Effects of gait intervention using the draw-in maneuver on knee joint function and the thoracic kyphosis angle in knee osteoarthritis

BACKGROUND

To evaluate whether the knee adduction moment (KAM) could be reduced by a short instruction in the Draw-in (DI) maneuver in healthy adults, and whether knee joint function would improve with a longer DI gait intervention in patients with knee osteoarthritis (OA).

METHOD

In Study 1, healthy adults received 10 minutes supervised instruction in DI gait in and then practiced the gait independently for 10 minutes. Three-dimensional motion analysis measurement was performed in each phase. In Study 2, patients with OA performed a 20-minute DI gait intervention daily for 6 weeks. At baseline and after 6 weeks, knee pain, the Knee injury and Osteoarthritis Outcome Score, the MOS 8 item Short-Form Health Survey, thoracic kyphosis angle, knee joint range of motion, knee extension muscle strength, hip abduction muscle strength, and activity level were evaluated.

RESULTS

In Study 1, the DI gait to decrease KAM could be learning following only 10 minutes of instruction and 10 minutes of self-practice in healthy adults. In Study 2, knee pain was reduced by 19 % and the thoracic kyphosis angle was reduced by 2.6° after 6 weeks. No significant changes in other parameters were detected, and the implementation rate was 86 ± 14 %.

SIGNIFICANCE

In healthy adults, DI gait instruction for 10 minutes of instruction and 10 minutes of self-practice reduced the KAM. In patients with knee OA, 20 minutes of DI gait per day for 6 weeks may reduce knee pain and thoracic kyphosis.

Long-term outcomes of neoadjuvant gemcitabine, nab-paclitaxel, and S1 (GAS) in borderline resectable pancreatic cancer with arterial contact: Results from a phase II trial

BACKGROUND/PURPOSE

This study reports the long-term results of a phase II trial evaluating the clinical efficacy of neoadjuvant gemcitabine, nab-paclitaxel, and S1 (GAS) in borderline resectable pancreatic cancer with arterial contact (BRPC-A).

METHODS

A multicenter, single-arm, phase II trial was conducted. Patients received six cycles of GAS and patients without progressive disease were intended for R0 resection.

RESULTS

Of the 47 patients, 45 (96%) underwent pancreatectomy. At the time of this analysis, all patients were updated with no loss to follow-up. A total of 30 patients died, while the remaining 17 patients were followed for a median of 68.1 months. The updated median overall survival (OS) was 41.0 months, with 2- and 5-year OS rates of 68.0% and 44.6%, respectively. Multivariate analysis in the preoperative model showed that a tumor diameter reduction rate ≥10% and a CA19-9 reduction rate ≥95% after neoadjuvant chemotherapy remained independently associated with favorable survival. In the postoperative multivariate model, no lymph node metastasis, no major surgical complications, and completion of adjuvant chemotherapy were independently associated with improved OS.

CONCLUSIONS

This long-term evaluation of the neoadjuvant GAS trial demonstrated the high efficacy of the regimen, suggesting that it is a promising treatment option for patients with BRPC-A.

Clinical Utility of the Combined Use of CA19-9 and DUPAN-2 in Pancreatic Adenocarcinoma

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) patients with normal carbohydrate antigen (CA) 19-9 levels can have early-stage cancer or advanced cancer without elevation of CA19-9 level; estimating their malignant potential is difficult. This study investigated the clinical utility of the combined use of preoperative CA 19-9 and Duke pancreatic monoclonal antigen type 2 (DUPAN-2) levels in patients with PDAC.

METHODS

Patients who underwent curative-intent surgery for PDAC between November 2005 and December 2021 were investigated. Eligible patients were classified into four groups based on these two markers. Among patients with normal CA19-9 levels, those with normal and high DUPAN-2 levels were classified into normal/normal (N/N) and normal/high (N/H) groups, respectively. Among patients with high CA19-9 levels, those with normal and high DUPAN-2 levels were classified into high/normal (H/N) and high/high (H/H) groups, respectively. Survival rates were compared between the groups.

RESULTS

Among 521 patients, the N/N, N/H, H/N, and H/H groups accounted for 25.0%, 10.6%, 35.1%, and 29.4% of patients, respectively. The proportions of resectable PDAC in the N/N and H/N groups (71.5% and 66.7%) were significantly higher than those in the N/H and H/H groups (49.1% and 54.9%) (P < 0.01). The 5-year survival rates in the N/N, N/H, H/N, and H/H groups were 66.0%, 31.1%, 34.9%, and 29.7%, respectively; the rate in the N/N group was significantly better than those in the other three groups (P < 0.0001, P < 0.0001, and P < 0.0001, respectively).

CONCLUSIONS

Only patients with normal CA19-9 and DUPNA-2 values should be diagnosed with early-stage PDAC.

Safe suprapancreatic lymph node dissection for gastric cancer with ectopic common hepatic artery

Suprapancreatic lymph node dissection for patients with gastric cancer in whom the common hepatic artery is located neither at the suprapancreatic margin nor in front of the portal vein is a more difficult procedure than when the common hepatic artery is in a more typical position. There is an increased risk of injury to the vessels that need to be preserved and inadequate lymph node dissection. Measures that have been reported for use in this situation are preoperative diagnosis with three-dimensional computed tomography angiography, dissection using the portal vain as a guide, and safe exposure of the portal vein with dissection to preserve the nerves at the suprapancreatic margin and in front of the portal vein. We review the literature and report our experience with a patient whose common hepatic artery was not located in the suprapancreatic margin who safely underwent suprapancreatic lymph node dissection using these methods.

Prognostic impact of peritoneal washing cytology in patients with biliary tract cancer

PURPOSE

To elucidate the clinical significance of peritoneal washing cytology (PWC) in patients with resectable biliary tract cancer (BTC).

METHODS

Clinical data of patients with BTC, who received PWC at curative intent surgery from March 2009 to December 2021, were retrospectively analyzed. Eligible patients were stratified into two groups according to positive or negative PWC. Recurrence-free survival and overall survival were compared between the two groups. Independent factors associated with positive PWC were investigated using multivariate analysis.

