Major arterial resection for stage 3 adenocarcinoma of the pancreas.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 362-362
Author(s):  
Benjamin Loveday ◽  
Koji Tomiyama ◽  
Nathan Zilbert ◽  
Amélie Tremblay St-Germain ◽  
Pablo Emilio Serrano Aybar ◽  
...  
Keyword(s):  
Overall Survival ◽  
Treatment Program ◽  
Oncologic Outcomes ◽  
Ductal Adenocarcinoma ◽  
R0 Resection ◽  
Negative Resection Margin ◽  
Surgical Exploration ◽  
Intention To Treat ◽  
Pancreas Resection ◽  
Adenocarcinoma Of The Pancreas

362 Background: Stage 3 pancreas ductal adenocarcinoma (PDAC) is defined by arterial involvement, and its resection remains controversial. The objective of this study was to evaluate clinical and oncologic outcomes for patients with stage 3 PDAC who entered a treatment program of neoadjuvant therapy (NAT) and pancreatic resection, with comparison between those who underwent arterial (AR) vs. standard resection (SR). Methods: This cohort study included patients from 2009-2016 in a single academic institution, with biopsy-proven potentially resectable stage 3 PDAC who entered a treatment program of NAT followed by surgical exploration if non-progressive disease on imaging. AR was performed if required to achieve R0 resection. Oncological outcomes were analyzed as intention to treat from diagnosis date. Results: Eighty-nine patients met inclusion criteria, of whom 87 (97.8%) received chemotherapy and 50 (56.2%) received radiotherapy. 46/89 (51.7%) underwent surgical exploration; 31 underwent pancreas resection (AR n = 20, SR n = 11), and 15 were found to have metastatic or unresectable disease. The AR group had a longer operative time (681 vs. 563 minutes, p = 0.0059) and more blood loss (1600 vs. 575 mL, p = 0.0004) compared with SR, with no difference between groups for blood transfusion, overall complications, pancreatic fistula, length of stay, reoperation, readmission or mortality. R0 rate was 100% for resected patients. Post-operative 90-day mortality was 1.1%. Median overall survival of resected patients was longer than in non-resected patients (25.9 vs. 14.8 months, p = 0.01), while AR had comparable overall survival to SR (19.7 vs. 28.4 months, p = 0.41). Conclusions: Patients with non-progressive stage 3 PDAC after NAT should be considered for pancreas resection. AR had comparable clinical and oncologic outcomes to SR. Resection may offer a survival advantage over non-surgical therapy alone, and AR should be considered if required to obtain a negative resection margin.

CONKO-005: Adjuvant Chemotherapy With Gemcitabine Plus Erlotinib Versus Gemcitabine Alone in Patients After R0 Resection of Pancreatic Cancer: A Multicenter Randomized Phase III Trial

2017 ◽  
Vol 35 (29) ◽  
pp. 3330-3337 ◽  
Author(s):  
Marianne Sinn ◽  
Marcus Bahra ◽  
Torsten Liersch ◽  
Klaus Gellert ◽  
Helmut Messmann ◽  
...  
Keyword(s):  
Overall Survival ◽  
Adjuvant Treatment ◽  
Kinase Inhibitor ◽  
Growth Factor Receptor ◽  
Disease Free Survival ◽  
Phase Iii ◽  
Ductal Adenocarcinoma ◽  
R0 Resection ◽  
Open Label ◽  
Term Survival

