Borderline Pancreatic Cancer Research Articles

Case Report: complete pathological response after chemotherapy for borderline pancreatic cancer

Background: Patients with borderline pancreatic cancer have a poor prognosis despite the recent development of multidisciplinary treatments that include chemotherapy. Nowadays induction chemotherapy is developing into a powerful cure to convert borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancers (LAPC) into a resectable cancer. This report supplements published data on the management border line pancreatic cancer and emphasizes the possibility of complete pathological response after chemotherapy in such cases. Case presentation: A 60-year-old man, with a type 2 Diabetes Mellitus, was diagnosed with a 3-centimeter T2N1M0 borderline pancreatic head tumor. Ultrasound endoscopy found a close contact with the superior mesenteric vein (< 180°) and an endoscopically guided biopsy confirmed the diagnosis of ductal adenocarcinoma. The patient underwent systemic chemotherapy with six injections of FOLFIRINOX without radiotherapy. The radiological re-staging revealed a cancer down-sizing of 2cm and tumor became resectable. The patient underwent a Whipple procedure with uneventful follow-up. The pathological examination of the specimen concluded to pathological complete response. The twelve lymph nodes evaluated were negative. Following surgery, adjuvant chemotherapy FOLFIRINOX was given. After three years of follow-up, there is no evidence of recurrence.

Pancreatectomía posneoadyuvancia en cáncer resecable “borderline”

Background: Pancreatectomy after neoadjuvant therapy in patients without disease progression is the standard treatment for borderline pancreatic cancer; however, no national series have been published to date. Objective: The aim of this study is to evaluate morbidity and mortality of patients with borderline resectable pancreatic cancer undergoing pancreatectomy after neoadjuvant therapy. Material and methods: A total of 15 patients treated between 2011 and 2018 were analyzed. The epidemiologic data, type of neodajuvant therapy, radiological evaluation of the response to neoadjuvant therapy, morbidity, mortality and survival were evaluated. These 15 patients who underwent pancreatectomy after neoadjuvant therapy were compared with 15 pancreatectomized patients without previous neoadjuvant therapy. Results: Mean age was 66.5 years and 8 patients were men. The most common neoadjuvant therapy regimens were FOLFIRINOX (n = 6) and gemcitabine/paclitaxel (n = 5); 8 patients required additional radiation therapy. The radiological evaluation of the response to neoadjuvant therapy showed stable disease in 10 patients and partial response in 4. Eleven patients underwent pancreaticoduodenectomy and 4 underwent splenectomy and pancreatectomy. Ten patients required some type of vascular resection. Morbidity was 60% (9/15), there were no deaths and mean survival was 23.4 months. There were no significant differences in morbidity, mortality and survival with the 15 pancreatectomized patients without previous neoadjuvant therapy. Conclusion: Neoadjuvant therapy has extended resectability of advanced pancreatic cancer. In high volume centers, pancreatectomy after neoadjuvant therapy has similar morbidity, and survival to those of pancreatic resections without previous neoadjuvant therapy.

GRECO-2: A randomized, phase 2 study of stereotactic body radiation therapy (SBRT) in combination with GC4711 in the treatment of unresectable or borderline resectable nonmetastatic pancreatic cancer (PC).