RESULTS

Among the 284 patients analyzed, all 53 patients with ampullary carcinoma showed negative PWC and these patients were excluded. Among the remaining eligible 231 patients, 41 patients had intrahepatic cholangiocarcinoma, 55 had gall bladder carcinoma, 72 had hilar cholangiocarcinoma, and 63 had distal cholangiocarcinoma. Eleven (4.8%) patients had positive PWC, and 220 (95.2%) had negative PWC. The median recurrence-free survival in the positive and negative PWC groups were 12.0 vs. 60.7 months (p = 0.005); the median overall survival times were 17.0 vs. 60.6 months (p = 0.008), respectively. Multivariate analysis revealed that serum carbohydrate antigen 19-9 level over 80 U/mL and multiple lymph node metastasis were independently associated with positive PWC (odds ratio [OR]: 5.84, p = 0.031; OR: 5.28, p = 0.021, respectively).

CONCLUSION

Patients with positive PWC exhibited earlier recurrence and shorter survival times compared with those with negative PWC.

Difficulty of adjuvant chemotherapy administration in patients with biliary tract cancer

PURPOSE

This study aimed to elucidate the difficulty of adjuvant chemotherapy administration in patients with biliary tract carcinoma (BTC).

METHODS

Clinical data of patients with BTC who underwent curative-intent surgery were retrospectively analyzed. The eligible patients were stratified into two groups according to the presence or absence of adjuvant chemotherapy administration (adjuvant and non-adjuvant groups), and the clinicopathological features were compared between the two groups. The ratios of adjuvant chemotherapy administration were investigated in each surgical procedure. Independent factors associated with no administration of adjuvant chemotherapy were analyzed using multivariate analyses.

RESULTS

Among 168 eligible patients, 141 (83.9%) received adjuvant chemotherapy (adjuvant group), while 27 (16.1%) did not (non-adjuvant group). The most common surgical procedure was pancreaticoduodenectomy in the adjuvant group, and it was hepatectomy with extrahepatic bile duct resection (BDR) in the non-adjuvant group, respectively. The rate of no adjuvant chemotherapy was significantly higher in patients who underwent hepatectomy with BDR than in those who underwent other surgeries (p < 0.001). The most common cause of no adjuvant chemotherapy was bile leak in 12 patients, which occurred after hepatectomy with BDR in ten patients. Multivariate analyses revealed that hepatectomy with BDR and preoperative anemia were independently associated with no adjuvant chemotherapy (p < 0.001 and p < 0.001, respectively).

CONCLUSIONS

Hepatectomy with BDR and subsequent refractory bile leak can be the obstacle to adjuvant chemotherapy administration in patients with BTC.

Optimal Lymphadenectomy in Patients with Well-Differentiated Nonfunctioning Pancreatic Neuroendocrine Neoplasms

This study aimed to evaluate the optimal extent of lymphadenectomy in patients with nonfunctioning pancreatic neuroendocrine neoplasms. We retrospectively analyzed the clinicopathological data of patients with nonfunctioning pancreatic neuroendocrine neoplasms who underwent surgical resection. We investigated the frequency of metastases at each lymph node station according to tumor location and analyzed the factors contributing to poor overall survival (OS) and disease-free survival (DFS). Overall, data of 84 patients were analyzed. Among patients with pancreatic head tumors, metastases at stations 8, 13, and 17 were found in one (3.1%), four (12.5%), and three (9.3%) patients, respectively. However, none of the other stations showed metastases. For pancreatic body and tail tumors, metastases only at station 11 were found in two (5.1%) patients. Additionally, multivariate DFS and OS analyses showed that lymph node metastasis was the only independent prognostic factor. In conclusion, lymph node metastasis near the primary tumor was the only independent factor of poor prognosis in patients with nonfunctioning pancreatic neuroendocrine neoplasms after undergoing curative surgery. Peri-pancreatic lymphadenectomy might be recommended for nonfunctioning pancreatic neuroendocrine neoplasms.

A Nomogram Based on Pretreatment Radiomics and Dosiomics Features for Predicting Overall Survival for Esophageal Squamous Cell Cancer: Multi-Institutional Study

PURPOSE/OBJECTIVE(S)

The current study aims to propose a nomogram-based 2- and 3-years survival prediction model for esophageal squamous cell carcinoma treated by definitive radiotherapy using pretreatment computed tomography (CT), positron emission tomography (FDG PET) radiomic features and dosiomics features in addition to the common clinical factors using multi-institution data.

MATERIALS/METHODS

Data of 112 patients from one institution and 28 patients from the other institution were retrospectively collected. Radiomics and dosiomics features were extracted using five segmentations on CT and PET images and dose distribution. The least absolute shrinkage and selection operator (LASSO) with logistic regression was used to select radiomics and dosiomics features by calculating the radiomics and dosiomics scores (Rad-score and Dos-score), respectively, in the training model. The predictive clinical factors, Rad-score, and Dos-score were identified to develop a nomogram model.

RESULTS

We extracted 15219 features from the radiomics and dosiomics analysis. By LASSO Cox regression analysis, 13 CT-based radiomics features, 11 PET-based radiomics features, and 19 dosiomics features were selected. Clinical factors of T-stage, N-stage, and clinical stage were selected as significant prognostic factors by univariate Cox regression analysis. A predictive nomogram for prognosis in was established using these factors. In the external validation cohort, the C-index of the combined model of CT-based radiomics, PET-based radiomics, and dosiomics features with clinical factors were 0.74, 0.82, and 0.92, respectively. Moreover, we divided the cohort into high-risk and low-risk groups using the median nomogram score. Significant differences in overall survival (OS) in the combine model of CT-based radiomics, PET-based radiomics, and dosiomics features with clinical factors were observed between the high-risk and low-risk groups (P = 0.019, P = 0.038, and 0.014, respectively).

CONCLUSION

The current study established and validated 2- and 3-year survival prediction models based on radiomics and dosiomics features with clinical factors. The prediction model with dosiomics analysis could better predict OS than CT- and PET-based radiomics analysis in esophageal cancer patients treated with radiotherapy.

Laryngo-Esophageal Dysfunction Free Survival of Chemoradiation for Cervical Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Chemoradiotherapy is often the treatment of choice for cervical esophageal cancer due to the invasiveness of surgery. However, toxicity after chemoradiotherapy often affects the quality of life related to swallowing and speech. This study evaluated laryngoesophageal dysfunction-free survival (LEDFS) in patients with cervical esophageal cancer, which has recently been used in head and neck cancer.

MATERIALS/METHODS

We analyzed 59 patients with cervical esophageal cancer without distant metastases other than supraclavicular lymph node metastases who received radical chemoradiotherapy with 5-fluorouracilplus platinum between 2002 and 2018. Loco-regional control (LRC), overall survival (OS), LEDFS, metachronous esophageal cancer incidence rates, and late toxicities were evaluated. LEDFS events were defined as death, local recurrence, total or partial laryngectomy, tracheostomy for more than 2 years, and feeding tube use for more than 2 years, as recommended by the Larynx Preservation Consensus Panel. The Kaplan-Meier method was used to calculate survival rates. The generalized Wilcoxon test was used to compare the two groups. The Common Terminology Criteria for Adverse Events v5.0 was used to assess toxicities.

