Candidates For Curative Resection Research Articles

Role of genomics in intrahepatic cholangiocarcinoma for liver-directed therapy

Only a minority of patients with intrahepatic cholangiocarcinoma are candidates for curative resection. Even those with disease limited to the liver may not be surgical candidates due to patient, liver, and tumor factors, including comorbidities, intrinsic liver disease, inability to establish a future liver remnant, and tumor multifocality. In addition, even after surgery, recurrence rates are high, with the liver being a predominant site of relapse. Lastly, tumor progression in the liver can sometimes result in demise for those with advanced disease. Therefore, it is not surprising that non-surgical, liver-directed therapies have emerged as both primary and complementary treatments for intrahepatic cholangiocarcinoma for multiple stages. Liver-directed therapies can be performed directly into the tumor via thermal or non-thermal ablation, catheter-based infusion into the hepatic artery containing either cytotoxic chemotherapy or radioisotope bearing spheres/beads, or delivered via external beam radiation. Presently, these therapies' selection criteria have been based on tumor size, location, liver function, and referral to particular specialists. In recent years, molecular profiling of intrahepatic cholangiocarcinoma has revealed a high rate of actionable mutations, and several targeted therapies have been approved for treatment in the second-line metastatic setting. However, little is known about these alterations' role in localized disease treatments. Therefore, we will review the current molecular landscape of intrahepatic cholangiocarcinoma and how it has been applied to liver-directed therapy.

Textbook outcomes among patients undergoing curative resection of pancreatic ductal adenocarcinoma in the era of neoadjuvant therapy

BackgroundNeoadjuvant therapy has been the standard care for borderline resectable or locally advanced pancreatic ductal carcinoma (BR/LA PDAC). The textbook outcome (TO) for curative resection after neoadjuvant therapy (NAT) remains understudied. MethodPatients underwent curative resection for PDAC between 2019 and 2020 were confirmed from the multidisciplinary team (MDT) database prospectively maintained by the Department of Pancreatic Hepatobiliary Surgery of Changhai hospital. TO of patients received NAT was compared to those received upfront surgery (UFS), and multivariate analysis of clinicopathological parameters was performed to explore predictors for TO. ResultsOf 435 patients, 329(76%) patients received UFS whereas 106(24%) patients received NAT. The TO was 82.1% for the NAT cohort, 77.8% for pancreaticoduodenectomy (PD) and 86.8% for distal pancreatectomy (DP). In the UFS cohort, the TO was 73.3% overall, 70.6% for PD and 77.3% for DP. Patients in the NAT cohort had longer time of operation, more intra-operative blood loss and more vascular resection. However, TO of the NAT cohort were not statistically different compared to that in the UFS cohort (p ​= ​0.27 for PD and p ​= ​0.20 for DP). On multivariable analysis, only diabetes-free was predictive for a better TO rate after PD in the UFS cohort(p ​= ​0.003). There were no factors associated with TO after DP in the UFS cohort, nor after PD or DP in the NAT cohort. ConclusionAs a composite indicator of desired surgical outcome, TO for curative resection after neoadjuvant therapy is similar to that in upfront surgery. All patients with stable or regressed tumors after NAT should be candidates for curative resection in an MDT setting.

Does distance traveled impact management and outcomes in patients with pancreatic adenocarcinoma who are candidates for curative resection?

668 Background: We investigated the impact of distance traveled to a tertiary care center for treatment in the management and outcomes of patients with pancreatic adenocarcinoma (PDAC). Methods: Patients treated for operable PDAC at a single institution from 2010-2019 were retrospectively reviewed. Data was collected on demographics, tumor characteristics, social determinants of health, diagnostic/staging work-up, surgical details, and outcomes. Patients were divided into three groups based on distance from our institution: Group A, <10 miles, Group B, >11-50 miles, or Group C, > 50 miles. The primary outcome was two-year survival. Results: There were 314 patients included. The mean age was 67.6+10.5 years. Patients farther from the hospital were less likely to undergo CT with contrast (Group B 97.1% versus Group C 89.0%, p = 0.02) and more likely to get MRCP (Group A 17.0% versus Group C 36.3%, p = 0.01) for staging. Distance was also associated with increased time to first encounter with medical or surgical oncology (Group A 6 days versus Group C 9 days, p = 0.02) and treatment initiation (Group A 22 days versus Group C 28 days, p < 0.001). There were no differences in postoperative complications, length of stay, discharge disposition, or follow-up. Two-year survival was better in Group A than Group B (54.1% versus 35.5%, p = 0.04). There was no difference in five-year survival. In the multivariable model for two-year survival, no patient or tumor characteristics were significant. Conclusions: In this PDAC population, patients living farther from a tertiary cancer center had worse two-year postoperative survival. Prospective studies in this area are needed.

