Randomized, controlled, multi-center phase II study of postoperative enoxaparin treatment for venous thromboembolism prophylaxis in patients undergoing surgery for hepatobiliary-pancreatic malignancies.

Purpose: Postoperative venous thromboembolism (VTE) risk is pronounced after abdominal cancer surgery. Enoxaparin shows promise in preventing VTE in gastrointestinal, gynecological, and urological cancers, but its application after surgery for hepatobiliary-pancreatic malignancy has been under-evaluated due to bleeding concerns. We confirmed the safety of enoxaparin administration in patients undergoing curative hepatobiliary-pancreatic surgery for malignancies in a prospective, multi-center, phase I study. Methods: The study was conducted from April 2015 to May 2021 across eight specialized centers. Patients (n = 262) were randomized to enoxaparin prophylaxis given postoperatively for 8 days (n = 131) or control (n = 131). The primary endpoint was the efficacy in reducing VTE. Secondary endpoints examined safety. Results: The full analysis set included 259 patients (131 control, 129 enoxaparin). The per-protocol population included 233 patients (117 control, 116 enoxaparin). Most cases were hepatic malignancies (111 control, 111 enoxaparin). The median administration duration of enoxaparin was 7 days, with 92% receiving 4000 units/day. Despite a reduction in the relative risk (RR) of VTE due to postoperative enoxaparin administration, the results were not significant (control: four cases, 3.4% vs. treatment: two cases, 1.7%; RR 0.50, 95% CI 0.09-2.70; p = 0.6834). No significant difference was found in the incidence of bleeding events (control: five cases, 4.3% vs. treatment: five cases, 4.3%, RR 1.00, 95% CI 0.53-1.89; p = 1.0000). Conclusions: The perioperative administration of enoxaparin in hepatobiliary-pancreatic malignancies is feasible and safe. However, further case accumulation and investigation are necessary to assess its potential in reducing the occurrence of VTE.

Clinical impact of high-quality testing for peritoneal lavage cytology in pancreatic cancer.

In pancreatic ductal adenocarcinoma (PDAC) patients, the importance of peritoneal lavage cytology, which indicates unresectability, remains controversial. This study sought to determine whether positive peritoneal lavage cytology (CY+) precludes pancreatectomy. Furthermore, we propose a novel liquid biopsy using peritoneal lavage fluid to detect viable peritoneal tumor cells (v-PTCs) with TelomeScan F35, a telomerase-specific replication-selective adenovirus engineered to express green fluorescent protein. Resectable cytologically or histologically proven PDAC patients (n = 53) were enrolled. CY was conducted immediately following laparotomy. The resulting fluid was examined by conventional cytology (conv-CY; Papanicolaou staining and MOC-31 immunostaining) and by the novel technique (Telo-CY; using TelomeScan F35). Of them, 5 and 12 were conv-CY+ and Telo-CY+, respectively. All underwent pancreatectomy. The two double-CY+ (conv-CY+ and Telo-CY+) patients showed early peritoneal recurrence (P-rec) postoperatively, despite adjuvant chemotherapy. None of the three conv-CY+ Telo-CY- patients exhibited P-rec. Six of the 10 Telo-CY+ conv-CY- patients (60%) relapsed with P-rec. Of the remaining 38 double-CY- [conv-CY-, Telo-CY-, conv-CY± (Class III)] patients, 3 (8.3%) exhibited P-rec. Although conv-CY+ status predicted poor prognosis and a higher risk of P-rec, Telo-CY was more sensitive for detecting v-PTC. Staging laparoscopy and performing conv-CY and Telo-CY are needed to confirm the indication for pancreatectomy.

[Ascending Colon Cancer with Radical Resection after Stent Reimplantation Due to Colonic Stent Obstruction for Palliation-A Case Report].

Since the insurance coverage of colorectal stents for bowel obstruction due to colorectal cancer in 2012, the use of colorectal stenting for palliation has rapidly spread. We report a case of ascending colon cancer in which a colorectal stent was placed for palliation, but the stent was reimplanted due to obstruction, followed by radical resection. The patient was a 92- year-old woman who was brought to the emergency room at the age of 90 years with repeated vomiting and abdominal pain, and was diagnosed as colorectal cancer ileus caused by ascending colon cancer, and a colorectal stent was inserted. She received palliative care and had been asymptomatic for 1 year and 3 months, but due to in-stent stenosis, she had bowel obstruction and sent to emergency room, and another stent was installed. The patient had a good course, but 4 months after the second stenting, she was concerned about restenosis and referred to the department of surgery, then performed a radical resection. The indication for colorectal stents for palliative purposes should be considered on a case-by- case basis, including ADL, stage of the disease, and prognosis.

