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Objective:To study the combined use of neoadjuvant chemotherapy and immunotherapy in patients with borderline resectable pancreatic cancer.Methods:The clinical data of patients with pancreatic cancer who were planned to undergo perioperative treatment before surgical treatment at the Fifth Medical Center of PLA General Hospital from January 2019 to June 2021 were retrospectively studied. Of 22 patients with pancreatic cancer, there were 10 males and 12 females, aged (56.0±10.2) years old. Preoperative treatment with chemotherapy (nab-paclitaxel and S-1, AS) and immunotherapy regimen before surgery were given. The baseline characteristics, treatment efficacy, surgical pathology and prognosis were analyzed.Results:Of 22 patients who were treated with neoadjuvant chemotherapy combined with programmed death-1 (PD-1) monoclonal antibody, 11 patients (50%) had tumors in the head, neck and uncinated process of pancreas. On radiographic assessment, one patient achieved CR (4.5%, 1/22), 9 patients PR (40.9%, 9/22), and 11 patients SD (50.0%, 11/22). All patients subsequently underwent R 0 resection. The postoperative pTNM staging showed 91% (20/22) of patients were in stage IA-IIB, 31.8% (7/22) of patients had pT2, 63.6% (14/22) had N0, and 1 patient had pCR. Thirteen patients (54.2%, 13/22) received postoperative adjuvant therapy. The median recurrence-free survival (RFS) was 6.4 months and the median time to progression (TTP) was 12.8 months. The median overall survival of patients was not reached. Postoperative pathology TNM staging IIA to III ( HR=3.63, 95% CI: 1.18-11.20, P=0.025) and postoperative pathology T2-3 stage ( HR=2.02, 95% CI: 1.01-5.05, P=0.049) were significantly associated with RFS. Postoperative pathology TNM stages IIA to III ( HR=2.39, 95% CI: 1.04-5.50, P=0.041) and postoperative pathology T2-3 stage ( HR=2.53, 95% CI: 1.26-5.09, P=0.009) were significantly associated with TTP. Conclusion:AS combined with PD-1 monoclonal antibody showed good efficacy as a neoadjuvant therapy for patients with borderline-resectable pancreatic cancer.
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Borderline resectable pancreatic ductal adenocarcinoma accounts for approximately 20% of newly diagnosed pancreatic cancer patients. This type of adenocarcinoma is between resectable and unresectable. It has a high degree of heterogeneity and features in anatomy, biology, and physical condition. The biological characteristics of invasiveness determine that, rather than direct surgery, neoadjuvant therapy should be primarily given to patients to achieve R0 resection and avoid early postoperative recurrence. However, this treatment model is still controversial. According to the latest research on this topic, the full text summarizes the definition of BR-PDAC, resectable evaluation, neoadjuvant treatment selection and evaluation, surgical results after neoadjuvant therapy, and the efficacy of adjuvant therapy after neoadjuvant therapy.
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Large hepatocellular carcinoma (HCC) is one of the most common malignancies and was mistaked as "advanced and unresectable" . Liver resection is still the best curable treatment for HCC.The resection of large HCC is very difficult, which seriously restrict the progress of liver surgery.Our study proved that solitary large HCC (SLHCC) has unique clinicopathological and molecular biological characteristics.No matter how big the tumor size is, it belongs to early stage if there is no vascular invasion.Liver resection should be aggressively recommended for the patients with SLHCC, in which they can obtain good outcome, with 40% 5-year survival rate.We has also defined the borderline resectable hepatocellular carcinoma, and suggested that strictly master and correctly judge the surgical indications, syntheticly evaluate the surgical safety and patient′s tolerability for liver resection.After that, with hands of experienced surgeons, liver resection for SLHCC can be safely and reliablely performed.
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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 ClavienDindo 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％.Condusion 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.
