Jonas Henn
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Patricia K Wyzlic
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Irene Esposito
- Institute of Pathology, Heinrich-Heine University, Düsseldorf, Germany
| | - Alexander Semaan
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Vittorio Branchi
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Carsten Klinger
- German Society of General and Visceral Surgery (DGAV), Berlin, Germany
| | - Heinz J Buhr
- German Society of General and Visceral Surgery (DGAV), Berlin, Germany
| | | | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Philipp Lingohr
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Tim R Glowka
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany.
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12
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Ungefroren H, Künstner A, Busch H, Franzenburg S, Luley K, Viol F, Schrader J, Konukiewitz B, Wellner UF, Meyhöfer SM, Keck T, Marquardt JU, Lehnert H. Differential Effects of Somatostatin, Octreotide, and Lanreotide on Neuroendocrine Differentiation and Proliferation in Established and Primary NET Cell Lines: Possible Crosstalk with TGF-β Signaling. Int J Mol Sci 2022; 23:ijms232415868. [PMID: 36555512 PMCID: PMC9781720 DOI: 10.3390/ijms232415868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
GEP-NETs are heterogeneous tumors originating from the pancreas (panNET) or the intestinal tract. Only a few patients with NETs are amenable to curative tumor resection, and for most patients, only palliative treatments to successfully control the disease or manage symptoms remain, such as with synthetic somatostatin (SST) analogs (SSAs), such as octreotide (OCT) or lanreotide (LAN). However, even cells expressing low levels of SST receptors (SSTRs) may exhibit significant responses to OCT, which suggests the possibility that SSAs signal through alternative mechanisms, e.g., transforming growth factor (TGF)-β. This signaling mode has been demonstrated in the established panNET line BON but not yet in other permanent (i.e., QGP) or primary (i.e., NT-3) panNET-derived cells. Here, we performed qPCR, immunoblot analyses, and cell counting assays to assess the effects of SST, OCT, LAN, and TGF-β1 on neuroendocrine marker expression and cell proliferation in NT-3, QGP, and BON cells. SST and SSAs were found to regulate a set of neuroendocrine genes in all three cell lines, with the effects of SST, mainly LAN, often differing from those of OCT. However, unlike NT-3 cells, BON cells failed to respond to OCT with growth arrest but paradoxically exhibited a growth-stimulatory effect after treatment with LAN. As previously shown for BON, NT-3 cells responded to TGF-β1 treatment with induction of expression of SST and SSTR2/5. Of note, the ability of NT-3 cells to respond to TGF-β1 with upregulation of the established TGF-β target gene SERPINE1 depended on cellular adherence to a collagen-coated matrix. Moreover, when applied to NT-3 cells for an extended period, i.e., 14 days, TGF-β1 induced growth suppression as shown earlier for BON cells. Finally, next-generation sequencing-based identification of microRNAs (miRNAs) in BON and NT-3 revealed that SST and OCT impact positively or negatively on the regulation of specific miRNAs. Our results suggest that primary panNET cells, such as NT-3, respond similarly as BON cells to SST, SSA, and TGF-β treatment and thus provide circumstantial evidence that crosstalk of SST and TGF-β signaling is not confined to BON cells but is a general feature of panNETs.
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Affiliation(s)
- Hendrik Ungefroren
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, D-23538 Lübeck, Germany
- Institute of Pathology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, D-24105 Kiel, Germany
- Correspondence:
| | - Axel Künstner
- Medical Systems Biology Group, Lübeck Institute of Experimental Dermatology, University of Lübeck, D-23538 Lübeck, Germany
- Institute for Cardiogenetics, University of Lübeck, D-23538 Lübeck, Germany
| | - Hauke Busch
- Medical Systems Biology Group, Lübeck Institute of Experimental Dermatology, University of Lübeck, D-23538 Lübeck, Germany
- Institute for Cardiogenetics, University of Lübeck, D-23538 Lübeck, Germany
| | - Sören Franzenburg
- Institute for Clinical Molecular Biology, University of Kiel, D-24118 Kiel, Germany
| | - Kim Luley
- Clinic of Oncology, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, D-23538 Lübeck, Germany
| | - Fabrice Viol
- Medical Clinic and Policlinic, University Hospital Hamburg-Eppendorf, D-20251 Hamburg, Germany
| | - Jörg Schrader
- Medical Clinic and Policlinic, University Hospital Hamburg-Eppendorf, D-20251 Hamburg, Germany
| | - Björn Konukiewitz
- Institute of Pathology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, D-24105 Kiel, Germany
| | - Ulrich F. Wellner
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, D-23538 Lübeck, Germany
| | - Sebastian M. Meyhöfer
- Institute of Endocrinology and Diabetes, University of Lübeck, D-23538 Lübeck, Germany
- German Center of Diabetes Research, D-85764 Neuherberg, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, D-23538 Lübeck, Germany
| | - Jens-Uwe Marquardt
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, D-23538 Lübeck, Germany
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Ungefroren H, Braun R, Lapshyna O, Konukiewitz B, Wellner UF, Lehnert H, Marquardt JU. Suppressive Role of ACVR1/ALK2 in Basal and TGFβ1-Induced Cell Migration in Pancreatic Ductal Adenocarcinoma Cells and Identification of a Self-Perpetuating Autoregulatory Loop Involving the Small GTPase RAC1b. Biomedicines 2022; 10:biomedicines10102640. [PMID: 36289908 PMCID: PMC9599656 DOI: 10.3390/biomedicines10102640] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/10/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) cells are known for their high invasive/metastatic potential, which is regulated in part by the transforming growth factor β1 (TGFβ1). The involvement of at least two type I receptors, ALK5 and ALK2, that transmit downstream signals of the TGFβ via different Smad proteins, SMAD2/3 and SMAD1/5, respectively, poses the issue of their relative contribution in regulating cell motility. Real-time cell migration assays revealed that the selective inhibition of ALK2 by RNAi or dominant-negative interference with a kinase-dead mutant (ALK2-K233R) strongly enhanced the cells’ migratory activity in the absence or presence of TGFβ1 stimulation. Ectopic ALK2-K233R expression was associated with an increase in the protein levels of RAC1 and its alternatively spliced isoform, RAC1b, both of which are implicated in driving cell migration and invasion. Conversely, the RNAi-mediated knockdown or CRISPR/Cas9-mediated knockout of RAC1b resulted in the upregulation of the expression of ALK2, but not that of the related BMP type I receptors, ALK3 or ALK6, and elevated the phosphorylation of SMAD1/5. PDAC is a heterogeneous disease encompassing tumors with different histomorphological subtypes, ranging from epithelial/classical to extremely mesenchymal. Upon treatment of various established and primary PDAC cell lines representing these subtypes with the ALK2 inhibitor, LDN-193189, well-differentiated, epithelial cell lines responded with a much stronger increase in the basal and TGFβ1-dependent migratory activity than poorly differentiated, mesenchymal ones. These data show that (i) ALK2 inhibits migration by suppressing RAC1/RAC1b proteins, (ii) ALK2 and RAC1b act together in a self-perpetuating the autoregulatory negative feedback loop to mutually control their expression, and (iii) the ALK2 antimigratory function appears to be particularly crucial in protecting epithelial subtype cells from becoming invasive, both spontaneously and in a TGFβ-rich tumor microenvironment.
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Affiliation(s)
- Hendrik Ungefroren
- First Department of Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany
- Correspondence:
| | - Rüdiger Braun
- Clinic for Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
| | - Olha Lapshyna
- Clinic for Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
| | - Björn Konukiewitz
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany
| | - Ulrich F. Wellner
- Clinic for Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
| | | | - Jens-Uwe Marquardt
- First Department of Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
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14
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Braun R, Klinkhammer-Schalke M, Zeissig SR, Kleihus van Tol K, Bolm L, Honselmann KC, Petrova E, Lapshyn H, Deichmann S, Abdalla TSA, Heckelmann B, Bronsert P, Zemskov S, Hummel R, Keck T, Wellner UF. Clinical Outcome and Prognostic Factors of Pancreatic Adenosquamous Carcinoma Compared to Ductal Adenocarcinoma-Results from the German Cancer Registry Group. Cancers (Basel) 2022; 14:cancers14163946. [PMID: 36010939 PMCID: PMC9406158 DOI: 10.3390/cancers14163946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Adenosquamous carcinoma of the pancreas (ASCP) is a rare malignancy and its pathophysiology is poorly understood. Sparse clinical data suggest that clinical outcome and overall survival is worse in comparison to common pancreatic ductal adenocarcinoma (PDAC). Methods: We evaluated clinical outcome and prognostic factors for overall survival of patients with ASCP in comparison to patients with PDAC recorded between 2000 and 2019 in 17 population-based clinical cancer registries at certified cancer centers within the Association of German Tumor Centers (ADT). Results: We identified 278 (0.5%) patients with ASCP in the entire cohort of 52,518 patients with pancreatic cancer. Significantly, more patients underwent surgical resection in the cohort of ASCP patients in comparison to patients with PDAC (p < 0.001). In the cohort of 142 surgically resected patients with ASCP, the majority of patients was treated by pancreatoduodenectomy (44.4%). However, compared to the cohort of PDAC patients, significantly more patients underwent distal pancreatectomy (p < 0.001), suggesting that a significantly higher proportion of ASCP tumors was located in the pancreatic body/tail. ASCPs were significantly more often poorly differentiated (G3) (p < 0.001) and blood vessel invasion (V1) was detected more frequently (p = 0.01) in comparison with PDAC. Median overall survival was 6.13 months (95% CI 5.20−7.06) for ASCP and 8.10 months (95% CI 7.93−8.22) for PDAC patients, respectively (p = 0.094). However, when comparing only those patients who underwent surgical resection, overall survival of ASCP patients was significantly shorter (11.80; 95% CI 8.20−15.40 months) compared to PDAC patients (16.17; 95% CI 15.78−16.55 months) (p = 0.007). ASCP was a highly significant prognostic factor for overall survival in univariable regression analysis (p = 0.007) as well as in multivariable Cox regression analysis (HR 1.303; 95% CI 1.013−1.677; p = 0.039). Conclusions: In conclusion, ASCP showed poorer differentiation and higher frequency of blood vessel invasion indicative of a more aggressive tumor biology. ASCP was a significant prognostic factor for overall survival in a multivariable analysis. Overall survival of resected ASCP patients was significantly shorter compared to resected PDAC patients. However, surgical resection still improved survival significantly.