RESULTS

The median age was 66 years (range, 38-83). There were 13 women and 46 men. Stage I, II, III, IVA, and IVB disease according to UICC 8th staging were 15, 9, 9, 10, and 16 patients, respectively. 22 received conventional radiotherapy and 37 received volumetric modulated arc therapy. The median total irradiation dose was 66 Gy. Platinum plus 5-fluorouracil chemotherapy was administered to all patients. The median follow-up for survivors was 87.5 months. The 5-year LRC, OS, and LEDFS rates were 54.2%, 48.9%, and 41.9%, respectively. The prognostic factors for OS were performance status (PS), hypopharyngeal extension, and clinical stage in univariate analysis and only clinical stage (hazard ratio [HR] 3.87, 95% Confidence interval [CI]: 1.52-9.87, p<0.01) in multivariate analysis; the prognostic factors for LEDFS were PS, hypopharyngeal extension and clinical stage in univariate analysis and hypopharyngeal extension (HR 2.38, 95% CI: 1.12-5.03, p = 0.02) and clinical stage (HR 4.07, 95% CI: 1.48-11.06, p<0.02) in multivariate analysis. Metachronous esophageal cancer was observed in 28.6% of patients at 5 years. As severe late toxicities, grade 3 pneumonitis, esophageal stricture, esophageal fistula, laryngeal stricture, and laryngeal edema were observed in 1 (2%), 1 (2%) and 4 (7%), 1 (2%) and 1 (2%), respectively. Grade 2 hypothyroidism was observed in 31 (53%) patients.

CONCLUSION

Chemoradiation for cervical esophageal cancer showed good results. The prognostic factors for LEDFS were pharyngeal extension and clinical stage. Late esophageal and laryngeal toxicity, hypothyroidism, and metachronous esophageal cancer should be noted.

Impact of the G8 Score on Treatment Strategies and Outcome in Definitive Radiotherapy for the Elderly Esophageal Cancer Patients

PURPOSE/OBJECTIVE(S)

Although chemoradiotherapy (CRT) is widely used as a curative treatment for esophageal cancer, it is often difficult to perform standard CRT for the elderly in the real world. This study aimed to investigate the impact of the Geriatric 8 (G8) score on treatment strategies and outcome in definitive radiotherapy (RT) for elderly esophageal cancer patients.

MATERIALS/METHODS

We analyzed 81 esophageal cancer patients aged ≥65 years who received definitive RT between 2018 and 2021. The G8 score was acquired at the first visit to the radiation oncology department. The treatment strategy was decided by a multi-disciplinary conference, and the G8 score was not used to determine the treatment strategy. Standard treatment (standard CRT) was defined as RT with elective nodal irradiation and a total dose ≥50 Gy, and chemotherapy with two cycles of platinum (70 mg/m2) and 5FU (700 mg/m2 for 4 days) concurrently. The Kaplan-Meier method was used to generate actual survival curves. The Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 was used to assess toxicities. The Mann-Whitney U test was used to compare the two groups, and statistical significance was set at p<0.05. The Receiver Operating Characteristic (ROC) curve was used to calculate the cutoff value.

RESULTS

The Median follow-up time was 30 months (range: 8-51) for survivors. The mean G8 scores by treatment strategy were 13.9 (range: 9-17) for standard CRT group (n = 26), 12.1 (range: 7-16) for reduced CRT group (n = 30), and 9.7 (range: 4.5-14) for RT alone group (n = 25). G8 score was significantly higher for standard CRT (p = 0.017) and significantly lower for RT alone (p<0.01). The cut-off value of the G8 score for standard treatment, calculated by the ROC curve, was 12.5 points. In the non-standard treatment group, the cut-off value of the G8 score for RT alone, calculated by the ROC curve, was 10.5 points. The 2-year overall survival (OS) rates for standard CRT, reduced CRT and RT alone were 74%, 71% and 35%, respectively, and significantly lower in RT alone (p<0.001). The 2-years OS rates for G8 score >10.5 points and ≤10.5 points were 69% and 48%, respectively (p = 0.039). Grade 3 or higher acute toxicities were observed in 33 patients (41%); 14 (54%) in standard CRT, 17 (57%) in reduced CRT and 2 (8%) in RT alone. Grade 5 acute toxicity was not observed. G8 scores tended to be higher in the patients with grade 3 or higher acute toxicities, but the difference was not statistically significant (p = 0.057). Grade 3 or higher late toxicities were observed in 7 patients.

CONCLUSION

Our results suggest that there is an association between the G8 score and clinicians' treatment decisions. Although RT alone could be safely performed even in patients with low G8 scores, administration of chemotherapy strongly affected prognosis. These results suggest the importance of developing less toxic systemic therapy regimens for patients with low G8 scores.

Predictive Modeling of Radiation Pneumonitis Induced by Chemoradiotherapy for Locally Advanced Non-Small Cell Lung Cancer Using Radiomics and Clinical Features

PURPOSE/OBJECTIVE(S)

The purpose of this study is to establish a prediction model for the development of grade 2 or higher radiation pneumonitis (RP) using radiomics analysis of pretreatment CT images, PET images, and dose distribution, in addition to clinical factors, in patients with locally advanced non-small cell lung cancer (NSCLC) treated with radical chemoradiotherapy.

MATERIALS/METHODS

We retrospectively evaluated 128 cases of locally advanced NSCLC treated with radical radiotherapy at our institution from 2008 to 2021. Clinical factors included age, sex, performance status (PS), KL-6, smoking history, histological type, clinical stage, and total radiation dose. Radiomics analysis was performed by analyzing treatment planning CT images, PET images, and dose distribution, and Rad-score (Radiomics-score) was calculated for the extracted features using Lasso-Cox regression. Rad-score (Radiomics-score) was calculated by Lasso-Cox regression for the extracted features. Risk factors were selected by univariate/multivariate analysis of clinical factors and Rad-score. Three models for predicting RP were developed from the identified risk factors using Nomogram: Clinical, Rad-score, and Combined model. The model was evaluated using area under the curve (AUC) based on receiver operating characteristic (ROC) curves and concordance index (C-index). RP was evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The cumulative incidence of Grade 2 or higher RP was evaluated using the Kaplan-Meier method.