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Pancreatic cancer has a extremely high malignancy,and simple surgical resection can not significantly improve the long-term survival rate of patients.Neoadjuvant therapy is the preoperative chemotherapy or combined chemo radiotherapy,which is used for downstaging tumors,eliminating subclinical metastases,transforming unresectable into resectable tumors,and improving the R0 resection rate of pancreatic cancer,thus ultimately improving the efficacy of pancreatic cancer.At present,neoadjuvant therapy has gradually become the mainstream treatment for locally advanced and borderline resectable pancreatic cancer.New adjuvant therapy for resectable pancreatic cancer has been supported by some high-quality clinical research data,which will become a hot topic in clinical research.The author believes that there will be more clinical research data to help individualized neoadjuvant treatment selection,accurate efficacy evaluation and prognosis judgement,and ultimately improve the efficacy of patients with pancreatic cancer.
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Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected.The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements),and tumors of 13 patients were BR-A type (SMV,celiac trunk and / or hcpatic artcry involvements).The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection,the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway.Observation indicators:(1) intraoperative and postoperative situations;(2) results of postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018.Measurement data with skewed distribution were described as M (range).The survival curve was drawn by the Kaplan-Meir method,and Log-rank test was used for survival analysis.Results (1)Intraoperative and postoperative situations:38 patients underwent intraoperative segmental resection of PV and / or SMV,including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis.Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ.There was no intraoperative celiac trunk resection.The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range,280-520 minutes) and 530 mL (range,420-650 mL).The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4％ (7/38),and some patients were combined with multiple complications,including 6 with pulmonary infection,4 with pancreatic fistula (B and C grade),4 with intra-abdominal infection,3 with delayed gastric emptying,2 with postoperative bleeding and 2 with venous thrombosis.Five patients were cured by postoperative symptomatic treatment,and 2 with postoperative bleeding died of worsened condition after reoperation.The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3％(2/38) and 12 days (range,9-52 days).(2) Results of postoperative pathological examination:the R0 resection rate of 38 patients was 81.6％ (31/38).The R0 resection rate of 25 patients in BR-PV type was 92.0％ (23/25),and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients without R0 resection;R0 resection rate of 13 patients in BR-A type was 8/13,and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients and resection margin of SMV ＜ 1 mm was in 4 patients (1 margined with resection margin of multiple sites ＜ 1 mm) of patients without R0 resection.The resection margins of pancreatic trailing edge,venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm.The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0％ (25/25) and 9/13.(3) Follow-up and survival situations:38 patients were followed up for 6-40 months,with a median time of 15 months,and survival time was 18 months (range,6-40 months).The survival time and 1-,2-and 3-year cumulative survival rates were respectively 23 months (range,8-40 months),89.5％,33.1％,22.1％ in 25 patients with BR-PV type and 16 months (range,6-25 months),83.9％,16.8％,0 in 13 patients with BR-A type.The tumor-free survival time and 1-and 2-year cumulative tumor-free survival rates were respectively 15 months (range,5-30 months),63.0％,7.5％ in patients with BR-PV type and 9 months (range,4-18 months),11.5％,0 in patients with BR-A type.Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements,pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV,and increase negative rates of venous and pancreatic resection margins.
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The borderline resectable pancreatic cancer is high a controversial hotspot in the field of pancreatic surgery,and the controversy mainly focuses on definition and treatment.Five famous experts and their teams in pancreatic surgery discussed present situation and dilemmas in treatment of borderline resectable pancreatic cancer based on clinical experiences.Professor Hao Chunyi has reviewed and analyzed origin of the definition and treatment model of borderline resectable pancreatic cancer,and proposed that high-level pancreatic disease center and multidisciplinary collaboration diagnosis and treatment may be the best choice for resectable pancreatic cancer.Professor Liu Xubao suggested surgical treatment for most of borderline resectable pancreatic cancer,and whether or not tumor invades adjacent blood vessels and invasion level will be used to decide direct surgery or neoadjuvant therapy.Professor Sun Bei proposed 6 causes,and direct surgery may be more realistic and feasible option for borderline resectable pancreatic cancer.Professors Liang Tingbo and Bai Xueli recommended that neoadjuvant therapy should be performed due to defeat hiding micrometastasis lesions and reduce tumor burden,and there was a higher R0 resection rate and lower lymph node metastasis rate after neoadjuvant therapy,meanwhile,it can also increase cure rate and is benefited to survival.