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Affiliation(s)
- Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Monika Klinkhammer-Schalke
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Sylke Ruth Zeissig
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Kees Kleihus van Tol
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Kim C. Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Thaer S. A. Abdalla
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Benjamin Heckelmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Faculty of Medicine, Medical Center, University of Freiburg, 79085 Freiburg, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical University, 01601 Kiev, Ukraine
| | - Richard Hummel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Ulrich F. Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Correspondence:
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15
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Bolm L, Zemskov S, Zeller M, Baba T, Roldan J, Harrison JM, Petruch N, Sato H, Petrova E, Lapshyn H, Braun R, Honselmann KC, Hummel R, Dronov O, Kirichenko AV, Klinkhammer-Schalke M, Kleihues-van Tol K, Zeissig SR, Rades D, Keck T, Fernandez-del Castillo C, Wellner UF, Wegner RE. Concepts and Outcomes of Perioperative Therapy in Stage IA-III Pancreatic Cancer-A Cross-Validation of the National Cancer Database (NCDB) and the German Cancer Registry Group of the Society of German Tumor Centers (GCRG/ADT). Cancers (Basel) 2022; 14:cancers14040868. [PMID: 35205616 PMCID: PMC8870242 DOI: 10.3390/cancers14040868] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/05/2023] Open
Abstract
(1) Background: The aim of this study is to assess perioperative therapy in stage IA-III pancreatic cancer cross-validating the German Cancer Registry Group of the Society of German Tumor Centers-Network for Care, Quality, and Research in Oncology, Berlin (GCRG/ADT) and the National Cancer Database (NCDB). (2) Methods: Patients with clinical stage IA-III PDAC undergoing surgery alone (OP), neoadjuvant therapy (TX) + surgery (neo + OP), surgery+adjuvantTX (OP + adj) and neoadjuvantTX + surgery + adjuvantTX (neo + OP + adj) were identified. Baseline characteristics, histopathological parameters, and overall survival (OS) were evaluated. (3) Results: 1392 patients from the GCRG/ADT and 29,081 patients from the NCDB were included. Patient selection and strategies of perioperative therapy remained consistent across the registries for stage IA-III pancreatic cancer. Combined neo + OP + adj was associated with prolonged OS as compared to neo + OP alone (17.8 m vs. 21.3 m, p = 0.012) across all stages in the GCRG/ADT registry. Similarly, OS with neo + OP + adj was improved as compared to neo + OP in the NCDB registry (26.4 m vs. 35.4 m, p < 0.001). (4) Conclusion: The cross-validation study demonstrated similar concepts and patient selection criteria of perioperative therapy across clinical stages of PDAC. Neoadjuvant therapy combined with adjuvant therapy is associated with improved overall survival as compared to either therapy alone.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
- Correspondence:
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical Unoversity, 01601 Kyiv, Ukraine; (S.Z.); (O.D.)
| | - Maria Zeller
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Taisuke Baba
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
| | - Jorge Roldan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
| | - Jon M. Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
| | - Natalie Petruch
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Hiroki Sato
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Kim C. Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Richard Hummel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Oleksii Dronov
- Department of General Surgery, Bogomolets National Medical Unoversity, 01601 Kyiv, Ukraine; (S.Z.); (O.D.)
| | - Alexander V. Kirichenko
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA; (A.V.K.); (R.E.W.)
| | - Monika Klinkhammer-Schalke
- German Cancer Registry Group, Society of German Tumor Centers—Network for Care, Quality and Research in Oncology, 14057 Berlin, Germany; (M.K.-S.); (K.K.-v.T.)
| | - Kees Kleihues-van Tol
- German Cancer Registry Group, Society of German Tumor Centers—Network for Care, Quality and Research in Oncology, 14057 Berlin, Germany; (M.K.-S.); (K.K.-v.T.)
| | - Sylke R. Zeissig
- Institute for Clinical Epidemiology and Biometry, University of Wuerzburg, 97070 Wuerzburg, Germany;
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Campus Luebeck, 23538 Luebeck, Germany;
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Carlos Fernandez-del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; (T.B.); (J.R.); (J.M.H.); (N.P.); (H.S.); (C.F.-d.C.)
| | - Ulrich F. Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, 23562 Luebeck, Germany; (M.Z.); (E.P.); (H.L.); (R.B.); (K.C.H.); (R.H.); (T.K.); (U.F.W.)
| | - Rodney E. Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA; (A.V.K.); (R.E.W.)
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16
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Lapshyn H, Schulte T, Petruch N, Petrova E, Honselmann K, Deichmann S, Braun R, Kulemann B, Hoeppner J, Rades D, Keck T, Wellner UF, Bausch D, Bolm L. Postoperative Outcomes of Tangential versus Segmental Resection and End-to-end Reconstruction of the Superior Mesenterico-Portal Vein During Pancreatoduodenectomy for Pancreatic Adenocarcinoma: A Single-Center Experience. Anticancer Res 2021; 41:5123-5130. [PMID: 34593463 DOI: 10.21873/anticanres.15329] [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: 08/04/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The impact of venous resections and reconstruction techniques on morbidity after surgery for pancreatic cancer (PDAC) remains controversial. PATIENTS AND METHODS A total of 143 patients receiving pancreatoduodenectomy (PD) for PDAC between 2013 and 2018 were identified from a prospective database. Morbidity and mortality after PD with tangential resection versus end-to-end reconstruction were assessed. RESULTS Fifty-two of 143 (36.4%) patients underwent PD with portal venous resection (PVR), which was associated with longer operation times [398 (standard error (SE) 12.01) vs. 306 (SE 13.09) min, p<0.001]. PVR was associated with longer intensive-care-unit stay (6.3 vs. 3.8 days, p=0.054); morbidity (Clavien-Dindo classification (CDC) grade IIIa-V 45.8% vs. 35.8%, p=0.279) and 30-day mortality (4.1% vs. 4.2%, p>0.99) were not different. Tangential venous resection was associated with similar CDC grade IIIa-IV (42.9% vs. 50.0%, p=0.781) and 30-day mortality rates (3.5% vs. 4.1%, p=0.538) as segmental resection and end-to-end venous reconstruction. CONCLUSION Both tangential and segmental PVR appear feasible and can be safely performed to achieve negative resection margins.
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Affiliation(s)
- Hryhoriy Lapshyn
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Theresa Schulte
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Natalie Petruch
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Kim Honselmann
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Birte Kulemann
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Jens Hoeppner
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany;
| | - Ulrich F Wellner
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany.,Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Louisa Bolm
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Lübeck, Germany
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17
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Lindner K, Binte D, Hoeppner J, Wellner UF, Schulte DM, Schmid SM, Luley K, Buchmann I, Tharun L, Keck T, Gebauer J, Kulemann B. Resection of Non-Functional Pancreatic Neuroendocrine Neoplasms-A Single-Center Retrospective Outcome Analysis. ACTA ACUST UNITED AC 2021; 28:3071-3080. [PMID: 34436034 PMCID: PMC8395435 DOI: 10.3390/curroncol28040268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/07/2021] [Accepted: 08/08/2021] [Indexed: 01/08/2023]
Abstract
Surgery remains the only curative treatment of pancreatic neuroendocrine neoplasms (pNEN). Here, we report the outcome after surgery for non-functional pNEN at a European Neuroendocrine Tumor Society (ENETS) center in Germany between 2000 and 2019; cases were analyzed for surgical (Clavien–Dindo classification; CDc) and oncological outcomes. Forty-nine patients (tumor grading G1 n = 25, G2 n = 22, G3 n = 2), with a median age of 56 years, were included. Severe complications (CDc ≥ grade 3b) occurred in 11 patients (22.4%) and type B/C pancreatic fistulas (POPFs) occurred in 5 patients (10.2%); in-hospital mortality was 2% (n = 1). Six of seven patients with tumor recurrence (14.3%) had G2 tumors in the pancreatic body/tail. The median survival was 5.7 years (68 months; [1–228 months]). Neither the occurrence (p = 0.683) nor the severity of complications had an influence on the relapse behavior (p = 0.086). This also applied for a POPF (≥B, p = 0.609). G2 pNEN patients (n = 22) with and without tumor recurrence had similar median tumor sizes (4 cm and 3.9 cm, respectively). Five of the six relapsed G2 patients (83.3%) had tumor-positive lymph nodes (N+); all G2 pNEN patients with recurrence had initially been treated with distal pancreatic resection. Pancreatic resections for pNEN are safe but associated with relevant postoperative morbidity. Future studies are needed to evaluate suitable resection strategies for G2 pNEN.
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Affiliation(s)
- Kirsten Lindner
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
| | - Daniel Binte
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
| | - Jens Hoeppner
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
| | - Ulrich F. Wellner
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
| | - Dominik M. Schulte
- Division of Endocrinology, Diabetology and Clinical Nutrition, Department of Internal Medicine I, University Medical Center Schleswig-Holstein-Campus Kiel, 23538 Lübeck, Germany;
| | - Sebastian M. Schmid
- Institute for Endocrinology and Diabetes, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (S.M.S.); (J.G.)
| | - Kim Luley
- Clinic for Hematology and Oncology, University Hospital Schleswig-Holstein-Campus Lübeck, 23538 Lübeck, Germany;
| | - Inga Buchmann
- Department of Radiology and Nuclear Medicine, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany;
| | - Lars Tharun
- Institute of Pathology, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany;
| | - Tobias Keck
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
| | - Judith Gebauer
- Institute for Endocrinology and Diabetes, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (S.M.S.); (J.G.)
| | - Birte Kulemann
- Department of Surgery, University Medical Center of Schleswig-Holstein-Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany; (K.L.); (D.B.); (J.H.); (U.F.W.); (T.K.)
- Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
- Correspondence:
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18
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Lapshyn H, Petruch N, Thomaschewski M, Sondermann S, May K, Frohneberg L, Petrova E, Zemskov S, Honselmann KC, Braun R, Keck T, Wellner UF, Bolm L. A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology 2021; 21:957-964. [PMID: 33775565 DOI: 10.1016/j.pan.2021.03.009] [Citation(s) in RCA: 9] [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: 12/20/2020] [Revised: 01/28/2021] [Accepted: 03/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine. METHODS Patients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram. RESULTS A total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726-0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed. CONCLUSION The preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.
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Affiliation(s)
- Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Natalie Petruch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Michael Thomaschewski
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Stefan Sondermann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Katharina May
- Department of Radiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Laura Frohneberg
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical Unoversity, Kiev, Ukraine
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
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19
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Latenstein AEJ, Mackay TM, Beane JD, Busch OR, van Dieren S, Gleeson EM, Koerkamp BG, van Santvoort HC, Wellner UF, Williamsson C, Tingstedt B, Keck T, Pitt HA, Besselink MG. The use and clinical outcome of total pancreatectomy in the United States, Germany, the Netherlands, and Sweden. Surgery 2021; 170:563-570. [PMID: 33741182 DOI: 10.1016/j.surg.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/16/2021] [Accepted: 02/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries. METHODS Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014-2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo ≥3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume ≥40 pancreatoduodenectomies annually; data available for the Netherlands and Germany). RESULTS In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age ≥75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P = .002), but not in Germany (9.8% vs 10.6%; P = .733). CONCLUSION Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/anouklatenstein
| | - Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/tarammackay
| | - Joal D Beane
- Department of Surgical Oncology, Ohio State University, Columbus, OH
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Tobias Keck
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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20
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Deichmann S, Manschikow SG, Petrova E, Bolm L, Honselmann KC, Frohneberg L, Keck T, Wellner UF, Bausch D. Evaluation of Postoperative Quality of Life After Pancreatic Surgery and Determination of Influencing Risk Factors. Pancreas 2021; 50:362-370. [PMID: 33835967 DOI: 10.1097/mpa.0000000000001780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The postoperative quality of life (QoL) after pancreatic surgery is frequently impaired. The aim of this study was to evaluate the QoL after pancreatic surgery and its influencing risk factors. Furthermore, an age-adjusted comparison with the normal population of Germany was performed. METHODS A total of 94 patients were surveyed. The Short Form-36 questionnaire was sent to all patients undergoing pancreatic surgery between 2013 and 2017. All pathologies and types of pancreatic resections were included. Statistical analyses were performed, and an analysis by the Robert Koch-Institute to determine the health-related age-adjusted QoL in Germany served as control group. RESULTS Response rate was 29%. Median time of survey was 28 months. As compared with a normative population, QoL after pancreaticoduodenectomy was significantly impaired. Distal pancreatic resection showed no significant differences. Univariate and Lasso analyses showed that the following factors had a negative impact: coronary artery disease, chronic pancreatitis, and open access. Postoperative enzyme supplementation seemed to have a positive impact. CONCLUSIONS Pancreatic surgery leads to long-lasting negative effect on QoL. Distal pancreatic resections and laparoscopic access seemed to be the best tolerated. Complications seems to have less impact, whereas maintaining exocrine and endocrine function seems to have a positive effect.