RESULTS

Of the 128 cases, grade 2 or higher RP was observed in 50 cases (39%). Regarding clinical factors, gender, smoking status, and histology were selected as significant predictors of RP. Lasso-Cox analysis of radiomics features selected 11 features from CT images, 7 features from PET images, and 16 features from dose distribution as predictors of RP, yielding a total of 34 factors. The combined model (C-index: 0.96, AUC: 0.92) showed the best discrimination performance compared to the clinical model (C-index: 0.73, AUC: 0.56) and the Rad-score model (C-index: 0.87, AUC: 0.92). Risk classification using the combined model showed that the 1-year cumulative incidence of grade 2 or higher RP was 65% in the high-risk group, significantly higher than 15% in the low-risk group (p<0.001).

CONCLUSION

The combined model with Rad-score and clinical factors can predict grade 2 or higher RP in NSCLC patients with high accuracy.

Intrahepatic cholangiocarcinoma with extensive intraductal extension of high-grade biliary intraepithelial neoplasia: a case report

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is frequently associated with precursor lesions, and biliary intraepithelial neoplasia (BilIN) may play a significant role in the development of ICC. However, the exact sequence and progression of these lesions remain to be elucidated. We report a rare case of ICC that exhibited extensive longitudinal intraductal extension of high-grade BilIN in the posterior bile ducts and involved the hepatic hilum and the peripheral hepatic parenchyma.

CASE PRESENTATION

A 70-year-old female presented with anorexia. Computed tomography (CT) revealed a 15 mm enhancing intrahepatic tumor extending to the right intrahepatic secondary confluence. This was associated with a 7 mm diameter cystic dilatation of the segment 6 bile duct (B6). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis at the bifurcation of the posterior bile duct branch. Bile cytology confirmed the diagnosis of adenocarcinoma cells. Therefore, the patient was diagnosed with an ICC involving the right glissonean pedicle and underwent a right hepatectomy and lymph node dissection. Histologic examination revealed the tumor consisted of moderately differentiated adenocarcinoma. In connection with this lesion, diffuse intraductal atypical epithelial cells, which were diagnosed as high-grade BilIN, was observed not only in the dilated B6 but in the entire posterior bile ducts, which measured approximately 120 mm in diameter. Furthermore, two distinct foci of adenocarcinomas were identified in the peripheral hepatic parenchyma. A lymph node metastasis was also present. The pathological diagnosis was ICC pT4N1M0 stage IVA. The patient underwent adjuvant chemotherapy and has shown no recurrence 5 years after surgery. Imaging modalities were unable to accurately assess the extent of the intraductal neoplastic lesions due to their low papillary or sessile intraductal tubular growth. No risk factors for BilIN development, which has the potential to predispose to cholangiocarcinoma, were identified in the present case.

CONCLUSIONS

We present a case of ICC involving the right hepatic hilum, accompanied by extensive longitudinal extensions of high-grade BilIN and multifocal microscopic invasions in peripheral hepatic parenchyma. Notably, the intraductal lesions involved the entire posterior intrahepatic bile ducts. The presence of biliary neoplasia with extensive intraductal extension, in conjunction with ICC, should be considered as a variant of BilIN.

Insights from managing clinical issues in distal pancreatectomy with en bloc coeliac axis resection: experiences from 626 patients

BACKGROUND

Distal pancreatectomy with en bloc coeliac axis resection (DP-CAR) for pancreatic body cancer has been reported increasingly. However, its large-scale outcomes remain undocumented. This study aimed to evaluate DP-CAR volume and mortality, preoperative arterial embolization for ischaemic gastropathy, the oncological benefit for resectable tumours close to the bifurcation of the splenic artery and coeliac artery using propensity score matching, and prognostic factors in DP-CAR.

METHODS

In a multi-institutional analysis, 626 DP-CARs were analysed retrospectively and compared with 1325 distal pancreatectomies undertaken in the same interval.

RESULTS

Ninety-day mortality was observed in 7 of 21 high-volume centres (1 or more DP-CARs per year) and 1 of 41 low-volume centres (OR 20.00, 95 per cent c.i. 2.26 to 177.26). The incidence of ischaemic gastropathy was 19.2 per cent in the embolization group and 7.9 per cent in the no-embolization group (OR 2.77, 1.48 to 5.19). Propensity score matching analysis showed that median overall survival was 33.5 (95 per cent c.i. 27.4 to 42.0) months in the DP-CAR and 37.9 (32.8 to 53.3) months in the DP group. Multivariable analysis identified age at least 67 years (HR 1.40, 95 per cent c.i. 1.12 to 1.75), preoperative tumour size 30 mm or more (HR 1.42, 1.12 to 1.80), and preoperative carbohydrate antigen 19-9 level over 37 units/ml (HR 1.43, 1.11 to 1.83) as adverse prognostic factors.

CONCLUSION

DP-CAR can be performed safely in centres for general pancreatic surgery regardless of DP-CAR volume, and preoperative embolization may not be required. This procedure has no oncological advantage for resectable tumour close to the bifurcation of the splenic artery, and should be performed after appropriate patient selection.

Prognostic factor in patient with recurrent pancreatic adenocarcinoma

PURPOSE

To elucidate prognostic factors for post-recurrence survival in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients who underwent curative-intent surgery for PDAC between January 2014 and May 2020 were identified. Among them, patients who had postoperative recurrences and received chemotherapy were retrospectively investigated. Independent prognostic factors for survival after recurrence were investigated using multivariate analyses. Eligible patients were divided into two groups according to the presence or absence of the identified prognostic factors, and survival times after recurrence were compared.

RESULTS

Eighty-four patients with recurrent PDAC were included. Multivariate analysis showed that red blood cell (RBC) transfusion (HR, 2.80; p = 0.0051), low albumin level (HR, 1.84; p = 0.0402), and high carbohydrate antigen 19-9 (CA19-9) level at recurrence (HR, 2.11; p = 0.0258) were significant predictors of shorter survival after recurrence. The median survival times after recurrence in the transfusion and non-transfusion groups were 5.5 vs. 18.1 months (p < 0.0001), respectively; those in the low and normal albumin groups were 10.1 vs. 18.7 months (p = 0.0049), and those in the high and normal CA19-9 groups were 11.5 vs. 22.6 months (p = 0.0023), respectively.

CONCLUSIONS

RBC transfusion, low albumin, and high CA19-9 levels at recurrence negatively affected survival after recurrence in patients with PDAC.

