Pancreaticoduodenectomy For Pancreatic Head Adenocarcinoma Research Articles

Cerebellopontine angle metastasis from pancreatic cancer: a case report

Introduction: Pancreatic cancer metastasis to the cerebellopontine angle (CPA) is extremely rare and often misdiagnosed preoperatively. The clinical characteristics and prognosis of this uncommon condition remain largely unknown. Case presentation: We report the case of a 68-year-old male who presented with recurrent headaches, dizziness, and gait disturbances. The patient had undergone pancreaticoduodenectomy for pancreatic head adenocarcinoma two years prior. Preoperative imaging suggested a right CPA meningioma. The patient underwent resection of the CPA tumor under general anesthesia. Postoperative pathology revealed a metastatic pancreatic adenocarcinoma. Despite treatment with adjuvant chemotherapy, the patient developed widespread metastatic disease and succumbed 2 months after the CPA tumor resection. Discussion: The rarity of pancreatic cancer metastasizing to the CPA presents diagnostic challenges, as evidenced by the initial misdiagnosis of meningioma in this case. The clinical presentation can mimic benign conditions, leading to delays in appropriate management. This case underscores the importance of considering metastatic disease in patients with a history of cancer, even when presenting with symptoms typical of more common CPA lesions. Conclusion: Vigilant monitoring is crucial in pancreatic cancer patients, as neurological symptoms may herald metastatic spread to uncommon sites like the CPA. Despite surgical intervention, widespread metastasis can lead to poor outcomes. Early diagnosis and a high index of suspicion are essential for optimal management of these rare cases.

Impact of Total Mesopancreas Excision on the Superior Mesenteric Artery Margin Status

Introduction: Pancreatic ductal head adenocarcinoma (PDHAC) is a lethal disease with poor prognosis and surgical resection with complete microscopic resection (R0) in association with multimodal treatment currently represents the only curative strategy. The dissected margins around the superior mesenteric artery (SMA) are reported to be the most favorable R1 site for PDHAC. Therefore, modifications have been made to the classic surgical technique (Whipple) to improve the rate of R1 resections, such as the total mesopancreas excision (TMpE). The purpose of this study was to evaluate the impact of TMpE on the SMA margin status. Methods: This study included 93 patients with PDHAC who were treated in the Hepatobiliary Surgery Department of Miguel Servet University Hospital in Saragossa, Spain, during a 7-years period (2010-2017). They were divided into two groups. Group A included patients who underwent pancreaticoduodenectomy (PD) with TMpE and group B included standar PD (S-PD). The collected data were prospectively collected and statistically analyzed by SPSS 19.0 statistical software package. Results: The R0 resection rate was 52.1% (25/48) in Group A and 31.1% (14/45) in Group B. There was significant difference in the R0 resection rate between the two groups (p=0.027). The R1 SMA resection margin rate was 18. Conclusions: TMpE improves the oncological results of PD for pancreatic head adenocarcinoma as it halves the rate of R1 resections at the SMA resection margin.

The role of sarcopenia in the pancreatic adenocarcinoma.

Pancreaticoduodenectomy is still associated with prolonged hospitalization and with a lot of complications. For these reasons, it is fundamental to improve strategies for preoperative risk stratification, and sarcopenia is one of the new identified markers of frailty. The purpose of our study was to retrospectively detect sarcopenia in patients undergoing pancreaticoduodenectomy and evaluate its importance as a preoperative marker. We retrospectively identified a total amount of 76 consecutive patients who underwent pancreaticoduodenectomy for pancreatic head adenocarcinoma. Patients' and tumor's characteristics were recorded retrospectively. It appears that sarcopenia might be a useful preoperative prognostic factor for patients undergoing PD for PA. We found that Recurrence Free Survival may be influenced by presence or absence of preoperative sarcopenia, and we can confirm that in sarcopenic patients the average hospital stay is 20% longer than in non sarcopenic ones. Sarcopenia has a central role because it is a very common condition found in pancreatic cancer patients; there is growing evidence showing that it is associated with worse surgical outcomes. We can state that evaluating sarcopenia in cancer patients could improve the postoperative outcomes, overall survival rates and, nevertheless, the recurrence free survival ones.