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Affiliation(s)
- Steffen Deichmann
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Sanda G Manschikow
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Ekaterina Petrova
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Louisa Bolm
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Kim C Honselmann
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Laura Frohneberg
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Tobias Keck
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
| | - Ulrich F Wellner
- From the Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck
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21
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Lapshyn H, Schulte T, Sondermann S, May K, Petrova E, Honselmann KC, Braun R, Zemskov S, Keck T, Wellner UF, Bausch D, Bolm L. Radiological prediction of portal vein infiltration in patients with pancreatic ductal adenocarcinoma. Pancreatology 2021; 21:155-162. [PMID: 33309623 DOI: 10.1016/j.pan.2020.11.015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/02/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy characterized by early loco-regional invasion. Portal vein resection (PVR) during pancreatoduodenectomy (PD) for PDAC is performed if tumor cell invasion to the venous wall (PVI) is suspected. The aim of this study is to evaluate radiological criteria for predicting PVR and PVI. METHODS Patients undergoing PD for PDAC were identified from a prospectively maintained database. On the basis of CT- and MRI-based imaging portal vein tumor contact (PV), stranding of the superior mesenteric artery (SMA) and any alterations of the superior mesenterico-portal vein (SMPV) were evaluated. The accuracy of PVI and PVR prediction based on the radiological parameters was calculated. RESULTS 143 patients were included in the study. 48 patients underwent PVR (34%), PVI was diagnosed in 23 patients (16%). Median overall survival was 22 months. Prediction of PVR (sensitivity 79%, negative predictive value 88%, p = 0.010) and PVI (sensitivity 95%, negative predictive value 99%, p = 0.002) was most accurate for any SMPV alterations as compared to the other radiological parameters. SMPV alterations qualified as an independent prognostic parameter (26.5 months vs. 33.5months, p = 0.034). CONCLUSION Radiological evaluation of any SMPV alterations is a simple preoperative method to accurately predict PVI. Assessing SMPV alterations may help to identify candidates for neoadjuvant therapy.
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Affiliation(s)
- Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Theresa Schulte
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Stefan Sondermann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Katharina May
- Department of Radiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical University, Bogomolets, 01601, Kiev, No 13, Shevchenko Av, Ukraine
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany; Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
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22
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Ungefroren H, Wellner UF, Keck T, Lehnert H, Marquardt JU. The Small GTPase RAC1B: A Potent Negative Regulator of-and Useful Tool to Study-TGFβ Signaling. Cancers (Basel) 2020; 12:E3475. [PMID: 33266416 PMCID: PMC7700615 DOI: 10.3390/cancers12113475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 02/06/2023] Open
Abstract
RAC1 and its alternatively spliced isoform, RAC1B, are members of the Rho family of GTPases. Both isoforms are involved in the regulation of actin cytoskeleton remodeling, cell motility, cell proliferation, and epithelial-mesenchymal transition (EMT). Compared to RAC1, RAC1B exhibits a number of distinctive features with respect to tissue distribution, downstream signaling and a role in disease conditions like inflammation and cancer. The subcellular locations and interaction partners of RAC1 and RAC1B vary depending on their activation state, which makes RAC1 and RAC1B ideal candidates to establish cross-talk with cancer-associated signaling pathways-for instance, interactions with signaling by transforming growth factor β (TGFβ), a known tumor promoter. Although RAC1 has been found to promote TGFβ-driven tumor progression, recent observations in pancreatic carcinoma cells surprisingly revealed that RAC1B confers anti-oncogenic properties, i.e., through inhibiting TGFβ-induced EMT. Since then, an unexpected array of mechanisms through which RAC1B cross-talks with TGFβ signaling has been demonstrated. However, rather than being uniformly inhibitory, RAC1B interacts with TGFβ signaling in a way that results in the selective blockade of tumor-promoting pathways, while concomitantly allowing tumor-suppressive pathways to proceed. In this review article, we are going to discuss the specific interactions between RAC1B and TGFβ signaling, which occur at multiple levels and include various components such as ligands, receptors, cytosolic mediators, transcription factors, and extracellular inhibitors of TGFβ ligands.
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Affiliation(s)
- Hendrik Ungefroren
- First Department of Medicine, Campus Lübeck, University Hospital Schleswig-Holstein, D-23538 Lübeck, Germany;
- Clinic for General Surgery, Visceral, Thoracic, Transplantation and Pediatric Surgery, Campus Kiel, University Hospital Schleswig-Holstein, D-24105 Kiel, Germany
| | - Ulrich F. Wellner
- Clinic for Surgery, Campus Lübeck, University Hospital Schleswig-Holstein, D-23538 Lübeck, Germany; (U.F.W.); (T.K.)
| | - Tobias Keck
- Clinic for Surgery, Campus Lübeck, University Hospital Schleswig-Holstein, D-23538 Lübeck, Germany; (U.F.W.); (T.K.)
| | | | - Jens-Uwe Marquardt
- First Department of Medicine, Campus Lübeck, University Hospital Schleswig-Holstein, D-23538 Lübeck, Germany;
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23
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Honselmann KC, Finetti P, Birnbaum DJ, Monsalve CS, Wellner UF, Begg SKS, Nakagawa A, Hank T, Li A, Goldsworthy MA, Sharma H, Bertucci F, Birnbaum D, Tai E, Ligorio M, Ting DT, Schilling O, Biniossek ML, Bronsert P, Ferrone CR, Keck T, Mino-Kenudson M, Lillemoe KD, Warshaw AL, Fernández-Del Castillo C, Liss AS. Neoplastic-Stromal Cell Cross-talk Regulates Matrisome Expression in Pancreatic Cancer. Mol Cancer Res 2020; 18:1889-1902. [PMID: 32873625 DOI: 10.1158/1541-7786.mcr-20-0439] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/28/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is characterized by a highly desmoplastic reaction, warranting intense cancer-stroma communication. In this study, we interrogated the contribution of the BET family of chromatin adaptors to the cross-talk between PDAC cells and the tumor stroma. Short-term treatment of orthotopic xenograft tumors with CPI203, a small-molecule inhibitor of BET proteins, resulted in broad changes in the expression of genes encoding components of the extracellular matrix (matrisome) in both cancer and stromal cells. Remarkably, more than half of matrisome genes were expressed by cancer cells. In vitro cocultures of PDAC cells and cancer-associated fibroblasts (CAF) demonstrated that matrisome expression was regulated by BET-dependent cancer-CAF cross-talk. Disrupting this cross-talk in vivo resulted in diminished growth of orthotopic patient-derived xenograft tumors, reduced proliferation of cancer cells, and changes in collagen structure consistent with that of patients who experienced better survival. Examination of matrisome gene expression in publicly available data sets of 573 PDAC tumors identified a 65-gene signature that was able to distinguish long- and short-term PDAC survivors. Importantly, the expression of genes predictive of short-term survival was diminished in the cancer cells of orthotopic xenograft tumors of mice treated with CPI203. Taken together, these results demonstrate that inhibiting the activity BET proteins results in transcriptional and structural differences in the matrisome are associated with better patient survival. IMPLICATIONS: These studies highlight the biological relevance of the matrisome program in PDAC and suggest targeting of epigenetically driven tumor-stroma cross-talk as a potential therapeutic avenue.
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Affiliation(s)
- Kim C Honselmann
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pascal Finetti
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France
| | - David J Birnbaum
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France.,Département de Chirurgie Générale et Viscérale, AP-HM, Marseille, France
| | - Christian S Monsalve
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Sebastian K S Begg
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Akifumi Nakagawa
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annie Li
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mathew A Goldsworthy
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Himanshu Sharma
- Partners Healthcare Personalized Medicine Center, Cambridge, Massachusetts
| | - François Bertucci
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France.,Département d'Oncologie Médicale, Institut Paoli-Calmettes, Marseille, France
| | - Daniel Birnbaum
- Laboratoire d'Oncologie Prédictive, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille University, Marseille, France
| | - Eric Tai
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - Matteo Ligorio
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - David T Ting
- MGH Cancer Research Center, Harvard Medical School, Boston, Massachusetts
| | - Oliver Schilling
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin L Biniossek
- Institute of Molecular Medicine and Cell Research, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Freiburg, Germany
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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24
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Mackay TM, Gleeson EM, Wellner UF, Williamsson C, Busch OR, Groot Koerkamp B, Keck T, van Santvoort HC, Tingstedt B, Pitt HA, Besselink MG. Transatlantic registries of pancreatic surgery in the United States of America, Germany, the Netherlands, and Sweden: Comparing design, variables, patients, treatment strategies, and outcomes. Surgery 2020; 169:396-402. [PMID: 32868111 DOI: 10.1016/j.surg.2020.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Registries of pancreatic surgery have become increasingly popular as they facilitate both quality improvement and clinical research. We aimed to compare registries for design, variables collected, patient characteristics, treatment strategies, clinical outcomes, and pathology. METHODS Registered variables and outcomes of pancreatoduodenectomy (2014-2017) in 4 nationwide or multicenter pancreatic surgery registries from the United States of America (American College of Surgeons National Surgical Quality Improvement Program), Germany (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie - Studien-, Dokumentations- und Qualitätszentrum), the Netherlands (Dutch Pancreatic Cancer Audit), and Sweden (Swedish National Pancreatic and Periampullary Cancer Registry) were compared. A core registry set of 55 parameters was identified and evaluated using relative and absolute largest differences between extremes (smallest versus largest). RESULTS Overall, 22,983 pancreatoduodenectomies were included (15,224, 3,558, 2,795, and 1,406 in the United States of America, Germany, the Netherlands, and Sweden). Design of the registries varied because 20 out of 55 (36.4%) core parameters were not available in 1 or more registries. Preoperative chemotherapy in patients with pancreatic ductal adenocarcinoma was administered in 27.6%, 4.9%, 7.0%, and 3.4% (relative largest difference 8.1, absolute largest difference 24.2%, P < .001). Minimally invasive surgery was performed in 7.8%, 4.5%, 13.5%, and unknown (relative largest difference 3.0, absolute largest difference 9.0%, P < .001). Median length of stay was 8.0, 16.0, 12.0, and 11.0 days (relative largest difference 2.0, absolute largest difference 8.0, P < .001). Reoperation was performed in 5.7%, 17.1%, 8.7%, and 11.2% (relative largest difference 3.0, absolute largest difference 11.4%, P < .001). In-hospital mortality was 1.3%, 4.7%, 3.6%, and 2.7% (relative largest difference 3.6, absolute largest difference 3.4%, P < .001). CONCLUSION Considerable differences exist in the design, variables, patients, treatment strategies, and outcomes in 4 Western registries of pancreatic surgery. The absolute largest differences of 24.3% for the use of preoperative chemotherapy, 9.0% for minimally invasive surgery, 11.4% for reoperation rate, and 3.4% for in-hospital mortality require further study and improvement. This analysis provides 55 core parameters for pancreatic surgery registries.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Elizabeth M Gleeson