Is surgical resection justified for pancreatic ductal adenocarcinoma with distant abdominal organ metastasis? A position paper by experts in pancreatic surgery at the Joint Meeting of the International Association of Pancreatology (IAP) & the Japan Pancreas Society (JPS) 2022 in Kyoto

Pancreatic ductal adenocarcinoma (PDAC) is a typical refractory malignancy, and many patients have distant organ metastases at diagnosis, such as liver metastasis and peritoneal dissemination. The standard treatment for unresectable PDAC with distant organ metastasis (UR-M) is chemotherapy, but the prognosis remained poor. However, with recent dramatic developments in chemotherapy, the prognosis has gradually improved, and some patients have experienced marked shrinkage or disappearance of their metastatic lesions. With this trend, attempts have been made to resect a small number of metastases (so-called oligometastases) in combination with the primary tumor or to resect the primary and metastatic tumor in patients with a favorable response to anti-cancer treatment after a certain period of time (so-called conversion surgery). An international consensus meeting on surgical treatment for UR-M PDAC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of the Japan Pancreas Society (JPS) in Kyoto in July 2022. The presenters showed their indications for and results of surgical treatment for UR-M PDAC and discussed their advantages and disadvantages with the experts. Although these reports were limited to a small number of patients, findings suggest that these surgical treatments for patients with UR-M PDAC who have had a significant response to chemotherapy may contribute to a prognosis of prolonged survival. We hope that this article summarizing the discussion and agreements at the meeting will serve as the basis for future trials and guidelines.

Prognostic impact of lung recurrence in patients with biliary tract cancer

PURPOSE

This study aimed to evaluate the prognostic impact of the initial recurrence site following resection for biliary tract carcinoma (BTC), focusing on lung recurrence.

METHODS

The clinical data of patients with recurrent BTC who underwent curative intent surgery between March 2009 and December 2021 were retrospectively analyzed. The prognosis of patients with recurrent BTC was investigated in each recurrence site. Eligible patients were classified into two groups according to lung or non-lung recurrence. Clinicopathological factors, survival after recurrence, and overall survival were compared between the two groups. Independent factors associated with survival after recurrence were investigated using multivariate analysis.

RESULTS

Of 119 patients, the initial recurrence site was local in 26 (21.8%) patients, liver in 19 (16.8%), peritoneum in 14 (11.8%), lymph node in 12 (10.1%), lung in 11 (9.2%), multiple organs in 32 (26.9%), and others in 5 (4.2%). The survival period after recurrence in patients with lung recurrence was significantly longer than those in patients with other six recurrence patterns. The median survival after recurrence was 34.3 and 9.3 months in lung recurrence and non-lung recurrence groups, respectively (p < 0.0001); that after initial surgery was 50.8 and 26.4 months, respectively (p = 0.0383). Multivariate analysis revealed that lung recurrence and normal albumin level at recurrence were independently associated with survival after recurrence (Hazard Ratio (HR), 0.291; p = 0.0128; HR, 0.476; p = 0.00126, respectively).

CONCLUSIONS

Survival period after recurrence was significantly longer in patients with lung recurrence.

Surgical resection for liver recurrence after curative resection of pancreatic ductal adenocarcinoma

PURPOSE

This study aimed to evaluate the clinical significance of surgical resection for liver recurrence in patients with curatively resected pancreatic ductal adenocarcinoma.

METHODS

The medical records of patients with a liver recurrence after undergoing curative pancreatectomy for pancreatic ductal adenocarcinoma were retrospectively reviewed. Clinicopathological and prognostic factors were analyzed, as was the clinical impact of surgical resection for liver recurrence.

RESULTS

Overall, 502 patients underwent curative pancreatic ductal adenocarcinoma resection. Of the 311 patients with recurrence after curative pancreatectomy, 71 (23%) had an initial recurrence in the liver, with 35 having solitary recurrence (11%). Patients with solitary, two or three, or more than four recurrences had median overall survival times of 28.5, 18.0, and 12.2 months, respectively (p < 0.001). Surgical indications for liver recurrence in our institution included solitary tumor, good disease control under chemotherapy after recurrence for > 6 months, and sufficient remnant liver function. Ten patients who met our institutional policy inclusion criteria underwent liver resection. Among 35 patients with initially solitary liver recurrence, those who underwent liver resection outlived those who did not (57.6 months vs. 20.1 months, p < 0.001). In multivariate analysis of overall survival, solitary liver recurrence and liver resection were independent favorable prognostic factors in patients with initial liver recurrence.

CONCLUSION

In selected patients with solitary liver recurrence after curatively resected pancreatic ductal adenocarcinoma, liver resection may be a treatment option.

Optimal lymph-node dissection for pancreatic tail cancer

PURPOSE

The optimal range of lymph-node dissection for pancreatic tail cancer remains unclear. We investigated the location and frequency of lymph-node metastases to identify the correct range of lymph-node dissection for pancreatic tail cancer.

METHODS

We analyzed clinical data retrospectively, on patients who underwent distal pancreatectomy for resectable left-sided pancreatic cancer, between February, 2006 and March, 2021. Eligible patients were divided into two groups according to the tumor location: those with pancreatic tail cancer (Pt group) and those with pancreatic body or body and tail cancer (non-Pt group).

RESULTS

Of the 96 patients analyzed, 61 (64%) were assigned to the Pt group and 35 (36%) were assigned to the non-Pt group. Metastases to stations 7, 8, 9, 10, 11, 14, and 18 were found in 0 (0%), 0 (0%), 0 (0%), 4 (7%), 18 (30%), 2 (4%), and 10 (17%) patients in the Pt group, and in 1 (3%), 4 (12%), 2 (6%), 1 (3%), 18 (51%), 3 (9%), and 6 (17%) patients in the non-Pt group, respectively.

CONCLUSION

Lymph-node dissection at stations 7, 8, and 9 might not be necessary in patients with resectable pancreatic cancer confined to the pancreatic tail.

Prognosis following an extended duration of adjuvant gemcitabine plus S-1 chemotherapy in patients with pancreatic ductal adenocarcinoma: Analysis using inverse probability of treatment weighting

BACKGROUND/PURPOSE

The aim of this study was to assess whether the duration of adjuvant gemcitabine plus S-1 (GS) chemotherapy has any effect on survival in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Of the 290 patients who received adjuvant GS chemotherapy, 100 (34%) received the standard duration (20-29 weeks) and 190 (66%) received an extended duration (≥30 weeks). To reduce selection bias, the prognostic impact (recurrence-free survival [RFS] and overall survival [OS]) based on the duration of adjuvant GS chemotherapy was analyzed using inverse probability of treatment weighting (IPTW). Moreover, to reduce immortal time bias, time-dependent multivariate analyses in which implementation of adjuvant GS chemotherapy was treated as time-varying covariate was also performed.