Purpose Gemcitabine is standard of care in the adjuvant treatment of resectable pancreatic ductal adenocarcinoma (PDAC). The epidermal growth factor receptor tyrosine kinase inhibitor erlotinib in combination with gemcitabine has shown efficacy in the treatment of advanced PDAC and was considered to improve survival in patients with primarily resectable PDAC after R0 resection. Patients and Methods In an open-label, multicenter trial, patients were randomly assigned to one of two study arms: gemcitabine 1,000 mg/m2 days 1, 8, 15, every 4 weeks plus erlotinib 100 mg once per day (GemErlo) or gemcitabine (Gem) alone for six cycles. The primary end point of the study was to improve disease-free survival (DFS) from 14 to 18 months by adding erlotinib to gemcitabine. Results In all, 436 patients were randomly assigned at 57 study centers between April 2008 and July 2013. A total of 361 instances (83%) of disease recurrence were observed after a median follow-up of 54 months. Median treatment duration was 22 weeks in both arms. There was no difference in median DFS (GemErlo 11.4 months; Gem 11.4 months) or median overall survival (GemErlo 24.5 months; Gem 26.5 months). There was a trend toward long-term survival in favor of GemErlo (estimated survival after 1, 2, and 5 years for GemErlo was 77%, 53%, and 25% v 79%, 54%, and 20% for Gem, respectively). The occurrence or the grade of rash was not associated with a better survival in the GemErlo arm. Conclusion To the best of our knowledge, CONKO-005 is the first study to investigate the combination of chemotherapy and a targeted therapy in the adjuvant treatment of PDAC. GemErlo for 24 weeks did not improve DFS or overall survival over Gem.

Retrospective determination of the correlation between the distance of tumor manifestation to peripancreatic arteries and overall survival in primary resected pancreatic ductal adenocarcinoma.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e15745-e15745
Author(s):  
Uwe A Wittel ◽  
Michael Uhl ◽  
Frank Makowiec ◽  
Ulrich Theodor Hopt ◽  
Stefan Fichtner-Feigl ◽  
...  
Keyword(s):  
Overall Survival ◽  
Pancreatic Ductal Adenocarcinoma ◽  
Median Survival ◽  
Average Distance ◽  
Ductal Adenocarcinoma ◽  
Rank Test ◽  
Resection Margins ◽  
R0 Resection ◽  
Borderline Resectable ◽  
R1 Resection

e15745 Background: Current guidelines determine the resectability of PDAC by evaluating the contact of the tumor to peripancreatic vasculature. We wanted to evaluate the influence of this distance of the tumor to peripancreatic arteries on the overall survival of patients with primary resection of pancreatic ductal adenocarcinoma. Methods: Preoperative radiographs of 208 consecutive patients after distal pancreatectomy and/or pancreatoduodenectomy operated between 2007 and 2014 were included in the analysis. In reconstructions of CT and MRI data 90° planes to the centerline of the celiac trunc (CT), hepatic artery(HA) and superior mesenteric artery(SMA) were computed with Aquarius Intuition Viewer (V4.4.11, Terarecon). The closest distance between the tumor and the CT /HA and SMA was determined by an experienced pancreatic surgeon and radiologist independently and upon a deviation greater than 3 mm consent was reached by additional review in 33,2% (69/208) of the cases. Results: 176 CT and 32 MRI scans of 208 patients were evaluated. 2.4 % (5/208) of the radiographs were excluded due to insufficient quality. Average distance of the tumor to the CT/HA and SMA was 16.3 and 6.5 mm for PD and 12.7 and 11.0 mm for DP. Distance between the artery and the tumor did not influence the R0 resection rates (overall R0 > 1mm resection margin 64%) and median overall survival was 24.0 months after R0 resection and 13.5 months after R1 resection (log-rank test P < 0.05). Borderline resectable patients (n = 57) showed a median survival of 13.4 months, patients with their tumor 1-5mm distant to the closest artery (n = 65) and greater than 5 mm distance (n = 81) showed a median survival of 20.3 and 32.9 months respectively. Patients with 0-5 and greater than 5 mm distance between arteries and tumor showed a survival benefit from R0 resection (R0/R1 0-5mm 20.3/13.5 months; > 5mm 37.3/12.8 months) while R0 resected borderline resectable patients showed a similar survival than R1 resected patients (R0 12.7months, R1 15.1 months). Conclusions: The negative resection margins in borderline resectable patients not increase the survival when compared to R1 resected patients. Patients with primary R0 resection and initially large distance of the tumor to peripancreatic vasculature show a prolonged survival.