Novel Palliative Chemotherapy for Cholangiocarcinoma

The term cholangiocarcinoma (CC) refers to all tumors arising from bile duct epithelium. CCs are characterized by their rarity, difficulty in diagnosis, and overall poor prognosis. This leads to a paucity of data from which to define the natural history and optimal treatment regimens. Currently, surgical resection remains the only potentially curative treatment, but many patients develop recurrence. In addition, a limited number of patients can be candidates for curative resection at diagnosis. Therefore, chemotherapy is inevitable choice for the treatment of advanced CC. Gemcitabine plus cisplatin (GP) is considered a standard option for advanced biliary cancer. A randomized phase III trial (ABC-02 trial) showed the superiority of gemcitabine plus cisplatin over gemcitabine alone. Treatment with nab-paclitaxel plus gemcitabine-cisplatin prolonged median progression-free survival and overall survival vs. those reported for historical controls treated with gemcitabine-cisplatin alone in a phase II study of 60 patients with locally advanced unresectable or metastatic biliary tract cancer. Recent data of the ABC-06 trial has provided slight evidence for the use of second-line chemotherapy after progression on cisplatin plus gemcitabine combination. Other active regimens, that could be considered in patients who include have disease progression while receiving GP and who retain an adequate performance status, includes capecitabine plus cisplatin, liposomal irinotecan plus leucovorin-modulated fluorouracil and a fluoropyrimidine alone. We herein review recent published data regarding the use of palliative chemotherapies in CC patients, with a particular focus on novel cytotoxic agents.

Comparing outcomes of robotic versus open mesorectal excision for rectal cancer

BackgroundThe outcomes of robot-assisted mesorectal excision for rectal cancer, compared with open resection, have not been fully characterized.MethodsA retrospective analysis of pathologic, short-term, and long-term outcomes in patients with rectal adenocarcinoma who underwent total or tumour-specific mesorectal excision at a high-volume cancer centre between 2008 and 2017 was conducted. Outcomes after robotic and open surgery were compared on an intention-to-treat basis.ResultsOut of 1048 resections performed, 1018 patients were reviewed, with 638 who underwent robotic surgery and 380 open surgery. Robotic surgery was converted to the open approach in 17 (2.7 per cent) patients. Patients who underwent robotic surgery were younger (median 54 (range 22–91) years versus median 58 (range 18–97) years; P < 0.001), had higher tumours (median 80 (range 0–150) mm from the anal verge versus median 70 (0–150) mm; P = 0.001), and were less likely to have received neoadjuvant therapy (64 per cent versus 73 per cent; P = 0.003). For patients who underwent a robotic total mesorectal excision, the operating time was longer (median 283.5 (range 117–712) min versus median 249 (range 70–661) min; P < 0.001). However, the rate of complications was lower (29 per cent versus 45 per cent; P < 0.001) and length of hospital stay was shorter (median 5 (range 1–32) days versus median 7 (range 0–137) days; P < 0.001). Median follow-up of survivors was 2.9 years. The proportion of patients with a positive circumferential resection margin did not differ between the groups, nor did the rate of local recurrence (robotic versus open: 3.7 per cent, 95 per cent c.i. 1.9 to 5.6 versus 2.8 per cent, 95 per cent c.i. 1.0 to 4.6; P = 0.400), systemic recurrence (robotic versus open: 11.7 per cent, 95 per cent c.i. 8.5 to 14.8 versus 13.0 per cent, 95 per cent c.i. 9.2 to 16.5; P = 0.300), or overall survival (robotic versus open: 97.8 per cent, 95 per cent c.i. 96.3 to 99.3 versus 93.5 per cent, 95 per cent c.i. 90.8 to 96.2; P = 0.050). The same results were documented in a subanalysis of 370 matched patients, including 185 who underwent robotic surgery and 185 open surgery, for the overall incidence of any postoperative complications, overall survival, disease-free survival, local recurrence, and systemic recurrence.ConclusionIn patients with rectal cancer who are candidates for curative resection, robotic mesorectal excision is associated with lower complication rates, shorter length of stay, and equivalent oncologic outcomes, compared with open mesorectal excision.