- Department of Surgery, Hahnemann University Hospital and Drexel University College of Medicine, Philadelphia, PA
| | - Ulrich F Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henry A Pitt
- Temple University Health System, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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25
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Bolm L, Zghurskyi P, Lapshyn H, Petrova E, Zemskov S, Vashist YK, Deichmann S, Honselmann KC, Bronsert P, Keck T, Wellner UF. Alignment of stroma fibers, microvessel density and immune cell populations determine overall survival in pancreatic cancer-An analysis of stromal morphology. PLoS One 2020; 15:e0234568. [PMID: 32658932 PMCID: PMC7357746 DOI: 10.1371/journal.pone.0234568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction The aim of this study was to define histo-morphological stroma characteristics by analyzing stromal components, and to evaluate their impact on local and systemic tumor spread and overall survival in pancreatic ductal adenocarcinoma (PDAC). Methods and materials Patients who underwent oncologic resections with curative intent for PDAC were identified from a prospectively maintained database. Histological specimens were re-evaluated for morphological stroma features as stromal fibers, fibroblast morphology, stroma matrix density, microvessel density and distribution of immune cell populations. Results A total of 108 patients were identified undergoing curative resection for PDAC in the period from 2011–2016. 33 (30.6%) patients showed parallel alignment of stroma fibers while 75 (69.4%) had randomly oriented stroma fibers. As compared to parallel alignment, random orientation of stroma fibers was associated with larger tumor size (median 3.62 cm vs. median 2.87cm, p = 0.037), nodal positive disease (76.0% vs. 54.5%, p = 0.040), higher margin positive resection rates (41.9% vs. 15.2%, p = 0.008) and a trend for higher rates of T3/4 tumors (33.3% vs. 15.2%, p = 0.064). In univariate analysis, patients with parallel alignment of stroma fibers had improved overall survival rates as compared to patients with random orientation of stroma fibers (42 months vs. 22 months, p = 0.046). The combination of random orientation of stroma fibers and low microvessel density was associated with impaired overall survival rates (16 months vs. 36 months, p = 0.019). A high CD4/CD3 ratio (16 months vs. 33 months, p = 0.040) and high stromal density of CD163 positive cells were associated with reduced overall survival (27 months vs. 34 months, p = 0.039). In multivariable analysis, the combination of random orientation of stroma fibers and low microvessel density (HR 1.592, 95%CI 1.098–2.733, p = 0.029), high CD4/CD3 ratio (HR 2.044, 95%CI 1.203–3.508, p = 0.028) and high density of CD163 positive cells (HR 1.596, 95%CI 1.367–1.968, p = 0.036) remained independent prognostic factors. Conclusion Alignment of stroma fibers and microvessel density are simple histomorphological features serving as surrogate markers of local tumor progression dissemination and surgical resectability and determine prognosis in PDAC patients. High CD4/CD3 ratio and CD163 positive cell counts determine poor prognosis.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Petro Zghurskyi
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Sergiy Zemskov
- Department of General Surgery #1, Bogomolets National Medical University, Kyiv, Ukraine
| | - Yogesh K. Vashist
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Kim C. Honselmann
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
| | - Peter Bronsert
- Department of Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Tumorbank Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
- * E-mail:
| | - Ulrich F. Wellner
- Department of Surgery, University Medical Center Luebeck, Luebeck, Germany
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Begg SKS, Birnbaum DJ, Clark JW, Mino-Kenudson M, Wellner UF, Schilling O, Lillemoe KD, Warshaw AL, Castillo CFD, Liss AS. FOLFIRINOX Versus Gemcitabine-based Therapy for Pancreatic Ductal Adenocarcinoma: Lessons from Patient-derived Cell Lines. Anticancer Res 2020; 40:3659-3667. [PMID: 32620605 DOI: 10.21873/anticanres.14355] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM FOLFIRINOX [fluorouracil (5-FU), irinotecan, oxaliplatin] and gemcitabine plus nab-paclitaxel are standard treatments for patients with pancreatic ductal adenocarcinoma (PDAC). Despite efficacy rates of less than 32%, evidence is lacking to guide the use of one drug over the other. Herein, we compared the sensitivity of patient-derived PDAC cell lines to each of these regimens. MATERIALS AND METHODS Changes in the growth of 19 low-passage patient-derived PDAC cell lines were evaluated in response to treatment with FOLFIRINOX and gemcitabine plus paclitaxel (Gem-Pac). RESULTS Six cell lines exhibited optimal sensitivity (high EMax and low GI50) to FOLFIRINOX and three cell lines exhibited optimal sensitivity to Gem-Pac. Several cell lines that were optimally sensitive to one drug regimen exhibited very poor response to the other. CONCLUSION Further characterization of cancer cells exhibiting preferential sensitivity to each of these regimens may allow the identification of biomarkers to guide the selection of appropriate chemotherapy for a given patient.
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Affiliation(s)
- Sebastian K S Begg
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - David J Birnbaum
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Oliver Schilling
- Institute of Surgical Pathology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, U.S.A.
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Bausch D, Fritz S, Bolm L, Wellner UF, Fernandez-Del-Castillo C, Warshaw AL, Thayer SP, Liss AS. Hedgehog signaling promotes angiogenesis directly and indirectly in pancreatic cancer. Angiogenesis 2020; 23:479-492. [PMID: 32444947 DOI: 10.1007/s10456-020-09725-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [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: 11/15/2019] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The inhibition of Hedgehog (Hh) signaling in pancreatic ductal adenocarcinoma (PDAC) reduces desmoplasia and promotes increased vascularity. In contrast to these findings, the Hh ligand Sonic Hedgehog (SHH) is a potent proangiogenic factor in non-tumor models. The aim of this study was to determine the molecular mechanisms by which SHH affects the tumor stroma and angiogenesis. METHODS Mice bearing three different xenografted human PDAC (n = 5/group) were treated with neutralizing antibodies to SHH. After treatment for 7 days, tumors were evaluated and the expression of 38 pro- and antiangiogenic factors was assessed in the tumor cells and their stroma. The effect of SHH on the regulation of pro- and antiangiogenic factors in fibroblasts and its impact on endothelial cells was then further assessed in in vitro model systems. RESULTS Inhibition of SHH affected tumor growth, stromal content, and vascularity. Its effect on the Hh signaling pathway was restricted to the stromal compartment of the three cancers. SHH-stimulated angiogenesis indirectly through the reduction of antiangiogenic THBS2 and TIMP2 in stromal cells. An additional direct effect of SHH on endothelial cells depended on the presence of VEGF. CONCLUSION Inhibition of Hh signaling reduces tumor vascularity, suggesting that Hh plays a role in the maintenance or formation of the tumor vasculature. Whether the reduction in tumor growth and viability seen in the epithelium is a direct consequence of Hh pathway inhibition, or indirectly caused by its effect on the stroma and vasculature, remains to be evaluated.
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Affiliation(s)
- Dirk Bausch
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.,Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Stefan Fritz
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.,Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Louisa Bolm
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Carlos Fernandez-Del-Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA
| | - Sarah P Thayer
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA. .,Division of Surgical Oncology and the Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, 68198-6895, USA.
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Their 623, Boston, MA, 02114, USA.
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Moekotte AL, Malleo G, van Roessel S, Bonds M, Halimi A, Zarantonello L, Napoli N, Dreyer SB, Wellner UF, Bolm L, Mavroeidis VK, Robinson S, Khalil K, Ferraro D, Mortimer MC, Harris S, Al-Sarireh B, Fusai GK, Roberts KJ, Fontana M, White SA, Soonawalla Z, Jamieson NB, Boggi U, Alseidi A, Shablak A, Wilmink JW, Primrose JN, Salvia R, Bassi C, Besselink MG, Abu Hilal M. Gemcitabine-based adjuvant chemotherapy in subtypes of ampullary adenocarcinoma: international propensity score-matched cohort study. Br J Surg 2020; 107:1171-1182. [PMID: 32259295 DOI: 10.1002/bjs.11555] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/14/2019] [Accepted: 01/23/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Whether patients who undergo resection of ampullary adenocarcinoma have a survival benefit from adjuvant chemotherapy is currently unknown. The aim of this study was to compare survival between patients with and without adjuvant chemotherapy after resection of ampullary adenocarcinoma in a propensity score-matched analysis. METHODS An international multicentre cohort study was conducted, including patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma between 2006 and 2017, in 13 centres in six countries. Propensity scores were used to match patients who received adjuvant chemotherapy with those who did not, in the entire cohort and in two subgroups (pancreatobiliary/mixed and intestinal subtypes). Survival was assessed using the Kaplan-Meier method and Cox regression analyses. RESULTS Overall, 1163 patients underwent pancreatoduodenectomy for ampullary adenocarcinoma. After excluding 187 patients, median survival in the remaining 976 patients was 67 (95 per cent c.i. 56 to 78) months. A total of 520 patients (53·3 per cent) received adjuvant chemotherapy. In a propensity score-matched cohort (194 patients in each group), survival was better among patients who received adjuvant chemotherapy than in those who did not (median survival not reached versus 60 months respectively; P = 0·051). A survival benefit was seen in patients with the pancreatobiliary/mixed subtype; median survival was not reached in patients receiving adjuvant chemotherapy and 32 months in the group without chemotherapy (P = 0·020). Patients with the intestinal subtype did not show any survival benefit from adjuvant chemotherapy. CONCLUSION Patients with resected ampullary adenocarcinoma may benefit from gemcitabine-based adjuvant chemotherapy, but this effect may be reserved for those with the pancreatobiliary and/or mixed subtype.