Impact of G-CSF during neoadjuvant therapy on outcomes of operable pancreatic cancer.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 4126-4126
Author(s):  
Pranav Murthy ◽  
Mazen S Zenati ◽  
Samer S. AlMasri ◽  
Aatur D. Singhi ◽  
Annissa DeSilva ◽  
...  
Keyword(s):  
Pancreatic Cancer ◽  
Overall Survival ◽  
Neoadjuvant Therapy ◽  
Tumor Staging ◽  
Neutrophil Extracellular Trap ◽  
Oncologic Outcomes ◽  
Ductal Adenocarcinoma ◽  
Common Side Effect ◽  
Interleukin 17 ◽  
The Impact

4126 Background: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease characterized by chronic inflammation and a tolerogenic immune response. Neutropenia is a common side effect of cytotoxic chemotherapy, managed with administration of recombinant granulocyte-colony stimulating factor (G-CSF, Filgrastim). The interleukin 17 – G-CSF – neutrophil extracellular trap (NET) axis promotes oncogenesis and progression of PDAC, inhibiting adaptive immunity. We evaluated the impact of G-CSF administration during neoadjuvant therapy (NAT) on oncologic outcomes in patients with operable pancreatic cancer. Methods: A retrospective review of all patients with localized PDAC treated with NAT prior to pancreatic resection between 2014 – 2020 was completed at a single institution. G-CSF administration, type, and dose were collected from inpatient and outpatient medical records. Results: Of 351 patients treated, 138 (39%) received G-CSF during NAT with a median follow-up of 45.8 months. Patients who received G-CSF were younger (64.0 vs 66.7, p = 0.008), had lower BMI (26.5 vs 27.9, p = 0.021), and were more likely to receive 5-FU based chemotherapy (42% vs 28.2%, p < 0.0001), NAT dose reduction (40.6% vs 25.4%, p = 0.003), or experience febrile neutropenia (8.7% vs 3.3%, p = 0.029). No differences were observed in baseline or pathologic tumor staging. In patients who received G-CSF, 130 (94%) received Pegfilgrastim with a median cumulative dose of 12 mg (IQR 6-12). Patients who received G-CSF were more likely to have an elevated post-NAT neutrophil to lymphocyte ratio (45% vs 29.6%, p = 0.004) and systemic immune-inflammation index (39.5% vs 29.6%, p = 0.061). Receiving G-CSF was an independent predictor of perineural invasion (HR 2.4, 95 CI [1.08, 5.5], p = 0.031) and margin positive resection (HR 1.69, 95 CI [1.01, 2.83], p = 0.043). Patients who received G-CSF had decreased overall survival compared to patients who did not receive G-CSF (median OS: 29.2 vs 38.7 months, p = 0.0001). Receiving G-CSF during NAT was an independent negative predictor of progression free (HR 1.38, 95 CI [1.04, 1.83], p = 0.022) and overall survival (HR 2.02, 95 CI [1.45, 2.79], p < 0.0001). In a subset of patients with available pre- and post-NAT serum specimens (n = 28), G-CSF administration resulted in an increased number of citrullinated histone H3 complexes following NAT (+1378±1502 vs -300.7±1147 pg/ml, p = 0.007), indicative of enhanced peripheral NET formation. Conclusions: In patients with localized PDAC receiving NAT prior to surgical extirpation, G-CSF administration is associated with worse oncologic outcomes and should be administered with caution. Prospective randomized as well as confirmatory clinical studies are in order.

The correlation between the proportion of patients with pancreatic ductal adenocarcinoma who received neoadjuvant therapy and overall survival between 2004 and 2015.

2019 ◽  
Vol 37 (4_suppl) ◽  
pp. 395-395
Author(s):  
George Molina ◽  
Akhil Chawla ◽  
Thomas E. Clancy ◽  
Jiping Wang
Keyword(s):  
Overall Survival ◽  
Pancreatic Ductal Adenocarcinoma ◽  
Neoadjuvant Therapy ◽  
Population Level ◽  
Ductal Adenocarcinoma ◽  
R0 Resection ◽  
Positive Correlation ◽  
R1 Resection ◽  
Spearman's Rho ◽  
Spearman’S Rho