The Impact on Survival and Morbidity of Portal–Mesenteric Resection During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma: A Systematic Review and Meta-Analysis of Comparative Studies

Background: The literature is conflicting regarding oncological outcome and morbidity associated to portal–mesenteric resection during pancreaticoduodenectomy (PD) in patients with pancreatic head adenocarcinoma (PHAC). Methods: A meta-analysis of studies comparing PD plus venous resection (PD+VR) and standard PD exclusively in patients with adenocarcinoma of the pancreatic head was conducted. Results: Twenty-three cohort studies were identified, which included 6037 patients, of which 28.6% underwent PD+VR and 71.4% underwent standard PD. Patients who received PD+VR had lower 1-year overall survival (OS) (odds radio OR 0.79, 95% CI 0.67–0.92, p = 0.003), 3-year OS (OR 0.72, 95% CI 0.59–0.87, p = 0.0006), and 5-year OS (OR 0.57, 95% CI 0.39–0.83, p = 0.003). Patients in the PD+VR group were more likely to have a larger tumor size (MD 3.87, 95% CI 1.75 to 5.99, p = 0.0003), positive lymph nodes (OR 1.24, 95% CI 1.06–1.45, p = 0.007), and R1 resection (OR 1.74, 95% CI 1.37–2.20, p < 0.0001). Thirty-day mortality was higher in the PD+VR group (OR 1.93, 95% CI 1.28–2.91, p = 0.002), while no differences between groups were observed in rates of total complications (OR 1.07, 95% CI, 0.81–1.41, p = 0.65). Conclusions: Although PD+VR has significantly increased the resection rate in patients with PHAC, it has inferior survival outcomes and higher 30-day mortality when compared with standard PD, whereas postoperative morbidity rates are similar. Further research is needed to evaluate the role of PD+VR in the context of multimodality treatment of PHAC.

Correlation of survival length after pancreaticoduodenectomy for pancreatic head adenocarcinoma depending on tumor characteristics detected by means of computed tomography and resection margins status.

Pancreatic carcinoma is an aggressive tumor with a grim prognosis. Accurate staging is essential for indicating surgery in patients with borderline resectable tumors. This paper examines the correlation between pre-operation characteristics of tumors found on CT, infiltration of individual resection margins as confirmed by a pathologist, and the survival of patients with resectable pancreatic head ductal adenocarcinoma. This prospective cohort study involved patients operated on for pancreatic head adenocarcinoma, which was clearly resectable based on the staging CT and intraoperative observation between 2011-2014. Only patients without postoperative complications who underwent adjuvant chemotherapy were analyzed. Seventy-nine patients were assessed, of which 16 (20.3%) had R0 resection and 63 (79.7%) had R1 resection. Patients with R1 results had up to 2.7 times higher risk of death than patients with R0 resection. We found a trend towards shorter survival associated with a closer relationship of the tumor to the superior mesenteric vein/portal vein (SMV/PV) wall in the pre-operation CT examination. Patients with a tumor interface between the vein wall of up to 180 ° circumference had up to 1.97 times higher risk of death than patients without (p=0.131). The results of our work confirmed that in our center, even surgically treated, clearly resectable pancreatic head tumors still have a high occurrence of positive surgical margins (R1 resection) and that tumors with R1 resection had statistically significantly reduced survival compared to R0 resection. A trend for shorter overall survival was found after tumor resection depending on the increasing interface between the tumor and the SMV/PV wall, but this result was not statistically significant.

Identification of Pancreaticoduodenectomy Resection for Pancreatic Head Adenocarcinoma: A Preliminary Study of Radiomics.