RESULTS

Extended duration of adjuvant GS chemotherapy was significantly correlated with prolonged RFS (P < .001) and OS (P < .001) after IPTW adjustment. Time-dependent multivariate analyses revealed that extended duration of adjuvant GS chemotherapy was an independent prognostic factor for prolonged RFS (hazard ratio [HR], 0.58, P = .002) and OS (HR, 0.56, P = .005).

CONCLUSION

Extended duration (≥30 weeks) of adjuvant GS chemotherapy in patients with PDAC was associated with an improved prognosis. These findings warrant a further prospective trial on PDAC to investigate the survival benefit of extended adjuvant chemotherapy.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.

Preoperative risk factors for positivity of peritoneal lavage cytology in patients with pancreatic ductal adenocarcinoma in the era of neoadjuvant therapy

BACKGROUND

The preoperative risk factors for positive peritoneal lavage cytology (CY) are unknown, especially in patients who received neoadjuvant therapy. In addition, the optimal indications for staging laparoscopy (SL) are still unclear. The aim of this study was to investigate the preoperative risk factors of CY positivity in patients with pancreatic ductal adenocarcinoma (PDAC) treated with surgical resection and to determine the optimal indications for SL.

METHODS

We retrospectively analyzed 493 patients with PDAC, including 356 treated with upfront surgery and 137 treated with neoadjuvant chemotherapy (NAC). The preoperative risk factor for CY positivity was investigated along with stratification according to NAC.

RESULTS

Among the 493 patients, 36 (7.3%) were CY-positive. The CY-positive frequency in patients who received and did not receive NAC was 9 (6.6%) and 27 (7.6%), respectively. In the multivariate analyses, no independent preoperative predictive factor was found in patients who received NAC, whereas body and tail PDAC were identified as an independent risk factor for CY positivity in patients who did not receive NAC.

CONCLUSIONS

The preoperative risk factors of CY-positive PDAC are body and tail PDAC in 356 patients who did not receive NAC. However, there is no useful predictive factor for CY positivity in patients treated with NAC. Based on these results, it was difficult to determine the optimal indication for SL especially in NAC cases.

Impact of disintegrin and metalloproteinase domain-containing protein 12 on pancreatic ductal adenocarcinoma treated with surgical resection and perioperative chemotherapy

BACKGROUND/OBJECTIVES

A disintegrin and metalloproteinase domain-containing protein 12 (ADAM12) has been reported to influence tumor progression and chemosensitivity in human cancers. We assessed the prognostic impact of ADAM12 and its predictive value for neoadjuvant chemotherapy (NAC) in patients with pancreatic ductal adenocarcinoma (PDAC) treated with surgical resection.

METHODS

ADAM12 expression was immunohistochemically examined in 428 patients with PDAC who underwent surgical resection. The association of ADAM12 expression with clinicopathological factors and survival was also analyzed.

RESULTS

Patients with high ADAM12 expression exhibited significantly shorter median disease-free survival (DFS) (high ADAM12: 17.8 vs. low ADAM12: 37.9 months; P < 0.001) and overall survival (OS) (high ADAM12: 33.1 vs. low ADAM12: 65.0 months; P < 0.001). A multivariate analysis revealed that high ADAM12 expression was an independent risk factor for poor DFS (P < 0.001) and OS (P < 0.001) in all eligible patients. Of 100 patients who received neoadjuvant chemotherapy (NAC), high ADAM12 expression was significantly associated with poor DFS in a subset of patients treated with the nab-paclitaxel (PTX) neoadjuvant regimen (P = 0.03), whereas the prognostic value of ADAM12 was not evident in patients not treated with nab-PTX (P = 0.12).

CONCLUSIONS

A negative prognostic value of high ADAM12 expression was observed in patients with PDAC treated with surgical resection, which was enhanced in patients treated with NAC, including nab-PTX. These results suggested that ADAM12 expression can predict nab-PTX chemosensitivity in PDAC and reflect PDAC progression.

High-power laser experiment forming a supercritical collisionless shock in a magnetized uniform plasma at rest

We present an experimental method to generate quasiperpendicular supercritical magnetized collisionless shocks. In our experiment, ambient nitrogen (N) plasma is at rest and well magnetized, and it has uniform mass density. The plasma is pushed by laser-driven ablation aluminum (Al) plasma. Streaked optical pyrometry and spatially resolved laser collective Thomson scattering clarify structures of plasma density and temperatures, which are compared with one-dimensional particle-in-cell simulations. It is indicated that just after the laser irradiation, the Al plasma is magnetized by a self-generated Biermann battery field, and the plasma slaps the incident N plasma. The compressed external field in the N plasma reflects N ions, leading to counterstreaming magnetized N flows. Namely, we identify the edge of the reflected N ions. Such interacting plasmas form a magnetized collisionless shock.

A phase II study of gemcitabine/nab-paclitaxel/S-1 combination neoadjuvant chemotherapy for patients with borderline resectable pancreatic cancer with arterial contact

BACKGROUND

The prognosis of patients with borderline resectable pancreatic cancer with arterial contact (BRPC-A) is extremely poor, and effective preoperative treatment is indispensable. We evaluated the clinical efficacy and safety of neoadjuvant chemotherapy, including gemcitabine, nab-paclitaxel and S-1 (GAS), for patients with BRPC-A.

MATERIAL AND METHODS

A multicentre, single-arm, phase II study was performed. Patients were administered 1000 mg/m² gemcitabine on day 1, 125 mg/m² nab-paclitaxel on day 1 and 60-100 mg/day S-1 on days 1-7 during a 14-day cycle. Patients were then assessed for resectability and response to treatment after six cycles. The primary end-points were 2-year overall survival (OS) rate and median OS time (trial registration: jRCTs061180045, UMIN000016630).

RESULTS

Forty-seven patients with BRPC-A were eligible for the present study. Six courses of neoadjuvant GAS regimen were completed in all eligible patients. The rate of grade III/IV toxicities occurred in 14 (30%) patients during the neoadjuvant GAS regimen. The response and disease control rates were 43% and 96%, respectively. Forty-five (96%) patients received potentially curative pancreatectomy, whereas two did not owing to disease progression. R0 resection was performed in 40 (86%) of 47 eligible patients. Eleven (24%) patients experienced postoperative major complications (>grade III), including one mortality. The 2-year OS rate and median OS time among 47 eligible patients were 70.1% and 41.0 months, respectively.