Results of a Randomized Clinical Study of Gemcitabine Plus Nab-Paclitaxel Versus Gemcitabine Plus S-1 as Neoadjuvant Chemotherapy for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma (RCT, CSGO-HBP-015).

BACKGROUND: The optimal neoadjuvant chemotherapy (NAC) regimen for patients with localized pancreatic ductal adenocarcinoma (PDAC) remains uncertain. This trial aimed to evaluate the efficacy and safety of two neoadjuvant chemotherapy (NAC) regimens, gemcitabine plus nab-paclitaxel (GA) and gemcitabine plus S-1 (GS), in patients with resectable/borderline-resectable (R/BR) PDAC. PATIENTS AND METHODS: Treatment-naïve patients with R/BR-PDAC were enrolled and randomly allocated. They received two cycles (2 months) of each standard protocol, followed by radical surgery for those without tumor progression in general hospitals belonging to our intergroup. The primary endpoint was to determine the superior regimen on the basis of achieving a 10% increase in the rate of patients with progression-free survival (PFS) at 2 years from allocation. RESULTS: A total of 100 patients were enrolled, with 94 patients randomly assigned to the GS arm (N = 46) or GA arm (N = 48). The 2-year PFS rates did not show the stipulated difference [GA, 31% (24-38%)/GS, 26% (18-33%)], but the Kaplan-Myer analysis showed significance (median PFS, GA/GS 14 months/9 months, P = 0.048; HR 0.71). Secondary endpoint comparisons yielded the following results (GA/GS arm, P-value): rates of severe adverse events during NAC, 73%/78%, P = 0.55; completion rates of the stipulated NAC, 92%/83%, P = 0.71; resection rates, 85%/72%, P = 0.10; average tumor marker (CA19-9) reduction rates, -50%/-21%, P = 0.01; average numbers of lymph node metastasis, 1.7/3.2, P = 0.04; and median overall survival times, 42/22 months, P = 0.26. CONCLUSIONS: This study found that GA and GS are viable neoadjuvant treatment regimens in R/BR-PDAC. Although the GA group exhibited a favorable PFS outcome, the primary endpoint was not achieved.

Removal of gemcitabine-induced senescent cancer cells by targeting glutaminase1 improves the therapeutic effect in pancreatic ductal adenocarcinoma.

Insufficient cancer treatment can induce senescent cancer cell formation and treatment resistance. The characteristics of induced senescent cancer (iSnCa) cells remain unclear. Pancreatic ductal adenocarcinoma (PDAC) has a low and nondurable response rate to current treatments. Our study aimed to analyze the properties of iSnCa cells and the relationship between cellular senescence and prognosis in PDAC. We evaluated the characteristics of gemcitabine-induced senescent cancer cells and the effect of senescence-associated secretory phenotype (SASP) factors released by iSnCa cells on surrounding PDAC cells. The relationship between cellular senescence and the prognosis was investigated in 50 patients with PDAC treated with gemcitabine-based neoadjuvant chemotherapy. Exposure to 5 ng/mL gemcitabine-induced senescence, decreased proliferation and increased senescence-associated ß-galactosidase-cell staining without cell death in PDAC cells; the expression of glutaminase1 (GLS1) and SASP factors also increased and caused epithelial-mesenchymal transition in surrounding PDAC cells. iSnCa cells were selectively removed by the GLS1 inhibitor bis-2-(5-phenylacetamido-1,2,4-thiadiazol-2-yl)ethyl sulfide (BPTES) through apoptosis induction. Cellular senescence was induced in PDAC cells via insufficient gemcitabine in subcutaneous tumor model mice. GLS1 expression was an independent prognostic factor in patients with PDAC who received gemcitabine-based neoadjuvant chemotherapy. This is the first study to identify the relationship between senescence and GLS1 in PDAC. Low-dose gemcitabine-induced senescence and increased GLS1 expression were observed in PDAC cells. Cellular senescence may contribute to treatment resistance of PDAC, hence targeting GLS1 in iSnCa cells may improve the therapeutic effect.

Influence of Percutaneous Transhepatic Gallbladder Aspiration and Drainage for Severe Acute Cholecystitis on the Surgical Outcomes of Subsequent Laparoscopic Cholecystectomy: Post Hoc Analysis of the CSGO-HBP-017 (CSGO-HBP-017C).

