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Background: Neighborhood adversity's impact on postoperative/adjuvant therapy delivery and overall survival (OS) is poorly described in patients with localized pancreatic cancer (PC)., Methods: Area Deprivation Index (ADI) is a validated measure classifying neighborhood adversity. Higher ADI signifies increasing adversity. The 2013 national ADI scores were obtained from patients who completed preoperative/neoadjuvant therapy and surgery. Patients were categorized as having high (>50%) or low (≤50%) ADI., Results: Of the 224 patients, 163 (73%) had low ADI and 61 (27%) had high ADI. Adjuvant therapy was delivered to 129 (58%) patients, including 62% (101/163) with low ADI and 46% (28/61) with high ADI (p = 0.03). Patients with high ADI had 55% (95%CI 0.23-0.86; p = 0.02) decreased odds of receiving adjuvant therapy, independent of other factors. The median OS was 45 months for 129 patients who received adjuvant therapy and 31 months for 94 patients who did not receive adjuvant therapy (p = 0.03)., Conclusions: Patients with high ADI are less likely to receive adjuvant therapy for localized PC. Future studies should address impediments to care in patients from higher ADI neighborhoods., (Copyright © 2020. Published by Elsevier Inc.)

Background: More than 70% of patients with localized pancreatic cancer treated with upfront surgery develop disease recurrence. Herein we describe the radiographic patterns and timing of disease recurrence after neoadjuvant therapy and surgery in patients with pancreatic cancer., Methods: Radiographic patterns of first disease recurrence were examined in patients with localized pancreatic cancer who completed neoadjuvant therapy and surgery. Disease recurrence was classified as local (pancreas, resection bed, or peripancreatic vasculature); regional (peritoneum or abdominal wall); or distant (liver, lung, bone). Progression-free survival was calculated from the date of diagnosis to the date of recurrence., Results: Of 306 consecutive patients who completed neoadjuvant therapy and surgery, 149 (49%) had resectable pancreatic cancer and 157 (51%) had borderline resectable disease. Neoadjuvant therapy consisted of chemoradiation (32%), chemotherapy (14%), or both therapies (54%). Overall, primary therapy (including preoperative and postoperative therapy) consisted of chemoradiation alone in 29 (9%), chemotherapy alone in 14 (5%), and both therapies in 263 (86%) patients. At a median follow-up of 27 months, 186 (61%) of the 306 patients had recurrent pancreatic cancer. Sites of first recurrence were local-only in 29 (9%), regional-only in 19 (6%), distant-only in 87 (28%), and multisite in 51 (17%). The overall median progression-free survival for all patients was 24 months. Neoadjuvant chemoradiation reduced the odds of local-only recurrence (odds ratio: 0.21; 95% confidence interval: 0.06-0.77; P = .02)., Conclusion: After neoadjuvant therapy and surgery, 9% of patients were found to have local-only recurrence. Treatment sequencing that incorporates neoadjuvant chemoradiation may improve local disease control., (Copyright © 2020. Published by Elsevier Inc.)

