Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater

Background: The prognosis for carcinoma of the ampulla of Vater (CAV) is better than for pancreatic cancer. The 5-year survival median rate after resection of CAV is 45%, but late recurrences remain possible. Several survival factors have been identified (lymph nodes, perineural invasion), but few data are available on the type of recurrences, their impact and their management. Patients and methods: A total of 41 patients treated by pancreatoduodenectomy (PD) for CAV from 1980 to 2003 were studied retrospectively. Patient selection, long-term survival recurrence rate and recurrence treatment were reviewed. Univariate and multivariate proportional hazards analysis were conducted on this series. Results: The mean follow-up was 48 months. Five-year survival was 62.8%. Eleven patients had recurrences (6–67 months). Recurrence was associated with time to all-causes death (hazard ratio [HR] 4.3, p=0.003). Factors predictive of recurrence were perineural invasion (HR 5.3, p=0.02), lymph node invasion (HR 5.3, p=0.02) and differentiation (HR 0.2, p=0.05). Three patients underwent surgical R0 treatment of their recurrences. Two who presented with solitary liver metastasis are alive and disease-free. Conclusions: Recurrence represents a serious threat in the prognosis of CAV after surgery. Some of these recurrences, in particular liver metastases, are accessible for a curative treatment. This finding supports the usefulness of a close and long-term follow-up after surgery to improve survival of patients with CAV, especially in the group of patients with a good prognosis.     

Proposed indications for limited resection of early ampulla of Vater carcinoma: clinico-histopathological criteria to confirm cure

Background

Limited resection is reserved for patients with high operative risk or benign adenomas. We aimed to define indications for limited resection of early ampulla of Vater carcinoma with curative intent through detailed preoperative examinations and histopathological evaluations.

Methods

We performed a retrospective cohort study of all consecutive Japanese patients who underwent resection for ampulla of Vater neoplasms at our hospital from 1986 to 2010.

Results

A total of 75 patients were identified. Moderately/poorly differentiated histology, lympho-vascular/perineural invasion, and duodenal/pancreatic invasion were significant risk factors for lymph node metastases. Macroscopically, non-exposed protruded- or ulcerative-type disease did not correlate directly with lymph node metastases; however, these tumor types were associated with other invasive features. In a subset of early carcinomas fulfilling the conditions of exposed protruded adenoma or papillary/well-differentiated adenocarcinoma determined by endoscopic biopsy, negative duodenal invasion determined by endoscopic ultrasonography, no tumor infiltration into the pancreatic duct determined by intraductal ultrasound, and diameter of the pancreatic duct ≤3?mm determined by endoscopic retrograde cholangiopancreatography (N?=?11), the incidence of lymph node metastasis and tumor infiltration into the pancreatic duct was 0%.

Conclusion

Strictly selected patients with early ampulla of Vater carcinomas may benefit from limited resection if the resected specimen is evaluated to confirm all histopathological criteria.     

KL-6 mucin expression in carcinoma of the ampulla of Vater： Association with cancer progression

AIM: To assess histochemical expression of KL-6 and its clinicopathological significance in carcinoma of the ampulla of Vater. METHODS: Ampullary carcinoma tissues were collected from 38 patients who underwent pancreatoduodenectomy or local resection. Tissues were subjected to immunohistochemical analysis using KL-6 antibody. RESULTS: Positive staining of ampullary carcinoma cells was observed in 26 (68.4%) cases. Staining was not found in the surrounding non-cancer regions of the ampullary tissues. Remarkable KL-6 expression was observed in invasive carcinoma cells in pancreatic and duodenal tissues and in metastatic carcinoma cells in lymph nodes. Positive KL-6 expression was related to lymph node metastasis (P=0.020), pancreatic invasion (P=0.016), duodenal invasion (P= 0.034), and advanced stage of TNM clinical classification (P=0.010). Survival analysis showed that positive expression of KL-6 was related to a poorer prognosis (P=0.029). CONCLUSION: The aberrant expression of KL-6 mucin is significantly related to unfavorable behaviors of carcinoma of the ampulla of Vater.     