OBJECTIVE: Percutaneous transhepatic gallbladder aspiration (PTGBA) and/or drainage (PTGBD) are useful approaches in the management of acute cholecystitis in patients who cannot tolerate surgery because of poor general condition or severe inflammation. However, reports regarding its effect on the surgical outcomes of subsequent laparoscopic cholecystectomy (LC) are sparse. The aim of this retrospective study was to investigate the influence of PTGBA on surgical outcomes of subsequent LC by comparing the only-PTGBA group, including patients who did not need the additional-PTGBD, versus the additional-PTGBD group, including those who needed the additional-PTGBD after PTGBA. PATIENTS AND METHODS: We conducted a post hoc analysis of our multi-institutional data. This study included 63 patients who underwent LC after PTGBA, and we compared the surgical outcomes between the only-PTGBA group (n = 56) and the additional-PTGBD group (n = 7). RESULTS: No postoperative complications occurred among the 63 patients, and the postoperative hospital stay was 11 ± 12 days. Fourteen patients (22.2%) had a recurrence of cholecystitis, of whom 7 patients (11.1%) needed the additional-PTGBD after PTGBA. Significantly longer operative time (245 ± 74 vs 159 ± 65 min, P = 0.0017) and postoperative hospital stay (22 ± 27 vs 10 ± 9 d, P = 0.0118) and greater intraoperative blood loss (279 ± 385 vs 70 ± 208 mL, P = 0.0283) were observed among patients in the additional-PTGBD group compared with the only-PTGBA group, whereas the rates of postoperative complications (Clavien-Dindo grade ≥3: 0% each) and conversion to open surgery (28.6% vs 8.9%, P = 0.1705) were comparable. CONCLUSION: PTGBA for acute cholecystitis could result in good surgical outcomes of subsequent LC, especially regarding postoperative complications. However, we should keep in mind that the additional-PTGBD after PTGBA failure, which sometimes happened, would be associated with increased operative difficulty and longer recovery.

Pancreatic cancer near the splenic hilum has a higher likelihood of splenic vessel invasion and unfavorable survival.

PURPOSE: This study aimed to investigate whether clinical outcomes varied based on the tumor location within the pancreatic body and tail in patients with pancreatic cancer (PC). METHODS: Ninety-five patients who had undergone a distal pancreatectomy for resectable (R) or borderline resectable (BR) PC within the pancreatic body or tail region were retrospectively investigated and divided into four groups (three subgroups of R-PC according to tumor location, and BR-PC): R-PC in the pancreatic body region (group A, n = 24), R-PC on the right side of the pancreatic tail region (group B, n = 17), R-PC on the left side of the pancreatic tail region (group C, n = 29), and BR-PC located in any region within the pancreatic body and tail (group BR, n = 25). RESULTS: Group C patients showed a higher incidence of pretreatment splenic artery and vein involvement than group A and B patients (splenic artery: 8.3/11.8/41.4%, p < 0.010; splenic vein: 25.0/23.5/79.3%, p < 0.010, in groups A/B/C, respectively). The overall survival of group C patients was significantly unfavorable compared to that of group A and B patients (median: 3.9/4.2/2.3 years in groups A/B/C, p = 0.029, respectively). Pretreatment clinical factors were comparable between group C and group BR. Median survival rates were comparable between group C and BR patients (2.3 and 2.0 years, respectively) (p = 0.93). CONCLUSIONS: Differences in anatomical location within the pancreatic body and tail characterize the unfavorable outcomes of PC near the splenic hilum.

A Ruptured Mucinous Cystadenocarcinoma of the Pancreas Extensively Evaluated Before and After the Rupture: A Case Report.

ABSTRACT: Pancreatic mucinous cystic neoplasm (MCN) rarely ruptures because of their surrounding fibrotic capsules and has never been reported with detailed information regarding prerupture and postrupture states. We report a case of MCN rupture where performed emergency surgery was performed while waiting for elective surgery. A 54-year-old woman was referred to our department for a pancreatic cystic tumor with slight abdominal pain. A cystic tumor with a nodular lesion was found, with a contrast effect measuring 78 mm in diameter. On day 21, the patient visited our hospital complaining of increased abdominal pain, but few signs of peritonitis were observed. Tests conducted revealed moderate ascites, marginal shrinkage of the cyst diameter, and a slight elevation of inflammatory markers. We suspected an MCN rupture and immediately performed distal pancreatectomy. Brown turbid ascites and rupture of the anterior wall of the cyst were observed. In the ascites, amylase levels were not elevated, and bacterial cultures were negative. The histopathological diagnosis was noninvasive mucinous cystadenocarcinoma. At 9 months after surgery, she started chemotherapy because of a recurrence of the peritoneal dissemination. This case provided valuable insight into the rupture of MCNs using thorough imaging techniques, laboratory, and physical findings before and after rupturing.

