Effects of cancer stigma on quality of life of patients with hepatobiliary and pancreatic cancer.

Backgrounds/Aims: Cancer stigma (CS), a self-inflicted sense of hopelessness, has been identified as a major factor affecting cancer patients' outcomes. However, few studies have investigated the CS-related outcomes in hepatobiliary and pancreatic (HBP) cancer. Thus, the aim of this study was to investigate effects of CS on quality of life (QoL) of HBP cancer. Methods: From 2017 to 2018, 73 patients who underwent curative surgery for HBP tumor at a single intuitive were enrolled prospectively. The QoL was measured using the European Organization for Research and Treatment of Cancer QoL score, and CS was evaluated in three categories, "impossibility of recovery," "cancer stereotypes," and "social discrimination." the stigma was defined by higher scores of attitudes compared with the median value. Results: The stigma group showed a lower QoL (-17.67, 95% confidence interval [CI]: -26.75 to 8.60, p < 0.001) than the no stigma group. Similarly, most function and symptoms of the stigma group showed worse results than the no stigma group. The difference in function scores between the two groups according to CS was highest in cognitive function (-21.20, 95% CI: -30.36 to 12.04, p < 0.001). Fatigue showed the largest difference between the two groups at 22.84 (95% CI: 12.88-32.07, p < 0.001) and was the most severe symptom in stigma group. Conclusions: CS was an important negative factor affecting the QoL, function, and symptoms of HBP cancer patients. Therefore, appropriate management of CS is crucial for improved postoperative QoL.

Preoperative serum carbohydrate antigen 19-9 levels predict early recurrence after the resection of early-stage pancreatic ductal adenocarcinoma.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is a serious disease with a poor prognosis. Only a minority of patients undergo surgery due to the advanced stage of the disease, and patients with early-stage disease, who are expected to have a better prognosis, often experience recurrence. Thus, it is important to identify the risk factors for early recurrence and to develop an adequate treatment plan. AIM: To evaluate the predictive factors associated with the early recurrence of early-stage PDAC. METHODS: This study enrolled 407 patients with stage I PDAC undergoing upfront surgical resection between January 2000 and April 2016. Early recurrence was defined as a diagnosis of recurrence within 6 mo of surgery. The optimal cutoff values were determined by receiver operating characteristic (ROC) analyses. Univariate and multivariate analyses were performed to identify the risk factors for early recurrence. RESULTS: Of the 407 patients, 98 patients (24.1%) experienced early disease recurrence: 26 (26.5%) local and 72 (73.5%) distant sites. In total, 253 (62.2%) patients received adjuvant chemotherapy. On ROC curve analysis, the optimal cutoff values for early recurrence were 70 U/mL and 2.85 cm for carbohydrate antigen 19-9 (CA 19-9) levels and tumor size, respectively. Of the 181 patients with CA 19-9 level > 70 U/mL, 59 (32.6%) had early recurrence, compared to 39 (17.4%) of 226 patients with CA 19-9 level ≤ 70 U/mL (P < 0.001). Multivariate analysis revealed that CA 19-9 level > 70 U/mL (P = 0.006), tumor size > 2.85 cm (P = 0.004), poor differentiation (P = 0.008), and non-adjuvant chemotherapy (P = 0.025) were significant risk factors for early recurrence in early-stage PDAC. CONCLUSION: Elevated CA 19-9 level (cutoff value > 70 U/mL) can be a reliable predictive factor for early recurrence in early-stage PDAC. As adjuvant chemotherapy can prevent early recurrence, it should be recommended for patients susceptible to early recurrence.

Clinical outcomes of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma depending on preservation or resection of pylorus.

BACKGROUNDS/AIMS: The comparative effectiveness of pylorus-resecting pancreaticoduodenectomy (PRPD) and pylorus- preserving pancreaticoduodenectomy (PPPD) in pancreatic head cancer is still disputed. The aim of this study was to analyze the data obtained from a large, single center with PPPD compared with PRPD in terms of postoperative outcomes, including blood glucose levels and survival in patients with pancreatic head cancer. METHODS: Between January 2007 and December 2016, a total of 556 patients with pancreatic head cancer underwent either PPPD or PRPD. We analyzed the clinicopathologic data to assess short- and long-term outcomes retrospectively. RESULTS: For underlying disease, patients with DM in PPPD were fewer than in PRPD (33.0% vs. 46.2%, p=0.002). The median value of CA19-9 was significantly higher in PRPD than in PPPD (129.36 vs. 86.47, p=0.037). The incidence of Clavien-Dindo grade III to V major complications in PPPD was significantly higher than in PRPD (20.4% vs. 13.4%, p=0.032). Resection of pylorus was shown to reduce complications in univariate and multivariate analyses (p=0.032 and = 0.021, respectively). The 5-year survival rates were 27.6% in the PPPD group and 22.4% in the PRPD group (p=0.015). CONCLUSIONS: The results of PPPD and PRPD showed no significant differences from those reported conventionally in previous studies. Although further well-designed studies are needed, it is more important to select the range of surgical resection for the patient's disease regardless of resection of pylorus.