Feasibility of endoscopic papillectomy in early stage ampulla of Vater cancer

Background and Aim:  Although endoscopic papillectomy has been attempted in early stage ampullary cancer (pTis, T1), its curative role and indications remain uncertain. The present study was designed to assess the factors that predict malignancy and lymph node metastasis and to suggest potential indications for endoscopic papillectomy by analyzing clinicopathological data.
Methods:  We performed a retrospective analysis of clinical and histopathological data of 216 patients with ampullary cancer between 1991 and 2006.
Results:  No tumor in pTis stage had metastasized to lymph nodes and only 9% of tumors in pT1 had metastasized. Tumor size ( P  = 0.018), depth of invasion ( P  = 0.021) and venous invasion ( P  = 0.014) were found to be significantly related to lymph node metastasis. Cases with early stage ampullary cancer of less than 2 cm with a well-differentiated histology and no angiolymphatic invasion ( n  = 13) showed no lymph node metastasis and no recurrence during a median follow up of 35.9 months.
Conclusion:  Endoscopic papillectomy can be adopted as a viable alternative to surgery in patients with early stage ampullary cancer of less than 2 cm in size and with a well-differentiated histology. When a resected specimen has a well-differentiated histology, and there is no resection margin involvement and no angiolymphatic invasion, our findings indicate that subsequent radical surgery is unnecessary.     

超声内镜对壶腹癌及肝外胆管癌术前分期诊断

超声内镜对手术前Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌的原发病变范围、浸润深度、是否有区域淋巴结转移及远隔转移作出诊断及分期，将有助于选择最佳治疗方案及判断预后。对２８例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌于手术前进行了超声内镜检查，并按照国际ＴＮＭ分期方案进行了手术前分期。其中２２例Ｖａｔｅｒ＇ｓ壶腹癌及１８例肝外胆管癌进行了根治性切除及详细的病理组织学检查，有可能将超声内镜与病理诊断结果进行对照以检验超声内镜诊断的准确性。超声内镜判断Ｖａｔｅｒ＇ｓ壶腹癌及肝外胆管癌病变范围及浸润深度的准确性分别为８１．８％及７２．２％；判断其区域淋巴结转移的准确性分别为５９％及６１．６％。Ｖａｔｅｒ＇ｓ壶腹癌伴门静脉受侵的３例中有２例于术前超声内镜检查中获得了正确诊断，但３例肝转移均未能发现。     

Guidelines for the management of biliary tract and ampullary carcinomas: surgical treatment

The only curative treatment in biliary tract cancer is surgical treatment. Therefore, the suitability of curative resection should be investigated in the first place. In the presence of metastasis to the liver, lung, peritoneum, or distant lymph nodes, curative resection is not suitable. No definite consensus has been reached on local extension factors and curability. Measures of hepatic functional reserve in the jaundiced liver include future liver remnant volume and the indocyanine green (ICG) clearance test. Preoperative portal vein embolization may be considered in patients in whom right hepatectomy or more, or hepatectomy with a resection rate exceeding 50%–60% is planned. Postoperative complications and surgery-related mortality may be reduced with the use of portal vein embolization. Although hepatectomy and/or pancreaticoduodenectomy are preferable for the curative resection of bile duct cancer, extrahepatic bile duct resection alone is also considered in patients for whom it is judged that curative resection would be achieved after a strict diagnosis of its local extension. Also, combined caudate lobe resection is recommended for hilar cholangiocarcinoma. Because the prognosis of patients treated with combined portal vein resection is significantly better than that of unresected patients, combined portal vein resection may be carried out. Prognostic factors after resection for bile duct cancer include positive surgical margins, especially in the ductal stump; lymph node metastasis; perineural invasion; and combined vascular resection due to portal vein and/or hepatic artery invasion. For patients with suspected gallbladder cancer, laparoscopic cholecystectomy is not recommended, and open cholecystectomy should be performed as a rule. When gallbladder cancer invading the subserosal layer or deeper has been detected after simple cholecystectomy, additional resection should be considered. Prognostic factors after resection for gallbladder cancer include the depth of mural invasion; lymph node metastasis; extramural extension, especially into the hepatoduodenal ligament; perineural invasion; and the degree of curability. Pancreaticoduodenectomy is indicated for ampullary carcinoma, and limited operation is also indicated for carcinoma in adenoma. The prognostic factors after resection for ampullary carcinoma include lymph node metastasis, pancreatic invasion, and perineural invasion.     