Anti-tumor effect of avadomide in gemcitabine-resistant pancreatic ductal adenocarcinoma.

PURPOSE: Although gemcitabine-based chemotherapy is most recommended for pancreatic ductal adenocarcinoma (PDAC), its effectiveness is limited because of drug resistance. Given thalidomide's anti-tumor effects in solid tumors, we investigated the effect of avadomide, a novel thalidomide analog, on PDAC and explored its anti-tumor mechanisms. METHODS: PDAC cell lines, including gemcitabine-resistant (GR) clones derived from MiaPaCa2 cells, were used to evaluate the effects of avadomide. An annexin V assay, a cell cycle assay, and western blot analysis were performed to explain the mechanism of avadomide as an anti-tumor reagent. Moreover, we investigated the anti-tumor effect on tumor growth using a subcutaneous xenograft murine model. RESULTS: Avadomide showed anti-tumor effects in human PDAC cell lines. The proportion of apoptotic cells and G0/G1 phase cells after avadomide treatment increased, especially in the GR PDAC clones. Western blot analysis also showed the induction of the apoptotic pathway by inhibiting the NF-κB process and G1 phase cell cycle arrest. The xenograft murine model revealed that the proportion of viable cells in the avadomide-treated group was lower than that in the untreated group. CONCLUSION: Our findings suggest that avadomide could be a novel therapeutic option to overcome gemcitabine resistance in patients with PDAC.

Long-Term Feasibility of Rescue Reconstruction for Isolated Bile Ducts With Using Cystic Duct in Living Donor Liver Transplantation.

BACKGROUND: The isolated bile duct is sometimes observed in the right liver graft of living donor liver transplantation (LDLT). Even though, as a rescue option, it is known to use the recipient's cystic duct (CyD) for duct-to-duct anastomosis, the long-term feasibility of rescue duct-to-CyD (D-CyD) anastomosis remains unclear. METHODS: We prospectively collected data in the right liver-LDLT cohort and compared rescue D-CyD anastomosis (n = 4) with standard duct-to-hepatic duct (D-HD, n = 45) anastomosis (D-CyD group, n = 4). RESULTS: The observation period was over 5 years (range, 68-171 mo) after LDLT. The D-CyD group included the following anastomosis procedures: anastomosis between the intrahepatic bile duct of the graft and the CyD of the recipient and anastomosis between the posterior HD and the CyD. Surgical outcomes between the 2 groups are similar, excluding the time for the biliary reconstruction (D-CyD, 116 ± 13 min vs D-HD, 57 ± 3 min). During the period, one recipient in the D-CyD group exhibited postoperative biliary stricture and biliary stone, and 6 recipients underwent those complications in the D-HD group (D-CyD, 25.0% vs D-HD, 13.3%) All recipients in the D-CyD group are presently alive and have not experienced liver dysfunction. CONCLUSIONS: Our findings suggest that rescue D-CyD anastomosis for an isolated bile duct in a right liver LDLT is acceptable as a life-saving option in terms of long-term feasibility.

SPARC accelerates biliary tract cancer progression through CTGF-mediated tumor-stroma interactions: SPARC as a prognostic marker of survival after neoadjuvant therapy.

PURPOSE: In biliary tract cancer (BTC), malignancy is strongest at the invasion front. To improve the BTC prognosis, the invasion front should be controlled. We evaluated tumor-stroma crosstalk at the tumor center and at the invasion front of BTC lesions. We investigated the expression of SPARC, a marker of cancer-associated fibroblasts, and determined its ability to predict BTC prognosis after neoadjuvant chemoradiotherapy (NAC-RT). METHODS: We performed immunohistochemistry to evaluate SPARC expression in resected specimens from patients that underwent BTC surgery. We established highly invasive (HI) clones in two BTC cell lines (NOZ, CCLP1), and performed mRNA microarrays to compare gene expression in parental and HI cells. RESULTS: Among 92 specimens, stromal SPARC expression was higher at the invasion front than at the lesion center (p = 0.014). Among 50 specimens from patients treated with surgery alone, high stromal SPARC expression at the invasion front was associated with a poor prognosis (recurrence-free survival: p = 0.033; overall survival: p = 0.017). Coculturing fibroblasts with NOZ-HI cells upregulated fibroblast SPARC expression. mRNA microarrays showed that connective tissue growth factor (CTGF) was upregulated in NOZ-HI and CCLP1-HI cells. A CTGF knockdown suppressed cell invasion in NOZ-HI cells. Exogeneous CTGF upregulated SPARC expression in fibroblasts. SPARC expression at the invasion front was significantly lower after NAC-RT, compared to surgery alone (p = 0.003). CONCLUSION: CTGF was associated with tumor-stroma crosstalk in BTC. CTGF activated stromal SPARC expression, which promoted tumor progression, particularly at the invasion front. SPARC expression at the invasion front after NAC-RT may serve as a prognosis predictor.