Background: When pancreatic neoplasms occlude or encase the superior mesenteric-portal-splenic vein confluence with abutment of the posterior lateral wall of the superior mesenteric artery, a mesocaval shunt with or without a distal splenorenal shunt allows for safe dissection of the porta hepatis and separation of the pancreatic tumor from the superior mesenteric artery. Herein we report long-term results of the largest known series of portosystemic shunts performed at the time of pancreatectomy., Methods: All patients who underwent pancreatic resection with a mesocaval shunt or distal splenorenal shunt were identified from our prospective database. Demographics, perioperative treatment, and outcomes were reviewed., Results: A total of 34 patients underwent mesocaval shunt or distal splenorenal shunt, including 25 at the time of pancreatoduodenectomy, 6 during total pancreatectomy, and 3 after prior pancreatectomy. There were 15 mesocaval shunts, 16 distal splenorenal shunts, 2 combined mesocaval/distal splenorenal shunts, and 1 distal splenoadrenal vein shunt. The mesocaval group included 11 temporary and 6 permanent (3 delayed) shunts. Median operative time was 9 hours (range 6.5-13), median estimated blood loss was 950 mL (range 200-5,000), and median duration of hospital stay was 11 days (range 7-35). Four patients experienced complications that required intervention (Clavien-Dindo grade ≥III), but there were no 90-day mortalities. For patients with adenocarcinoma, median overall survival was 31 months at a median follow-up of 19 months. All but 1 shunt (distal splenorenal) were patent at last follow-up., Conclusion: Mesenteric venous shunting facilitates a safe and complete tumor resection in patients who require a complex pancreatectomy, many of whom would otherwise be deemed inoperable., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Among patients with localized pancreatic cancer (PC), the benefit of adjuvant therapy after neoadjuvant therapy and surgery is unknown., Methods: Patients with localized PC who completed all intended neoadjuvant therapy and surgery were categorized based on the receipt of adjuvant therapy and by pathologic lymph node status (LN - /LN + )., Results: Data was available from 234 consecutive patients, 121 (52%) with resectable and 113 (48%) with borderline resectable PC. Of the 234 patients, 92 (39%) were LN + and 142 (61%) were LN - . The median overall survival (OS) for the 234 patients was 39 months, 42.3 months for patients who received any adjuvant therapy and 34.1 months for those who did not (p = 0.29). Of the 92 LN + patients, the median OS with and without adjuvant therapy was 29.5 and 23.2 months, respectively (p = 0.02). Of the142 LN - patients, the median OS was 45 months with or without adjuvant therapy (p = 0.86). In an adjusted hazard model, additional adjuvant therapy had a significant protective effect among LN + patients (HR 0.39; 95% CI 0.21-0.70; p = 0.002) but not in LN - patients (HR 0.89; 95% CI 0.53-1.52; p = 0.68)., Conclusion: Among patients with localized PC who received neoadjuvant therapy and surgery, the benefit of adjuvant therapy was limited to those with node-positive disease.

Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Enthusiasm for neoadjuvant therapy is growing from the emerging consensus that pancreatic cancer is a systemic disease at the time of diagnosis. Those who remain in favor of upfront surgery often cite the lack of reported data to support alternative treatment sequencing. We therefore report the results of all patients treated outside of a clinical trial under the direction of a multidisciplinary pancreatic cancer working group., Methods: We reviewed all patients with resectable pancreatic cancer treated with neoadjuvant therapy (NeoTx) from 2009 to 2013; we excluded those patients treated on prospective clinical trials as they will be the subject of subsequent reports. Data regarding demographics, NeoTx, operative outcomes, pathology, and survival data were abstracted from a prospective database., Results: NeoTx was initiated in 69 patients; median age was 65 years (interquartile range [IQR]: 11) and median carbohydrate antigen 19-9 at diagnosis was 96.5 (IQR 210). NeoTx consisted of chemotherapy alone (n = 10, 14%), chemotherapy and radiation (chemoradiation, n = 53, 77%), or both (n = 6, 9%). Median carbohydrate antigen 19-9 after NeoTx was 39 (IQR 104) corresponding to a median decrease of 60%. Operative resection was completed in 60 (87%) of the 69 patients. At restaging after NeoTx, 5 (7%) of 69 patients were not considered candidates for surgery because of the development of metastatic disease (n = 4) or an inadequate performance status (n = 1). At the time of surgery, 4 (6%) of 64 patients had metastatic disease found at laparoscopy. Of the 60 patients who underwent surgical resection, a complete pathologic response was observed in 2 (3%) patients; 20 (33%) had positive lymph nodes, and the median number of positive lymph nodes was 2 (IQR 3). R0 resections were achieved in 58 (97%) of the 60 patients. Additional postoperative adjuvant therapy was administered to 37 (62%) of the 60 patients. Median survival of all 69 patients was 31.5 months; 44.9 months for the 60 patients who completed all NeoTx and resection compared with 8.1 months for the 9 patients who were not resected (log rank P < .001)., Conclusion: NeoTx for resectable pancreatic cancer was associated with a median overall survival of 32 months; something not reported for patients treated with surgery first if based on intent-to-treat analysis. Treatment sequencing may provide an oncologic benefit beyond that of the selection bias afforded surgery after a period of induction therapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Treatment sequencing in older patients is difficult because of concomitant comorbidities and often decreasing performance status. The present study sought to examine the effect of neoadjuvant therapy and pancreatic surgery in older patients with resectable or borderline-resectable (BLR pancreatic cancer (PC)., Methods: Patients with resectable or BLR PC treated with neoadjuvant therapy were classified as older (≥ 75 years) or younger (<75 years)., Results: Neoadjuvant therapy was initiated in 246 patients; 210 (85%) younger than 75 years and 36 (15%) older. Older patients had a greater median Charlson comorbidity index (CCI): 6 vs 4 (P < .01). Completion of all intended therapy (neoadjuvant therapy and surgery) occurred in 177 (72%) of the 246 patients; 153 (73%) of the 210 younger and 24 (67%) of the 36 older patients (P = .43). Failure to complete all therapy was associated with BLR clinical stage (odds ratio [OR] 0.26, P = .001), increased posttreatment/preoperative serum levels of CA19-9 (OR 0.27, 95% confidence interval 0.14-0.53), and CCI ≥ 6 (OR 0.44, 95% confidence interval 0.22-0.86). Median overall survival for all study patients was 26.1 and 19.7 months (P = .13) for younger and older patients, respectively. Of the 177 patients who completed all therapy, the difference in survival between younger and older patients was not statistically significant (36.5 months vs 27.2 months, P = .47)., Conclusion: Failure to complete neoadjuvant therapy and eventual pancreatic resection is associated with BLR stage, increased posttreatment/preoperative CA19-9, and CCI ≥ 6, but not older age. Older patients who completed neoadjuvant therapy and underwent resection experienced a survival benefit compared with those who did not complete all intended therapy. Balancing the toxicity of sequential therapies with their cumulative effect on tolerance and risk for pancreatic surgery will be the key to developing optimal treatment sequencing in older patients with PC., (Published by Elsevier Inc.)

