Left-sided Pancreatic Ductal Adenocarcinoma Research Articles

Effect of resection margin status on recurrence pattern and survival in distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma.

675 Background: The association of resection margin status with recurrence and survival after pancreatectomy for pancreas ductal adenocarcinoma (PDAC) remains controversial. The aim of this study was to identify the effect of R1 resection on recurrence pattern and survival after distal pancreatectomy for left-sided PDAC. Methods: Patients who underwent distal pancreatectomy for PDAC at two high-volume institutions between January 2010 and December 2017 were retrospectively reviewed. Perioperative characteristics, pathological outcomes, recurrence pattern and survival data were collected to compare R0 resection and R1 resection. Results: Among 558 patients who underwent distal pancreatectomy for PDAC, 158 patients (28.3%) showed R1 resection margin. R1 patients were associated with large tumor size (3.3 cm vs. 3.7 cm, p= 0.006) and lower number of positive lymph nodes (1.3 vs. 2.0, p= 0.001). Median overall survival (37.3 months vs. 20.1 months, p< 0.001) and recurrence-free survival (14.6 months vs. 6.9 months, p< 0.001) significantly differed between the R0 and R1 groups. Disease recurrence patterns were not statistically different between the two groups ( p = 0.182). Among the recurrence patterns, peritoneal carcinomatosis had the shortest recurrence-free survival (5.6 months, p < 0.05) and overall survival (13.6 months, p < 0.05) compared with all other recurrence patterns. Conclusions: R1 resection margin after distal pancreatectomy was associated with poor survival and early recurrence. There is no significant difference in recurrence pattern between R0 and R1. Among the recurrence patterns, peritoneal carcinomatosis showed the worst prognosis.

Increased incidence of positive peritoneal lavage cytology early after fine needle aspiration in patients with pancreatic ducal adenocarcinoma

BackgroundThe influence of fine needle aspiration (FNA) on peritoneal lavage cytology (CY) in pancreatic ductal adenocarcinoma (PDAC) is unknown. MethodsWe retrospectively analyzed 29 patients with resectable left-sided PDAC undergoing FNA prior to CY examination. We assessed clinical factors related to CY+, scored the tumor diameter (<20 mm = 0, ≥20 mm = 1) and examination interval between FNA and CY (>18 days = 0, ≤18 days = 1), and investigated the probability of CY + by the sum of each score (0–2). ResultsThe probability of CY+ was 31%. The CY + group had larger tumors and shorter examination intervals than the CY− group. The CY + probability was 75%, 15%, and 13% for a score of 2, 1, and 0, respectively (P = 0.011). ConclusionA short interval between FNA and CY examination for a large tumor may be a risk factor for CY+ in patients with left-sided PDAC.

Minimally invasive radical antegrade modular pancreatosplenectomy: routine vs. modified.

Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 by Strasberg to improve survival outcomes in left-sided pancreatic ductal adenocarcinoma. Many investigators have shown the feasibility and safety of minimally invasive RAMPS (MI-RAMPS). However, the survival benefit of RAMPS is inconclusive, and possible risks following the procedure, such as exocrine and endocrine insufficiencies, cannot be ignored. Therefore, several modifications of RAMPS were designed. Modified RAMPS is not a specific technique but rather a reduced form of RAMPS that is undertaken without compromising oncologic principles. In this literature review, the surgical technique and strategies of MI-RAMPS were examined.

Impact of radiologic splenic vessel invasion in resectable left-sided pancreatic ductal adenocarcinoma: predictor of early systemic recurrence following upfront surgery.