The effects of sarcopenia and sarcopenic obesity after pancreaticoduodenectomy in patients with pancreatic head cancer.

BACKGROUND: Recently, several studies have reported that sarcopenia and sarcopenic obesity (SO) could worsen postoperative complications after PD. This study aims to evaluate the effects of preoperative sarcopenia and SO following PD in pancreatic head cancer (PHD). METHODS: Preoperative sarcopenia and SO were assessed in 548 patients undergoing PD for PHC at Samsung Medical Centre between 2007 and 2016. The visceral adipose tissue-to-skeletal muscle ratio was calculated from cross-sectional visceral fat and muscle areas on preoperative CT images. The overall survival (OS) and rate of clinically relevant postoperative pancreatic fistula (CR-POPF) among postoperative complications were extracted from prospectively maintained databases. RESULTS: Preoperative sarcopenia was present in 252 patients (45.9%). The 5-year survival rates of patients with non-sarcopenia and sarcopenia were 28.4% and 23.4% (p = 0.046). Preoperative SO was present in 202 patients (36.9%). After multivariable analysis, the presence of SO was the only independent risk factor for CR-POPF (p = 0.018). CONCLUSION: Sarcopenia can be a risk factor affecting decreased OS after PD in patients with PHC. SO is the only predictive factor for CR-POPF after PD in patients with PHC. More observational studies are needed to evaluate the effects of sarcopenia and SO on survival after PD.

Proposed Modification of Staging for Distal Cholangiocarcinoma Based on the Lymph Node Ratio Using Korean Multicenter Database.

The 8th American Joint Committee on Cancer (AJCC) staging system for distal cholangiocarcinoma (DCC) included a positive lymph node count (PLNC), but a comparison of the prognostic predictive power of PLNC and lymph node ratio (LNR) is still under debate. This study aimed to compare various staging models made by combining the abovementioned factors, identify the model with the best predictive power, and propose a modified staging system. We retrospectively reviewed 251 patients who underwent surgery for DCC at four centers. To determine the superiority of various staging models for predicting overall OSR, Akaike information criterion (AIC), Bayesian information criterion (BIC), AIC correction (AICc), and Harrell's C-statistic were calculated. In multivariate analysis, age (p = 0.003), total lymph node count (p = 0.033), and revised T(LNR)M staging (p < 0.001) were identified as independent factors for overall survival rate. The predictive performance of revised T (LNR) M staging (AIC: 1288.925, BIC: 1303.377, AICc: 1291.52, and Harrell's C statics: 0.667) was superior to other staging system. A modified staging system consisting of revised T category and LNR predicted better overall survival of DCC than AJCC 7th and AJCC 8th editions. In the future, external validation of the proposed new system using a larger cohort will be required.

Predictive Nomogram for Early Recurrence after Pancreatectomy in Resectable Pancreatic Cancer: Risk Classification Using Preoperative Clinicopathologic Factors.

The survival of patients with pancreatic ductal adenocarcinoma (PDAC) is closely related to recurrence. It is necessary to classify the risk factors for early recurrence and to develop a tool for predicting the initial outcome after surgery. Among patients with resected resectable PDAC at Samsung Medical Center (Seoul, Korea) between January 2007 and December 2016, 631 patients were classified as the training set. Analyses identifying preoperative factors affecting early recurrence after surgery were performed. When the p-value estimated from univariable Cox's proportional hazard regression analysis was <0.05, the variables were included in multivariable analysis and used for establishing the nomogram. The established nomogram predicted the probability of early recurrence within 12 months after surgery in resectable PDAC. One thousand bootstrap resamplings were used to validate the nomogram. The concordance index was 0.665 (95% confidence interval [CI], 0.637-0.695), and the incremental area under the curve was 0.655 (95% CI, 0.631-0.682). We developed a web-based calculator, and the nomogram is freely available at http://pdac.smchbp.org/. This is the first nomogram to predict early recurrence after surgery for resectable PDAC in the preoperative setting, providing a method to allow proceeding to treatment customized according to the risk of individual patients.

Subtype of intraductal papillary mucinous neoplasm of the pancreas is important to the development of metachronous high-risk lesions after pancreatectomy.