Metastasis of primary gallbladder carcinoma in lymph node and liver

AIM: To evaluate the patterns with metastasis of gallbladder carcinoma in lymph nodes and liver. METHODS: A total of 45 patients who had radical surgery were selected. The patterns with metastasis of primary gallbladder carcinoma in lymph nodes and liver were examined histopathologically and classified as TNM staging of the American Joint Committee on Cancer. RESULTS: Of the 45 patients, 29 (64.4%) had a lymph node positive disease and 20 (44.4%) had a direct invasion of the liver. The frequency of involvement of lymph nodes was strongly influenced by the depth of the primary tumor (P= 0.0001). The postoperative survival rate of patients with negative lymph node metastasis was significantly higher than that of patients with positive lymph node metastasis (P= 0.004), but the postoperative survival rate of patients with Nl lymph node metastasis was not significantly different from that of patients with N2 lymph node metastasis (P= 0.3874). The postoperative survival rate of patients without hepatic invasion was significantly better than that of patients with hepatic invasion (P= 0.0177). CONCLUSION: Complete resection of the regional lymph nodes is important in advanced primary gallbladder carcinoma (PGC). The initial sites of liver spread are located mostly in segments IV and V. It is necessary to achieve negative surgical margins 2 cm from the tumor. In patients with hepatic hilum invasion, extended right hepatectomy with or without bile duct resection or portal vein resection is necessary for curative resection.     

Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection

Background/Purpose

The prognosis of patients with pancreatic cancer is said to have not been improved markedly by any procedures in the past 20 years. Since 1973, we have gradually extended the area of dissection when performing curative resection for pancreatic cancer to improve the resection rate and prognosis. Nineteen patients have survived for 3 years or more, and the 5-year survival rates of patients with cancer of the head of the pancreas were 23.9% for macroscopically curative resection and 34.3% for histologically curative resection.

Methods

We histologically observed surgical specimens, cut into 3- to 5-mm sections and compared the histologic characteristics of the 19 patients who survived for 3 years or more with those of 41 patients who died of cancer within 3 years (excluding 6 operative and hospital deaths), in order to find the conditions required for long-term survival.

Results

The following conditions were associated with long-term survival: (1) tumor diameter 3?cm or less; (2) either absence of lymph node metastasis or metastasis limited to the n₁ group; (3) degree of invasion of the anterior pancreatic capsule of zero (s0); and (4) either no retropancreatic invasion (rp0) or exposed retropancreatic invasion (rpe) with no cancer invasion of dissected peripancreatic tissue ew(?).

Conclusions

At present, because the rpe rate is more than 70%, resection of the pancreas, including the superior mesenteric vein and the retropancreatic fusion fascia, is essential for a curative resection, because the retropancreatic tissue between the back of the pancreas and this fascia is anatomically considered to be in the position of the subserosal tissue in the gallbladder or stomach. Combined resection of the superior mesenteric artery may further improve the results of resection for pancreatic cancer, from the anatomical viewpoint.

     

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater

Background/Purpose

Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted.

Methods

From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated.

Results

The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively).

Conclusions

Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.     

Adenosquamous carcinoma in the biliary tract: association of the proliferative ability of the squamous component with its proportion and tumor progression

Objectives: The purpose of this study was to evaluate the association of the proliferative ability of squamous cell carcinoma (SCC) component with its proportion and tumor progression in adenosquamous carcinoma (ASC) in the biliary tract.