TPS4175 Background: While systemic treatment of PC has improved, rates of surgical resection - considered optimum treatment - remain low. Patients with un-resectable or borderline PC still have poor outcomes, with both toxicity and disease progression during induction chemotherapy limiting the number eligible for surgery. SBRT practice to enhance margin negative resection or to provide local control, if inoperable after neoadjuvant therapy, has shifted to higher dose delivery (Mellon 2015, Colbert 2018), but timing and appropriate patient selection are under constant debate. SBRT delivery over 50Gy exhibits superior cell killing compared to conventionally fractionated RT but carries potential GI toxicity risk (Zhong 2017). GC4711 is a selective superoxide dismutase mimetic that converts superoxide to hydrogen peroxide. As radiation response modifiers, dismutase mimetics have the potential to increase tumor control without compromising radiation safety (Sishc, AACR 2019). GC4711 consistently augmented tumor control by SBRT in PC experimental xenograft mouse models. In a pilot phase 1/2 trial (GC4419-101), subjects with locally advanced PC were randomized to receive SBRT plus either the selective dismutase mimetic GC4419 or placebo. This pilot trial has demonstrated acceptable safety with SBRT (5 × 10-11Gy), as well as apparent improvements in survival, surgical resection, locoregional control, and time to distant metastases. Altogether, these data support the hypothesis that GC4711 may improve tumor outcomes and the benefit-risk ratio of 5-fraction SBRT delivering 50Gy by improving efficacy without increasing GI-toxicity. Methods: GRECO-2 is a phase 2, multicenter, randomized, double-blind, placebo-controlled study to determine the effect on overall survival of adding GC4711 to SBRT following 4 months of chemotherapy in subjects with un-resectable or borderline non-metastatic PC. Approximately 160 subjects will be enrolled at over 20 sites to receive GC4711 100 mg or placebo IV given as IV infusion over 15 min, prior to each of 5 SBRT fractions of 10Gy). Subjects judged operable will be explored within 8 weeks after SBRT. All subjects will complete 2 additional months of adjuvant chemotherapy. Primary end point is overall survival and secondary endpoints address resection rates, local and distant disease progression, and safety, while exploratory studies include ctDNA, tumor exome/transcriptome sequencing, and immune profiling, patient-reported symptoms (PRO-CTCAE), CA19.9 normalization, and radiomics. Colbert L, Rebueno N, Moningi S et al Advances in Radiation Oncology (2018) 3, 693-700 Mellon EA, Hoffe SE, Springett GM, et al Acta Oncologica, 2015;54:7 Zhong J, Patel K, Switchenko J, et al. Cancer. 2017 Sep 15;123(18):3486-3493. Sishc BJ, Saha D, Story MD. AACR PADC 2019 C52. Clinical trial information: NCT04698915.

SEOM clinical guidelines for pancreatic and biliary tract cancer (2020)

Pancreatic cancer (PC) and biliary tract cancer (BTC) are both aggressive and highly fatal malignancies. Nowadays we have a profound knowledge about the molecular landscape of these neoplasms and this has allowed new therapeutic options. Surgery is the only potentially curative therapy in both cancers, but disease recurrence is frequent. In PC, adjuvant treatment with mFOLFIRINOX has improved overall survival (OS) and in BTC adjuvant treatment with capecitabine seems to improve OS and relapse-free survival. Concomitant radio-chemotherapy could also be considered following R1 surgery in both neoplasms. Neoadjuvant treatment represents the best option for achieving an R0 resection in borderline PC. Upfront systemic chemotherapy is the treatment of choice in unresectable locally advanced PC and BTC; then locoregional therapy could be considered after an initial period of at least 3–4 months of systemic chemotherapy. In metastatic PC, FOLFIRINOX or Gemcitabine plus nab-paclitaxel have improved OS compared with gemcitabine alone. In metastatic BTC, cisplatin plus gemcitabine constitute the standard treatment. Progress in the knowledge of molecular biology has enabled the identification of new targets for therapy with encouraging results that could in the future improve the survival and quality of life of patients with PC and BTC.

Prognostic analysis of pancreatic carcinoma with portal system invasion following curative resection.

To analyze the related factors affecting the prognosis of pancreatic carcinoma with portal system invasion. We retrospectively analyzed the clinical data of 118 patients with portal venous system invasion in Beijing Chaoyang Hospital between January 2011 and December 2018. Only patients with borderline resectable pancreatic cancer were included in this study. Borderline pancreatic cancer was defined according to NCCN (The National Comprehensive Cancer Network) guidelines. All patients underwent surgical treatment combined with vascular resection and reconstruction. The prognosis was evaluated according to the follow-up results, and the related risk factors for prognosis were analyzed. The survival curve was drawn by Kaplan-Meier method, and the survival rate was compared by log-rank test. Multivariate Cox regression was used to analyze the prognostic factors. In our research, all of 126 patients were successfully completed the operations. Complications occurred in 29.7% of patients and perioperative death in 4.0%. A total of 118 patients were followed up and the followed-up rate was 97.5% (118/121). The overall 1-year, 2-year and 3-year survival rates were 49.2%, 27.1% and 19.8%, And the median survival time was 20 months. Multivariate analysis showed that preoperative CA19-9 (RR 1.449, 95% CI: 1.053-1.994), N status (RR 2.533, 95% CI: 1.337-4.798), degree of tumor differentiation (RR 1.592, 95% CI: 1.064-2.381) and venous invasion depth (RR 2.03, 95% CI: 1.504-2.758) were independent risk factors for the prognosis. The long-term prognosis of pancreatic carcinoma patients with portal system invasion is poor. The venous invasion depth is an independent risk factor for the prognosis of pancreatic carcinoma with portal system invasion, the deeper of venous invasion, the worse the prognosis, and poorly differentiated tumors have the worst prognosis. Other independent risk factors included N status and the preoperative CA19-9. Those may help with patients' selection for different treatment protocols.