Intraductal papillary neoplasia of the bile duct (IPNB): case report and literature review

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare premalignant condition, defined as an epithelial neoplasm of the bile duct with exophytic papillary growth that can develop in any segment of the biliary tree. This pathology, with the highest prevalence in Asia, has been associated with the presence of hepatolithiasis and eastern liver infection (clonorchiasis). The diagnosis will depend on the clinical suspicion against the findings evidenced in the different diagnostic supports (invasive and non-invasive). Curative resection with negative margins is the treatment of choice in patients candidates for surgical management. In the event that the patient is not a candidate for curative resection, palliative treatment includes chemotherapy, percutaneous and endoscopic drainage, laser cholangioscopy ablation and intraluminal therapy with iridium 192. We present two cases of two patients with a diagnosis of IPNB confirmed by histology treated at our institution. The first case in an 86-yearold patient had a history of recurrent obstructive biliary syndrome and clinical suspicion of a new episode of cholangitis, and the second case in a 73-year-old patient who had a disseminated infectious process (spondylodiscitis, pelvic and intra-abdominal abscesses), and with the clinical suspicion of presenting a primary hepatobiliary focus. Both patients underwent single-operatorcholangioscopy plus biopsy, confirming the diagnosis by histology. The first case was managed with palliative intent, indicating endoscopic diversion of the bile duct, while surgical management was indicated in the second case.

Long-term oncologic safety of self-expandable metal stent as a bridge to surgery for malignant colorectal obstruction: Our experience.

153 Background: About 10-25% patients of colorectal cancer suffer from acute colonic obstruction. Traditional management of acute malignant bowel obstruction has focused on emergency resection but showed high mortality and morbidity rates. Recently, placement of a self-expanding metal stent(SEMS) was widely used and SEMS seems to be as a safe and effective “bridge to surgery” and to offer good palliation. But there is concern about long-term survival after the use of SEMS. Theoretically, tumor cell seeding can occur due to mechanical force during the stent insertion. To identify this theoretical validity, we surveyed long-term survival of malignant colonic obstruction using SEMS placement. Methods: This retrospective study included 303 patients who presented in Korea University Anam Hospital between 2006 and 2014 with obstructing CRC, and underwent surgical resection. Patients were devided into two group: the “SEMS” group included 148 patients who underwent endoscopic stent as a bridge to surgery, and the surgery group included 155 patients who underwent emergency or elective surgery without stenting. In addition, candidates for curative resection were identified (98 patients in “SEMS” group vs 101 patients in “surgery” group). The clinicopathologic characteristics, overall survival(OS), and recurrence-free survival (RFS) were compared between the two groups. Results: There was no significant difference in demographics, tumor stage between the two group. The median follow-up times were 48.5 months (IQR, 19.1-73.1 months) for the SEMS group and 39.4 months (IQR, 15.1-39.4 months) for the surgery group. There was no significant difference in 5-year OS rate between two groups (59.6% vs 56.8%; p = 0.3). The 5-year RFS rate did not significantly differ between two groups (71.0% vs. 61.3%; p = 0.221). The long-term oncologic safety did not significantly differ between two groups in either the 5-year OS rate (79.5% vs 74.5%; P= 0.6). or the 5-year RFS rate (95.8% vs 95.8%; P = 0.3). Conclusions: SEMS as bridge to surgery in obstructive CRC did not worsen the long-term oncologic outcomes compared to those of the primary surgery.

Diabetes Could Be a Warning Sign of Pancreatic Cancer: A Case Report and Literature Review