Methods: Nine patients with ASC in the biliary tract (four each in the gallbladder and the extrahepatic bile duct and one in the ampulla of Vater) who underwent surgical resection were retrospectively reviewed.

Results: The proportion of the SCC component in the primary sites ranged from 30% to 95%. The Ki-67 index of the SCC component was higher than that of the adenocarcinoma component in all cases, regardless of the component ratio in the patients’ primary lesions. Predominance of the SCC component in the advancing region of the tumor, in angiolymphatic invasion and in perineural invasion was observed in most of the cases. The component ratio in metastatic lymph nodes differed from that in the corresponding primary lesions in all six cases with lymph node metastasis. Among these cases, the proportion of the SCC component was increased in the metastatic lymph nodes compared with that in the corresponding primary lesion in two cases, whereas the proportion was decreased in four cases.

Conclusions: The SCC component of ASC in the biliary tract displayed a relatively higher proliferative ability, which might be associated with local invasiveness. However, not only the high proliferative ability of the SCC component but also other biological factors might contribute to tumor progression and metastasis in ASC of the biliary tract.     

Pylorus-preserving pancreatoduodenectomy for cancer treatment: Surgical procedure,indications, and analysis of outcomes

Factors determining the prognosis of cancer of the pancreatic head were analyzed in 100 patients who had undergone surgical treatment. So as to clarify the indications for pylorus-preserving pancreatoduodenectomy (PPPD), the prognosis was compared in two sets of such patients, 25 who had undergone PPPD and 25 who had undergone the Whipple procedure. Of these 50 patients, 20 (40%) also underwent portal vein resection and 29 (58%) were found to have lymph node metastasis. Curative resection was achieved in 33 of these 50 patients (66%) and the 5-year survival rate after the curative resection (42.0%) was significantly higher in these patients that in those given a non-curative resection (P <0.01). Further, the prognosis was better for patients who did not require a portal vein excision than for those who did (P<0.01), and for patients who showed no lymph node metastasis than for those with metastasis (P<0.01). The 5-year survival rate did not differ significantly between the PPPD group and the Whipple procedure group. These results indicate that PPPD can also be a useful procedure for treating malignant diseases.     

Modes of spread in early ampullary cancer in terms of establishing proper indications for endoscopic papillectomy

Background: Endoscopic papillectomy for adenomas of the ampulla of Vater has been reported and is gaining acceptance as an alternative to surgery in the treatment of early ampullary cancer. However, whether endoscopic treatment is justified as a treatment of choice for early ampullary cancer remains controversial. The aim of the present study was to elucidate the possibility of endoscopic papillectomy as a treatment of early ampullary cancer from the review of pathology of cases treated by surgical resection. Patients and methods: Twenty‐three cases of early ampullary cancer (m—tumor limited to the mucosa of the ampulla 14; od—tumor that invades Oddi's sphincter, 9) treated by surgical resection from January 1984 to March 2003 were investigated as to the following: (i) macroscopic type, maximum size, and histological type of tumor; (ii) main location and extension of tumor; (iii) prevalence of extension into the lower bile duct or pancreatic duct, and relationship between ductal infiltration and macroscopic type, maximum size, main location, or depth of invasion of tumor; (iv) lymphatic permeation, vascular invasion, and lymph node metastasis; and (v) prognosis. Results: All cases were classified macroscopically as exposed‐tumor type or non‐exposed‐tumor type without ulceration. Extension into the lower bile duct or the pancreatic duct was observed in 43% of the cases. There was no correlation between ductal infiltration and macroscopic type, maximum tumor size, main tumor location, or tumor depth. No lymphatic permeation, vascular invasion, or lymph node metastasis were proven in cases with ampullary cancer confined to the mucosa. In the nine cases with involvement of Oddi's sphincter, lymphatic permeation and lymph node metastasis were observed in two cases and one case, respectively. Conclusion: Endoscopic treatment for early ampullary cancer confined to the mucosa without spread to the bile duct or pancreatic duct is justified as a treatment of choice if detailed histological examination of the resected specimen indicated no invasion beyond its margin.     