395 Background: Neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) is associated with improved overall survival (OS), and this has led to its rising use. The aim of this study was to evaluate the correlation between use of NAT and OS among patients with PDAC. Methods: This population-level study evaluated the Spearman correlation between the annual proportion of patients receiving NAT and the annual 1-year and 5-year OS, respectively, using the 2004-2015 National Cancer Database. Annual 1-year and 5-year OS was calculated from year of diagnosis using Kaplan-Meier survival analysis. All patients with a confirmed diagnosis of PDAC (histology code 8500), without any metastasis, and who underwent an R0 or R1 resection were included. Results: A total of 18,852 patients (median age 67 (IQR 60–74); 49.4% female) with PDAC underwent an R0/R1 resection from 2004 to 2015. Among these patients, there was a significantly positive correlation between the proportion of patients who received NAT (12.1%; n = 2,133) and 1-year OS (Spearman’s rho = 0.9091; P = 0.0001) and 5-year OS (Spearman’s rho = 0.7833; P = 0.01), respectively. Patients who underwent R0 resection (n = 14,547; median age 67 (IQR 60-74); 49.9% female) had a significantly positive correlation between those who received NAT (13.1%; n = 1,773) and 1-year OS (Spearman’s rho = 0.8818; P = 0.0003) and 5-year OS (Spearman’s rho = 0.7333; P = 0.02), respectively. Among 9,142 patients who had upfront resectable disease with R0 resection margin status (median age 68 (IQR 60–75); 49.8% female), there was a significantly positive correlation between proportion of patients who received NAT (9.1%; n = 781) and 1-year OS (Spearman’s rho = 0.7273; P = 0.01) and 5-year OS (Spearman’s rho = 0.8000; P = 0.0096), respectively. Conclusions: Between 2004 and 2015 there has been an increase in the use of NAT for patients with PDAC. Concurrently, the OS has also increased during this time period. This study demonstrates that there is a statistically significant and positive correlation between the proportion of patients with R0/R1 resected PDAC who received NAT and 1-year OS and 5-year OS, respectively.

scholarly journals Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Meta-Analysis of Randomized Controlled Trials

2020 ◽  
Vol 9 (4) ◽  
pp. 1129 ◽  
Author(s):  
Jordan M. Cloyd ◽  
Victor Heh ◽  
Timothy M. Pawlik ◽  
Aslam Ejaz ◽  
Mary Dillhoff ◽  
...  
Keyword(s):  
Randomized Controlled Trials ◽  
Neoadjuvant Therapy ◽  
Meta Analysis ◽  
Ductal Adenocarcinoma ◽  
R0 Resection ◽  
Controlled Trials ◽  
Resectable Pancreatic Cancer ◽  
Borderline Resectable ◽  
Intention To Treat ◽  
Randomized Controlled

The efficacy of neoadjuvant therapy (NT) versus surgery first (SF) for pancreatic ductal adenocarcinoma (PDAC) remains controversial. A random-effects meta-analysis of only prospective randomized controlled trials (RCTs) comparing NT versus SF for potentially resectable (PR) or borderline resectable (BR) PDAC was performed. Among six RCTs including 850 patients, 411 (48.3%) received NT and 439 (51.6%) SF. In all included trials, NT was gemcitabine-based: four using chemoradiation and two chemotherapy alone. Based on an intention-to-treat analysis, NT resulted in improved overall survival (OS) compared to SF (HR 0.73, 95% CI 0.61–0.86). This effect was independent of anatomic classification (PR: hazard ratio (HR) 0.73, 95% CI 0.59–0.91; BR: HR 0.51 95% CI 0.28–0.93) or NT type (chemoradiation: HR 0.77, 95% CI 0.61–0.98; chemotherapy alone: HR 0.68, 95% CI 0.54–0.87). Overall resection rate was similar (risk ratio (RR) 0.93, 95% CI 0.82–1.04, I2 = 39.0%) but NT increased the likelihood of a margin-negative (R0) resection (RR 1.51, 95% CI 1.18–1.93, I2 = 0%) and having negative lymph nodes (RR 2.07, 95% CI 1.47–2.91, I2 = 12.3%). In this meta-analysis of prospective RCTs, NT significantly improved OS in an intention-to-treat fashion, compared with SF for localized PDAC. Randomized controlled trials using contemporary multi-agent chemotherapy will be needed to confirm these findings and to define the optimal NT regimen.