The aim of this study is to identify prognostic factors and the best candidates for neoadjuvant therapy among patients with resectable left-sided pancreatic ductal adenocarcinoma (PDAC) by analyzing the timing and pattern of recurrence following upfront surgery. This single-center retrospective study included patients with resectable left-sided PDAC who underwent upfront distal pancreatectomy from 2005 to 2015. A minimum P value approach was used to evaluate the optimal cutoff of early recurrence. The predictors of recurrence were assessed with Cox regression analysis. Among 311 included patients, 241 (77.5%) had a recurrence at a median follow-up of 29.3 months. Systemic recurrence occurred in 194 patients (80.5%) and isolated local recurrence in 47 patients (19.5%). A recurrence-free survival cutoff of 12 months was selected to distinguish between early and late recurrence. The patients with early recurrence had a shorter median overall survival (16.1 vs. 39.9 months, P<0.001) and post-recurrence survival (9.6 vs. 17.2 months, P<0.001) than those with late recurrence. The patients with systemic recurrence had a shorter median overall survival (19.6 vs. 29.1 months, P=0.007) and post-recurrence survival (11.0 vs. 15.3 months, P=0.024) than those with an isolated local recurrence. In multivariable analysis, preoperative CA 19-9 ≥500 U/mL [odd ratio (OR) 2.037, P=0.035], radiologic splenic vessels invasion (OR 5.014, P<0.001), positive radial resection margin (OR 2.638, P<0.001), and no adjuvant chemotherapy (OR 2.084, P=0.001) were predictors of an early systemic recurrence. Radiologic splenic vessels invasion may be considered to indicate a biologically borderline status in patients with anatomically resectable left-sided PDAC. Future clinical trials of neoadjuvant therapy targeting these patients should be conducted.

Clinical outcome comparison of laparoscopic radical antegrade modular pancreatosplenectomy vs. laparoscopic distal pancreatosplenectomy for left-sided pancreatic ductal adenocarcinoma surgical resection.

BackgroundLaparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) is a validated surgical treatment for patients with left-sided pancreatic ductal adenocarcinoma (PDAC). In addition, laparoscopic distal pancreatectomy (LDPS) has purported benefits. However, there is a limited analysis comparing the results between LRAMPS and LDPS. Thus, this study aims to compare the short-term and long-term outcomes of patients who underwent LRAMPS and LDPS for PDAC treatment.MethodsPatients with left-sided PDAC that underwent LRAMPS or LDPS from 2015 to 2021 were retrospectively identified. Demographic and clinic pathologic data were collected. Disease-free survival (DFS) and overall survival (OS) probabilities were obtained.ResultsThe number of lymph nodes retrieved was significantly greater in the LRAMPS group than in the LDPS group. Several clinicopathological factors, including CA19-9 levels greater than 37 U/ml, positive lymph nodes, moderate to poor tumor differentiation, and peripancreas fat invasion, were associated with DFS. Moderate with poor tumor differentiation was associated with poor DFS (HR 0.568; 95% CI 0.373–0.921; P = 0.021). Levels of CA19-9 greater than 37 U/ml, CEA levels greater than 5 μg/ml, larger tumor size, positive lymph nodes, moderate with poor tumor differentiation, peripancreas fat invasion, and adjuvant chemotherapy were all associated with OS. LRAMPS nearly improved OS but did not reach statistical significance. Serum carcinoembryonic antigen (CEA) levels greater than 5 ug/ml (HR 1.693; 95% CI 1.200–1.132; P = 0.001), and positive lymph nodes (HR 2.410; 95% CI 1.453–3.995; P = 0.001) were independently associated with poor OS. Treatment with adjuvant chemotherapy was associated with improved OS (HR 0.491; 95% CI 0.248–0.708; P = 0.001).ConclusionsThe LRAMPS procedure achieved comparable results to standard LDPS in terms of postoperative outcomes. Treatment with chemotherapy is important for the prognosis of patients with left-sided pancreatic cancer.

Radical Antegrade Modular Pancreatosplenectomy for Left-Sided Pancreatic Ductal Adenocarcinoma May Reduce the Local Recurrence Rate

Introduction: Although several clinical applications have reported the usefulness of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure for left-sided pancreatic ductal adenocarcinoma, few studies have reported the advantages of RAMPS with respect to the local recurrence (LR) rate. Methods: As of 2018, 68 and 62 patients underwent RAMPS and standard retrograde pancreatosplenectomy (SRPS). The first recurrence and all subsequent recurrence sites observed on images during a follow-up period and/or chemotherapy. The clinical variables are collected retrospectively. Results: LR only was found in 5 patients in the RAMPS group (5/68, 7.3%) and in 15 patients in the SRPS group (15/62, 24.2%; p = 0.008) as the first recurrence site. Any chemotherapies were not a risk factor for the incidence of LR. The 5-year cumulative LR rate was significantly lower in patients in the RAMPS group compared with those in the SRPS group (23.6% vs. 49.6%; p = 0.019). The 5-year overall survival was 42.2% in the RAMPS group and 33.0% in the SRPS group (p = 0.251). Conclusion: The RAMPS procedure for left-sided pancreatic ductal adenocarcinoma may reduce the LR, cumulative LR rates.