Automated Analysis for the Prevalence of Cancer-Associated Fibroblasts in Resected Specimens of Intrahepatic Cholangiocarcinoma is a Simple and Reliable Evaluation System.

BACKGROUND: Intrahepatic cholangiocarcinoma (iCCA) has a high recurrence rate and poor prognosis, and chemotherapy options are limited. The prevalence of cancer-associated fibroblasts (CAFs) in iCCA has recently emerged as a prognostic marker and therapeutic target. A method to quantify the expression of CAFs is needed; however, a simple and reliable quantification method has not yet been established. OBJECTIVE: The aim of this study was to establish a simple and reliable method of quantifying CAFs. METHODS: A total of 71 patients with iCCA who underwent curative resection from November 2006 to October 2020 in our hospital were investigated. Immunohistochemistry for alpha-smooth muscle actin (α-SMA) was performed and α-SMA-positive cells were quantified by an automated analysis system (new method) and visually counted (conventional method). The times required for measurement and the prognosis were compared. RESULTS: The results of the quantification of CAFs by the new method were significantly correlated with the results by the conventional method, and the time required for measurement was significantly shorter with the new method. Patients with high-intensity CAFs showed a significantly poorer prognosis in terms of overall survival (OS) and the cumulative hepatic recurrence rate. In addition, high α-SMA levels were a significant risk factor for OS in multivariate analysis. CONCLUSIONS: This new method may contribute to the management of patients with iCCA, not only for the prediction of prognosis of patients with iCCA, but also for the indication of targeted therapy against CAFs.

Efficacy of Autologous Skeletal Myoblast Cell Sheet Transplantation for Liver Regeneration in Liver Failure.

BACKGROUND: No effective therapies have yet been established for liver regeneration in liver failure. Autologous skeletal myoblast cell sheet transplantation has been proven to improve cardiac function in patients with heart failure, and one of the mechanisms has been reported to be a paracrine effect by various growth factors associated with liver regeneration. Therefore, the present study focused on the effect of myoblast cells on liver regeneration in vitro and in vivo. METHODS: We assessed the effect of myoblast cells on the cells comprising the liver in vitro in association with liver regeneration. In addition, we examined in vivo effect of skeletal myoblast cell sheet transplantation in C57/BL/6 mouse models of liver failure, such as liver fibrosis induced by thioacetamide and hepatectomy. RESULTS: In vitro, the myoblast cells exhibited a capacity to promote the proliferation of hepatic epithelial cells and the angiogenesis of liver sinusoidal endothelial cells, and suppress the activation of hepatic stellate cells. In vivo, sheet transplantation significantly suppressed liver fibrosis in the induced liver fibrosis model and accelerated liver regeneration in the hepatectomy model. CONCLUSIONS: Autologous skeletal myoblast cell sheet transplantation significantly improved the liver failure in the in vitro and in vivo models. Sheet transplantation is expected to have the potential to be a clinically therapeutic option for liver regeneration in liver failure.

Rubicon can predict prognosis in patients with pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy.