scholarly journals P-P42 Neo-adjuvant Chemoradiation for Borderline Resectable Pancreatic Adenocarcinoma: A UK Tertiary Surgical Oncology Centre Series

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Marina Likos-Corbett ◽  
Pranav Patel ◽  
Rachna Goburdhun ◽  
Satvinder Mudan ◽  
Amir Khan ◽  
...  
Keyword(s):  
Overall Survival ◽  
Pancreatic Ductal Adenocarcinoma ◽  
Disease Free Survival ◽  
Ductal Adenocarcinoma ◽  
R0 Resection ◽  
Positive Surgical Margin ◽  
Resection Rate ◽  
Adjuvant Chemoradiation ◽  
Borderline Resectable ◽  
Term Survival

Abstract Background Pancreatic ductal adenocarcinoma (PDAC) is associated with a historically poor long-term survival of 5-10%, despite surgical resection. Borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) is reported as potentially resectable disease with a degree of vascular involvement, increasing the risk of a positive surgical margin. This cohort of patients have the worst survival despite curative resection and adjuvant chemotherapy. Emerging evidence suggests that neo-adjuvant chemoradiation (NCR) improves R0 resection rates in BR-PDAC patients. We evaluated the R0 resection rate, disease free survival (DFS) and overall survival (OS) in our patients, who had undergone NCR for BR-PDAC at our institution. Methods Data was collected retrospectively for all patients undergoing NCR for BR-PDAC between Jan 2010 to Mar 2020 for this study. Surgical management was ratified by clinical assessment and cross-sectional imaging in a pancreatic multidisciplinary team meeting (MDM). Patients underwent NCR by a number of standardised regimens. Patients with proven regressive or stable disease on imaging underwent a pancreatic resection. All BR-PDAC patients underwent resection in the form of classical Whipple’s or pylorus preserving pancreaticoduodenectomy (PPPD) depending on intra-operative findings. Patient morbidity, R0 resection rate, histological parameters, DFS and OS were evaluated. Results 29 patients were included in the study (16 men and 13 women), with a median age of 65 years (range, 46-74 years). 17 patients received FOLFIRINOX and 12 patients received gemcitabine (GEM) based NCR regimens. All patients received chemoradiation at the end of chemotherapy (range 45-56Gy). 75% had an R0 resection, with a greater proportion in the FOLFIRINOX group. Whole cohort median DFS was 35 months, survival was superior in the FOLFIRINOX group (42 months). Median OS was 30 months for the whole group, with a greater median OS in the FOLFIRINOX versus the GEM cohort (42 versus 29 months). Conclusions We present a single centre retrospective study utilising NCR for BR-PDAC, we reiterate the strong association of an R0 resection with superior patient overall survival following surgery in this cohort. We show that in patients with BR-PDAC, NCR results in superior R0 resection rates with an associated increase in patient survival. Our results show that survival advantage is greatest in BR-PDAC patients who received neo-adjuvant FOLFIRINOX.  Our findings affirm the advantage of NCR prior to surgery, particularly FOLFIRINOX based treatment, in this cohort of patients.

Robotic-assisted pancreaticoduodenctomy at a high-volume pancreas center.

2011 ◽  
Vol 29 (4_suppl) ◽  
pp. 258-258 ◽  
Author(s):  
A. H. Zureikat ◽  
D. L. Bartlett ◽  
J. L. Steel ◽  
A. J. Moser ◽  
H. Zeh
Keyword(s):  
Blood Loss ◽  
High Volume ◽  
Oncologic Outcomes ◽  
Ductal Adenocarcinoma ◽  
Cystic Neoplasm ◽  
R0 Resection ◽  
Ampullary Adenocarcinoma ◽  
Robotic Assisted ◽  
Final Pathology ◽  
Estimated Blood Loss

