Borderline Resectable Pancreatic Head Cancer Research Articles

A Prospective Randomized Control Study of Neo-adjuvant Chemo Radiation Followed by Surgery versus Upfront Surgery in Resectable and Borderline Resectable Pancreatic Head Cancer: Pilot Study

A Prospective Randomized Control Study of Neo-adjuvant Chemo Radiation Followed by Surgery versus Upfront Surgery in Resectable and Borderline Resectable Pancreatic Head Cancer: Pilot Study

Comparison of access to the superior mesenteric arteryduring the execution of the pancreatoduodenal resectionin patients with borderline-resectable cancer of the pancreatic head

The purpose of the study is to study the technical aspects of surgical treatment of borderline-resectable pancreatic head tumors Materials and methods. An analysis of the implementation of the DA was performed in 102 patients with borderline-resectable pancreatic head cancer. In 20% of patients, the tumor grows in the region of the celiac-mesenteric gap of the tumor (mesopancreas germination). In 25.6%, the tumor grows on the wall of the portal-superior mesenteric segment. In 12.7%, the tumor tightly covers the walls of the branches of the celiac trunk or superior mesenteric artery by less than 180 degrees, extending to the fascial sheath and adventitia of the vessel. Results. During the implementation of the DA with various methods of access to the IWL, no significant differences were revealed in the early postoperative period. Conclusion. The choice of access is determined by the “anatomy” of the spread of the tumor. AMS rear access is most convenient for IPDA isolation and ligation. Mesenteric access allows the most secure ligation of PDJV

A case of pancreatic head cancer with Trousseau’s syndrome treated with radical resection and anticoagulant therapy

BackgroundThe primary disease of Trousseau’s syndrome is often highly advanced cancer, and treatment of the primary disease after cerebral infarction is often difficult. We herein report a case of pancreatic head cancer with Trousseau’s syndrome treated with radical resection and anticoagulant therapy.Case presentationA 78-year-old man was admitted with dizziness and diagnosed with cerebral infarction. Abdominal contrast-enhanced computed tomography for a thorough checkup indicated borderline resectable pancreatic head cancer. Radical resection after neoadjuvant chemotherapy (NAC; gemcitabine plus nab-paclitaxel) was scheduled. During the second course of NAC, multiple cerebral infarctions recurred, and the patient was diagnosed with Trousseau’s syndrome. Continuous intravenous infusion of heparin was started for cerebral infarction. Since it was impossible to continue NAC and there was no worsening of imaging findings, radical resection was planned. Thereafter, he underwent pancreatoduodenectomy with superior mesenteric vein resection. The patient progressed well and was discharged on the 19th day after surgery. He continued subcutaneous injection of heparin at home and is alive without recurrence of cancer or cerebral infarction at more than 21 months after surgery.ConclusionSurgical treatment may be an option for pancreatic cancer with Trousseau’s syndrome under favorable conditions.

Evaluation of local recurrence after pancreaticoduodenectomy for borderline resectable pancreatic head cancer with neoadjuvant chemotherapy: Can the resection level change after chemotherapy?

BackgroundNeoadjuvant treatment has significant survival benefits for patients with pancreatic cancer. However, local recurrence remains a serious issue, even after neoadjuvant treatment. This study investigated local recurrence after pancreaticoduodenectomy and determined the optimal resection level after neoadjuvant treatment. MethodsThis retrospective study analyzed consecutive patients who underwent pancreaticoduodenectomy for borderline resectable pancreatic cancer after 4 cycles of neoadjuvant treatment-gemcitabine plus nab-paclitaxel between April 2015 and March 2020. Patients with borderline resectable-artery pancreatic cancer were classified according to the dissection level around the artery: level 3 group, hemi-, or whole circumferential arterial nerve plexus was dissected; and level 2 group, the nerve plexus was preserved. ResultsFifty-six patients with borderline resectable-artery pancreatic cancer underwent pancreaticoduodenectomy after neoadjuvant treatment (level 3 group, n = 40; level 2 group, n = 16). The resection level in the level 2 group was changed based on post-neoadjuvant treatment computed tomography images or intraoperative frozen section diagnosis. The overall and local recurrence rates were significantly higher in the level 2 group than in the level 3 group (overall recurrence, 93.8% vs 70.0%; P = .037) (local recurrence, 50.0% vs 5.0%; P < .001). Ten patients experienced local recurrence, of which 8 belonged to the level 2 group. Among them, 4 patients were confirmed as cancer-negative by surgical margin analysis or intraoperative frozen section diagnosis but experienced recurrence around the arteries. ConclusionFor treating borderline resectable-artery pancreatic cancer, changing the resection level based on post-neoadjuvant treatment computed tomography images increased the risk of local recurrence. All patients with borderline resectable-artery should undergo level 3 dissection, regardless of the response to neoadjuvant treatment.