BACKGROUND: Despite previous therapeutic studies on autophagy in cancer, its role in the treatment of pancreatic ductal adenocarcinoma remains controversial, especially regarding its effect on chemotherapy, radiotherapy, and both combined. We focused on RUN domain Beclin-1 interacting and cysteine-rich-containing protein (Rubicon) to reveal its contribution to pancreatic ductal adenocarcinoma after chemoradiotherapy. METHODS: To evaluate the clinical significance of Rubicon, immunohistochemistry was performed, and Rubicon expression was analyzed across 81 specimens resected from patients with pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy. A gemcitabine-resistant pancreatic ductal adenocarcinoma cell line was established followed by Rubicon expression and autophagy flux estimation. Finally, gemcitabine sensitivity, invasion ability, and cell viability were evaluated using Rubicon-targeting small interfering RNA. RESULTS: Rubicon expression in resected pancreatic ductal adenocarcinoma samples after chemoradiotherapy revealed significantly worse overall survival and recurrence-free survival in the Rubicon-high expression group than in the Rubicon-low expression group (overall survival: median [years] 2.02 vs. 3.21, p = 0.0359; recurrence-free survival: median [years] 0.90 vs. 1.90, p = 0.0146). In vitro, gemcitabine-resistant pancreatic ductal adenocarcinoma cell lines exhibited higher Rubicon expression and lower autophagy flux than the parental cell line (p < 0.01). Transduction with small interfering RNA downregulated the expression without affecting gemcitabine sensitivity, but it reduced invasion ability and cell viability (p < 0.01) in the gemcitabine-resistant pancreatic ductal adenocarcinoma cell line. CONCLUSIONS: High Rubicon expression is a significant, unfavorable prognostic factor in pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy. Downregulation of Rubicon expression improves invasion ability and cell viability in gemcitabine-resistant pancreatic ductal adenocarcinoma.

Colorectal liver metastasis with bile duct tumor thrombus discovered 15 years post primary tumor resection: a case report and literature review.

Colorectal liver metastasis (CRLM) appears in 25-50% of patients with colorectal cancer (CRC). However, CRLM with bile duct tumor thrombus (BDTT) is rare and often diagnosed after surgical resection. We report a case of CRLM associated with BDTT in a 79 year-old woman. She underwent sigmoid colectomy for sigmoid colon carcinoma at the age of 64. Fifteen years later, abdominal computed tomography revealed a liver tumor with a biliary tumor thrombus in segment IV/V and localized dilation of the intrahepatic bile duct. Additionally, magnetic resonance imaging confirmed a tumor in liver segment IV/V and mass in the bile duct (B4). Extended left hepatic lobectomy was performed under the diagnosis of intrahepatic cholangiocarcinoma or metastatic liver tumor with tumor development in the intrahepatic bile duct. The resected specimen showed significant cancer infiltration into the intrahepatic bile duct (B4), forming a tumor thrombus. The tumor was a moderately differentiated adenocarcinoma, histologically similar to sigmoid colon cancer. CRLM with BDTT may have a relatively low invasive potential of malignancy with a long interval after primary resection. When a patient with a history of CRC presents with BDTT, the possibility of CRLM with BDTT and surgical treatment should be considered, because resection could lead to a good prognosis. It is important to ensure a secure surgical margin in the bile ducts during surgery and anatomical hepatic resection should be considered. Supplementary Information: The online version contains supplementary material available at 10.1007/s13691-022-00583-6.

Change Impact of Body Composition During Neoadjuvant Chemoradiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma Undergoing Pancreatectomy.

BACKGROUND: The change impact of body composition during neoadjuvant therapy on clinical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. The aim of this study was to investigate the association between changes in body composition during neoadjuvant chemoradiotherapy (NACRT) and postoperative outcomes in patients with PDAC undergoing pancreatectomy, using three-dimensional images. METHODS: We reviewed 66 consecutive patients with resectable/borderline resectable PDAC receiving gemcitabine and S-1 with radiotherapy between April 2010 and June 2016. Body compositions were evaluated pre- and post-NACRT. All patients were hospitalized and supplied with regulated diet during NACRT treatment. RESULTS: Psoas major muscle volume index (PMI), abdominal fat volume index, and visceral fat volume index decreased significantly after NACRT (P < 0.0001, P < 0.0001, P < 0.0001, respectively). The post-NACRT CA19-9 level decreased significantly in the small-PMI-decrease group compared with the large-PMI-decrease group (P = 0.046). Recurrence-free survival (RFS) and overall survival (OS) of the large-PMI-decrease group were significantly poorer than those of the small-PMI-decrease group (P = 0.002, P = 0.006, respectively). On the other hand, there were no significant differences in RFS and OS between groups with high and low PMI, at the point of either pre-NACRT (P = 0.117, P = 0.123, respectively) or post-NACRT (P = 0.065, P = 0.064, respectively). Multivariate analysis identified a large percentage decrease in PMI as an independent risk factor for recurrence and death (P = 0.003, P = 0.002, respectively). CONCLUSIONS: Loss of skeletal muscle mass during NACRT was an independent risk factor for survival in patients with PDAC.