1565P Clinical outcome after perioperative treatment on locally advanced and borderline pancreatic cancer: Experience of a single academic center

One third of pancreatic cancers (PC) are borderline-resectable (BL) or locally advanced (LA). Even in the absence of metastases, prognosis is poor. There is a lack of prospective data supporting the best approach for these tumors.

Preoperative CT staging of borderline pancreatic cancer patients after neoadjuvant treatment: accuracy in the prediction of vascular invasion and resectability

To assess the utility of MDCT tumor-vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT). This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient. Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact > 2cm to predict vascular invasion, the AUCs for the two readers were 0.85-0.88 for arterial invasion and 0.92-0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact < 2cm to predict R0 resection, the AUCs was 0.85-0.86 for the two readers. The overall inter-reader agreement was good (κ = 0.75-0.80). The κ values for venous invasion, arterial invasion and R0 resection were 0.76, 0.78, and 0.80. Tumor-vessel criteria demonstrated good diagnostic performance and reproducibility in the prediction of vascular invasion after NAT in BRPC. These criteria could be helpful in the prediction of R0 resection in cases with only venous involvement.

Su1026 PATIENTS UNDERGOING CHEMOTHERAPY FOR BORDELINE RESECTABLE PANCREATIC CANCER CAUSING BILIARY OBSTRUCTION: HOW TO STENT WHILE AWAITING SURGERY? A COST-EFFECTIVENESS ANALYSIS

Background: The initial stenting approach to patients with malignant obstruction attributable to a borderline pancreatic cancer scheduled to undergo chemotherapy while awaiting possible surgery remains controversial due to discrepant results in the literature. The aim of this study was to compare the use of 2 competing standard types of stents to treat borderline resectable pancreatic cancer with biliary obstruction wile receiving chemotherapy in view of possible surgery. A decision tree was created in this patient population to assess the two competing strategies of inserting a PS or an MS over a time horizon extending up to 15 months after start of chemotherapy to account for measuring impacts of possible complications during an average 6 month chemotherapy course up to the decision of whether the patient is a candidate for surgery or not. The possible scenarios following the insertion of the biliary stent were modeled until the patients were considered ready for the surgery or not. After the initial stent insertion, there is a possibility of complications which can resolve or not, with or without hospitalization. All patients undergo chemotherapy according cycles every 15 days that are suspended during the time of hospitalization, if a complication occurs, and are restarted one week later. The effectiveness measure is the probability of being ready for the surgery. Probabilities were provided by contemporary literature. Mean hospital costs and mean length of stay are derived from a national US database. Physician fees and drug costs are the national amounts provided by CMS. All costs are updated for 2018. MS is a dominant strategy being both US$2233 cheaper and 11% more effective than the PS alternative. The average costs per patient are US$9304 for MS and US$11538 for PS, associated with respective effectiveness probabilities of 96% and 84.7% (likelihood of being ready for surgery, 15 months after initial stent insertion). The probability of failure after first complication in the model that was fixed at 21% should fall below 5% for PS to no longer be dominated. PS would be then more efficient than MS but would remain more costly. The domination of MS over PS is not affected when varying any of the other 24 variables across their respective ranges. The probabilistic sensitivity analysis confirms the robustness of these results. At the time of stent insertion when managing biliary obstruction for borderline resectable pancreatic cancer patients undergoing chemotherapy while awaiting surgery, the current cost-effectiveness analysis shows that using an initial MS is less costly and more effective than choosing a PS. Deterministic and probabilistic sensitivity analyses confirm the dominance of MS over PS for all plausible values of probability and cost input variables.

