Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis.

BACKGROUND: Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy. METHODS: Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery. RESULTS: There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096). CONCLUSIONS: NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs.

BACKGROUND: There is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC. METHODS: Sequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL. RESULTS: Of 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62-1.37), oncologic treatment (CR 0.66, 95% CI 0.32-1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77-1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16-0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens. CONCLUSIONS: SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Total pancreatectomy with islet cell auto-transplantation: update and outcomes from major centers.

OPINION STATEMENT: Chronic pancreatitis is the result of irreversible damage to pancreatic acinar cells, and can result in debilitating chronic pain for patients. Treatment centers on pain relief, often with chronic narcotic use. Surgical therapy consists of both resection procedures to remove affected pancreatic parenchyma and drainage procedures to facilitate drainage of the main pancreatic duct. Total pancreatectomy historically was utilized in extreme cases due to the brittle glucose control that followed from the total loss of islet cells. Total pancreatectomy with islet cell auto-transplantation (TP-AIT) is gaining in popularity due to the maintenance of beta cell mass and the ability of patients to potentially be insulin independent post-operatively. TP-AIT is very helpful in the treatment of pain for patients with chronic pancreatitis. The overall majority of patients have an improvement in pain and quality-of-life scores. AIT also allows the majority of patients to have minimal insulin requirements post-operatively. With proper patient selection, these outcomes can be achieved.