BACKGROUNDS/AIMS: Although intraductal papillary mucinous neoplasm (IPMN) has showed a favorable prognosis compared to pancreatic ductal adenocarcinoma, its recurrence patterns have somewhat questionable in detail. After partial pancreatectomy for IPMN, the evaluation for risk of metachronous occurrence of high-risk lesions (HRL) in the residual pancreas is important to establish a postoperative surveillance modality and duration of follow-up. This study aimed to evaluate the factors that may predict the metachronous occurrence of HRL in the remnant pancreas after surgery of the IPMN. METHODS: From 2005 to 2016, clinicopathologic and surveillance data for 346 consecutive patients who underwent surgical resection for IPMN were reviewed retrospectively. Histologic subtype was classified as gastric, intestinal, pancreato-biliary, or oncocytic type. RESULTS: All of IPMN were classified as main duct (n=64, 18.5%), branch duct (n=171, 49.4%), and mixed type (n=111, 32.1%). Forty-eight patients (13.9%) experienced recurrence during follow-up. Among these, 9 patients (2.6%) were identified to metachronous development of HRL in the remnant pancreas. After multivariate analysis, high-grade dysplasia (HGD) or invasive carcinoma (IC) compared to low- or intermediate dysplasia was only independent risk factor for recurrence (HR 3.688, 95% CI 2.124- 12.524, p=0.009). The independent risk factors for metachronous development were HGD/IC (HR 8.414, 95% CI 4.310- 16.426, p=0.001), and intestinal/pancreato-biliary subtype compared to gastric subtype (HR 7.874, 95% CI 3.650- 27.027, p=0.010). CONCLUSIONS: Patients with high-grade dysplasia or invasive carcinoma, and with intestinal or pancreatobiliary subtype should undergo close, long-term surveillance of the remnant pancreas after initial resection.

Optimal timing of pancreaticoduodenectomy following preoperative biliary drainage considering major morbidity and postoperative survival.

BACKGROUND: The present study aimed to determine the optimal timing of pancreaticoduodenectomy (PD) following preoperative biliary drainage (PBD) with consideration of postoperative morbidity and survival. METHODS: Between January 2007 and December 2015, consecutive 1,568 patients underwent PD at a single institution. Their data were reviewed retrospectively. RESULTS: Of all, 831 patients underwent PBD. The mean duration between drainage and surgery was 16.9 days. Regarding postoperative outcomes, length of hospital stay was longer in the drainage group (P = 0.028). Postoperative pancreatic fistula was not significantly different between the non-drainage and drainage groups (P = 0.162), but major complications occurred more frequently in the drainage group (P = 0.002). Multivariable analysis showed major complications occurred significantly at third and fourth weeks (odds ratios 1.863 and 2.523) after PBD, whereas early surgery performed in the first 2 weeks did not noticeably increase postoperative complications. In multivariable survival comparison, weekly interval beyond 6 weeks was associated with poor survival in those with pancreatic cancer, while patients with bile duct cancer operated on at the fourth week showed worse prognosis. CONCLUSIONS: Early surgery that reduces the operative delay after PBD may improve both short- and long-term postoperative outcomes in cancer patients undergoing PBD.

Validation of original and alternative fistula risk scores in postoperative pancreatic fistula.

BACKGROUND: In 2013, the fistula risk score (FRS) was developed to assess the risk of clinically relevant postoperative pancreatic fistula (CR-POPF). In 2017, the alternative FRS (a-FRS) was proposed. The purpose of this study was to validate the original FRS (o-FRS) and a-FRS for CR-POPF in pancreaticoduodenectomy (PD). METHODS: From January 2007 to December 2016, 1,771 patients underwent PD for periampullary cancers. POPF was defined and classified according to the 2016 International Study Group for Pancreatic Fistula. All data were reviewed retrospectively. RESULTS: Pathologic diagnosis other than ductal adenocarcinoma (P < 0.001), pancreas duct diameter (P < 0.001), and body mass index (P < 0.001) were independent risk factors for CR-POPF. Pancreatic texture (P = 0.534) and estimated blood loss (P = 0.827) were not associated with CR-POPF. The CR-POPF incidence increased with increasing o-FRS score (P < 0.001), and also increased statistically significantly with increasing a-FRS in the higher risk group (P < 0.001). However, the correlations differed. The area under the curve was 0.629 for o-FRS and 0.622 for a-FRS. CONCLUSIONS: Both o-FRS and a-FRS might reflect CR-POPF incidence, but some risk factors had no or low statistical significance. Further research is needed to revise the FRS.

Bile duct segmental resection versus pancreatoduodenectomy for middle and distal common bile duct cancer.

PURPOSE: To compare survival outcomes between bile duct segmental resection (BDR) and pancreatoduodenectomy (PD) for the treatment of middle and distal bile duct cancer. METHODS: From 1997 to 2013, a total of 96 patients who underwent curative intent surgery for middle and distal bile duct cancer were identified. The patients were divided into 2 groups based on the type of operation; 20 patients were included in the BDR group and 76 patients were in the PD group. We retrospectively reviewed the clinical outcomes. RESULTS: The number of lymph nodes (LNs) was significantly greater in patients within the PD group compared to the BDR group. The total number of LNs was 6.5 ± 8.2 vs. 11.2 ± 8.2 (P = 0.017) and the number of metastatic LNs was 0.4 ± 0.9 vs. 1.0 ± 1.5 (P = 0.021), respectively. After a median follow-up period of 24 months (range, 4-169 months), the recurrence-free survival of the PD group was superior to that of the BDR group (P = 0.035). In the patients with LN metastases, the patients undergoing PD had significantly better survival than the BDR group (P < 0.001). CONCLUSION: Surgeons should be cautious in deciding to perform BDR for middle and distal common bile duct cancer. PD is recommended if LN metastases are suspected.