Pancreatic cancer (PC) is 1 of the deadliest cancers, representing the fourth leading cause of cancer death in the world; This high mortality is due to late symptom onset and because most of the cases of pancreatic cancer are stage IV at diagnosis, and hence not a candidate for curative resection. The following report will serve to emphasize the role of new-onset diabetes in certain patients as a warning sign necessitating further investigation for pancreatic cancer. It’ s about a 46-years old man was admitted in hospital «service of forensic and penitentiary medicine » for jaundice associated with progressive asthenia, abdominal pain, and weight loss. He had been diagnosed with diabetes 4 weeks earlier by his GP. Despite lifestyle changes, he had been commenced on metformin after just 2 weeks due to poor glycaemic control. Physical examination showed a mass of the upper right quadrant on palpation. Computed tomography of the abdomen showing a solid mass of 55 mm in the head of the pancreas, hypodense in particular, with mild Wirsung and bile ducts dilatation, and the focal thrombi is found at the level of the 9 mm splenomersaraic confluent, with hepatic secondary localization images. He was subsequently diagnosed with new-onset diabetes and metastatic pancreatic cancer. The treatment with basal insulin / bolus and anticoagulant therapy was instituted and after stabilization; the patient has been oriented for bilio-pancreatic derivation, and eventual biopsy in a specialized center, but unfortunately the patient died only a few weeks after. PC occurs with increased frequency in patients with type 2 diabetes mellitus (DM2) which is considered the third modifiable risk factor for pancreatic cancer after cigarette smoking and obesity. Although numerous studies have linked both entities since 1833 the mechanism behind this association are complex and not well understood by the moment.

Management of Locally Advanced Pancreatic Cancer: Results of an International Survey of Current Practice.

The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."

Role and limitation of neoadjuvant hepatic arterial infusion chemotherapy in advanced hepatocelluar carcinoma patients with Child-Pugh class A

BackgroundPatients with advanced hepatocellular carcinoma (HCC) have a poor oncologic outcome. In this study, we evaluated the role and limitation of neoadjuvant hepatic arterial infusion chemotherapy (HAIC) in advanced HCC patients with Child-Pugh class A and the efficacy of liver resection subsequent to downstaging after neoadjuvant HAIC.MethodsIn the present retrospective study, 103 patients with advanced HCC, who underwent neoadjuvant HAIC from April 2003 to March 2015 were analyzed. Response to HAIC was evaluated by dividing time period into after 3 cycles and after 6 cycles, each defined as early and late period. Liver resection after neoadjuvant HAIC was offered in patients who were considered as possible candidates for curative resection with tumor-free margin as well as sufficient future liver remnant volume.ResultsThe median survival time (MST) in all patients was 14 ± 1.7 months. Response rate and disease control rate were 36.3% (37) and 81.4% (83) in early period, respectively, and 26.4% (14) and 47.2% (25), in late period, respectively (P = 0.028). Twelve patients (11.7%) underwent liver resection after neoadjuvant HAIC and the MST was 37 ± 6.6 months. One-, 3-, and 5-year recurrence-free survival after liver resection were 58.3%, 36.5%, and 24.3% respectively. Liver resection was identified as the only independent prognostic factor that associated with overall survival in multivariate analysis (P = 0.002)ConclusionHAIC could be further alternative for the treatment of advanced HCC in patients with good liver function. If liver resection is possible after neoadjuvant HAIC, liver resection would provide better outcomes than HAIC alone.

Variation in the surgical management of locally advanced pancreatic cancer.

4122 Background: Recent reports suggest patients with locally advanced pancreatic cancer (LAPC) may become candidates for curative resection following neoadjuvant therapy, with encouraging survival outcomes. Yet the optimal management approach for LAPC remains unclear. We sought to investigate surgeon preferences for the management of patients with LAPC. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included surgeon practice characteristics, preferences for staging and management, and 6 clinical vignettes (with detailed videos of post-neoadjuvant arterial and venous imaging) to assess attitudes regarding eligibility for surgical exploration. Results: A total of 150 eligible responses were received from 4 continents. Median duration in practice was 12 years (IQR 6-20) and 75% respondents work in a university setting. Most (84%) are considered high volume, 33% offer a minimally-invasive approach, and 48% offer arterial resection in selected patients. A majority (70%) always recommend neoadjuvant chemotherapy, and 62% prefer FOLFIRINOX. Preferences for duration of neoadjuvant therapy varied widely: 39% prefer ≥2 months, 41% prefer ≥4 months, and 11% prefer 6 months or more. Forty-one percent frequently recommend neoadjuvant radiation, and 51% prefer standard chemoradiotherapy. Age ≥80 years and CA 19-9 of ≥1000 U/mL were commonly considered contraindications to exploration. In 5 clinical vignettes of LAPC, the proportion of respondents that would offer exploration following neoadjuvant varied extensively, from 15% to 54%. In a vignette of oligometastatic pancreatic liver metastases, 32% would offer exploration if a favorable biochemical and imaging response to therapy is observed. Conclusions: In an international cohort of high volume pancreas surgeons, there is substantial variation in attitudes regarding staging preferences and surgical management of LAPC. These results underscore the importance of coordinated multi-disciplinary care, and suggest an evolving concept of “resectability.” Patients and their oncologists should have a low threshold to consider a second opinion for the surgical management of LAPC, if desired.