Background: Tumor-induced arterial abutment/encasement has been traditionally a contraindication to surgery in patients with localized pancreatic cancer (PC). One recent meta-analysis reported greater mortality rates in this setting. We report herein a series of planned arterial resections in carefully selected patients who responded favorably to combined modality therapy for localized PC., Methods: We reviewed all patients with PC and arterial encasement treated between May 2011 and September 2013; all patients received an extensive course of neoadjuvant therapy before surgery., Results: Of 15 patients taken to surgery, 2 had peritoneal disease at laparoscopy, and therefore, laparotomy was not performed. Pancreatectomy (pancreaticoduodenectomy, 3; distal, 8; central pancreatectomy, 1; total, 1) was performed in the remaining 13, 10 of whom required arterial resection. The most common operation was an Appleby procedure. Of 10 patients who underwent combined pancreatectomy and arterial resection, their median age was 62 years (range, 33-75), median operative time was 7.5 hours, and median blood loss was 725 mL. Complications occurred in 3 of 15 patients with no perioperative mortality. Median duration of hospital stay was 9 days (range, 5-19). An R0 resection was achieved in 11 (85%) of 13 patients. At a median follow-up of 21 months, 8 of these 13 resected patients (62%) are alive without disease., Conclusion: Planned arterial resection at the time of pancreatectomy can be performed with acceptable morbidity and mortality; patient selection and induction therapy are likely critically important variables that seem to impact patient outcome. Those patients with stable or responding disease after induction therapy represent the subset of patients with potentially favorable tumor biology in whom extended resections may enhance survival duration., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Vascular resection/reconstruction at the time of pancreatectomy is performed when limited vascular involvement is the only barrier to complete resection. Splenic vein (SV) ligation facilitates resection/reconstruction of the superior mesenteric vein (SMV)-portal vein (PV) confluence and widely exposes the superior mesenteric artery and celiac origin. If the inferior mesenteric vein does not provide for retrograde decompression, SV ligation may result in sinistral portal hypertension; creation of a distal splenorenal shunt (DSRS) can prevent this complication. Additional complexity occurs in the setting of cavernous transformation of the PV. A mesocaval shunt (MCS) can be utilized to temporarily divert portal flow allowing for a safe portal dissection. Herein we report our initial experience utilizing DSRS and MCS at the time of pancreatectomy for cancer., Methods: We reviewed all patients who underwent pancreatic resection for cancer and had either a DSRS and/or MCS performed between January 1, 2009 and February 1, 2012., Results: Of 11 patients identified, 10 had adenocarcinoma, 9 underwent standard or extended pancreaticoduodenectomy, and 2 underwent total pancreatectomy. Median operative time was 9.5 hours, median blood loss was 1,000 mL and median duration of stay was 10 days. There were no mortalities. There was 1 Clavien grade III complication during the index admission and 3 others were readmitted. No patient required reoperation., Conclusion: We provide proof of concept that extended pancreatic resection in the setting of limited vascular involvement can be safely performed. This is the first report utilizing MCS and DSRS to facilitate resection of the SMV-PV confluence in the setting of cavernous transformation of the PV., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The aim of this study was to compare the outcomes of enucleation versus resection in patients with small pancreatic, ampullary, and duodenal neuroendocrine tumors (NETs)., Methods: Multi-institutional retrospective review identified all patients with pancreatic and peri-pancreatic NETs who underwent surgery from January 1990 to October 2008. Patients with tumors < or =3 cm and without nodal or metastatic disease were included., Results: Of the 271 patients identified, 122 (45%) met the inclusion criteria and had either an enucleation (n = 37) and/or a resection (n = 87). Enucleated tumors were more likely to be in the pancreatic head (P = 0.003) or functioning (P < 0.0001) and, when applicable, less likely to result in splenectomy (P = 0.0003). The rate of pancreatic fistula formation was higher after enucleation (P < 0.01), but the fistula severity tended to be worse following resection (P = 0.07). The enucleation and resection patients had similar operative times, blood loss, overall morbidity, mortality, hospital stay, and 5-year survival. However, for pancreatic head tumors, enucleation resulted in decreased blood loss, operative time, and length of stay compared to pancreaticoduodenectomy (P < 0.05)., Conclusion: These data suggest that most outcomes of enucleation and resection for small pancreatic and peri-pancreatic NETs are comparable. However, enucleation has better outcomes than pancreaticoduodenectomy for head lesions and the advantage of preserving splenic function for tail lesions.