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Affiliation(s)
- A L Moekotte
- Departments of Surgery, Southampton, UK.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - G Malleo
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - S van Roessel
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Bonds
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - A Halimi
- Pancreatic Surgery Unit, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - L Zarantonello
- Pancreatic Surgery Unit, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - N Napoli
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - S B Dreyer
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - U F Wellner
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - L Bolm
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - V K Mavroeidis
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Robinson
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - K Khalil
- Faculty of Medicine, University of Birmingham, Birmingham, UK
| | - D Ferraro
- Department of Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - M C Mortimer
- Department of Surgery, Morriston Hospital, Swansea, UK
| | - S Harris
- Medical Statistics, Faculty of Medicine, University of Southampton, Southampton, UK
| | - B Al-Sarireh
- Department of Surgery, Morriston Hospital, Swansea, UK
| | - G K Fusai
- Department of Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - K J Roberts
- Faculty of Medicine, University of Birmingham, Birmingham, UK
| | - M Fontana
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - S A White
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Z Soonawalla
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N B Jamieson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - U Boggi
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - A Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - A Shablak
- Departments of Medical Oncology, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - R Salvia
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - C Bassi
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Abu Hilal
- Departments of Surgery, Southampton, UK.,Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
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Bolm L, Ohrner K, Nappo G, Rückert F, Zimmermann C, Rau BM, Petrova E, Honselmann KC, Lapshyn H, Bausch D, Weitz J, Sandini M, Keck T, Zerbi A, Distler M, Wellner UF. Adjuvant therapy is associated with improved overall survival in patients with pancreatobiliary or mixed subtype ampullary cancer after pancreatoduodenectomy - A multicenter cohort study. Pancreatology 2020; 20:433-441. [PMID: 31987649 DOI: 10.1016/j.pan.2020.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 08/05/2019] [Revised: 12/11/2019] [Accepted: 01/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE The benefit of adjuvant therapy in ampullary cancer (AMPAC) patients following pancreatoduodenectomy (PD) is debated. The aim of this study was to determine the role of adjuvant therapy after pancreatoduodenectomy (PD) in histological subtypes of AMPAC. METHODS Patients undergoing PD for AMPAC at 5 high-volume European surgical centers from 1996 to 2017 were identified. Patient baseline characteristics, surgical and histopathological parameters, and long-term overall survival (OS) after resection were evaluated. RESULTS 214 patients undergoing PD for AMPAC were included. ASA score (ASA1-2 149 vs. ASA 3-4 82 months median OS, p = 0.002), preoperative serum CEA (CEA <0.5 ng/ml 128 vs. CEA >0.5 ng/ml 62 months, p = 0.013), preoperative serum CA19-9 (CA19-9 < 40 IU/ml 147 vs. CA19-9 > 40IU/ml 111 months, p = 0.042), T stage (T1-2 163 vs. T3-4 98 months, p < 0.001), N stage (N0 159 vs. N+ 110 months, p < 0.001), grading (G1-2 145 vs. G3-4 113 months, p = 0.026), R status (R0 136 vs. R+ 38 months, p = 0.031), and histological subtype (intestinal subtype 156 vs. PB/M subtype 118 months, p = 0.003) qualified as prognostic parameters. In multivariable analysis, ASA score (HR 1.784, 95%CI 0.997-3.193, p = 0.050) and N stage (HR 1.831, 95%CI 0.904-3.707, p = 0.033) remained independent prognostic factors. In PB/M subtype AMPAC, patients undergoing adjuvant therapy showed an improved median overall survival (adjuvant therapy 85 months vs. no adjuvant therapy 65 months, p = 0.005), and adjuvant therapy remained an independent prognostic parameter in multivariate analysis (HR 0.351, 95%CI 0.151-0.851, p = 0.015). There was no significant benefit of adjuvant therapy in intestinal subtype AMPAC patients. CONCLUSION Adjuvant treatment seems indicated in pancreatobiliary or mixed type AMPAC.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Kristina Ohrner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Gennaro Nappo
- Department of Surgery, Unit of Pancreatic Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano Milan, Italy
| | - Felix Rückert
- Department of Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Carolin Zimmermann
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Bettina M Rau
- Department of Surgery, University Hospital Rostock, Schilling Allee 35, 18057 Rostock and Hospital Neumarkt in der Oberpfalz, Nürnberger Straße 12, 92318, Neumarkt in der Oberpfalz, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Jürgen Weitz
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Marta Sandini
- School of Medicine and Surgery, Milano Bicocca University, Department of Surgery, San Gerardo Hospital, Piazza Dell'Ateneo Nuovo, 1, 20126, Milan, Italy
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Alessandro Zerbi
- Department of Surgery, Unit of Pancreatic Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano Milan, Italy
| | - Marius Distler
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
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Müller-Debus CF, Thomaschewski M, Zimmermann M, Wellner UF, Bausch D, Keck T. Robot-Assisted Pancreatic Surgery: A Structured Approach to Standardization of a Program and of the Operation. Visc Med 2020; 36:104-112. [PMID: 32355667 DOI: 10.1159/000506909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/28/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction The use of robots in minimal invasive surgery has become increasingly common in recent years. Robot-assisted pancreatoduodenectomy preponderates against a laparoscopic procedure especially due to the greater flexibility of instruments and therefore a better handling and a better angulation. Furthermore, there are benefits of enlarged 3-D visibility, software-based tremor control, and reduced physical exertion of the surgeon. Methods and Results This review delivers a point-by-point approach to the setup of a robot-assisted pancreatic program and a detailed approach to robot-assisted pancreatoduodenectomy. Results In our standardized standard operating procedure approach we use 5 trocars, i.e., 4 robotic trocars and 1 assist trocar. We prefer the position of the robot ports in a straight horizontal line with a distance of 20 cm from the operational field. The operation is dissected into 11 standardized procedural steps as follows: (1) access to the pancreas and visualization, (2) extended Kocher manoeuvre, (3) lower rim and mesentericoportal axis, (4) upper rim and hepatoduodenal ligament, (5) dissection of the pancreatic neck, (6) mesenteric root and pars IV duodeni, (7) mesopancreas, (8) pancreatic anastomosis reconstruction, (9) bilioenteric anastomosis, (10) dudenojejunal anastomosis, and (11) drainage and closure. The setup of the pancreas program and the structured approach to complex pancreatic resections are elucidated. Summary This review describes the approach to robot-assisted pancreatic surgery in a high-volume pancreas center on a structural and procedural level to support the establishment of such programs at other locations.
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Affiliation(s)
| | - Michael Thomaschewski
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Markus Zimmermann
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital of Schleswig Holstein (UKSH), Lübeck, Germany
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Bolm L, Petrova E, Weitz J, Rückert F, Wittel UA, Makowiec F, Lapshyn H, Bronsert P, Rau BM, Khatkov IE, Bausch D, Keck T, Wellner UF, Distler M. Prognostic relevance of preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 in a multicenter subset analysis of 179 patients with distal cholangiocarcinoma. HPB (Oxford) 2019; 21:1513-1519. [PMID: 30956162 DOI: 10.1016/j.hpb.2019.03.363] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Distal cholangiocarcinoma (DCC) is a rare malignancy and validated prognostic markers remain scarce. We aimed to evaluate the role of serum CA19-9 as a potential biomarker in DCC. METHODS Patients operated for DCC at 6 high-volume surgical centers from 1994 to 2015 were identified from prospectively maintained databases. Patient baseline characteristics, surgical and histopathological parameters, as well as overall survival after resection were assessed for correlation with preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 (CA19-9). Preoperative CA19-9 to bilirubin ratio (CA19-9/BR) was classified as elevated (≥ 25 U/ml/mg/dl) according to the upper serum normal values of CA19-9 (37 U/ml) and bilirubin (1.5 mg/dl) giving a cut-off at ≥ 25 U/ml/mg/dl. RESULTS In total 179 patients underwent resection for DCC during the study period. High preoperative CA19-9/BR was associated with advanced age and regional lymph node metastases. Median overall survival after resection was 27 months. Elevated preoperative serum CA19-9/bilirubin ratio (HR 1.6, p = 0.025), T3/4 stage (HR 1.8, p = 0.022), distant metastasis (HR 2.5, p = 0.007), tumor grade (HR 1.9, p = 0.001) and R status (HR 1.7, p = 0.023) were identified as independent negative prognostic factors following multivariable analysis. CONCLUSION Elevated preoperative bilirubin-adjusted serum CA19-9 correlates with regional lymph node metastases and constitutes a negative independent prognostic factor after resection of DCC.
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Affiliation(s)
- Louisa Bolm
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ekaterina Petrova
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jürgen Weitz
- Dept. for Visceral, Thoracic and Vascular Surgery at the University Hospital, Technical University Dresden, Dresden, Germany
| | - Felix Rückert
- Dept. of Surgery, University Medical Center Mannheim, Mannheim, Germany
| | - Uwe A Wittel
- Dept. of General and Visceral Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - Frank Makowiec
- Dept. of General and Visceral Surgery, University Medical Center Freiburg, Freiburg, Germany
| | - Hryhoriy Lapshyn
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Germany; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - Bettina M Rau
- Dept. of General, Visceral, and Thoracic Surgery, Municipal Hospital of Neumarkt, Neumarkt i.d.OPf., Germany; Dept. of General, Thoracic, Vascular, and Transplantation Surgery, University of Rostock, Rostock, Germany
| | | | - Dirk Bausch
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich F Wellner
- Clinic of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marius Distler
- Dept. for Visceral, Thoracic and Vascular Surgery at the University Hospital, Technical University Dresden, Dresden, Germany.
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Palade E, Günter J, Gomez JMM, Wellner UF, Schmid S, Wiesemann S, Passlick B. Morbidity, mortality and long-term outcome of lung cancer resections performed in palliative intent. J Thorac Dis 2019; 11:4308-4318. [PMID: 31737316 DOI: 10.21037/jtd.2019.09.61] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Surgery is seldom used for palliation in advanced lung cancer and the published data on this issue are very limited. We aimed to assess the results of palliative lung resections and identify criteria to guide surgical therapy in this situation. Methods This is a retrospective single-institution analysis of patients with palliative intended lung cancer resection. Survival analysis was performed by Kaplan-Meier method, log-rank test and Cox proportional hazards regression at a statistical significance level of P=0.05. Results Forty-eight patients received palliative intended lung resections (31 lobectomies, 4 bilobectomies, 13 pneumonectomies) with acceptable rates of severe complications (Clavien-Dindo >IIIa 29%) and 30-day mortality (4%). The most frequent indications were infection and hemoptysis. The median survival for the entire group was 12 months (95% CI: 6.9-17.1 months). Due to unexpectedly favorable histopathologic tumor stage, a switch to curative treatment in 17 completely resected patients resulted in a 2-year survival rate of 46%. In a subgroup of 20 patients with favorable prognostic factors as identified by uni- and multivariable analysis, a median survival of 26 months was observed. Conclusions In well selected patients with lung cancer, resection in palliative intent can offer symptom relief and even a survival benefit with acceptable morbidity and low mortality. Prognostic factors were identified and can be used to guide operative treatment. Due to the low specificity of CT and FDG-PET/CT in the presence of inflammation or centrally located lung tumors, a large proportion of patients with lung resection in palliative intent experience a down-staging and frequently also a switch from palliative to curative treatment with additional survival benefit. Factors like expected complete resection, a squamous cell type and the ability to receive adjuvant therapy are useful to support the decision to perform palliative tumor resection.
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Affiliation(s)
- Emanuel Palade
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany.,Department of Surgery, Medical University of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jutta Günter
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany
| | - Juan M M Gomez
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany
| | - Ulrich F Wellner
- Department of Surgery, Medical University of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Severin Schmid
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Sebastian Wiesemann
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Bernward Passlick
- Department of Thoracic Surgery, Medical Center - University of Freiburg, Freiburg im Breisgau, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Bolm L, Petrova E, Woehrmann L, Werner J, Uhl W, Nuessler N, Ghadimi M, Bausch D, Lapshyn H, Gaedcke J, Belyaev O, D'Haese JG, Klier T, Keck T, Wellner UF. The impact of preoperative biliary stenting in pancreatic cancer: A case-matched study from the German nationwide pancreatic surgery registry (DGAV StuDoQ|Pancreas). Pancreatology 2019; 19:985-993. [PMID: 31563328 DOI: 10.1016/j.pan.2019.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE The impact of preoperative biliary stenting (PBS) before pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) is controversial. METHODS Patients undergoing PD with or without PBS for PDAC were identified from the German DGAV-StuDoQlPancreas registry. The impact of PBS on perioperative complications was analyzed. RESULTS 1133 patients undergoing PD for PDAC were identified from the registry. After matching, 480 PBS patients vs. 480 patients without PBS were analyzed. Postoperative complications Clavien-Dindo classification (CDC) grade IIIa-IVb were higher in PBS patients (PBS 27% vs. no PBS 22%, p = 0.027). 320 PBS patients (66%) had no history of jaundice. In these patients, PBS was associated with higher morbidity. In contrast, PBS was not associated with higher complication rates in patients with history of jaundice. Serum bilirubin levels of 15 mg/dl and higher lead to more CDC IIIa-IVb (24% vs. 28%, p = 0.053) and higher mortality (3% vs. 7%, p < 0.001). PBS in patients with serum bilirubin levels of >15 mg/dl increased CDC IIa-IVb complications (21% vs. 50%, p = 0.001), mortality was equivalent. CONCLUSION Most PBS procedures were performed in patients with no history of jaundice and increased morbidity. Serum bilirubin levels >15 mg/dl lead to higher morbidity and mortality. PBS correlated with higher complication rates in these patients.