Abstract No. 455 Prostatic arterial embolization (PAE) for inoperable prostate cancer patients

To retrospectively evaluate PAE for palliation of symptoms in prostate cancer (PCa) patients who are non-surgical candidates. This single-center retrospective review was conducted December 2013- September 2018 in 21 inoperable PCa patients (mean age 70±9 years). Superselective PAE was performed via radial or femoral access using cooling of collaterals technique with 300-500 μ Embospheres and cone-beam CT. Indications included hematuria (n=14), Urinary retention (n=4), Nocturia (n=1), bladder stones and lower urinary tract symptoms (n=1), and pre-radiation volume reduction (n=1). Nine patients were stage IV, three stage II, one stage I and eight stage Tx. Gleason scores ranged from 6-10. Bilateral PAE was achieved with technical success of 95% (20/21 patients). In one patient, left PAE was unsuccessful secondary to severe prostate artery stenosis. On average, complete hematuria control was achieved in 1.6 days (SD±1.5). The average duration of follow up was 402 days (SD±338). There were significant improvements in blood transfusion requirements, PSA levels, prostate size, and PCa symptoms. Blood transfusion requirements reduced by an average of 79% for all patients following PAE. Hemoglobin levels rose moderately by an average of 3.9% and PSA levels reduced significantly by an average of 81%. In one patient with stage 2b PCa referred for pre-radiation volume reduction, prostate volume improved from 139cc to 65.4cc (Δ52.9%) within two months of PAE. The average prostate reduction for all patients three months after PAE was 37.3%. One patient spontaneously voided his bladder calculi 48 hours after PAE. Four patients died during follow-up from PAE-unrelated etiologies without recurrence of symptoms. One patient developed acute urinary retention 9 months after PAE and was successfully managed conservatively. Another at 4 months developed recurrent hematuria, which improved with repeat PAE. None of the other patients developed recurrent symptoms. No complications were noted on follow-up. Our study indicates that PAE provides a clinically and statistically significant outcome for palliation of patients with inoperable PCa who are not candidates for curative resection.

Pretreatment SUVmax value to predict outcome in patients with stage III NSCLC receiving concurrent chemoradiotherapy.

OBJECTIVE:Stage III disease accounts for approximately one-fourth of all non-metastatic non-small cell lung cancer (NSCLC). The patients who are not candidates for curative resection are offered concomitant chemoradiotherapy. In this subgroup, which is difficult to manage, studies that address the role of PET-CT to predict outcome measures specifically for stage III NSCLC receiving concurrent chemoradiotherapy may help better risk stratification. This study aimed to assess whether baseline PET maximum standardized uptake value (SUVmax) value in stage III NSCLC treated with concurrent chemoradiotherapy would independently identify patients with high risk of progression and death.METHODS:The study population consisted of patients aged 18 years or more with unresectable stage III histologically or cytologically proven NSCLC who received concurrent chemoradiotherapy. From 2007 to 2014, medical records of patients admitted to our institution were retrospectively analyzed. Pretreatment PET-CT SUVmax values were recorded for each patient. These values were categorized as low or high according to the median SUVmax measure of the study population.RESULTS:A total of 175 patients were analyzed. The median follow-up time was 23 months (range 6–109). The PET-CT SUVmax values ranged from 3.5 to 46 with a median value of 14. The median overall survival was 25 months in SUVmax <14 and 18 months in SUVmax ≥14 group (p=0.023). The median progression-free survival was 16 months in SUVmax <14 and 11 months in SUVmax ≥14 group (p=0.033). Multivariate analysis revealed that both PET-CT SUVmax value (p<0.001) and age (p=0.016) were independent significant predictors for overall survival (OS).CONCLUSION:The results of this study involving patients with stage III NSCLC receiving concurrent chemoradiotherapy provide evidence that suggests that high values of pretreatment SUVmax, an indicator of metabolic tumor burden, predicted a higher risk of disease progression and death.

Current role of palliative interventions in advanced pancreatic cancer.