Diagnostic Accuracy of CT for Evaluating Circumferential Resection Margin Status in Resectable or Borderline Resectable Pancreatic Head Cancer: A Prospective Study Using Axially Sliced Surgical Pathologic Correlation

ObjectiveCT plays a central role in determining the resectability of pancreatic cancer, which directs the use of neoadjuvant therapy. This study aimed to assess the diagnostic accuracy of CT in predicting circumferential resection margin (CRM) involvement in patients with resectable or borderline resectable pancreatic head cancer.Materials and MethodsSeventy-seven patients who were scheduled for upfront surgery for resectable or borderline resectable pancreatic head cancer were prospectively enrolled, and 75 patients (38 male and 37 female; mean age ± standard deviation, 68 ± 11 years) were finally analyzed. The CRM status was evaluated separately for the superior mesenteric artery (SMA) and posterior and superior mesenteric vein/portal vein (SMV/PV) margins. Three independent radiologists reviewed the preoperative CT images and evaluated the resection margin status. The reference standard for CRM status was pathologic examination of pancreaticoduodenectomy specimens in an axial plane perpendicular to the axis of the second portion of the duodenum. The diagnostic accuracy of CT was assessed for overall CRM involvement, defined as involvement of the SMA or posterior margins (per-patient analysis), and involvement of each of the three resection margins (per-margin analysis). The data were pooled using a crossed random effects model.ResultsForty patients had pathologically confirmed overall CRM involvement in pancreatic cancer, while CRM involvement was not seen in 35 patients. For overall CRM involvement, the pooled sensitivity and specificity were 15% (95% confidence interval: 7%–49%) and 99% (96%–100%), respectively. For each of the resection margins, the pooled sensitivity and specificity were 14% (9%–54%) and 99% (38%–100%) for the SMA margin, 12% (8%–46%) and 99% (97%–100%) for the posterior margin; and 37% (29%–53%) and 96% (31%–100%) for the SMV/PV margin, respectively.ConclusionCT showed very high specificity but low sensitivity in predicting pathological CRM involvement in pancreatic cancer.

Extended lymphadenectomy benefits patients with borderline resectable pancreatic head cancer-a single-center retrospective study.

Whether standard lymphadenectomy or extended lymphadenectomy should be performed is still under debate during pancreaticoduodenectomy (PD). We aimed to compare their morbidity and mortality rates among patients with pancreatic head cancer (PHC). In this retrospective study, a total of 322 patients were enrolled. According to the scope of intraoperative lymph node dissection, patients were divided into extended lymphadenectomy group (n=120) and standard lymphadenectomy group (n=202). Based on the resectability of the tumor, there were 198 cases of resectable PHC and 124 cases of borderline resectable PHC, respectively, in which further stratified analysis was carried out according to the extent of lymph node dissection. All patients completed the operation successfully, with a perioperative morbidity rate of 27.9% and mortality rate of 0.9%. As for the overall patients, patients in the extended lymphadenectomy group had higher neutrophil-to-lymphocyte ratio (NLR), longer operation time, more intraoperative blood loss, lymph node dissection and patients with borderline resectable pancreatic head cancer (BRPHC) (P<0.05). The 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 71.9%, 50.6%, 30.0% and 70.0%, 32.9%, 21.5%, respectively (P=0.068). With regards to patients with BRPHC, the number of lymph node dissection in the extended lymphadenectomy group was more (P<0.05), and the 1-, 2- and 3-year overall survival rates of patients with extended lymphadenectomy and standard lymphadenectomy were 60.7%, 43.3%, 27.4% and 43.2%, 17.7%, 17.7%, respectively (P=0.007). Patients with BRPHC tended to have vast lymph node metastasis. Extended lymphadenectomy can improve their long-term survival.