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Affiliation(s)
- Louisa Bolm
- Department of Surgery, University Medical Center Luebeck, Germany
| | | | - Lukas Woehrmann
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jens Werner
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Waldemar Uhl
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Natascha Nuessler
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Michael Ghadimi
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Dirk Bausch
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Luebeck, Germany
| | - Jochen Gaedcke
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Germany
| | - Orlin Belyaev
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Jan G D'Haese
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians University Munich, Germany
| | - Thomas Klier
- DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany; Department of Surgery, Municipal Hospital Munich, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Luebeck, Germany; DGAV STuDoQ
- Pancreas Registry of the German Association for General and Visceral Surgery, Germany
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Ligorio M, Sil S, Malagon-Lopez J, Nieman LT, Misale S, Di Pilato M, Ebright RY, Karabacak MN, Kulkarni AS, Liu A, Vincent Jordan N, Franses JW, Philipp J, Kreuzer J, Desai N, Arora KS, Rajurkar M, Horwitz E, Neyaz A, Tai E, Magnus NKC, Vo KD, Yashaswini CN, Marangoni F, Boukhali M, Fatherree JP, Damon LJ, Xega K, Desai R, Choz M, Bersani F, Langenbucher A, Thapar V, Morris R, Wellner UF, Schilling O, Lawrence MS, Liss AS, Rivera MN, Deshpande V, Benes CH, Maheswaran S, Haber DA, Fernandez-Del-Castillo C, Ferrone CR, Haas W, Aryee MJ, Ting DT. Stromal Microenvironment Shapes the Intratumoral Architecture of Pancreatic Cancer. Cell 2019; 178:160-175.e27. [PMID: 31155233 DOI: 10.1016/j.cell.2019.05.012] [Citation(s) in RCA: 330] [Impact Index Per Article: 66.0] [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: 08/28/2018] [Revised: 01/29/2019] [Accepted: 05/03/2019] [Indexed: 01/05/2023]
Abstract
Single-cell technologies have described heterogeneity across tissues, but the spatial distribution and forces that drive single-cell phenotypes have not been well defined. Combining single-cell RNA and protein analytics in studying the role of stromal cancer-associated fibroblasts (CAFs) in modulating heterogeneity in pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) model systems, we have identified significant single-cell population shifts toward invasive epithelial-to-mesenchymal transition (EMT) and proliferative (PRO) phenotypes linked with mitogen-activated protein kinase (MAPK) and signal transducer and activator of transcription 3 (STAT3) signaling. Using high-content digital imaging of RNA in situ hybridization in 195 PDAC tumors, we quantified these EMT and PRO subpopulations in 319,626 individual cancer cells that can be classified within the context of distinct tumor gland "units." Tumor gland typing provided an additional layer of intratumoral heterogeneity that was associated with differences in stromal abundance and clinical outcomes. This demonstrates the impact of the stroma in shaping tumor architecture by altering inherent patterns of tumor glands in human PDAC.
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Affiliation(s)
- Matteo Ligorio
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Srinjoy Sil
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jose Malagon-Lopez
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Linda T Nieman
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sandra Misale
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Mauro Di Pilato
- Division of Rheumatology, Allergy, and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Richard Y Ebright
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Murat N Karabacak
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Center for Engineering in Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02114, USA
| | | | - Ann Liu
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Joseph W Franses
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Julia Philipp
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Johannes Kreuzer
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Niyati Desai
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kshitij S Arora
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Mihir Rajurkar
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Elad Horwitz
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Azfar Neyaz
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Tai
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Kevin D Vo
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Francesco Marangoni
- Division of Rheumatology, Allergy, and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Myriam Boukhali
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Leah J Damon
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kristina Xega
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Rushil Desai
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Melissa Choz
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Francesca Bersani
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Adam Langenbucher
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Vishal Thapar
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Robert Morris
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Oliver Schilling
- Institute of Pathology, University Medical Center Freiburg, Germany
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Miguel N Rivera
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Vikram Deshpande
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Cyril H Benes
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Shyamala Maheswaran
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Daniel A Haber
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Rheumatology, Allergy, and Immunology, Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, MA 02114, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA
| | - Carlos Fernandez-Del-Castillo
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Wilhelm Haas
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martin J Aryee
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
| | - David T Ting
- Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
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Wicha SG, Mundkowski RG, Klock A, Hopt UT, Drewelow B, Kloft C, Wellner UF, Keck T, Wittel UA. Is Moxifloxacin a Treatment Option for Pancreatic Infections? A Pharmacometric Analysis of Serum and Pancreatic Juice. J Clin Pharmacol 2019; 59:1405-1414. [PMID: 31111505 DOI: 10.1002/jcph.1445] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/30/2019] [Indexed: 01/09/2023]
Abstract
Postoperative local infection is a major complication after pancreatic surgery. The aim of this prospective clinical trial was to assess the potential of moxifloxacin (MXF) to treat pancreatic infections from a pharmacokinetic (PK)/pharmacodynamic (PD) perspective. The PK of MXF in serum and pancreatic juice, via an inserted tube in the pancreatic duct, was determined in 19 patients up to day 7 after pancreatoduodenectomy. PK data in both specimens was analyzed with NONMEM 7.3. Intraoperative swipes were performed for microbiological examination. PK/PD target attainment was assessed in both matrices using unbound area under the plasma concentration-time curve/minimum inhibitory concentration (MIC) targets of ≥30 and ≥100, for gram-positive and gram-negative pathogens, respectively. A 2-compartment population PK model in which the measurements in pancreatic juice were assigned to a scaled peripheral compartment best described the PK in both specimens simultaneously. Median (10th-90th percentile) area under the plasma concentration-time curve values after the third dose were 28.9 mg · h/L (18.6-42.0) in serum and 55.8 mg · h/L (23.7-81.4) in pancreatic juice. Target attainment rate for the intraoperatively isolated bacterial strains was ≥0.88 after the third MXF dose. For gram-negatives, high probability of target attainment ≥0.84 was observed in serum for MIC ≤ 0.125 mg/L and in pancreatic juice for MIC ≤ 0.25 mg/L. For gram-positives, the probability of target attainment was 0.84-1 in serum for MIC ≤ 0.5 mg/L and in pancreatic juice for MIC ≤ 1 mg/L. In conclusion, penetration of MXF into pancreatic juice was substantial. The PK/PD analysis indicated that treatment of pancreatic infections by isolates with MIC ≤ 0.25 mg/L (gram-negative) and ≤1 mg/L (gram-positive) should be evaluated in further studies.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Ralf G Mundkowski
- Institute of Clinical Pharmacology, University Medical Center, Rostock, Germany
| | - Andrea Klock
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Bernd Drewelow
- Institute of Clinical Pharmacology, University Medical Center, Rostock, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Ulrich F Wellner
- Clinic of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | - Tobias Keck
- Clinic of Surgery, University Hospital Schleswig Holstein, Campus Lübeck, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
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36
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Mackay TM, Wellner UF, van Rijssen LB, Stoop TF, Busch OR, Groot Koerkamp B, Bausch D, Petrova E, Besselink MG, Keck T, van Santvoort HC, Molenaar IQ, Kok N, Festen S, van Eijck CHJ, Bonsing BA, Erdmann J, de Hingh I, Buhr HJ, Klinger C. Variation in pancreatoduodenectomy as delivered in two national audits. Br J Surg 2019; 106:747-755. [DOI: 10.1002/bjs.11085] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractBackgroundNationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.MethodsAnonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.ResultsOverall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.ConclusionThis comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.
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Affiliation(s)
- T M Mackay
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - U F Wellner
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - L B van Rijssen
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T F Stoop
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - D Bausch
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - E Petrova
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T Keck
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - H C van Santvoort
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - I Q Molenaar
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - N Kok
- Antoni van Leeuwenhoek Hospital, Amsterdam
| | | | | | | | - J Erdmann
- Leiden University Medical Centre, Leiden
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37
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Oria VO, Bronsert P, Thomsen AR, Föll MC, Zamboglou C, Hannibal L, Behringer S, Biniossek ML, Schreiber C, Grosu AL, Bolm L, Rades D, Keck T, Werner M, Wellner UF, Schilling O. Proteome Profiling of Primary Pancreatic Ductal Adenocarcinomas Undergoing Additive Chemoradiation Link ALDH1A1 to Early Local Recurrence and Chemoradiation Resistance. Transl Oncol 2018; 11:1307-1322. [PMID: 30172883 PMCID: PMC6121830 DOI: 10.1016/j.tranon.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 04/23/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis with frequent post-surgical local recurrence. The combination of adjuvant chemotherapy with radiotherapy is under consideration to achieve a prolonged progression-free survival (PFS). To date, few studies have determined the proteome profiles associated with response to adjuvant chemoradiation. We herein analyzed the proteomes of primary PDAC tumors subjected to additive chemoradiation after surgical resection and achieving short PFS (median 6 months) versus prolonged PFS (median 28 months). Proteomic analysis revealed the overexpression of Aldehyde Dehydrogenase 1 Family Member A1 (ALDH1A1) and Monoamine Oxidase A (MAOA) in the short PFS cohort, which were corroborated by immunohistochemistry. In vitro, specific inhibition of ALDH1A1 by A37 in combination with gemcitabine, radiation, and chemoradiation lowered cell viability and augmented cell death in MiaPaCa-2 and Panc 05.04 cells. ALDH1A1 silencing in both cell lines dampened cell proliferation, cell metabolism, and colony formation. In MiaPaCa-2 cells, ALDH1A1 silencing sensitized cells towards treatment with gemcitabine, radiation or chemoradiation. In Panc 05.04, increased cell death was observed upon gemcitabine treatment only. These findings are in line with previous studies that have suggested a role of ALDH1A1 chemoradiation resistance, e.g., in esophageal cancer. In summary, we present one of the first proteome studies to investigate the responsiveness of PDAC to chemoradiation and provide further evidence for a role of ALDH1A1 in therapy resistance.
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Affiliation(s)
- V O Oria
- Institute of Molecular Medicine and Cell Research, Freiburg, Germany; Faculty of Biology, University of Freiburg, Freiburg, Germany; Spemann Graduate School of Biology and Medicine, Freiburg, Germany
| | - P Bronsert
- Institute of Surgical Pathology, University Medical Center, Freiburg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; Tumorbank Comprehensive Cancer Center Freiburg, Medical Center- University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - A R Thomsen
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; Faculty of Medicine, University of Freiburg, Germany; Department of Radiation Oncology, Medical Center - University of Freiburg, Germany
| | - M C Föll
- Institute of Molecular Medicine and Cell Research, Freiburg, Germany; Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - C Zamboglou
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; Faculty of Medicine, University of Freiburg, Germany; Department of Radiation Oncology, Medical Center - University of Freiburg, Germany
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department for Pediatrics, Medical Center, University of Freiburg, Freiburg, Germany
| | - S Behringer
- Laboratory of Clinical Biochemistry and Metabolism, Department for Pediatrics, Medical Center, University of Freiburg, Freiburg, Germany
| | - M L Biniossek
- Institute of Molecular Medicine and Cell Research, Freiburg, Germany
| | - C Schreiber
- Institute of Pathology, UKSH Campus Lübeck, Lübeck, Germany
| | - A L Grosu
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; Faculty of Medicine, University of Freiburg, Germany; Department of Radiation Oncology, Medical Center - University of Freiburg, Germany
| | - L Bolm
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - D Rades
- Department of Radiation Oncology, UKSH Campus Lübeck, Lübeck, Germany
| | - T Keck
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - M Werner
- Institute of Surgical Pathology, University Medical Center, Freiburg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; Tumorbank Comprehensive Cancer Center Freiburg, Medical Center- University of Freiburg, Germany; Faculty of Medicine, University of Freiburg, Germany
| | - U F Wellner
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - O Schilling
- Institute of Molecular Medicine and Cell Research, Freiburg, Germany; Institute of Surgical Pathology, University Medical Center, Freiburg, Germany; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg, Germany; BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany.