CONCLUSIONS

The neoadjuvant GAS chemotherapy regimen for BRPC-A showed good efficacy with mild toxicity, resulting in a high R0 resection rate and prolonged survival in patients with BRPC-A.

Prognostic Value of Peritoneal Lavage Cytology in Patients with Pancreatic Ductal Adenocarcinoma Stratified by the Resectability Status

BACKGROUND

The prognostic value of peritoneal lavage cytology (CY) for pancreatic ductal adenocarcinoma (PDAC) remains controversial. We assessed the prognostic impact of CY status stratified by resectability in PDAC patients treated with surgical resection.

METHODS

Clinical data from 440 patients with PDAC who underwent surgical resection were retrospectively analyzed to examine the association of CY status with clinicopathological factors and survival.

RESULTS

Positive CY status (CY+) was found in 30 patients (7%). These patients had significantly worse overall survival in both the resectable (R) (P = 0.002) and borderline resectable (BR) (P < 0.001) groups. The median survival time of CY+ patients in the R and BR groups was 25.6 and 6.7 months, respectively. Multivariate analysis revealed that CY+ was an independent prognostic factor in the BR group (P < 0.001) but not in the R group (P = 0.08). In the R group, CY+ patients who received adjuvant chemotherapy had significantly longer overall survival than those without adjuvant chemotherapy (34.3 vs. 9.8 months, respectively; P < 0.001).

CONCLUSIONS

The prognosis of CY+ patients in the BR group was extremely poor. In the R group, surgical resection combined with adjuvant chemotherapy may improve the prognosis of CY+ patients.

Neoadjuvant therapy contributes to nodal downstaging of pancreatic cancer

PURPOSE

This study aimed to assess the impact of neoadjuvant therapy (NAT) for borderline resectable or locally advanced pancreatic cancer (BR/LAPC) on the American Joint Commission on Cancer (AJCC) nodal status.

METHODS

The medical records of BR/LAPC patients who underwent surgery with curative intent were retrospectively reviewed. The nodal status was compared between patients who underwent upfront surgery (UFS) and those who received NAT. Moreover, clinicopathological factors and prognostic factors for overall survival were analyzed.

RESULTS

In all, 200 patients with BR/LAPC, 78 with UFS, and 122 with NAT were enrolled. The nodal status was significantly lower in patients after NAT than after UFS (p = 0.011). A multivariate analysis of overall survival showed that UFS (hazard ratio (HR) 1.61, p = 0.024) and N2 status (HR 2.69, p < 0.001) were independent poor prognostic factors. The median serum carbohydrate antigen (CA) 19-9 level after NAT in N2 patients was 105 U/mL, which was significantly higher than that of patients with N0 (p = 0.004) and N1 (p = 0.008) status.

CONCLUSION

Patients with BR/LAPC who underwent surgery after NAT had significantly lower N2 status and better prognosis than patients who underwent UFS. Elevated CA19-9 levels after NAT indicated a higher nodal status.

Is surgery justified for elderly patients with extrahepatic cholangiocarcinoma? Reappraisal from a viewpoint of comorbidity and organ function

PURPOSE

The benefit of surgery for older patients with extrahepatic cholangiocarcinoma (EHCC) has not been established and the differences in the general condition of younger vs. older patients remain unclear.

METHODS

Patients who underwent curative surgery for EHCC were divided into two groups according to age: those younger than 75 years old (younger group) and those aged 75 years or older (older group). We analyzed the clinical data of the two groups retrospectively.

RESULTS

Among the 116 patients analyzed, 45 (38.8%) were in the older group. Regarding comorbidity, only cardiac disease was significantly more common in the older patients; however, the cardiac function of the two groups was identical. There were no significant differences in the prevalence of kidney and lung disease, but renal function was significantly deteriorated and the incidence of the mixed ventilatory defect was significantly greater in the older group. The overall 5-year survival rates for the younger and older groups were 52.4% vs. 50.4% of all cholangiocarcinoma patients (p = 0.458), 42.4% vs. 51.3% of those with hilar cholangiocarcinoma (p = 0.718), and 69.0% vs. 49.1% of those with distal cholangiocarcinoma (p = 0.534), respectively.

CONCLUSIONS

Improved survival after surgery can be expected in well-selected older cholangiocarcinoma patients. Comorbidities were not necessarily reflected in organ function, with precise organ function assessment being more important when selecting surgical candidates.

Relationship between vancomycin-associated nephrotoxicity and the number of combined nephrotoxic agents

Vancomycin is associated with nephrotoxicity; however, the influence of the number of combined nephrotoxic agents on the incidence of vancomycin nephrotoxicity has not been clarified. We investigated patient backgrounds in 148 inpatients who received vancomycin treatment. The patients were divided into nephrotoxicity (n=35) and non-nephrotoxicity (n=113) groups. A comparison of the patient backgrounds in the two groups revealed significant differences in weight, changes in serum creatinine before vancomycin administration, blood urea nitrogen to serum creatinine ratio, length of vancomycin therapy, vancomycin trough concentration, and number of combined nephrotoxic agents. Multiple logistic regression analysis using these six factors as autonomous variables showed that the highest vancomycin trough concentration (odds ratio, 1.080; 95% confidence interval, 1.030-1.140; p = 0.003) and the number of combined nephrotoxic agents (odds ratio, 1.590; 95% confidence interval, 1.120-2.260; p = 0.010) were significantly related to nephrotoxicity.

Impact of Proteinuria and Low eGFR on Lifetime Risk of Cardiovascular Disease Death: A Pooled Analysis of Data From the Evidence for Cardiovascular Prevention From Observational Cohorts in Japan Study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): H20–Junkankitou [Seishuu]–Ippan–013; H23–Junkankitou [Seishuu]–Ippan–005; H26-Junkankitou [Seisaku]-Ippan-001; H29–Junkankitou–Ippan–003 and 20FA1002

OnBehalf

EPOCH-JAPAN

Introduction

Absolute risk of Lifetime risk (LTR) is useful estimate for risk communication compared with short term risk or relative risk especially for young people. Proteinuria is leading cause of end-stage kidney disease (ESKD) and independent risk factor for cardiovascular disease (CVD). Although nonproteinuric renal disease is global burden of ESKD, it has been poorly focused. To date, there have been no reports of impact of proteinuria and low eGFR on LTR with the outcome of CVD death in Asian population.

Purpose

We aimed to estimate LTR of CVD death stratified by the status of proteinuria and low eGFR.