Hepatic artery reconstruction after extended resection for borderline resectable pancreatic head cancer: A case report

Pancreatic head cancer is frequently associated with invasion of the surrounding vascular structures, such cases being considered for a long period of time as unresectable. Improvement of the vascular surgery techniques allowed association of extended vascular resections and reconstructions, increasing in this way the percentage of patients benefiting from radical surgery. We present the case of a 47-year-old male patient with no significant medical history diagnosed with a large pancreatic head tumor invading the common and proper hepatic artery as well as the portal vein. The venous reconstruction was performed using a synthetic prosthesis while the left hepatic artery was sutured to the left gastric artery; meanwhile the right hepatic artery was reconstructed using the splenic artery. In conclusion, extended hepatic artery resection followed by arterial reconstruction in association with portal vein resection and prosthetic replacement might be needed in cases presenting large pancreatic head tumors with vascular invasion.

Neoadjuvant therapy followed by pancreaticoduodenectomy for resectable and borderline resectable pancreatic head cancer: A propensity score matched per protocol analysis

Neoadjuvant therapy followed by pancreaticoduodenectomy for resectable and borderline resectable pancreatic head cancer: A propensity score matched per protocol analysis

Abstract B34: The impact of lymphocyte-to-monocyte ratio (LMR) in patients with borderline resectable pancreatic head cancer after curative surgery

Abstract Introduction: The outcome of patients with borderline resectable pancreatic ductal adenocarcinoma (BR PDAC) remains dismal even if the patients received neoadjuvant chemotherapy followed by radical resection. Pancreatic resection is highly invasive and sometimes fatal; thus, useful preoperative indicators for favorable prognosis of patients with PDAC are needed. Lymphocyte-to-monocyte ratio (LMR) is a systemic inflammatory response marker associated with cancer outcome. In the present study, we evaluated the clinical significance of LMR for BR head-PDAC patients. Materials and Methods: Consecutive 67 borderline resectable (BR) head-PDAC patients who underwent pancreaticoduodenectomy from Jan. 2008 to Dec. 2017 at Chiba University Hospital were analyzed retrospectively. The levels of LMR were calculated by simply dividing the absolute lymphocyte count by the monocyte count from routine preoperative blood sample, and the cut-off value of LMR was determined by receiver operating curve analysis. All the participants were divided into two groups (High/Low) based on the level of LMR. Among the clinicopathologic factors, we analyzed the clinical significance of preoperative LMR using the Kaplan-Meier analysis and Cox proportional regression model. Results: The characteristics of participants were as follows: median age: 67 (interquartile range (IQR) 61-72) years old, sex M/F: 49/18, resectability based on NCCN 2018.2 (BR-PV/BR-A): 38/29, neoadjuvant chemotherapy (done/none): 36/31, adjuvant chemotherapy (done/none): 59/8, R0/1 resection: 51/16, respectively. The median level of preoperative LMR was 4.17 (IQR 2.51-6.09). The cut-off value of LMR was calculated to be 5.63 by applying Youden Index. All PDAC patients were classified into high LMR group (n=20) and low LMR group (n=47). The Kaplan-Meier analysis showed that the outcome of patients in high LMR group was significantly better compared to that in low LMR group (P=0.029 log-rank test). The median overall survival time after surgery was 17.6 months in low LMR group versus 38.1 months in high LMR group. Furthermore, multivariate analysis revealed that high LMR (P=0.012) and low preoperative CA19-9 level (P=0.012) were identified as independent prognostic factors of favorable outcomes in patients with BR head-PDAC. Conclusions: The present study demonstrated both LMR and preoperative CA19-9 were independent prognostic factors in patients with BR head-PDAC. Because these markers can be obtained preoperatively, they will contribute to determination of the strategy for treatment of BR PDAC patients. Citation Format: Yoji Miyahara, Shigetsugu Takano, Hideyuki Yoshitomi, Shingo Kagawa, Katsunori Furukawa, Tsukasa Takayashiki, Satoshi Kuboki, Daisuke Suzuki, Nozomu Sakai, Takashi Mishima, Eri Nakadai, Masayuki Ohtsuka. The impact of lymphocyte-to-monocyte ratio (LMR) in patients with borderline resectable pancreatic head cancer after curative surgery [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr B34.

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

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

Significance of neoadjuvant chemoradiotherapy for borderline resectable pancreatic head cancer: Pathological local invasion and microvessel invasion analysis.