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

Post-operative albumin-bilirubin grade predicts long-term outcomes among Child–Pugh grade A patients with hepatocellular carcinoma after curative resection

Although Child-Pugh grade A patients with hepatocellular carcinoma (HCC) are candidates for curative resection, some may have a poor prognosis. The albumin-bilirubin (ALBI) grade, a measure of liver function based on albumin and bilirubin, has the potential to detect Child-Pugh grade A HCC patients with poor prognosis. Because components of the ALBI grade can be measured easily even after surgery, we explored the predictive values of ALBI in patient prognosis after HCC resection. In this retrospective case-control study, we included 136 HCC patients who underwent curative resection between January 2004 and December 2013 at our hospital. ALBI grade was calculated from laboratory data recorded the day before surgery and at post-operative day 5. Pre- and post-operative ALBI grade predicted patients' long-term outcomes (P = 0.020 and P < 0.001, respectively, for overall survival, and P = 0.012 and P = 0.015, respectively, for recurrence-free survival). Post-operative ALBI grade was associated with patients' surgical factors of repeated hepatic resection (P = 0.012), intra-operative bleeding (P = 0.006), and surgery duration (P = 0.033). Furthermore, post-operative ALBI grade, rather than pre-operative ALBI grade, was an independent predictive factor of long-term outcome of Child-Pugh grade A patients with HCC. Post-operative ALBI grade is useful to predict the prognosis in patients after HCC resection.

Interventional endoscopy in the diagnosis and management of pancreatic adenocarcinoma.

Pancreatic cancer accounts for approximately 3% of all cancers in US, and is the fourth leading cause of mortality in both men and women. It is a silent killer due to lack of early symptoms and the majority of patients present at advanced stage at the time of initial diagnosis. Only 15-20% of patients are candidates for curative resection and even then, the 5-year survival rates range from 10-25%. Despite recent advances in the treatment of advanced pancreatic cancer, the prognosis remains grim with 5-year overall survival (OS) of approximately 10%. Early detection is key for improving patient outcomes in this lethal disease. Contributing to the difficulty in the diagnosis and management is the anatomic location of the pancreas within the abdomen (retroperitoneal location and being adjacent to hollow viscus, solid organs and major vessels), and suboptimal response to systemic chemotherapy. Multimodality imaging (pancreatic protocol CT and MRI/MRCP) is often used for the diagnosis and staging of pancreatic adenocarcinoma. Interventional endoscopy is a relatively new field, and with Endoscopic techniques becoming more advanced, their role in diagnosis and management of pancreatic cancer is expanding rapidly. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are the two main modalities used in cases of pancreatic neoplasms.

111 Successful Creation of Pancreatic Cancer Organoids By Means of Eus-Guided Fine-Needle Biopsy (EUS-FNB) for Personalized Cancer Treatment

The vast majority of patients with pancreatic ductal adenocarcinoma (PDA) are not candidates for curative resection. Overall survival rates in this group of patients remain exceptionally low. Pancreatic cancer organoids are tumor models of individualized human PDA that can be rapidly generated from surgically resected tumors. Organoids simulate the full spectrum of a patient’s tumor, including stromal elements believed to be responsible for chemotherapy resistance. Hence, they can be used for testing personalized treatment strategies. For surgically unresectable patients, creation of human PDA organoids at the time of tissue diagnosis could allow this group of patients to benefit from precision medicine with personalized treatment.

P1.03-073 Predictors for Pathological N1 and N2 Disease in Clinical N1 Non-Small-Cell Lung Cancer