Routine RAMPS for left-sided pancreatic ductal adenocarcinoma

Routine RAMPS for left-sided pancreatic ductal adenocarcinoma

Prognostic relevance of the tumor location in patients with resected left-sided pancreatic ductal adenocarcinoma

Eunhye LEE, Yoo-Seok YOON*, Jun Suh LEE, Boram LEE, Moonhwan KIM, Yeongsoo JO, Jin-Young JANG, Wooil KWON, Hongbeom KIM, Hee Ju SOHN, Mirang LEE, Chang-Sup LIM, Ho-Seong HAN. Ann Hepatobiliary Pancreat Surg 2022;26:S64. https://doi.org/10.14701/ahbps.2022S1.OP-1-6

Clinical Outcome of RAMPS for Left-Sided Pancreatic Ductal Adenocarcinoma: A Comparison of Anterior RAMPS versus Posterior RAMPS for Patients without Periadrenal Infiltration.

Radical antegrade modular pancreatosplenectomy (RAMPS) is considered an effective procedure for left-sided pancreatic ductal adenocarcinoma (PDAC). However, whether there are differences in perioperative outcomes, pathologies, or survival outcomes between anterior RAMPS (aRAMPS) and posterior RAMPS (pRAMPS) has not been reported previously. We retrospectively reviewed and compared the demographic, perioperative, histopathologic, and survival data of patients who underwent aRAMPS or pRAMPS for PDAC. We also compared these two groups among patients without periadrenal infiltration or adrenal invasion. A total of 112 aRAMPS patients and 224 pRAMPS patients were evaluated. Periadrenal infiltration, neoadjuvant treatment, and concurrent vessel resection were more prevalent in the pRAMPS group. After excluding patients with periadrenal infiltration, 106 aRAMPS patients were compared with 157 pRAMPS patients. There were no significant differences between the aRAMPS and pRAMPS groups in the pathologic tumor size, resection margin, proportion of tangential margin in the R1 resection, and number of harvested lymph nodes. The median overall survival and disease-free survival also did not differ significantly between the two groups. We cautiously suggest that pRAMPS will not necessarily provide more beneficial histopathologic outcomes and survival rates for left-sided PDAC cases without periadrenal infiltration. If periadrenal infiltration is not suspected, aRAMPS alone should be sufficiently effective.

Radical antegrade modular pancreatosplenectomy (RAMPS) versus conventional distal pancreatosplenectomy (CDPS) for left-sided pancreatic ductal adenocarcinoma.

The insufficient clearance of regional lymph nodes and unsatisfactory R0 resection rate may result in the metastasis of left-sided pancreatic ductal adenocarcinoma (PDAC) after conventional distal pancreatosplenectomy (CDPS). Radical antegrade modular pancreatosplenectomy (RAMPS) was designed to achieve R0 resection more successfully with better lymph-node clearance; however, there is still insufficient evidence of its short- and long-term results to confirm its superiority. We conducted this study to compare the efficiency of these two procedures. The subjects of this retrospective analysis were 103 patients with left-sided PDAC who underwent either RAMPS (n = 46) or CDPS (n = 57). We assessed perioperative data and surgical information and used univariate and multivariate analyses to identify prognostic factors for survival. There were no significant differences in baseline data between the groups. RAMPS was associated with a significantly shorter hospital stay (12.11days vs. 22.98days; P < 0.001), and significantly less blood loss (451.09ml vs. 764.04ml, P = 0.002), as well as a significantly lower rate of blood transfusion (15.22% vs. 33.33%, P = 0.035). RAMPS and CDPS had comparable perioperative complication rates. Moreover, RAMPS achieved more effective lymph-node retrieval (17.87 vs. 10.23; P < 0.001). The RAMPS group had a higher overall survival (OS) rate (28.73months vs. 18.30months; P = 0.003) and a higher disease-free survival (DFS) rate (21.97months vs. 9.40months; P < 0.001). RAMPS achieved better survival and surgical outcomes than CDPS for patients with left-sided PDAC.