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Objective@#To compare the clinical therapeutic effects of arterial first approach pancreaticoduodenectomy(AFA-PD) with standard approach pancreaticoduodenectomy(SPD) in the treatment of borderline resectable pancreatic cancer (BRPC).@*Methods@#A retrospective analysis of the clinical data of 113 cases of pancreatic cancer patients from January 2014 to August 2015 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, including 43 cases in AFA-PD group and 70 cases in SPD group.Every patient had gone high-resolusion computed tomography before the surgery, when BRPC was definitely diagnosed by both experienced radiologist and pancreatic surgeon.There were 24 males and 19 females in the AFA-PD group, with average age of (61.6±10.2)years.And in the SPD group, there were 47 males and 23 females, with average age of (62.7±9.4)years.@*Results@#The operation time was (210.7±31.5)minutes in AFA-PD group, (187.9±27.4)minutes in SPD group, and peroperative bleeding volume was (1 007.1±566.3)ml in AFA-PD group, (700.0±390.0)ml in the other group.Those two indicators of AFA-PD group, compared with SPD group, were relatively higher, the difference was statistically significant(all P<0.01). And with regard to postoperative diarrhea(9.3% vs.5.7%), postoperative 1, 3 days of white blood cells(postoperative 1 day: (13.3±1.1)×109/L vs.(12.4±2.4)×109/L; postoperative 3 days: (12.7±1.6)×109/L vs.(11.7±2.5)×109/L), postoperative 1, 3, 5 days of peritoneal drainage fluid volume(postoperative 1 day: (184±42)ml vs.(156±54)ml; postoperative 3 days: (155±48)ml vs.(133±35)ml; postoperative 5 days: (66±20)ml vs.(47±31)ml), the differences between the two groups were statistically significant (all P<0.05). One patient in the SPD group was treated with unplanned secondary surgery for postoperative intraperitoneal hemorrhage, and the patient was cured and discharged.There was no death in the two groups within 30 days after surgical operation and no patient with positive gastric margin, duodenal margin, or anterior margin.The resection rate of superiormesenteric artery(SMA) margin R0 in AFA-PD group was higher than that in SPD group (P=0.019). The two groups were followed up for 14 to 30 months.As for AFA-PD group, the average survival time, progression free survival time and median survival time was respectively (20.4±1.2)months, (21.5±1.4)months and 20 months.There were 3 cases(7.0%) with local recurrence and 8 cases(18.6%) with liver metastasis or distant metastasis.In the SPD group, the average survival time, progression free survival time and median survival time was (17.1±1.1)months, (16.4±1.3)months and 16 months, respectively.There were 13 cases(18.6%) with local recurrence and 25 cases(35.7%) with liver metastasis or distant metastasis.As a result, the AFA-PD group had longer survival time(P=0.001)and progression free survival time(P=0.002). However, the lower local recurrence and distant metastasis rate in AFA-PD group did not reach statistical standard (P>0.05).@*Conclusion@#The arterial first approach pancreaticoduodenectomy is safe and effective in the treatment of borderline resectable pancreatic cancer, which can improve the resection rate of SMA margin R0, and prolong patient survival time.
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Locally advanced pancreatic cancer (LAPC) involves with adjacent vascular structures,which is divided into the borderline resectable pancreatic cancer (BRPC) and unresectable pancreatic cancer.BRPC is usually treated with vascular restruction.Neoadjuvant therapy plays an important role in achieving an R0 resection in BRPC.Generally,the goal of treatment for unresectable pancreatic cancer is to control tumor progress and improve patients' quality of life.The latest cheering clinical trials have shown that some LAPC may be downstaged to resectable tumors after preoperative chemotherapy and chemoradiotherapy.In this article,the rationale for and results following treatment with neoadjuvant chemotherapy,chemoradiation and possibly subsequent surgical resection of the primary tumor are described in detail and existing data are reviewed.