TRIANGLE operation for borderline resectable pancreatic cancer in total pancreatectomy

Background: Pancreatic cancer is a highly aggressive cancer featured by early metastasis and multiple chemoresistance. Surgical resection remains the only way for the radical cure of pancreatic cancer. The aim of this study was to assess the safety, feasibility and oncological effect of the Heidelberg TRIANGLE operation in total pancreatectomy (TP) for borderline resectable pancreatic cancer (BRPC). Methods: Patients with BRPC eligible for TP were selected and underwent total pancreatectomy with Heidelberg TRIANGLE operation. Sharp dissection was applied to separate tumor and involved artery. Then we completely dissected the soft tissues surround celiac axis (CA) and superior mesenteric artery (SMA) in each case. If superior mesenteric vein (SMV) or portal vein (PV) were invaded by the tumor, resection and reconstruction of veins were performed. Operation time, blood loss, post-operative complications, perioperative mortality, number of lymph node examined and R0 resection rate were collected and analyzed. Results: Nine BRPC patients underwent TRIANGLE operation in TP. No perioperative death occurred. 3 cases developed postoperative complications: biliary leakage and colon fistula in 1 case and lymphatic leakage in 2 cases. The R0 resection rate of operation was 88.89% (8/9). Conclusions: For patients with BRPC, upfront surgery should be encouraged when they were unwilling or unable to received neoadjuvant therapy. Especially for those patients with artery involvement eligible for TP, TRIANGLE operation can help to achieve arterial sparing resection. Thus, the risk of postoperative hemorrhage for vascular reconstruction and skeletonization can be reduced. After postoperative adjuvant therapy, the prognosis is acceptable.

Neoadjuvant therapy for pancreatic cancer

Pancreatic cancer has a extremely high malignancy, and simple surgical resection can not significantly improve the long-term survival rate of patients. Neoadjuvant therapy is the preoperative chemotherapy or combined chemo-radiotherapy, which is used for downstaging tumors, eliminating subclinical metastases, transforming unresectable into resectable tumors, and improving the R0 resection rate of pancreatic cancer, thus ultimately improving the efficacy of pancreatic cancer. At present, neoadjuvant therapy has gradually become the mainstream treatment for locally advanced and borderline resectable pancreatic cancer. New adjuvant therapy for resectable pancreatic cancer has been supported by some high-quality clinical research data, which will become a hot topic in clinical research. The author believes that there will be more clinical research data to help individualized neoadjuvant treatment selection, accurate efficacy evaluation and prognosis judgement, and ultimately improve the efficacy of patients with pancreatic cancer. Key words: Pancreatic neoplasms; Pancreatic cancer; Resectable pancreatic cancer; Borderline resectable pancreatic cancer; Unresectable pancreatic cancer; Neoadjuvant therapy

Selection strategy of neoadjuvant therapy for pancreatic cancer

Pancreatic cancer is a common malignancy with the worst prognosis. Radical surgery has been the only curative treatment for pancreatic cancer. With the advancement of surgical techniques and the implementation of the concept of comprehensive treatment for cancer in recent years, neoadjuvant therapy for pancreatic cancer has received more attention. There are continuing controversies in the hotspots and difficulties, with opportunities and challenges coexisting. Four famous experts and their teams in pancreatic surgery discussed selection strategy of neoadjuvant therapy for pancreatic cancer based on clinical experiences. Professor Wang Chunyou proposed that surgery was prior for patients with a higher likelihood of achieving R0 resection for pancreatic cancer to avoid the possibility of tumor progression and loss the opportanity of radical resection during neoadjuvant therapy. For patients with less chance of radical resection for pancreatic cancer and unresectable pancreatic cancer, neoadjuvant therapy is worthy of a positive attempt. Professor Jin Gang and his team believed that neoadjuvant therapy played an important role in improving the survival time of patients with pancreatic head cancer, especially with borderline resectable pancreatic head cancer. After neoadjuvant therapy, pancreatic surgeons should pay attention to improvement of surgery safety and R0 resection rate. Professor Dai Menghua and his team suggested that patients with resectable pancreatic cancer and borderline resectable pancreatic cancer could benefit from neoadjuvant therapy, which required proof from clinical trials. Surgeons should choose the appropriate treatment strategy based on guidelines and individual conditions for patients with pancreatic cancer. Professor Shao Cheghao and his team suggested that surgical treatment after neoadjuvant therapy or translational therapy for locally advanced pancreatic head cancer is safe, effective and feasible, especially for pancreaticoduodenectomy with combined revascularization. For the treatment of patients with pancreatic head cancer after neoadjuvant chemotherapy, the choice of next treatment options, evaluation indicators, timing of surgery and surgical methods need to be further studied. Key words: Pancreatic neoplasms; Pancreatic cancer; Pancreatic head neoplasms; Pancreatic head cancer; Neoadjuvant therapy; Surgical procedures, operative

Clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma

Objective To explore the clinical efficacy of radical resection with individualized surgical approach for borderline resectable pancreatic head carcinoma. Methods The retrospective descriptive study was conducted. The clinicopathological data of 54 patients with borderline resectable pancreatic head carcinoma who underwent radical resection with individualized surgical approach in the West China Hospital of Sichuan University from January 2015 to January 2018 were collected. There were 37 males and 17 females, aged from 37 to 73 years, with a median age of 59 years. For venous type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via inferior mesenteric vein, and surgery for pancreatic uncinate process carcinoma was performed via inferior colon artery. For arterial type borderline resectable pancreatic head carcinoma, surgery for pancreatic head carcinoma and (or) pancreatic head and neck carcinoma was performed via medial uncinate artery, and surgery for pancreatic uncinate process carcinoma was performed via left posterior artery. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative pathological examination; (4) follow-up. Patients were followed up by outpatient examination or telephone interview once every 3 months to detect survival up to March 2019. Measurement data with normal distribution were represented by Mean±SD. Measurement data with skewed distribution were represented by M (range), and count data were represented by absolute numbers or percentage. Kaplan-meier method was used to draw the survival curve and calculate the survival rate. Results (1) Surgical situations: all the 54 patients underwent expanded pancreatoduodenectomy combined with superior mesenteric vein/portal vein (SMV/PV) resection, including 15 via inferior mesenteric vein, 20 via inferior colon artery, 12 via medial uncinate artery, and 7 via left posterior artery. The operation time was (320±83)minutes, and the volume of intraoperative blood loss was (865±512)mL. (2) Postoperative complications: of 54 cases, 28 had postoperative complications, including 13 with grade 1 Clavien-Dindo complications, 12 with grade 2 Clavien-Dindo complications, 3 with grade 3 or above Clavien-Dindo complications. One of the 28 patients with postoperative complications died and 27 were improved after symptomatic and supportive treatment. (3) Postoperative pathological examination: of 54 patients, 31 had R0 resection and 23 had R1 resection. In the 23 patients with R1 resection, 5 underwent surgery via the inferior mesenteric vein (4 with involvement of pancreatic anterior surface, 1 with involvement of both pancreatic anterior and posterior surface), 9 underwent surgery via the inferior colon artery (2 with involvement of both pancreatic anterior and posterior surface, 2 with involvement of superior mesenteric artery margin, 2 with involvement of pancreatic posterior surface, 2 with involvement of pancreatic anterior surface, 1 with involvement of superior mesenteric artery margin and pancreatic posterior surface), 5 underwent surgery via the medial uncinate process artery (2 with involvement of superior mesenteric artery margin, 2 with involvement of both pancreatic anterior and posterior surface, 1 with involvement of pancreatic neck transected margin), and 4 underwent surgery via the left posterior artery (3 with involvement of superior mesenteric artery margin, 1 with involvement of both pancreatic anterior and posterior surface). Of 54 patients, 16 had no positive lymph nodes, 26 had 1-3 positive lymph nodes, and 12 had 4 or more positive lymph nodes. The tumor diameter was (3.20±0.14)cm. There were 48 of 54 patients with nerve infiltration, 41 with superior mesenteric vein and/or portal vein infiltration, and 11 with vascular thrombus. There were 17 of 54 patients with high differentiation and medium differentiation, and 37 with low differentiation and undifferentiation. (4) Follow-up: 54 patients were followed up for 1-42 months, with a median time of 19 months. The 1-, 3-year overall survival rate was 78.0%, 11.4%. Conclusion As for the borderline resectable pancreatic head cancer, individualized and customized surgical approach according to the location of tumor and the relationship with blood vessels is helpful to standardize the radical resection and avoid R2 resection. Key words: Pancreatic neoplasms; Pancreatic cancer; Borderline resectable; pancreaticoduodenectomy; Surgical approach; R2 resection; Efficacy