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38
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Seidl M, Bader M, Vaihinger A, Wellner UF, Todorova R, Herde B, Schrenk K, Maurer J, Schilling O, Erbes T, Fisch P, Pfeiffer J, Hoffmann L, Franke K, Werner M, Bronsert P. Morphology of Immunomodulation in Breast Cancer Tumor Draining Lymph Nodes Depends on Stage and Intrinsic Subtype. Sci Rep 2018; 8:5321. [PMID: 29593307 PMCID: PMC5871837 DOI: 10.1038/s41598-018-23629-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Cancer research of immune-modulating mechanisms mainly addresses the role of tumor-infiltrating immune cells. Mechanisms modulating the adaptive immune system at the primary activation site - the draining lymph node (LN) - are less investigated. Here we present tumor-caused histomorphological changes in tumor draining LNs of breast cancer patients, dependent on the localization (sentinel LN vs. non-sentinel LN), the tumor size, the intrinsic subtype and nodal metastatic status. The quantitative morphological study was conducted in breast cancer patients with at least one sentinel LN and no neoadjuvant therapy. All LNs were annotated considering to their topographical location, stained for IgD/H&E, digitized and quantitatively analyzed. In 206 patients, 394 sentinels and 940 non-sentinel LNs were categorized, comprising 40758 follicles and 7074 germinal centers. Subtype specific immunomorphological patterns were detectable: Follicular density was higher in LNs of Her2 enriched hormone receptor positive and triple-negative breast cancers whereas hormone receptor positive breast cancers showed more macrophage infiltrations in the LN cortex. Follicles are rounder in metastatic LNs and non-sentinel LNs. The identified immunomorphological changes reflect different underlying immunomodulations taking place in the tumor-draining LNs and should therefore be considered as possible prognostic and predictive markers for LN metastasis and therapy associated immunomodulation.
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Affiliation(s)
- Maximilian Seidl
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany.
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Freiburg, Germany.
- Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Moritz Bader
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Division of Cranio-maxillo-facial Surgery, Department of Reconstructive Surgery, University of Basel, Basel, Switzerland
| | - Astrid Vaihinger
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich F Wellner
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lubeck, Germany
| | - Rumyana Todorova
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bettina Herde
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaudia Schrenk
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Maurer
- Department of Gynecology, RWTH Aachen University Hospital, Aachen, Germany
| | - Oliver Schilling
- German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute for Molecular Medicine and Cell Research, University of Freiburg, Freiburg, Germany
- BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany
| | - Thalia Erbes
- Department of Obstetrics and Gynecology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul Fisch
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jens Pfeiffer
- Department of Oto-Rhino-Laryngology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Kai Franke
- Department of Trauma, Hand and Reconstructive Surgery Giessen, University Hospital Giessen-Marburg, Giessen, Germany
| | - Martin Werner
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Freiburg, Germany
- German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Freiburg, Germany
- German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Muhl Chair E, Fellermann K, Angele MK, Hartl WH, Hummel R, Hunold P, Kähler G, Wellner UF. Management of Complications after Major Gastrointestinal Surgery. Visc Med 2017; 33:212-215. [PMID: 28785570 DOI: 10.1159/000475540] [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: 11/19/2022] Open
Affiliation(s)
- Elke Muhl Chair
- Operative Intensivmedizin IOI-II/37a, Department of Anesthesiology and Intensive Care, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | | | - Martin K Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Wolfgang H Hartl
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Richard Hummel
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Hunold
- Clinic for Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Unit, Medical Faculty Mannheim, Heidelberg University, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Abstract
BACKGROUND Leakage of a hepaticojejunal anastomosis is a rare event with potential major morbidity. Surgeons must be aware of the technical armamentarium and pitfalls in revisional surgery for hepaticojejunal anastomosis leakage. METHODS Review of the available literature and discussion of technical details based on experience and expert opinion. RESULTS Early bile leaks as well as failed interventional therapy are indications for reoperation. Almost all reports only mention rates of leakage as a secondary endpoint but do not report details of treatment and outcome. Few authors have compared outcome after reoperation versus interventional approaches in observational studies, with the latter resulting in lower morbidity. The complex and individual situation of the complication makes evidence-based argumentation difficult; this is why personal expert opinions have to be taken into account in this review. The technical aspects and pitfalls of revisional surgery are outlined but represent anecdotal evidence as comparative studies are lacking. CONCLUSION Bile leak after bilioenteric anastomosis is a rare condition that requires differentiated workup and therapy. Early leaks usually result from technical problems and are amenable to repair by reoperation. Reoperation technique can only be discussed on a low evidence level.
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Affiliation(s)
- Ulrich F Wellner
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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Wellner UF, Klinger C, Lehmann K, Buhr H, Neugebauer E, Keck T. The pancreatic surgery registry (StuDoQ|Pancreas) of the German Society for General and Visceral Surgery (DGAV) - presentation and systematic quality evaluation. Trials 2017; 18:163. [PMID: 28381291 PMCID: PMC5382382 DOI: 10.1186/s13063-017-1911-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/21/2017] [Indexed: 12/19/2022] Open
Abstract
Background Pancreatic resections are among the most complex procedures in visceral surgery. While mortality has decreased substantially over the past decades, morbidity remains high. The volume-outcome correlation in pancreatic surgery is among the strongest in the field of surgery. The German Society for General and Visceral Surgery (DGAV) established a national registry for quality control, risk assessment and outcomes research in pancreatic surgery in Germany (DGAV SuDoQ|Pancreas). Methods Here, we present the aims and scope of the DGAV StuDoQ|Pancreas Registry. A systematic assessment of registry quality is performed based on the recommendations of the German network for outcomes research (DNVF). Results The registry quality was assessed by consensus criteria of the DNVF in regard to the domains Systematics and Appropriateness, Standardization, Validity of the sampling procedure, Validity of data collection, Validity of statistical analysis and reports, and General demands for registry quality. In summary, DGAV StuDoQ|Pancreas meets most of the criteria of a high-quality clinical registry. Conclusion The DGAV StuDoQ|Pancreas provides a valuable platform for quality assessment, outcomes research as well as randomized registry trials in pancreatic surgery. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1911-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulrich F Wellner
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117, Berlin, Germany. .,German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany. .,Klinik für Chirurgie, UKSH Campus Lübeck, Lübeck, Germany.
| | - Carsten Klinger
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117, Berlin, Germany.,German Society for General and Visceral Surgery (DGAV), StuDoQ Registry, Berlin, Germany
| | - Kai Lehmann
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117, Berlin, Germany.,German Society for General and Visceral Surgery (DGAV), StuDoQ Registry, Berlin, Germany
| | - Heinz Buhr
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117, Berlin, Germany
| | - Edmund Neugebauer
- German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany.,Private Universität Witten/Herdecke, Witten, Germany
| | - Tobias Keck
- German Society for General and Visceral Surgery (DGAV), Haus der Bundespressekonferenz, Schiffbauerdamm 40, Mieteinheit 3.200, 10117, Berlin, Germany.,German Society for General and Visceral Surgery (DGAV), Integrated National Study Group Pancreas, Berlin, Germany.,Klinik für Chirurgie, UKSH Campus Lübeck, Lübeck, Germany
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Fuellgraf H, Schilling O, Lai ZW, Kulemann B, Timme S, Makowiec F, Shahinian JH, Hoeppner J, Werner M, Hopt UT, Wellner UF, Bronsert P. The Prognostic Impact of the Carcinoembryonic Antigen in Ampullary Cancer - A Retrospective Single Center Study. J Cancer 2017; 8:657-664. [PMID: 28367245 PMCID: PMC5370509 DOI: 10.7150/jca.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/04/2016] [Indexed: 11/23/2022] Open
Abstract
Background: Carcinoembryonic antigen cell adhesion molecule (CEA) is a commonly immunohistochemically used antibody in pathological routine diagnostics with an overexpression in different cancers. We aimed to examine the immunohistochemically detectable CEA level in ampullary cancer and to correlate it with clinico-pathological data. Methods: Shot-gun proteomics revealed CEA in undifferentiated ampullary cancer cell lines. Next, tumor tissue of 40 ampullary cancers of a retrospective single center cohort of 40 patients was stained immunohistochemically for CEA; CEA expression was determined and correlated with clinico-pathological data. Results: Thirty-six patient specimens were included in statistical analysis. CEA expression and lymph node ratio (LNR) were the only independent predictors of overall survival in multivariate analysis. Conclusion: To our knowledge, cell line and patient cohorts are the largest and characterized cohorts examined for CEA so far. Hereby, CEA expression in ampullary cancer cells permits an estimation of outcome and suggests an opportunity for individualized CEA-directed therapy. Further trials with larger cohorts are needed to verify our results and to integrate CEA immunohistochemistry into clinical routine.
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Affiliation(s)
- Hannah Fuellgraf
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Oliver Schilling
- German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany;; Institute of Molecular Medicine and Cell Research, University of Freiburg, Freiburg, Germany;; BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany
| | - Zon Weng Lai
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Freiburg, Germany
| | - Birte Kulemann
- Clinic for General and Visceral Surgery, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Sylvia Timme
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Frank Makowiec
- Clinic for General and Visceral Surgery, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany
| | - Jasmin H Shahinian
- Division of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Jens Hoeppner
- Clinic for General and Visceral Surgery, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany
| | - Martin Werner
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ulrich T Hopt
- Clinic for General and Visceral Surgery, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Ulrich F Wellner
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Germany
| | - Peter Bronsert
- Institute for Surgical Pathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Medical Center - University of Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany
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43
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Abstract
BACKGROUND Political and public interest in quality management in surgery is increasing. The German Society for General and Visceral Surgery (DGAV) established the DGAV StuDoQ, a nationwide registry for quality assessment in visceral surgery, with the organ-specific module DGAV StuDoQ|Pancreas. The first prerequisite for the measurement of quality is the definition of quality indicators. These can be related to risk factors which are also documented in the registry. METHODS Quality indicators for pancreatic surgery were developed by review of the current literature and expert consensus. After ranking the potential quality indicators, three essential indicators for outcome quality were selected for further review of the literature. Current figures were extracted from the DGAV StuDoQ|Pancreas registry and the correlation with selected risk factors was tested. RESULTS Three essential outcome quality indicators were selected: in-hospital mortality, TV30, and severe complications according to the Clavien-Dindo Classification. Preliminary data confirms the validity of risk factors included in the DGAV StuDoQ|Pancreas registry. CONCLUSION Essential quality indicators were defined for pancreatic surgery. The DGAV StuDoQ|Pancreas constitutes a valid platform for risk-adjusted quality assessment in Germany.
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Affiliation(s)
- Ulrich F Wellner
- Clinic for Surgery, German Society for General and Visceral Surgery (DGAV), Berlin, Germany.,Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Lübeck, Germany
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Lapshyn H, Bolm L, Kohler I, Werner M, Billmann FG, Bausch D, Hopt UT, Makowiec F, Wittel UA, Keck T, Bronsert P, Wellner UF. Histopathological tumor invasion of the mesenterico-portal vein is characterized by aggressive biology and stromal fibroblast activation. HPB (Oxford) 2017; 19:67-74. [PMID: 27825542 DOI: 10.1016/j.hpb.2016.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 06/03/2016] [Revised: 09/08/2016] [Accepted: 10/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mesenterico-portal vein resection (PVR) during pancreatoduodenectomy for pancreatic head cancer was established in the 1990s and can be considered a routine procedure in specialized centers today. True histopathologic portal vein invasion is predictive of poor prognosis. The aim of this study was to examine the relationship between mesenterico-portal venous tumor infiltration (PVI) and features of aggressive tumor biology. METHODS Patients receiving PVR for pancreatic ductal adenocarcinoma of the pancreatic head were identified from a prospectively maintained database. Immunohistochemical staining of tumor tissue was performed for the markers of epithelial-mesenchymal transition (EMT) E-Cadherin, Vimentin and beta-Catenin. Morphology of cancer-associated fibroblasts (CAFs) was assessed as inactive or activated. Statistical calculations were performed with MedCalc software. RESULTS In total, 41 patients could be included. Median overall survival was 25 months. PVI was found in 17 patients (41%) and was significantly associated with loss of membranous E-Cadherin in tumor buds (p = 0.020), increased Vimentin expression (p = 0.03), activated CAF morphology (p = 0.046) and margin positive resection (p = 0.005). CONCLUSION Our findings suggest that PVI is associated with aggressive tumor biology and disseminated growth less amenable to margin-negative resection.