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Locally advanced pancreatic cancer (LAPC) involves with adjacent vascular structures,which is divided into the borderline resectable pancreatic cancer (BRPC) and unresectable pancreatic cancer.BRPC is usually treated with vascular restruction.Neoadjuvant therapy plays an important role in achieving an R0 resection in BRPC.Generally,the goal of treatment for unresectable pancreatic cancer is to control tumor progress and improve patients' quality of life.The latest cheering clinical trials have shown that some LAPC may be downstaged to resectable tumors after preoperative chemotherapy and chemoradiotherapy.In this article,the rationale for and results following treatment with neoadjuvant chemotherapy,chemoradiation and possibly subsequent surgical resection of the primary tumor are described in detail and existing data are reviewed.
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As for the surgeons,surgical treatment of pancreatic cancer promises to be very challenging.The concept of borderline resectable pancreatic cancer has further improved diagnostic and treatment systems of pancreatic cancer recently,but there is no verdict on the controversial problems of borderline resectable pancreatic cancer,such as the significance and indications combined with vascular resection,feasibility combined with artery resection and effect of neoadjuvant treatment.This article will go into in-depth discussions concerning the hot issues of borderline resectable pancreatic cancer in order to further improve the standardized diagnosis and surgical treatment for pancreatic cancer.
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Surgical resection offers the only chance of cure for nonmetastatic exocrine pancreatic cancer. However, only 15 to 20 percent of patients have potentially resectable disease at diagnosis; approximately 40 percent have distant metastases, and another 30 to 40 percent have locally advanced unresectable tumors. Typically, patients with locally advanced unresectable pancreatic cancer have tumor invasion into adjacent critical structures, particularly the celiac and superior mesenteric arteries. The optimal management of these patients is controversial, and there is no internationally embraced standard approach. Therapeutic options include chemoradiotherapy or chemotherapy alone. While it is reasonable to restage and reevaluate the potential for resectability after neoadjuvant therapy, the frequency of a complete resection and long-term survival is low for patients who initially have categorically unresectable tumors. Others have disease that is categorized as "borderline resectable." While these patients are potentially resectable, the high likelihood of an incomplete resection has prompted interest in strategies to "downstage" the tumor or to increase the likelihood of a margin-negative resection prior to surgical exploration using neoadjuvant therapy. The rationale for neoadjuvant therapy is as follows. First, it is to improve the selection of patients for whom resection will not offer a survival benefit (i.e., those who rapidly progress to metastatic disease during preoperative therapy). Second, it is to increase rates of margin-negative resections, which is the major goal of surgery. Third, it is to start an early treatment of micrometastatic disease. Initial attempt at downstaging with chemotherapy, chemoradiotherapy, or a combination followed by restaging and surgical exploration in responders rather than upfront surgery is suggested.
Subject(s)
Humans , Chemoradiotherapy , Diagnosis , Drug Therapy , Mesenteric Artery, Superior , Neoadjuvant Therapy , Neoplasm Metastasis , Pancreatic NeoplasmsABSTRACT
With the advances in the imaging techniques, it is now possible to more accurately diagnose and stage pancreatic cancer. However, there is no uniform definition of "borderline resectable pancreatic cancer (BRPC)" and consensus on this terminology has not been reached yet. Although there has been much progress in the therapeutic strategies for pancreatic cancer, the optimal treatment scheme for BRPC is still under debate. In order to overcome these problems, prospective studies using multidisciplinary approaches are warranted. This article is intended to review the currently available definitions and management of BRPC. Promising novel ablative methods that are used as local treatments for locally advanced pancreatic cancer are also introduced. In the near future, these ablative methods might prove to be invaluable for those with BRPC.
Subject(s)
Consensus , Pancreatic NeoplasmsABSTRACT
The diagnosis and therapy of borderline resectable pancreatic cancer are foci in clinical research.We summarized the status of research on neoadjuvant therapy and discussed the safety and effectiveness of combined vascular resection in borderline resectable pancreatic cancer.We discussed the scope of surgical resection,and evaluated the prognostic markers of post-resectional surgery.