258 Background: Robotic-assisted pancreatic surgery is gaining momentum due to improved ergonomics, dexterity, and visualization compared to standard laparoscopy. These technical advantages in combination with experience and improved robotic technology may reduce the significant morbidity associated with pancreaticoduodenectomy (PD). Methods: Retrospective analysis of consecutive robotic-assisted PD performed for all indications. Patients with potentially resectable tumors were selected for robotic PD on the basis of our EUS/CT predictive model. We evaluated perioperative events, final pathology, and complications occurring within the first 30 days on an intention-to-treat basis. Results: 42 robotic-assisted PD (22 women) were attempted between October 2008 and June 2010. Mean age was 67 years (SD=16, range 27-85), with median BMI 26.5 (IQR=7.8). 52.4% of patients had an ASA score of III. Final pathology included 13 pancreatic ductal adenocarcinoma, 9 peri-ampullary adenocarcinoma, 8 pancreatic neuroendocrine tumors, 5 IPMN, 2 cholangiocarcinoma, 2 pseudo-papillary neoplasm, 1 serous cystadenoma, 1 mucinous cystic neoplasm, and 1 duodenal adenoma. The first 34 patients underwent classic PD, and the final 8 patients had pylorus-preserving PD. Conversion to open was necessary in 8 patients (19%). Mean operative time was 576 min (SD=327, range 327-848 min) with 400mL median estimated blood loss (IQR=475). For malignancies, the R0 resection rate was 88% (4/34) with mean lymph node harvest of 17 (SD=7.3, range 8-37). The pancreatic fistula rate was 21% with ISGPF Grades B and C leaks observed in 9.6%. 10 patients (23.8%) developed minor complications (Clavien grade 1/2), whereas 11 had major complications (26.2%). There was one late death (2.4%). Median length of stay was 10 days (IQR=5). Statistically significant reductions in estimated blood loss (643mL vs. 317mL, p=0.003) and conversion to open (7 vs. 1, p=0.02) were observed in the latter half of the series. Conclusions: Robotic-assisted PD can be performed safely with postoperative and oncologic outcomes comparable to open surgery. The learning curve continues to evolve after 40 cases. No significant financial relationships to disclose.

scholarly journals Is surgery after neoadjuvant chemoradiotherapy feasible for elderly patients with resectable or borderline resectable pancreatic ductal adenocarcinoma?

2020 ◽  
Author(s):  
Hironobu Suto ◽  
Keiichi Okano ◽  
Minoru Oshima ◽  
Yasuhisa Ando ◽  
Hiroyuki Matsukawa ◽  
...  
Keyword(s):  
Overall Survival ◽  
Adjuvant Chemotherapy ◽  
Elderly Patients ◽  
Pancreatic Ductal Adenocarcinoma ◽  
Neoadjuvant Chemoradiotherapy ◽  
The Elderly ◽  
Elderly Group ◽  
Ductal Adenocarcinoma ◽  
Borderline Resectable ◽  
Pancreas Resection

Abstract Background The benefit and safety of pancreas resection for pancreatic ductal adenocarcinoma for elderly patients, especially after preoperative adjuvant therapy, is still unknown. This study attempted to evaluate perioperative and long-term outcomes after pancreas resection in elderly patients with pancreatic ductal adenocarcinoma and to detect the potential impact of neoadjuvant chemoradiotherapy. Methods One hundred and thirty-four consecutive patients undergoing curative resection for resectable and borderline resectable pancreatic ductal adenocarcinoma between March 2008 and February 2018 at our institution were analyzed. Patients were divided into two groups: patients older than or equal to 75 years (the elderly group, n=46) and those younger than 75 years (the younger group, n= 88). Results There were no significant differences both in overall survival and relapse free survival between the two groups (P=0.270, P=0.699). Although the induction rate of adjuvant chemotherapy was not significantly different (P=0.458), the completion rate was significantly lower in elderly group than that in younger group (35% and 56%; P=0.022). Neoadjuvant chemoradiotherapy was performed for 82 patients (61%), and the induction and completion rates were not significantly different (P=0.668, P=0.794) between the two groups. The elderly patients with completion of adjuvant chemotherapy had significantly better overall survival than those without it (P=0.032). Neoadjuvant chemoradiotherapy did not significantly affect overall survival in elderly patients, however, there was a trend toward longer overall survival in patients who had neoadjuvant chemoradiotherapy (P=0.072). Conclusions Neoadjuvant chemoradiotherapy could be introduced and completed even for elderly patients without serious complications and might lead to improved prognosis for those who are difficult to complete postoperative adjuvant chemotherapy.

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