Background In a pathological examination of pancreaticoduodenectomy for pancreatic head adenocarcinoma, a resection margin without cancer cells in 1 mm is recognized as R0; a resection margin with cancer cells in 1 mm is recognized as R1. The preoperative identification of R0 and R1 is of great significance for surgical decision and prognosis. We conducted a preliminary radiomics study based on preoperative CT (computer tomography) images to evaluate a resection margin which was R0 or R1. Methods We retrospectively analyzed 258 preoperative CT images of 86 patients (34 cases of R0 and 52 cases of R1) who were diagnosed as pancreatic head adenocarcinoma and underwent pancreaticoduodenectomy. The radiomics study consists of five stages: (i) delineate and segment regions of interest (ROIs); (ii) by solving discrete Laplacian equations with Dirichlet boundary conditions, fit the ROIs to rectangular regions; (iii) enhance the textures of the fitted ROIs combining wavelet transform and fractional differential; (iv) extract texture features from the enhanced ROIs combining wavelet transform and statistical analysis methods; and (v) reduce features using principal component analysis (PCA) and classify the resection margins using the support vector machine (SVM), and then investigate the associations between texture features and histopathological characteristics using the Mann–Whitney U-test. To reduce overfitting, the SVM classifier embedded a linear kernel and adopted the leave-one-out cross-validation. Results It achieved an AUC (area under receiver operating characteristic curve) of 0.8614 and an accuracy of 84.88%. Setting p ≤ 0.01 in the Mann–Whitney U-test, two features of the run-length matrix, which are derived from diagonal sub-bands in wavelet decomposition, showed statistically significant differences between R0 and R1. Conclusions It indicates that the radiomics study is rewarding for the aided diagnosis of R0 and R1. Texture features can potentially enhance physicians' diagnostic ability.

Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma

BackgroundAdjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma. MethodsPatients with stage I-III pancreatic head adenocarcinoma in the 2006–2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6–12-weeks, and 12–24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy. ResultsOf 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6–12 weeks, and 1194 (8.9%) within 12–24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6–12-weeks: 0.744, and 12–24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens. ConclusionsFor patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.

Impact on survival and recurrence of positive histological resection after pancreatoduodenectomy in patients with lymph node invasion: an international multicentric study

The aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone.From 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group).A total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow‐up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease‐free (35% and 37%, respectively) survival (P = 0.10).In patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.

Is Perineural Invasion More Accurate Than Other Factors to Predict Early Recurrence after Pancreatoduodenectomy for Pancreatic Head Adenocarcinoma?

Some patients operated by pancreaticoduodenectomy for resectable pancreatic head adenocarcinoma will present with a recurrence during the first year (early recurrence). The aim of this study was to determine prognostic factors associated with early recurrence in a large retrospective study. From January 1995 to November 2010, all patients operated by pancreaticoduodenectomy for pancreatic head adenocarcinoma in our institution were retrospectively included. Univariate and multivariate analyses were performed to determine factors associated with early recurrence. A total of 166 patients were included; 57 patients (34%) developed early recurrence. In univariate analysis, factors associated with early recurrence were perineural invasion (p = 0.0002), preoperative bilirubin (p = 0.01), lymph node ratio (LNR) ≥0.2 (p = 0.009), and T stage (p = 0.02). In multivariate analysis, perineural invasion (odds ratio [OR] 3.31; 95% confidence interval [CI] 1.42-7.72; p = 0.005), LNR ≥0.2 (OR 2.55; 95% CI 1.17-5.52; p = 0.02), and preoperative bilirubin (OR 1.04; 95% CI 1.01-1.07; p = 0.03) were independent factors associated with early recurrence. Perineural invasion was also associated with poor overall survival (p = 0.001) and poor disease-free survival (p = 0.07). In our study, perineural invasion (OR 3.31) is more accurate than T stage and lymph node status (OR 2.55) to predict early recurrence after pancreatoduodenectomy for pancreatic head adenocarcinoma.

