Neoadjuvant therapy and vascular resection during pancreaticoduodenectomy: shifting the survival curve for patients with locally advanced pancreatic cancer.

BACKGROUND: Neoadjuvant therapy and vascular resection may offer patients with locally advanced pancreatic cancer potential cure. METHODS: We reviewed medical records of patients with ductal adenocarcinoma who underwent pancreaticoduodenectomy (PD) from 1992 through 2011. We identified patients who received neoadjuvant therapy (NA+) or required vascular resection (VR+) for locally advanced disease and compared outcomes to those who did not. RESULTS: Of the 643 patients who were initially explored, 506 (143 NA+ and 363 NA- patients) ultimately underwent PD. There were no significant differences in R0 resection or morbidity. Mortality was higher in the NA+ versus NA- group (7.0 vs 3.0 %, p = 0.04). More NA+ patients underwent PD VR+ (p < 0.001). Among VR+ patients, neoadjuvant therapy resulted in significantly lower R1 resection. Among resected patients, survival of NA+ patients was significantly longer than both NA- patients (27.3 vs 19.7 months, p < 0.05) and patients abandoned because of locally advanced disease. Age, tumor grade, lymph node ratio, and R1 resection were independent predictors of poor survival. CONCLUSIONS: Neoadjuvant therapy and vascular resection offer patients with locally advanced pancreatic cancer the chance for cure with acceptable morbidity and mortality. These patients have improved survival over patients deemed locally inoperable by traditional criteria.

Second harmonic ultrasonic blood perfusion measurement.

In vitro and in vivo testing of a recently introduced method of evaluating blood perfusion is presented, where the Doppler shift of the second harmonic component of the backscattered echo is measured. Central to this measurement is the administration of a galactose-based contrast agent (Schering AG, Berlin, Germany, SHU-508 or derivative) which has been shown in vitro to exhibit extraordinary nonlinear backscattering properties. Two types of experiments are described: in vitro studies on excised sheep kidneys and in vivo studies on living rabbits. In the animal model, blood perfusion was manipulated by various mechanisms to obtain some indication of the quantitative ability of the measurement. Comparisons between measurements made at the fundamental component of the backscattered echo and at the second harmonic show that use of the second harmonic measurement results in a much improved ratio of blood echo intensity to tissue echo intensity (signal-to-clutter ratio), allowing detection of blood flowing in smaller vessels and opening up the potential for real-time determination of blood volume fluctuations in tissue.