Surgical resection strategies for locally advanced pancreatic cancer.

BACKGROUND: Despite all improvements in tumor diagnostics and treatment, pancreatic cancer is still the fourth leading cause of cancer-related death in the Western world. It is mostly diagnosed at a locally advanced or metastasized stage because of the lack of early symptoms. A radical margin-free surgical resection offers the only potential cure for locoregional disease. Over the last decades, several surgical strategies and techniques have evolved to optimize oncologic radical resections and thus to improve long-term outcome of patients. PURPOSE: The purpose of this review was to describe the various surgical strategies and techniques for locally advanced pancreatic cancer and to evaluate their influence on long-term outcome. CONCLUSIONS: Locally advanced pancreatic cancer should not generally be deemed unresectable. Various surgical techniques offer a good chance of margin-free tumor resection, even if surrounding organs or vessels are involved. Because of potentially higher peri- and postoperative morbidity rates, patients should be selected properly and are best treated in specialized high-volume centers.

GaSb-based SESAM mode-locked Tm:YAG ceramic laser at 2 µm.

Tunable and mode-locked laser operation near 2 µm based on different Tm-doped YAG ceramics, 4 at.% and 10 at.%, is demonstrated. Several designs of GaSb-based surface-quantum-well SESAMs are characterized and studied as saturable absorbers for mode-locking. Best mode-locking performance was achieved using an antireflection-coated near-surface quantum-well SESAM, resulting in a pulse duration of ~3 ps and ~150 mW average output power at 89 MHz. All mode-locked Tm:YAG ceramic lasers operated at 2012 nm, with over 133 nm demonstrated tuning for continuous-wave operation.

Mode-locked Tm,Ho:KLu(WO(4))(2) laser at 2060 nm using InGaSb-based SESAMs.

Passive mode-locking of a Tm,Ho:KLu(WO(4))(2) laser operating at 2060 nm using different designs of InGaAsSb quantum-well based semiconductor saturable absorber mirrors (SESAMs) is demonstrated. The self-starting mode-locked laser delivers pulse durations between 4 and 8 ps at a repetition rate of 93 MHz with maximum average output power of 155 mW. Mode-locking performance of a Tm,Ho:KLu(WO(4))(2) laser is compared for usage of a SESAM to a single-walled carbon nanotube saturable absorber.

Pancreatic adenocarcinoma: number of positive nodes allows to distinguish several N categories.

OBJECTIVE: To determine the prognostic value of PLN and LNR based on a large series with standardized lymphadenectomy and pathological workup. BACKGROUND: Lymph node (LN) involvement is a major prognostic factor in pancreatic adenocarcinoma. However, the distinction N0/N1 is not sufficient to accurately predict prognosis. To improve prognostic accuracy in N1 tumors, different LN parameters have been tested. Previous studies were based on series with variable numbers of examined lymph nodes (ELN) and came to inconsistent conclusions as to the value of the number of positive lymph nodes (PLN) and the lymph node ratio (LNR). METHODS: 811 patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma between October 2001 and June 2012 were identified from a prospective database. Clinicopathological parameters included LN status (N0/N1), ELN, PLN, and LNR. Univariate and multivariate survival analyses were performed. RESULTS: The median number of ELN was 24 (interquartile range: 18-32). By univariate analysis, both PLN and LNR were significantly associated with survival in N1 tumors. However, by multivariate analysis, only the number of PLN was confirmed as independent predictor of survival. Median survival in patients with only 1 PLN was 31.1 months and comparable to the survival in N0 (33.2 months). With increasing numbers of PLN median survival significantly decreased (2-3 PLN: 26.1 months, 4-7 PLN: 21.9 months, ≥8 PLN: 18.3 months, P < 0.0001). CONCLUSIONS: This study demonstrates that, based on high numbers of ELN, PLN is superior to LNR in predicting survival and allows to distinguish several N-categories that improve prognostic accuracy in LN-positive resectable pancreatic adenocarcinoma.

Total pancreatectomy for primary pancreatic neoplasms: renaissance of an unpopular operation.