The Role of Radical Antegrade Modular Pancreatosplenectomy Compared to Conventional Distal Pancreatosplenectomy in Patients with Left-sided Pancreatic Cancer: A Retrospective Multicenter Propensity- Score Matching Analysis

Introduction: The purpose of this study aimed to evaluate the role of radical antegrade modular pancreatosplenectomy (RAMPS) in terms of postoperative outcomes compared to conventional distal pancreatosplenectomy (DPS) in patients with left- sided pancreatic ductal adenocarcinoma (PDAC). Method: From 2005 to 2017, consecutive 316 left-sided PDAC patients who underwent RAMPS (n=236) or DPS (n=80) for curative intent in four tertiary referral hospitals in Korea were included in this study. Among these, after 1:2 Propensity score matching with age, sex, differentiation, T and N stage, 71 patients with DPS and 139 patients with RAMPS were analyzed for clinicopathological outcomes. Result: There was no difference in complication rate between the two groups. RAMPS was superior than DPS in terms of R0 rate (99.3% vs 88.6%, p< 0.01) and harvested LN numbers (16.3±10.57 vs. 10.3±7.06, p< 0.01). RAMPS showed prolonged DFS (median survival 11 vs 9months), but statistically not significant (p=0.148). In a subgroup analysis with node-negative patients (n=107), RAMPS showed superior disease-free survival than DPS with statistically marginal significance (MS 15 vs 9m, p= 0.05). After multivariate analysis, preoperative CA19-9≥37, tail cancer, poorly or undifferentiated carcinoma, R1 resection, and absence of adjuvant treatment were identified as independent risk factors for survival. Also, preoperative CA19-9≥37, advanced T stage, LN metastasis, poorly or undifferentiated carcinoma were independent risk. Conclusion: Although we could not find an eminent survival benefit of RAMPS, it could be considered a standard surgical method for left-sided PDAC because of the similar complication rate and several oncologic benefits.

Relationship between the tumor location and clinicopathological features in left-sided pancreatic ductal adenocarcinoma.

Although the same distal pancreatectomy (DP) is performed regardless of the location of left-sided pancreatic ductal adenocarcinoma (PDAC), the clinicopathological features may differ depending on the tumor location. The present study investigated the relationship between the tumor location and clinicopathological features in patients with left-sided PDAC. The records of 59 patients who underwent DP for PDAC were enrolled. The relationship between the tumor location and clinicopathological features was investigated. The tumor location was classified into three groups according to the 7th AJCC/UICC TNM classification: body (Pb), body and tail (Pbt), and tail (Pt). Tumors were located at the Pb in 26 patients, Pbt in 15, and Pt in 18. There was no metastasis to the lymph nodes around the common hepatic artery in Pt. The rate of peritoneal dissemination in the Pt was higher than that in the Pb (P = 0.034) or Pbt (P = 0.002). There were no significant differences in the overall survival among the three groups. There was no metastasis to the lymph nodes around the common hepatic artery, and peritoneal dissemination was the most common site of recurrence in Pt tumors.

Prognostic value of adjacent organ resection in patients with left-sided pancreatic ductal adenocarcinoma following distal pancreatectomy.

We evaluated whether distal pancreatectomy (DP) with adjacent organ resection (AOR) affected perioperative outcomes and survival in patients with left-sided pancreatic ductal adenocarcinoma (PDAC). Retrospective cohort study was conducted at single large volume academic medical center from January 2000 to December 2016. Five hundred and twenty-three patients had undergone standard DP (without additional vessel/organ resection) and 40 had undergone DP with AOR due to adjacent organ infiltration. There were no differences of postoperative morbidity and hospital stay between the two groups. In the patients with AJCC 8th stage I and II PDAC, there were significant differences of median disease-specific and progression-free survivals between the standard and AOR groups (37.9 vs. 20.2months; P = 0.05, 20 vs. 10months; P = 0.028, respectively). DP with AOR was identified as independent prognostic factor of stage I and II PDAC by multivariate Cox regression analysis. Distal pancreatectomy with AOR could be an acceptable surgical treatment for left-sided PDAC. However, AOR group shows poor prognosis than that of the standard group in patients with AJCC 8th stage I and II PDAC. AOR should be considered indicative of a more aggressive tumor in AJCC 8th stage I and II PDAC.