Borderline resectable pancreatic head cancer (BR-PHC) has low resectability due to vascular invasion. Although the clinical effects of neoadjuvant chemoradiotherapy (NAC-RT) for BR-PHC have been examined, few studies have reported its pathological aspects. The present study retrospectively investigated the effect of NAC-RT on the histological features of BR-PHC. A total of 29 patients with BR-PHC who underwent NAC-RT, and 55 controls with resectable PHC, who underwent pancreaticoduodenectomy at the Kurume University Hospital. Tumor staging, lymphovascular invasion (LVI), and microvessel invasion (MVI) were evaluated. The median tumor size in the NAC-RT group was 2.0 cm, and it was smaller than that of the control group (P=0.006). The rates of lymph node metastasis, LVI, and MVI were significantly lower in the NAC-RT group (P<0.001, 0.002, and 0.015, respectively). Overall survival in the NAC-RT group was comparable to that in the control group, although patients with BR-PHC generally had a poorer prognosis than those with resectable PHC. Patients in the NAC-RT group without portal vein invasion (PVI) had a significantly better prognosis than those with PVI in the control group (P=0.002). NAC-RT may be beneficial for patients with BR-PHC by inhibiting local invasion and metastasis as prognosis following resection could be equivalent to that of patients with conventional ductal adenocarcinoma.

Diagnostic Performance of Computed Tomography in Predicting a Positive Circumferential Resection Margin for Resectable and Borderline Resectable Pancreatic Head Cancer

Introduction: To measure the diagnostic performance of computed tomography (CT) for the circumferential resection margin (CRM) status in patients with resectable and borderline resectable pancreatic head cancer. Method: We included 75 patients (37 females, mean age, 71 ± 11 years) who had a resectable and borderline resectable pancreatic head cancer and underwent upfront surgery. For the analysis, the CRM was subdivided into superior mesenteric artery (SMA), superior mesenteric vein/portal vein (SMV/PV) and posterior margins. Three abdominal radiologists retrospectively reviewed the preoperative CT images and evaluated CT resection margin status. The reference standard for the CRM status was pathologically made. A positive resection margin was defined as the presence of tumor cells within 1 mm of the CRM. The diagnostic performance of CT was measured for the overall CRM (per-patient analysis) and each of resection margin (per-margin analysis). We pooled the data across the radiologists using the generalized linear mixed model. Result: Thirty-eight patients were pathologically confirmed to have involved CRM. In per-patient analysis, the pooled sensitivity and specificity was 13.7% and 98.1%, respectively. In per-margin analysis, the pooled sensitivity and specificity for SMA margin was 12.4% and 98.1%, respectively; for posterior margin, 10.3% and 99.4%, respectively; for SMV/PV, 26.9% and 96.3%, respectively. Conclusion: Very low sensitivity and high specificity of CT in predicting a positive CRM suggests that CT has poor performance to select patients who would benefit from neoadjuvant therapy rather than upfront surgery in patients with resectable and borderline resectable pancreatic head cancer.

Pancreaticoduodenectomy for borderline resectable pancreatic head cancer with a modified artery-first approach technique

The treatment of borderline resectable pancreatic head cancer (BRPHC) is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach (MAFA), with conventional techniques for the surgical treatment of BRPHC. A total of 117 patients with BRPHC undergone pancreaticoduodenectomy (PD) from January 2013 to June 2015 were included. They were divided into an MAFA group (n=78) and a conventional-technique group (n=39). Background characteristics, operative data and complications were compared between the two groups. Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group (313 vs 384 min; P=0.014); mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group (534 vs 756 mL; P=0.043); and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group (61.5% vs 35.9%; P=0.014). Pathologic data, early mortality and morbidity were not different significantly between the two groups. MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.

Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer

BackgroundA superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy. MethodsA modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration. ResultsOf 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years. ConclusionsShort-term results with the procedure may encourage surgical management for BRPHC.

脾動脈切除再建を伴う膵頭十二指腸切除にて膵全摘術を回避し長期生存を得たBorderline resectable膵頭部癌の1例

症例は71歳の女性．心窩部痛を契機に上部消化管内視鏡検査で十二指腸第II部に変形・狭窄および易出血病変を認めた．腹部造影CTでは膵頭部に径50mm大の充実性腫瘤を認め，門脈・脾動脈および十二指腸への浸潤が疑われた．ERPで主膵管は膵頭部で途絶していた．膵液細胞診はadenocarcinomaであり，門脈および脾動脈浸潤を伴う切除可能境界膵頭部癌（cT4, N1, M0, cStage IVa）と診断．門脈および脾動脈切除・再建を伴う膵頭十二指腸切除術を施行した．病理組織所見では，腺管構造の不整を伴う高分化型腺癌が主体で，腫瘍間質の線維化が強く，門脈浸潤を認めた．術後補助療法として放射線化学療法（GEM＋RT）およびS-1による6ヶ月間の維持療法を施行した．術後の栄養状態とQOLは良好で，7年7ヶ月経過した現在，無再発生存中である．