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Affiliation(s)
- Hryhoriy Lapshyn
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany; Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
| | - Louisa Bolm
- Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
| | - Ilona Kohler
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany
| | - Martin Werner
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany; Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, Germany; German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Franck G Billmann
- Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
| | - Dirk Bausch
- Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
| | - Ulrich T Hopt
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany; Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, Germany.
| | - Frank Makowiec
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany; Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, Germany
| | - Uwe A Wittel
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany
| | - Tobias Keck
- Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
| | - Peter Bronsert
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany; Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, Germany; German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ulrich F Wellner
- Clinic for Surgery, University Clinic Schleswig-Holstein, Campus Lübeck, Germany
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Wellner UF, Bolm L, Keck T. Reply to: "Half the truth is Often a Great Lie: Over a Hundred Years of Controversy on Pancreatic Fistula Between Pancreaticogastrostomy and Pancreaticojejunostomy After Pancreaticoduodenectomy". Ann Surg 2016; 267:e54-e55. [PMID: 27922838 DOI: 10.1097/sla.0000000000002086] [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: 11/25/2022]
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Abstract
BACKGROUND Pancreaticojejunostomy and pancreaticogastrostomy are the two techniques for pancreatic anastomosis that are widely established for the reconstruction after pancreaticoduodenectomy. Pancreaticogastrostomy is the most recent and to date less frequently performed method, the history, techniques and indications of which are presented. METHOD Review of the literature and current evidence. RESULTS Current evidence from randomized controlled trials and meta-analyses does not demonstrate significant differences in complication rates or pancreatic function after pancreaticogastrostomy versus pancreaticojejunostomy. CONCLUSION Pancreaticogastrostomy is the technically less demanding procedure, offering at least the same level of safety as pancreaticojejunostomy. Minimally invasive and parenchyma-sparing procedures provide new areas of application for this anastomotic technique.
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Affiliation(s)
| | - T Keck
- Klinik für Chirurgie, UKSH Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - U F Wellner
- Klinik für Chirurgie, UKSH Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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Shahinian JH, Fuellgraf H, Tholen S, Mastroianni J, Knopf JD, Kuehs M, Mayer B, Schlimpert M, Kulemann B, Kuesters S, Hoeppner J, Wellner UF, Werner M, Hopt UT, Zeiser R, Bronsert P, Schilling O. Pregnancy Specific β-1 Glycoprotein 1 is Expressed in Pancreatic Ductal Adenocarcinoma and its Subcellular Localization Correlates with Overall Survival. J Cancer 2016; 7:2018-2027. [PMID: 27877217 PMCID: PMC5118665 DOI: 10.7150/jca.15864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 04/16/2016] [Accepted: 09/18/2016] [Indexed: 12/14/2022] Open
Abstract
Proteins of the pregnancy specific β-1 glycoprotein (PSG) family are renowned for their elevated expression during pregnancy. Only few reports have investigated their expression in adenocarcinomas. We studied the expression of PSG1 in pancreatic adenocarcinoma (PDAC). In a cohort of 104 patient samples, immunohistochemical analysis determined PSG1 expression in every specimen. PSG1 was found at apical and cytoplasmic localization or solely at cytoplasmic localization, with the latter case being correlated to shortened median survival (25 vs 11 months, logrank p-value < 0.001). At the same time, enzyme linked immunosorbent assay (ELISA) did not detect elevated PSG1 levels in the plasma of PDAC patients as opposed to the plasma of healthy, non-pregnant control individuals. We also probed the impact of PSG1 expression in a murine tumor model system, using subcutaneous injection of Colo-26 cells into immunocompetent BALB/c mice. Here, tumor growth was not affected by the expression of human PSG1. Our study reaffirms interest into the tumor-contextual biology of PSG proteins.
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Affiliation(s)
- Jasmin H Shahinian
- Division of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Hannah Fuellgraf
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany
| | - Stefan Tholen
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Germany
| | - Justin Mastroianni
- Department of Hematology and Oncology, University Medical Center Freiburg, Germany
| | - Julia Daniela Knopf
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Germany;; present address: Zentrum für Molekulare Biologie der Universität Heidelberg (ZMBH), DKFZ-ZMBH Allianz, Im Neuenheimer Feld 282, 69120 Heidelberg, Germany
| | - Markus Kuehs
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Germany
| | - Bettina Mayer
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Germany
| | - Manuel Schlimpert
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Germany
| | - Birte Kulemann
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany
| | - Simon Kuesters
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany
| | - Jens Hoeppner
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Germany
| | - Ulrich F Wellner
- Clinic for Surgery, University Clinic Schleswig-Holstein Campus Lübeck, Germany
| | - Martin Werner
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, German
| | - Ulrich T Hopt
- Clinic for General and Visceral Surgery, University Medical Center Freiburg, Germany
| | - Robert Zeiser
- Department of Hematology and Oncology, University Medical Center Freiburg, Germany;; BIOSS Centre for Biological Signaling Studies, University of Freiburg, D-79104 Freiburg, Germany
| | - Peter Bronsert
- Institute of Surgical Pathology, University Medical Center Freiburg, Germany;; Comprehensive Cancer Center Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, German
| | - Oliver Schilling
- Institute of Molecular Medicine and Cell Research, University of Freiburg, Germany;; BIOSS Centre for Biological Signaling Studies, University of Freiburg, D-79104 Freiburg, Germany;; German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, German
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Ghadban T, Jessen A, Reeh M, Dibbern JL, Mahner S, Mueller V, Wellner UF, Güngör C, Izbicki JR, Vashist YK. In vitro study comparing the efficacy of the water-soluble HSP90 inhibitors, 17-AEPGA and 17-DMAG, with that of the non‑water-soluble HSP90 inhibitor, 17-AAG, in breast cancer cell lines. Int J Mol Med 2016; 38:1296-302. [PMID: 27498942 DOI: 10.3892/ijmm.2016.2696] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/22/2016] [Indexed: 11/05/2022] Open
Abstract
Heat shock protein (HSP)90 has emerged as an important target in cancer therapeutics. Diverse HSP90 inhibitors are under evaluation. The aim of the present study was to investigate the growth inhibitory effects of the newly developed water-soluble HSP90 inhibitors, 17-[2-(Pyrrolidin-1-yl)ethyl]amino-17-demethoxygeldanamycin (17-AEPGA) and 17-dimethylaminoethylamino-17-demethoxygeldanamycin (17-DMAG), compared to that of the non-water-soluble HSP90 inhibitor, 17-allylamino-17-demethoxygeldanamycin (17-AAG). The anti-proliferative effects of the 3 drugs on the human breast cancer cell lines, MCF-7, SKBR-3 and MDA-MB-231, were examined in vitro. In addition, tumor progression factors, including human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor 1 (EGFR1) and insulin-like growth factor type 1 receptor (IGF1R), as well as apoptotic markers were analysed. We found a time- and dose-dependent effect in all the tested cell lines. The effects of 17-AEPGA and 17-DMAG were equal or superior to those of 17-AAG. The 50% growth inhibition concentration was <2 µM for the water-soluble compounds following 72 h of exposure. The significant inhibition of HER2, EGFR1 and IGF1R protein expression was already evident at the concentration of 1 µM. Apoptosis was examined by caspase-3 and poly(ADP-ribose) polymerase (PARP) assay at the concentration of 1 µM of the inhibitors. HSP70 was upregulated, but HSP27 expression was not affected. Our data indicate that 17-AEPGA and 17-DMAG are highly active in breast cancer cell lines and may help to overcome the delivery issues associated with the use of 17-AAG.
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Affiliation(s)
- Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - André Jessen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Judith L Dibbern
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Sven Mahner
- Gynecology Department and Clinic, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Volkmar Mueller
- Gynecology Department and Clinic, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Ulrich F Wellner
- Clinic for Surgery, University Clinic of Schleswig-Holstein, Campus Lübeck, D-23538 Lübeck, Germany
| | - Cenap Güngör
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Yogesh K Vashist
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
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Honselmann KC, Krauss T, Geserick S, Wellner UF, Wittel U, Hopt UT, Keck T, Bausch D. Cystic lesions of the pancreas—is radical surgery really warranted? Langenbecks Arch Surg 2016; 401:449-56. [DOI: 10.1007/s00423-016-1416-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 03/30/2016] [Indexed: 01/24/2023]
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Wellner UF, Krauss T, Csanadi A, Lapshyn H, Bolm L, Timme S, Kulemann B, Hoeppner J, Kuesters S, Seifert G, Bausch D, Schilling O, Vashist YK, Bruckner T, Langer M, Makowiec F, Hopt UT, Werner M, Keck T, Bronsert P. Mesopancreatic Stromal Clearance Defines Curative Resection of Pancreatic Head Cancer and Can Be Predicted Preoperatively by Radiologic Parameters: A Retrospective Study. Medicine (Baltimore) 2016; 95:e2529. [PMID: 26817896 PMCID: PMC4998270 DOI: 10.1097/md.0000000000002529] [Citation(s) in RCA: 16] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is characterized by a strong fibrotic stromal reaction and diffuse growth pattern. Peritumoral fibrosis is often evident during surgery but only distinguishable from tumor by microscopic examination. The aim of this study was to investigate the role of clearance of fibrotic stromal reaction at the mesopancreatic resection margin as a criterion for radical resection and preoperative assessment of resectability.Mesopancreatic stromal clearance status (S-status) was defined as the presence or absence (S+/S0) of fibrotic stromal reaction at the mesopancreatic resection margin. Detailed retrospective clinicopathologic re-evaluation of margin status and preoperative cross-sectional imaging was performed in a cohort of 91 patients operated for pancreatic head PDAC from 2001 to 2011.Conventional margin positive resection (R+, tumor cells directly at the margin) was found in 36%. However, S-status further divided the margin negative (R0) group into patients with median survival of 14 months versus 31 months (S+ versus S0, P = 0.005). Overall rate of S+ was 53%. S-status and lymph node ratio constituted the only independent predictors of survival. Stranding of the superior mesenteric artery fat sheath was the only independent radiologic predictor of S+ resection, and achieved a 71% correct prediction of S-status.Mesopancreatic stromal clearance is a major determinant of curative resection in PDAC, and preoperative prediction by cross-sectional imaging is possible, setting the basis for a new definition of borderline resectability.
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Affiliation(s)
- Ulrich F Wellner
- From the Clinic for Surgery, UKSH Campus Lübeck, Lübeck (UFW, HL, LB, DB, TK); Clinic for Radiology (TK, ML); Institute of Pathology (AC, ST, MW, PB); Clinic for General and Visceral Surgery, University Medical Center Freiburg (BK, JH, SK, GS, FM, UTH); Institute for Molecular Medicine and Cell Research, University of Freiburg, Freiburg (OS); Department of Surgery, University Hospital Hamburg-Eppendorf (UKE), Hamburg (YKV); Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Heidelberg (TB); Comprehensive Cancer Center Freiburg, Freiburg (ML, FM, UTH, MW, PB); and German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Heidelberg, Germany (OS, MW, PB)
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