Surgical outcome of porto-mesenteric resection for borderline pancreatic cancer. A single tertiary referral centre experience

Background: Although recent series have concluded that major venous resection (VR) for borderline pancreatic cancer (BLPC) with porto-mesenteric involvement may be considered safe with comparable long-term survival compared to standard pancreaticoduodenenctomy (PD), the matter is still debated due to controversial evidences. The present study aims to evaluate in-hospital complication rate and surgical outcome after VR in a tertiary referral center. Methods: A retrospectively collected database running from April 2011 to January 2017 was performed selecting for patients undergoing PD with or without VR for pancreatic cancer. Perioperative data and pathological findings were statistically analyzed. Results: We identified 314 patients, of whom 277 (88.2%) underwent standard PD and 37 (11.8%) received concomitant VR. No statistically significant differences between the two groups were identified comparing mean age, median CA19.9 level, post-operative morbidity and mortality rate (p>0.05). Conversely, RV was associated with significantly higher median blood loss (p<0.001) and positive margin status rate (43.2% vs 21.7%; p<0.001) compared to standard PD. Conclusion: Porto-mesenteric resection for BLPC is feasible and safe when performed by experienced surgeon with overall morbidity and mortality comparable to standard PD. However, our series suggests that patients affected by BLPC should be addressed to neoadjuvant treatment first, as upfront VR seems to lead to a significantly lower rate of radical surgery.

Total Duodenopancreatectomy and Splenectomy with portal vein resection for borderline pancreatic cancer after neoajuvant chemoradiotherapy

Total Duodenopancreatectomy and Splenectomy with portal vein resection for borderline pancreatic cancer after neoajuvant chemoradiotherapy

Surgical outcome of porto-mesenteric resection for borderline pancreatic cancer. A single tertiary referral centre experience

Surgical outcome of porto-mesenteric resection for borderline pancreatic cancer. A single tertiary referral centre experience

Single-center experience of neoadjuvant therapy with gemcitabine and S-1 for borderline pancreatic cancer

Single-center experience of neoadjuvant therapy with gemcitabine and S-1 for borderline pancreatic cancer

Total duodenopancreatectomy and splenectomy with portal vein resection for borderline pancreatic cancer after neoajuvant chemoradiotherapy

Total duodenopancreatectomy and splenectomy with portal vein resection for borderline pancreatic cancer after neoajuvant chemoradiotherapy

Current status and controversies in the management of borderline resectable pancreatic cancer

The borderline resectable pancreatic cancer is high a controversial hotspot in the field of pancreatic surgery, and the controversy mainly focuses on definition and treatment. Five famous experts and their teams in pancreatic surgery discussed present situation and dilemmas in treatment of borderline resectable pancreatic cancer based on clinical experiences. Professor Hao Chunyi has reviewed and analyzed origin of the definition and treatment model of borderline resectable pancreatic cancer, and proposed that high-level pancreatic disease center and multidisciplinary collaboration diagnosis and treatment may be the best choice for resectable pancreatic cancer. Professor Liu Xubao suggested surgical treatment for most of borderline resectable pancreatic cancer, and whether or not tumor invades adjacent blood vessels and invasion level will be used to decide direct surgery or neoadjuvant therapy. Professor Sun Bei proposed 6 causes, and direct surgery may be more realistic and feasible option for borderline resectable pancreatic cancer. Professors Liang Tingbo and Bai Xueli recommended that neo-adjuvant therapy should be performed due to defeat hiding micrometastasis lesions and reduce tumor burden, and there was a higher R0 resection rate and lower lymph node metastasis rate after neoadjuvant therapy, meanwhile, it can also increase cure rate and is benefited to survival. Key words: Pancreatic neoplasms; Pancreatic cancer; Resectable; Borderline resectable; Direct surgery; Neoadjuvant therapy

Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected. The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements), and tumors of 13 patients were BR-A type (SMV, celiac trunk and / or hepatic artery involvements). The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection, the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway. Observation indicators: (1) intraoperative and postoperative situations; (2) results of postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018. Measurement data with skewed distribution were described as M (range). The survival curve was drawn by the Kaplan-Meir method, and Log-rank test was used for survival analysis. Results (1) Intraoperative and postoperative situations: 38 patients underwent intraoperative segmental resection of PV and / or SMV, including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis. Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ. There was no intraoperative celiac trunk resection. The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range, 280-520 minutes) and 530 mL (range, 420-650 mL). The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4%(7/38), and some patients were combined with multiple complications, including 6 with pulmonary infection, 4 with pancreatic fistula (B and C grade), 4 with intra-abdominal infection, 3 with delayed gastric emptying, 2 with postoperative bleeding and 2 with venous thrombosis. Five patients were cured by postoperative symptomatic treatment, and 2 with postoperative bleeding died of worsened condition after reoperation. The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3%(2/38) and 12 days (range, 9-52 days). (2) Results of postoperative pathological examination: the R0 resection rate of 38 patients was 81.6%(31/38). The R0 resection rate of 25 patients in BR-PV type was 92.0%(23/25), and resection margin of pancreatic leading edge < 1 mm was in 2 patients without R0 resection; R0 resection rate of 13 patients in BR-A type was 8/13, and resection margin of pancreatic leading edge < 1 mm was in 2 patients and resection margin of SMV < 1 mm was in 4 patients (1 margined with resection margin of multiple sites < 1 mm) of patients without R0 resection. The resection margins of pancreatic trailing edge, venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm. The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0%(25/25) and 9/13. (3) Follow-up and survival situations: 38 patients were followed up for 6-40 months, with a median time of 15 months, and survival time was 18 months (range, 6-40 months). The survival time and 1-, 2- and 3-year cumulative survival rates were respectively 23 months (range, 8-40 months), 89.5%, 33.1%, 22.1% in 25 patients with BR-PV type and 16 months (range, 6-25 months), 83.9%, 16.8%, 0 in 13 patients with BR-A type. The tumor-free survival time and 1- and 2-year cumulative tumor-free survival rates were respectively 15 months (range, 5-30 months), 63.0%, 7.5% in patients with BR-PV type and 9 months (range, 4-18 months), 11.5%, 0 in patients with BR-A type. Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements, pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV, and increase negative rates of venous and pancreatic resection margins. Key words: Pancreatic neoplasms; Borderline resectable pancreatic cancer; Resectable pancreatic neoplasms; Pancreaticoduodenectomy; Combined venous resection; Inferior mesenteric vein pathway

FOLFIRINOX as a first line therapy in locally advanced pancreatic cancer and borderline resectable pancreatic cancer: a Meta-analysis

Objective To evaluate the efficacyof the first line chemotherapy FOLFIRINOX (5-Fu, Leucovorin calcium, Irinotecan, Oxaliplatin) as the treatment of pancreatic cancer. Methods Pertinent studies were identified from the PubMed, Cochrane Library and EMBASE. The outcomes were resection rate and radical (R0) resection rate were analyzed. Data were expressed as weighted pooled proportions with 95% confidence intervals (95%CI). Results There were thirteen studies with 408 patients with LAPC and BRPC included. After the treatment, 42.0% (95% CI: 28.0%~56.0%) tumorswere resected and 41.0% (95% CI: 37.0%~45.0%) were underwentR0 resection, and median overall survival ranged from 15.5 to 34.5 months, median progression-free survival ranged from 10.0 to 17.8 months. Conclusion The meta-analysis shows that down-staging after first line FOLFIRINOX-based therapy is noticeable in patients with borderline resectable/unresectable PC, and the adverse events were in control. Key words: Pancreatic cancer; FOLFIRINOX; Resection; Chemotherapy