Methods

We used modified Kaplan-Meier approach to estimate the remaining lifetime risk of cardiovascular death based on EPOCH-JAPAN(Evidence for Cardiovascular Prevention From Observational Cohorts in Japan) database. LTR was estimated at each index age starting from 40 years for those with proteinuria and without proteinuria stratified by low eGFR, which is defined as eGFR &lt;60 ml/min/1.73 m². Participants were classified into three groups, which were those with proteinuria (Proteinuria (+)), those without proteinuria with low eGFR (Proteinuria (-)/Low eGFR (+)), those without proteinuria without low eGFR (Proteinuria (-)/Low eGFR (-)).

Results

A total of 47,292 participants from 9 cohorts was included in the analysis. Mean follow-up period was 14.6 years with 690,463 person years and total CVD death was 1,075 in men and 1,193 in women. The LTRs at the index age of 40 years were as follows: 17.7% (95% confidence interval: 15.4 – 19.0%) in Proteinuria (-)/Low eGFR (-) group, 26.2% (20.2 – 31.1%) in Proteinuria (-)/low eGFR (+) group, 24.5% (15.1 – 29.3%) in Proteinuria (+) group for men; 15.3%(13.7 – 16.5%), 29.9%(14.7 – 46.8%) , 28.3%(19.4 – 34.7%) for women.

Conclusions

We observed that those without proteinuria with low eGFR have equivalently high LTR with those with proteinuria. These results indicate that even in the absence of proteinuria, low eGFR has high impact on LTR. Lifestyle modification from young age is necessary to prevent from renal dysfunction.

Triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction: a case report

BACKGROUND

Metachronous pancreatic and gallbladder cancer is a rare condition and has a dismal prognosis. Herein, we present a patient with triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction who achieved long-term survival after undergoing repeat curative surgery.

CASE PRESENTATION

A 65-year-old female patient with advanced gallbladder cancer associated with pancreaticobiliary maljunction underwent extended cholecystectomy with extrahepatic bile duct resection. The pathological diagnosis was T3N0M0 stage III A papillary adenocarcinoma with hepatic invasion. During a monthly follow-up, a diffuse hypovascular 2.0 × 1.5-cm mass was detected in the pancreatic head 6.2 years after the initial surgery. Hence, the patient underwent pancreaticoduodenectomy. Histological examination revealed T3N0M0 stage IIA well-differentiated adenocarcinoma without lymph node metastases. Marked inflammatory reaction was observed in the non-cancerous lesions of the proximal pancreatic head parenchyma containing bile pigment within ductular lumens. After 12.5 years from the initial surgery, total pancreatectomy for a 4.0 × 3.0-cm mass in the remnant pancreas was performed. Histological examination revealed T3N1M0 stage IIB moderately differentiated adenocarcinoma with lymph node metastases. Hence, surgical curative resection was achieved. Based on the pathological findings, a definitive diagnosis of triple metachronous pancreatic and gallbladder cancer was made. The pathology suggests no precursor lesions such as pancreatic intraepithelial neoplasia (PanIN) and atypical flat lesions, but marked inflammations in the non-cancerous lesions, strengthening our hypothesis that chronic inflammation induced by the pancreaticobiliary maljunction is related to carcinogenesis of the pancreas. Despite further adjuvant chemotherapy, the patient's general condition worsened; however, she remained alive 15.2 years after the initial surgery while receiving the best supportive care.

CONCLUSIONS

Repeat curative surgery for triple metachronous cancer was associated with a favorable prognosis. Both the biliary tract and the pancreas should be closely monitored during follow-up among patients with pancreaticobiliary maljunction, which can be managed with curative surgery.

Survival impact of distal pancreatectomy with en bloc celiac axis resection combined with neoadjuvant chemotherapy for borderline resectable or locally advanced pancreatic body carcinoma

BACKGROUND

The survival benefit associated with distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for patients with borderline resectable or locally advanced pancreatic body carcinoma is controversial. The aim of this study was to evaluate the impact of DP-CAR following neoadjuvant chemotherapy on survival in patients with borderline resectable or locally advanced pancreatic body carcinoma.

METHODS

Medical records of patients with pancreatic ductal adenocarcinoma who underwent distal pancreatectomy (DP, n = 102) and DP-CAR following neoadjuvant chemotherapy (n = 32) between 2008 and 2019 were analyzed retrospectively. Short- and long-term outcomes were compared between the two groups.

RESULTS

All patients who underwent DP-CAR had tumor contact with the celiac axis. Of these, 30 patients underwent preoperative embolization of the common hepatic artery. The pretreatment tumor size of patients who underwent DP-CAR was larger (P < 0.001), and rates of blood transfusion (P = 0.003) and postoperative complications (P = 0.016) were higher in patients who underwent DP-CAR compared with patients who underwent DP. The 5-year survival rate of patients who underwent DP and DP-CAR were 50.6% and 41.1%, respectively (median survival time, 65.9 vs 37.0 months). For all 134 patients, pretreatment serum CA19-9 levels (P < 0.001), adjuvant chemotherapy (P < 0.001), and lymph node status (P = 0.035) were independent prognostic factors of overall survival by multivariate analysis.

CONCLUSIONS

DP-CAR following neoadjuvant chemotherapy for patients with borderline resectable or locally advanced pancreatic body carcinoma may bring the same survival impact as DP, despite increased morbidity.

The prognostic impact of peritoneal washing cytology for otherwise resectable extrahepatic cholangiocarcinoma patients

The clinical importance of peritoneal washing cytology (PWC) for cholangiocarcinoma patients remains unclear. The clinical data of 137 extrahepatic cholangiocarcinoma patients who received PWC and curative surgery were retrospectively analyzed. Among the 137 patients analyzed, five (3.6%) had positive PWC, and 132 (96.4%) had negative PWC. The median survival time in patients with negative PWC was 6.45 years, and the overall 1-, 2-, and 5-year survival rates were 86.5%, 75.3%, and 51.6%, respectively. The median survival time in patients with positive PWC was 2.56 years, and the overall 1-, 2-, and 5-year survival rates were 60.0%, 60.0%, and 40.0%, respectively. A multivariate analysis revealed that positive lymph node metastasis (P < 0.001), positive perineural invasion (P = 0.014) and no use of adjuvant chemotherapy (P < 0.001), but not positive PWC were independently associated with a worse overall survival. In conclusion, surgery and subsequent chemotherapy might be a therapeutic option for cholangiocarcinoma patients with positive PWC.