Patients with clinical N1 (cN1) non-small-cell lung cancer (NSCLC) is usually considered to be candidates for curative resection. However, they sometimes have unexpected mediastinal nodal involvement (pN2). To avoid futile pulmonary resection, accurate preoperative evaluation of nodal status would be necessary. The purpose of this study was to identify predictors for lymph node metastasis in cN1 NSCLC patients. We retrospectively reviewed data on the clinicopathological and radiological features of 170 patients with cN1 NSCLC who had undergone complete resection at Nagoya University Hospital between 2004 and 2015. Hilar and/or intrapulmonary lymph nodes with ≥ 1.0 cm in the short axis on computed tomography or with high accumulation of [18F] Fluorodeoxyglucose (FDG) in positron emission tomography compared with that of the adjacent mediastinal tissue were considered as cN1 in our institution. The association between clinicoradiological variables and nodal status was analyzed to identify predictors for lymph node metastasis. The cohort consisted of 125 males and 45 females, ranging in age 39 to 84 years. There were 62 (36%) adenocarcinomas, 82 (48%) squamous-cell carcinomas, 10 (6%) large-cell carcinomas, and 16 (10%) other types of cancers. The breakdown by pathological N category was 61 (36%) pN0, 72 (42%) pN1, and 37 (22%) pN2 patients. Among pN2 patients, only three showed negative N1 lymph nodes (skip pN2 metastasis). Female gender, adenocarcinoma histology, middle or lower lobe origin and positive N1 lymph node (pN1) were significantly associated with pN2 by univariate analysis. Logistic regression analysis showed that the female and pN1 were significant predictor for pN2 with the odds ratio of 3.0 and 13.1, respectively (P = 0.02 and 0.0001, respectively). In addition, using the 63 patients extracted from our cohort of this study, we sought the predictor of pN1. The maximum size of the lymph node and standardized uptake value of the FDG were significant factor for pN1 with the cut-off value of 1.3 cm and 4.28, respectively. Female gender and pN1 was significantly associated with pN2 in cN1 NSCLC patients of our cohort. The large size and a high accumulation of FDG of hilar or intrapulmonary lymph node might predict the pN1.

Utility of 18 Fludeoxyglucose in Preoperative Positon-Emission Tomography-Computed Tomography (PET-CT) in the Early Diagnosis of Exocrine Pancreatic Cancer: A Study of 139 Resected Cases

IntroductionIn pancreatic ductal adenocarcinoma (PDA), surgical resection is the only curative treatment, but due to its late clinical presentation only 15–25% patients are candidates for curative resection. The aim of this prospective, single-center study is to determine the diagnostic utility of preoperative PET-CT for early detection of PDA and early panIN lesions. MethodsWe studied the histopathological features of PDA and different panIN lesions in 139 surgical samples from patients undergoing pancreatic resection (from 2010 to 2014), comparing these results with preoperative PET-CT and MDCT study. For tumor diagnosis in PET-CT maximum standard SUV 2.5 was used. Pancreatic baseline SUVmax is the maximum uptake of the radiotracer 18-2FDG on the ROI curve determined for the area of the normal pancreas after pathological reassessment with areas not affected by tumors or preneoplastic lesions. Tumor Uptake Index is the ratio between the tumor SUVmax and pancreatic baseline SUVmax. ResultsUsing an standard maximum SUV value of 2.5, PET-CT sensitivity was 77.7% (108 of the 139 cases) against 75.5% (105 of the 139 cases) of MDCT. But when we combined this value with maximum SUV of normal pancreatic tissue from each patient, PET-CT sensitivity improved its value to 94.9%. ConclusionA combination of studies of PET-CT in tumor and non-tumor tissue of each patient might be a very useful diagnostic tool not only for preoperative diagnosis of PDA, but also for early panIN lesions.

Utilidad de la 18-fluorodeoxiglucosa en la tomografía por emisión de positrones-tomografía computarizada (PET-TC) preoperatoria en el diagnóstico precoz del cáncer de páncreas exocrino: estudio en 139 casos resecados

IntroductionIn pancreatic ductal adenocarcinoma (PDA), surgical resection is the only curative treatment, but due to its late clinical presentation only 15-25% patients are candidates for curative resection. The aim of this prospective, single-center study is to determine the diagnostic utility of preoperative PET-CT for early detection of PDA and early panIN lesions. MethodsWe studied the histopathological features of PDA and different panIN lesions in 139 surgical samples from patients undergoing pancreatic resection (from 2010-2014), comparing these results with preoperative PET-CT and MDCT study. For tumor diagnosis in PET-CT maximum standard SUV 2.5 was used. Pancreatic baseline SUVmax is the maximum uptake of the radiotracer 18-2FDG on the ROI curve determined for the area of the normal pancreas after pathological reassessment with areas not affected by tumours or preneoplastic lesions. Tumour Uptake Index is the ratio between the tumour SUVmax and pancreatic baseline SUVmax. ResultsUsing an standard maximum SUV value of 2.5, PET-CT sensitivity was 77.7% (108 of the 139 cases) against 75.5% (105 of the 139 cases) of MDCT. But when we combined this value with maximum SUV of normal pancreatic tissue from each patient, PET-CT sensitivity improved its value to 94.9%. ConclusionA combination of studies of PET-CT in tumor and non-tumor tissue of each patient might be a very useful diagnostic tool not only for preoperative diagnosis of PDA, but also for early panIN lesions.