Association of preoperative total lymphocyte count with prognosis in resected left-sided pancreatic cancer.

Immunologic factors such as neutrophil-lymphocyte ratio and platelet-lymphocyte ratio play an important role in predicting the oncologic outcome of patients in pancreatic ductal adenocarcinoma (PDAC). It is hypothesized that host immunity represented by total lymphocyte count at diagnostic stage would influence oncologic outcome in left-sided PDAC. Between January 1992 and August 2017, total of 112 patients who underwent distal pancreatectomy for left-sided PDAC were included and analysed. At the time of the diagnosis, total lymphocyte count at diagnosis of left-sided PDAC was 1.8 ± 0.7 103 /μL (mean value ± standard deviation). Among different cut-off values, 1.7 showed most powerful significant differences in long-term oncologic outcomes. The patients with preoperative lymphocyte count (≤1.7) was associated with early recurrence (median 8.4 months versus 18.1 months, P = 0.011) and shorter survival (median 18.6 months versus 35.9 months, P = 0.028). Patients with preoperative total lymphocyte count over 1.7 showed higher white blood cell count (P < 0.001), platelet count (P = 0.039), neutrophil count (P = 0.004) and monocyte count (P = 0.001). However, more interestingly, neutrophil-lymphocyte ratio (P < 0.001) and platelet-lymphocyte ratio (P < 0.001) were found to be significantly higher in those with total lymphocyte count less than 1.7. Lymphocyte to monocyte ratio was inversely related to preoperative total lymphocyte count (P < 0.001). Only age was identified to be significantly different (P = 0.007). However, other clinicopathological parameters generally known to be related to tumour aggressiveness, were not different between two groups. In conclusion, preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left-sided pancreatic cancer.

Surgical outcomes in octogenarians with left-sided pancreatic ductal adenocarcinoma: a multi-institutional analysis

Background: Surgical resection for pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) accounts for 11.5% of all pancreatectomies. Of those, only 20% are performed on patients older than 80 years. This study characterizes this extremely small population of octogenarian patients with left-sided PDAC to establish their unique clinicopathologic, surgical, and treatment outcomes. Methods: Patients at five high-volume pancreatic centers with PDAC-NBT who underwent surgical resection with curative intent were retrospectively analyzed. Clinical, radiographic, pathologic, and treatment outcomes for the octogenarian cohort were compared to those of younger patients. Results: 370 patients were surgically treated between 2001 and 2016. Of those, 44 patients were greater than or equal to 81 years of age at diagnosis. Compared to patients aged less than 61 (n = 87), octogenarians exhibited no differences in presentation symptoms but exhibited significantly lower BMI (24.4 vs 29.2, p < 0.0001). Clinical characteristics were similar except that octogenarians presented with smaller tumors (3.4 cm vs 5.1 cm, p = 0.016) and were more likely to have elevated CA 19-9 (88% vs 52.9%, p = 0.020). The use of neoadjuvant therapy was similar between all age groups, but adjuvant chemotherapy was significantly under-utilized in octogenarians (36.6% vs 80.5%, p < 0.00001). Surgically, octogenarians had significantly shorter operative time (247 vs 300 minutes, p = 0.04), had fewer lymph nodes recovered (14.3 vs 22.2, p = 0.03) and were more likely to undergo a non-R0 resections (38.5% vs 18.5%, p = 0.02). Postoperatively, there were no differences in blood transfusions, complications, pancreatic fistulas, or hospital length of stay. Pathologically, no differences were found between tumor stage, lymph node ratio, perineural or lymphovascular invasion. Likewise, there were no significant survival differences attributable to age. Conclusion: Octogenarians with PDAC-NBT have significant differences in surgical and medical treatment metrics, including lower rates of R0 resection and adjuvant therapy. Despite this, there were no overall differences in perioperative morbidity, mortality, or survival. These data suggest that resection should be pursued in the appropriately selected octogenarian as outcomes are not associated with age-related clinicopathologic factors.