Extended Neoadjuvant Chemotherapy for Borderline Resectable Pancreatic Cancer Demonstrates Promising Postoperative Outcomes and Survival

The optimum approach to neoadjuvant therapy for patients with borderline resectable pancreatic cancer is undefined. Herein we report the outcomes of an extended neoadjuvant chemotherapy regimen in patients presenting with borderline resectable adenocarcinoma of the pancreatic head. Patients identified as having borderline resectable pancreatic head cancer by American Hepato-Pancreato-Biliary Association/Society of Surgical Oncology consensus criteria from 2008 to 2012 were tracked in a prospectively maintained registry. Included patients were initiated on a 24-week course of neoadjuvant chemotherapy. Medically fit patients who completed neoadjuvant treatment without radiographic progression were offered resection with curative intent. Clinicopathologic variables and surgical outcomes were collected retrospectively and analyzed. Sixty-four patients with borderline resectable pancreatic cancer started neoadjuvant therapy. Thirty-nine (61 %) met resection criteria and underwent operative exploration with curative intent, and 31 (48 %) were resected. Of the resected patients, 18 (58 %) had positive lymph nodes, 15 (48 %) required en-bloc venous resection, 27 (87 %) had a R0 resection, and 3 (10 %) had a complete pathologic response. There were no postoperative deaths at 90 days, 16 % of patients had a severe complication, and the 30-day readmission rate was 10 %. The median overall survival of all 64 patients was 23.6 months, whereas that of unresectable patients was 15.4 months. Twenty-five of the resected patients (81 %) are still alive at a median follow-up of 21.6 months. Extended neoadjuvant chemotherapy is well tolerated by patients with borderline resectable pancreatic head adenocarcinoma, selects a subset of patients for curative surgery with low perioperative morbidity, and is associated with favorable survival.

Covered self‐expandable metal stent deployment promises safe neoadjuvant chemoradiation therapy in patients with borderline resectable pancreatic head cancer

Patients with borderline resectable pancreatic head cancer (BRPHC) have been treated with neoadjuvant chemoradiation therapy (NACRT) using metallic stents. The aim of the present study was to evaluate the efficacy and complications of covered self-expanding metallic stents (CSEMS) during the NACRT and surgical period. We reviewed the outcomes of patients with BRPHC, then divided them chronologically into three groups as follows. Group A: upfront surgery with plastic stent (PS) deployment; group B: PS deployment plus neoadjuvant chemotherapy (NAC) and/or NACRT; group C: CSEMS deployment plus NAC/NACRT. Patients were categorized as borderline resectable based on National Comprehensive Cancer Network Guidelines, 2010. Days to reintervention (DR), reintervention rate, and the rate of R0 and complications were studied. Safe margin-negative resection (R0) surgery was defined as R0 surgery without reintervention during the NACRT period and no postoperative complications. DR were as follows. Groups A, B and C were 32, 55 and 97 days, respectively (P < 0.05). R0 surgery obtained in groups A, B and C was 53% (9/17), 100% (17/17) and 93% (14/15), respectively. CSEMS did not interfere with surgery. Safe R0 surgery obtained in groups B and C was 11% (2/19) and 67% (10/15), respectively (P < 0.05). Multivariate analysis showed that the odds ratio for safe R0 surgery was 16.210 (95% CI 2.457-106.962, P = 0.003) for CSEMS placement. CSEMS should be considered to relieve symptomatic biliary obstruction in patients with BRPHC receiving NACRT in view of the high attainability rate of safe R0 surgery compared to that with PS deployment.

Covered self-expandable metal stent deployment promise safe neoadjubant chemotherapy in patients with borderline resectable pancreatic head cancer

Covered self-expandable metal stent deployment promise safe neoadjubant chemotherapy in patients with borderline resectable pancreatic head cancer

Su1360 Covered Self-Expandable Metal Stent Deployment Promises Safe Neoadjuvant Chemotherapy in Patients With Borderline Resectable Pancreatic Head Cancer

Neoadjuvant chemotherapy (NAC) may lead to successful margin-negative resection (R0) in patients with borderline resectable pancreatic head cancer (BRPHC). NAC using a metallic stent has been attempted in patients with BRPHC, however, the efficacy of this therapy and the influence of use of a covered self-expanding metal stent (CSEMS) for its delivery in the treatment of BRPHC has not been evaluated yet.