Background The prognostic value of CA19-9 in patients with pancreatic cancer ( PC) treated with neoadjuvant therapy has not been well described. Methods Pre-treatment CA19-9 levels (with concomitant normal bilirubin level) in patients with localized PC were categorized as normal (≤35), low (36-200), moderate (201-1000), or high (>1000). Post-treatment CA19-9 was measured after neoadjuvant therapy, prior to surgery. Results Pre-treatment CA19-9 levels were evaluable in 235 patients, levels were normal in 60 (25%) patients, low in 78 (33%) patients, moderate in 69 (29%) and high in 28 (12%). After neoadjuvant therapy, post-treatment CA19-9 normalized (≤ 35) in 40 (51%) of the patients in the low group, 14 (21%) of the moderate and 5 (19%) of the high group ( P < 0.001). Of the 235 patients, 168 (71%) completed all intended therapy including a pancreatectomy; 44 (73%), 62 (79%), 46 (67%) and 16 (57%) of the normal, low, moderate and high groups ( P = 0.10). Among these 168 patients, the median overall survival was 38.4, 43.6, 44.7, 27.2 and 26.4 months for normal, low, moderate and high CA19-9 groups (log rank P = 0.72). Among resected patients, an elevated pre-treatment CA19-9 was of little prognostic value; instead, it was the CA19-9 response to neoadjuvant therapy that was prognostic [hazard ratio (HR): 1.80, P = 0.02]. Conclusions Among patients who completed neoadjuvant therapy and surgery, pre-treatment CA19-9 obtained at the time of diagnosis was not predictive of overall survival, but normalization of post-treatment CA19-9 in response to neoadjuvant therapy was highly prognostic. [ABSTRACT FROM AUTHOR]

Background: Resection of the superior mesenteric vein (SMV)-portal vein (PV)-splenic vein (SV) confluence during pancreatectomy for pancreatic cancer requires management of the SV. Discussion: Simple SV ligation can result in sinistral portal hypertension if the inferior mesenteric vein (IMV) enters the confluence and is thereby resected, or if the IMV is insufficient to drain the SV. We describe herein three patients whose clinical course confirms the importance of the IMV decompressing the SV to avoid sinistral hypertension. [ABSTRACT FROM AUTHOR]

Background Concerns for morbidity after a pancreaticoduodenectomy ( PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer ( AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD. Methods All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared. Results There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging ( PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity ( P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio ( HR) 0.19; 95% confidence interval ( CI) 0.05-0.61, P < 0.005] or a PD ( HR 0.23; 95% CI 0.15-0.36, P < 0.001). Conclusion Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients. [ABSTRACT FROM AUTHOR]