The role of radical antegrade modular pancreatosplenectomy compared to conventional distal pancreatosplenectomy in patients with left-sided pancreatic ductal adenocarcinoma: a retrospective multicenter propensity- score matching analysis

The role of radical antegrade modular pancreatosplenectomy compared to conventional distal pancreatosplenectomy in patients with left-sided pancreatic ductal adenocarcinoma: a retrospective multicenter propensity- score matching analysis

Role of laparoscopic radical antegrade modular pancreatosplenctomy for adenocarcinoma of the body and tail of the pancreas: a retrospective study

Introduction: Radical antegrade modular pancreatosplenectomy (RAMPS) as a creative way for resectable pancreatic cancer was proposed more than a decade ago, there is debate about the survival benefit and the accessibility for laparoscopic approach. Method: From August 2012 to March 2018, 51 patients undergoing open-RAMPS or laparoscopic RAMPS(lap-RAMPS) for left-sided pancreatic ductal adenocarcinoma (PDAC) were reviewed. The surgical and oncologic outcomes of lap-RAMPS were compared with those of open-RAMPS. Univariate and multivariate analyses were used to identify prognostic factors associated with survival. Result: A total of 51 PDAC patients were enrolled (26 underwent lap-RAMPS and 25 underwent open RAMPS). There were no significant differences in demographic or peri-operative outcomes between two groups. Complications were comparable between the lap-RAMPS and RAMPS groups. In lap-RAMPS group, R0 resection margin was achieved in 24 of 26 patients (92.31%) (R1: 2 cases, 7.69%; R2: 0 cases, 0%), and R0 inferior-posterior retroperitoneal resection was achieved in 24 of 26 patients (92.31%). In open RAMPS group, R0 resection margin was achieved in 23 of 25 patients (92%) (R1: 2cases, 8%; R2: 0 cases, 0%), R0 inferior-posterior retroperitoneal resection was 24 of 25 patients (96%). There were no differences in differentiation grade, tumor size, TNM stage, perineural, and peripancreatic soft tissue invasion, carcinoma cell embolus, resection margin status between the two groups. The number of lymph nodes retrieved between two groups was not significant difference (15.73 vs 18.32; P=0.201). Median disease free survial was analogous (26.56 vs 27.49, P=0.951). Median survival was 31.57 months in lap-RAMPS group and 34.39 months in the open group (P = 0.641). Surgical procedure (lap-RAMPS or open RAMPS) was not an independent influencing factor of disease free survial or overall survival. Conclusion: Without increased risks for short-term outcome and patient's survival, Lap-RAMPS is a safe and beneficial surgical procedure for the left-sided PDAC patients.

New laparoscopic procedure for left-sided pancreatic cancer\u2014artery-first approach laparoscopic RAMPS using 3D technique

BackgroundFor left-sided pancreatic ductal adenocarcinoma (PDAC), radical antegrade modular pancreatosplenectomy (RAMPS) is a reasonable surgical approach for tumor-free margin resection and systemic lymph node clearance. In pancreaticoduodenectomy for PDAC, the superior mesenteric artery (SMA)-first approach (or the “artery-first approach”) has become the standard procedure. With improvements in laparoscopic instruments and techniques, some surgeons attempted to apply laparoscopic RAMPS (L-RAMPS) for carefully selected patients with left-sided PDAC. However, owing to several technical difficulties in this procedure, its application remains uncommon. Moreover, the artery-first approach in L-RAMPS has not been reported. Here, we developed the artery-first approach L-RAMPS for left-sided PDAC and have presented the same in this report.Case presentationBetween June 2014 and July 2015, 16 patients with left-sided PDAC were referred to our division for pancreatic resection. The following technique was used for performing L-RAMPS on 3 of the 16 patients (19%). Six trocars were placed. After opening the omental bursa, only the middle segment of the pancreas was initially separated from both the left renal vein and the SMA. We termed this procedure as the “artery-first approach using a dome-shaped dorsomedial dissection (3D) technique.” This 3D technique enabled the interruption of the entire arterial supply to the specimen while preserving the venous drainage through the splenic vein for preventing venous congestion. The technique also contributed to the early detection of no tumor infiltration into the SMA and the early determination of posterior dissection plane. After pancreatic neck transection, the splenic artery and vein were divided. Finally, the pancreatic tail and spleen were dissected in a right-to-left direction. All operations were completed without any intraoperative complications. The median blood loss and retrieved lymph node count were 75 mL and 37, respectively, which were superior to those reported by other previous studies on L-RAMPS. All resection margins were free of carcinoma. No severe postoperative complications were observed.ConclusionsThe artery-first approach L-RAMPS using 3D technique is safe and feasible to perform. The significance of our proposed procedure is minimal blood loss and precise lymphadenectomy. Therefore, this novel technique may become the preferred treatment for left-sided PDAC in selected cases.