Pancreaticoduodenectomy following chemoradiotherapy for locally advanced adenocarcinoma of the pancreatic head

ObjectivesThe aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone. MethodsFrom 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group). ResultsA total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow‐up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease‐free (35% and 37%, respectively) survival (P = 0.10). ConclusionsIn patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.

Cirrhosis should not be considered as an absolute contraindication for pancreatoduodenectomy.

Liver cirrhosis is considered to be a contraindication for pancreaticoduodenectomy (PD). The aim of this study was to present 4 cases of successful PD in cirrhotic patients. Among the charts of 90 patients who underwent PD between 2004 and 2008, 4 patients with liver cirrhosis were retrospectively reviewed. There were 3 males and 1 female, aged from 53 to 66 years, who underwent PD for pancreatic head adenocarcinoma (n=3) or ampullary carcinoma (n=1). The median tumor size was 21mm (18-26) and 2 patients had preoperative biliary drainage. All patients had biopsy showing cancer prior to the operation. Cirrhosis was preoperatively suspected due to chronic alcoholism or liver dismorphy on CTscan and confirmed histologically in all patients. All patients were Child Pugh A without portal hypertension. The median operating time was 575 minutes (480-600) and 2 patients received an intraoperative blood transfusion. No patient died postoperatively. All patients had postoperative complications: ascites (n=2), pancreatic fistula (soft pancreas) (n=2) and pulmonary infection (n=1). There was neither liver failure nor postoperative bleeding. Two patients required re-operation for suspected mesenteric ischemia (n=1) and pancreatic fistula (n=1). The median length of hospitalization was 50 days (41-74). The median survival was 12.5 months (3 patients are alive and disease free). Our data shows that PD in patients with Child A liver cirrhosis should not be systematically considered as a contraindication.

Metachronous double cancer after curative resection for pancreatic adenocarcinoma: report of four cases.

We experienced four cases of metachronous double cancer after curative resection for pancreatic adenocarcinoma without the background of intraductal papillary mucinous neoplasm. Case 1, a 67-year-old Japanese female developed tongue cancer 53months after a pylorus-preserving Whipple resection for pancreatic head adenocarcinoma. Case 2, a 66-year-old female developed multiple breast cancers 52months after a pylorus-preserving pancreaticoduodenectomy for pancreatic head adenocarcinoma. Case 3, a 59-year-old male developed an adenocarcinoma in the remnant pancreatic head 63months after a distal pancreatectomy for pancreatic body cancer. Case 4, a 68-year-old male developed lung cancer 92months after a Whipple procedure for pancreatic head adenocarcinoma. Gemcitabine was administered to three patients as adjuvant chemotherapy at an average administrated dose of 38,199mg per body surface area. Since primary pancreatic ductal adenocarcinoma is aggressive and always associated with a devastating outcome, metachronous double cancer is scarcely seen. All four cases received curative-intent surgery for each metachronous cancer and were alive for at least 20months.

Significance of Common Hepatic Artery Lymph Node Metastases During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma

Common hepatic artery lymph nodes (CHALN) are frequently sampled during pancreaticoduodenectomy for adenocarcinomas of the head of the pancreas. In some institutions, if metastatic disease is detected intraoperatively in these lymph nodes, the tumor is considered unresectable and a curative operation is not performed. No solid data exist to support this practice. A retrospective review of a prospectively collected database was conducted of the records of all patients who underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma between September 1991 and April 2005. Clinical and pathologic factors were analyzed to determine their influence on survival. Fifty-five of 175 patients had CHALN separately identified and evaluated; these patients constituted the study population. Thirty-eight patients (69%) had one or more lymph nodes with metastatic involvement; 10 of these had disease in CHALN. The median overall survival for patients with node-negative, node-positive (but CHALN-negative), and CHALN-positive disease were 22.9, 16.1, and 14.7 months, respectively. The 5-year overall survival rates for the respective groups were 22%, 17%, and 0%. CHALN metastases correlate with poor prognosis and no long-term survival. Further studies examining CHALN status are indicated and could lead to modifications of pancreatic cancer staging and management.