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Borderline resectable pancreatic cancer (BRPC),characterized by low resectability rate and high postoperative recurrence rate,is a special kind of pancreatic cancer between resectable type and nonresectable one.Currently,the efficacy of neoadjuvant therapy for BRPC has become a hot topic in the field of pancreatic cancer.Although neoadjuvant therapy plays a critical role in obviously improving the R0 resectability rate and survival status of BRPC patients,the normalized therapeutic regimen has not been established.In this article,we overviewed the recent progress on the neoadjuvant therapy in treating BRPC.
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BACKGROUND: Use of any treatment modality in cancer depends not only on the effectiveness of the modality, but also on other factors such as local expertise, tolerance of the modality, cost and prevalence of the disease. Oropharyngeal and laryngeal cancer are the major subsites in which majority of neoadjuvant chemotherapy (NACT) literature in the head and neck cancers is available. However, oral cancers form a major subsite in India. MATERIALS AND METHODS: This is an analysis of a prospectively maintained data on NACT in the head and neck cancers from 2008 to 2012. All these patients were referred for NACT for various indications from a multidisciplinary clinic. Descriptive analysis of indications for NACT in this data base is presented. RESULTS: A total of 862 patients received NACT within the stipulated time period. The sites where oral cavity 721 patients (83.6%), maxilla 41 patients (4.8%), larynx 33 patients (3.8%), laryngopharynx 8 patients (0.9%) and hypopharynx 59 patients (8.2%). Out of oral cancers, the major indication for NACT was to make the cancer resectable in all (100%) patients. The indication in carcinoma of maxilla was to make the disease resectable in 29 patients (70.7% of maxillary cancers) and in 12 patients (29.3% of maxillary cancers) it was given as an attempt to preserve the eyeball. The indication for NACT in laryngeal cancers was organ preservation in 14 patients (42.4% of larnyngeal cancer) and to achieve resectability in 19 patients (57.6% of larnyngeal cancer). The group with laryngopharynx is a cohort of eight patients in whom NACT was given to prevent tracheostomy, these patients had presented with early stridor (common terminology criteria for adverse events Version 4.02). The reason for NACT in hypopharyngeal cancers was for organ preservation in 24 patients (40.7% of hypopharyngeal cancer) and for achievement of resectability in 35 patients (59.3% of hypopharyngeal cancer). CONCLUSION: The major indication for NACT is to make disease resectable at our center while cases for organ preservation are few.
Subject(s)
Chemotherapy, Adjuvant , Head and Neck Neoplasms/drug therapy , Head and Neck Neoplasms/pathology , Humans , Neoadjuvant Therapy , Referral and Consultation , Retrospective Studies , Tertiary Care CentersABSTRACT
The role of multimodality therapy and surgery for the treatment of locally advanced pancreatic cancer remains to be determined. Although no randomized trials have been done to determine the optimal management of this difficult clinical problem, numerous series reporting successful surgical resection with negative (R0) or microscopic margin (R1) showing favorable long-term survival provide a basis for an aggressive approach in selected cases of advanced cancer of the pancreas. In the absence of conclusive clinical trials, neoadjuvant treatment followed by surgical resection seems to be the optimal approach for locally advanced pancreatic cancers when the potential for surgical resection is suggested by preoperative high quality CT imaging. In particular, when the tumor is within the criteria for borderline resectable pancreatic cancer, efforts to achieve R0 resection are warranted. For those selected cases invading the hepatic artery and superior mesenteric artery, combined arterial resection and reconstruction may be performed to achieve R0 resection. Nonetheless, such a complex procedure should be balanced by a high rate of postoperative complications. In contrast, in cases of tumors invading the celiac axis, R0 resection by combined celiac axis resection can be performed without a high rate of postoperative complications. Survival benefit needs to be verified by further studies in the future.