Yonsei criteria: a clinical reflection of stage I left-sided pancreatic cancer.

In this study, we examined associations between pancreatic cancer that met the Yonsei criteria (YC) and classifications from the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Clinicopathological and survival data were collected from132 patients who underwent distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma between January 2000 and December 2015, and the utility of the YC for selecting treatment and predicting survival was evaluated using the 8th AJCC staging manual. Of the 102 patients who ultimately qualified for the study, 45 patients were reclassified as stage I based on the 8th AJCC cancer staging system. Disease-free survival and disease-specific survival periods were longer in stage I patients who met the YC than in those who did not. Clinicopathological characteristics did not differ between stage I patients who did and did not meet the YC. These results suggest that meeting the YC criteria may be a clinical indicator that left-sided pancreatic cancer patients who are candidates for resection have early-stage disease according to the 8th edition of the AJCC staging manual.

Prognostic impact of the tumor-infiltrating regulatory T-cell (Foxp3+)/activated cytotoxic T lymphocyte (granzyme B+) ratio on resected left-sided pancreatic cancer.

Among the subsets of tumor-infiltrating lymphocytes (TILs), activated cytotoxic T lymphocytes (granzyme B+) have an antitumor effect, while regulatory T lymphocytes [forkhead box P3 (Foxp3)+] suppress the antitumor immune response. The aim of the present study was to investigate the possible associations between TIL subsets and survival outcomes in patients with left-sided pancreatic ductal adenocarcinoma (PDAC). From January 2000 to December 2008, 30 patients who underwent curative distal pancreatectomy without neoadjuvant chemoradiotherapy due to left-sided PDAC were enrolled in the present study. TIL subsets were enumerated by immunohistochemical staining for cluster of differentiation (CD)3, CD4, CD8, Foxp3 and granzyme B in the intra-tumoral areas of tissue blocks. Patients were divided into two groups according to the median value of the absolute counts and relative ratios of TIL subsets. In the univariate analysis, age, gender, tumor size, nodal stage, tumor differentiation and lymphovascular/perineural invasion were not significantly associated with survival outcome. However, low levels of preoperative cancer antigen (CA) 19–9 were associated with a longer overall survival (OS), although the association was not significant (37 vs. 18 months; P=0.061). A high level of granzyme B+ was associated with enhanced disease-free survival (DFS) (25 vs. 10 months; P=0.023), and a low Foxp3+/granzyme B+ ratio was associated with a favorable prognosis in terms of DFS (25 vs. 8 months; P=0.008) and OS (47 vs. 17 months; P=0.003). In the multivariate analysis, the ratio of Foxp3+/granzyme B+ was an independent prognostic factor for determining DFS [Exp(B), 3.060; 95% confidence interval (CI), 1.259–47.436; P=0.014] and OS [Exp(B), 3.580; 95% CI, 1.460–8.780; P=0.005]. Among the clinicopathological factors, low levels of CA 19–9 were significantly associated with a low Foxp3+/granzyme B+ ratio (P=0.016). The results of the present study suggested that a low Foxp3+/granzyme B+ ratio may be useful for predicting a good prognosis in surgically resected left-sided PDAC.