OBJECTIVE: To assess the long-term survival and quality of life in total pancreatectomies and to identify risk factors for perioperative morbidity and mortality. BACKGROUND: Total pancreatectomy may be required in locally advanced or centrally located pancreatic neoplasms to achieve complete tumor clearance, but available data on short- and long-term results are limited. METHODS: A total of 434 consecutive total pancreatectomies for primary pancreatic or periampullary tumors were performed between October 2001 and September 2012 at the authors' institution and were prospectively documented and analyzed. Long-term outcome was assessed using Kaplan-Meier and quality of life analysis (EORTC-QLQ-C30 and PAN26). Uni- and multivariate analysis was performed to identify perioperative risk factors and predictors for long-term survival. RESULTS: Extended total pancreatectomies were performed in 54% of cases, with arterial and portal vein resections in 15% and 32%, respectively. Overall 30-day and in-hospital mortality rates were 3.7% and 7.8%, respectively. High blood loss, long operative time, and arterial resections were independently associated with increased perioperative mortality (P ≤ 0.018). In malignant disease, median and 5-year survival were good for standard total pancreatectomies (28.6 months and 24.3%, respectively) and were significantly impaired after vascular resections (P < 0.001). Poor tumor grading, high American Joint Commission on Cancer tumor stage, age more than 70 years, and an R1 resection were independent prognostic parameters. Long-term global quality of life was comparable with a matched healthy control group. CONCLUSIONS: Standard total pancreatectomy, if needed, is associated with good long-term outcome in pancreatic cancer. Marked surgical morbidity and impaired survival associated with vascular resections reflect the invasiveness of extended total pancreatectomies and the underlying advanced malignant disease.

Tm,Ho:KLu(WO4)2 laser mode-locked near 2 µm by single-walled carbon nanotubes.

We demonstrate passive mode-locking of a Tm,Ho-codoped crystalline laser operating on the Ho³âº-ion transition 5I7→5I8 near 2 µm using a single-walled carbon nanotube saturable absorber. The Tm,Ho:KLu(WO4)2 laser emits nearly transform-limited pulses with duration of 2.8 ps at a repetition rate of 91 MHz. The output power amounts to 97 mW.

Pancreatic cancer surgery in the new millennium: better prediction of outcome.

BACKGROUND: Surgery is the only therapy with potentially curative intention in pancreatic cancer. This analysis aimed to determine prognostic parameters in a patient cohort with resected pancreatic adenocarcinoma with a special focus on the revised R1-definition. METHODS: Between October 2001 and August 2009, data from 1071 consecutively resected patients with pancreatic adenocarcinoma were prospectively collected in an electronical database. Parameters tested for survival prediction in univariate analysis included patient, tumor, and resection characteristics as well as adjuvant therapy. The parameters with significant results were used for multivariate survival analysis. Identified parameters with positive or negative prognostic effect were used to define risk groups and to assess the effects on patient survival. RESULTS: Age, ASA-score, CEA and CA19-9 levels, preoperative insulin-dependent diabetes mellitus, T-, N-, M-, R-, G-tumor classification, advanced disease, and LNR were all significant in univariate analysis, whereas gender, NYHA score, BMI, insurance status, type of surgical procedure, and adjuvant therapy were not. In multivariate analysis, age ≥70 years, preoperative insulin-dependent diabetes, CA19-9 ≥400 U/mL, T4-, M1- or G3-status, and LNR > 0.2 were independent negative predictors, whereas Tis/T1/T2-status, G1-differentiation, and R0-status (revised definition) were independently associated with good prognosis. Using these risk factors, patients were stratified into 4 risk-groups with significantly different prognosis; 5-year survival varied between 0% and 54.5%. Risk stratification resulted in improved survival prognostication within the predominant AJCC IIA and AJCC IIB stages. CONCLUSIONS: A newly defined prognostic profiling including the revised R1-definition discriminates survival of patients with resectable pancreatic adenocarcinoma better than the AJCC staging system, and may be of particular relevance for patient-adjusted therapy in the heterogeneous group of AJCC stage II tumors.