Surgical treatment for carcinoma of the papilla of vater

Eighty of 89 patients who underwent radical resection (resectability 89.9%) for carcinoma of the papilla of Vater between 1976 and 1992 were retrospectively reviewed. Seventy-three patients underwent pancreaticoduodenectomy (PD) and 7 underwent pylorus-preserving pancreaticoduodenectomy (PPPD). The postoperative mortality rate was only 3.8% (3 patients). The 3- and 5-year survival rates were 63.6% and 57.4%, respectively. Important factors influencing long-term survival were Stage (clinical stage = Stage), microscopic lymph node metastasis (n), duodenal wall invasion (d), vascular invasion (v), and the epithelium of origin. Early carcinoma of the papilla of Vater is defined as tumor in which invasion is limited within the papilla of Vater; in particular, carcinomatous invasion is within the muscle of Oddi (d₀) with n₀. PD and/or PPPD with radical lymph node dissection should be performed for carcinoma of the papilla of Vater, as these procedures can be performed with low morbidity and mortality.     

Relationship between autophagy and perineural invasion,clinicopathological features,and prognosis in pancreatic cancer

AIM To investigate the relationship between autophagy and perineural invasion(PNI), clinical features, and prognosis in patients with pancreatic cancer. METHODS Clinical and pathological data were retrospectively collected from 109 patients with pancreatic ductal adenocarcinoma who underwent radical resection at the First Affiliated Hospital of Zhengzhou University from January 2011 to August 2016. Expression levels of the autophagy-related protein microtubuleassociated protein 1 A/1 B-light chain 3(LC3) and PNI marker ubiquitin carboxy-terminal hydrolase(UCH) in pancreatic cancer tissues were detected by immunohistochemistry. The correlations among LC3 expression, PNI, and clinical pathological features in pancreatic cancer were analyzed. The patients were followed for further survival analysis. RESULTS In 109 cases of pancreatic cancer, 68.8%(75/109) had evidence of PNI and 61.5%(67/109) had high LC3 expression. PNI was associated with lymph node metastasis, pancreatitis, and CA19-9 levels(P 0.05). LC3 expression was related to lymph node metastasis(P 0.05) and was positively correlated with neural invasion(P 0.05, r = 0.227). Multivariate logistic regression analysis indicated that LC3 expression, lymph node metastasis, pancreatitis, and CA19-9 level were factors that influenced neural invasion, whereas only neural invasion itself was an independent factor for high LC3 expression. Univariate analysis showed that LC3 expression, neural invasion, and CA19-9 level were related to the overall survival of pancreatic cancer patients(P 0.05). Multivariate COX regression analysis indicated that PNI and LC3 expression were independent risk factors for poor prognosis in pancreatic cancer(P 0.05). CONCLUSION PNI in patients with pancreatic cancer is positively related to autophagy. Neural invasion and LC3 expression are independent risk factors for pancreatic cancer with a poor prognosis.     

Recurrence after endoscopic mucosal resection of esophageal squamous cell carcinoma invading the muscularis mucosae or upper submucosa

Background: Endoscopic mucosal resection (EMR) is recommended for cases of squamous cell carcinoma of the esophagus in which the tumor is confined to the lamina propria mucosa. However, EMR is often performed in patients whose tumors invade the muscularis mucosae (m3) or upper submucosa (sm1) to minimize surgical invasion, despite the increased risk of lymph node metastasis. We evaluated patients who were found to have distant or lymph node metastasis after EMR for such lesions. Methods: Thirty‐four consecutive patients with esophageal carcinoma invading m3 or sm1 who underwent EMR during the period from June 1992 through March 2001 (extended EMR group) were studied. Results: Five of these patients were found to have distant or lymph node metastasis on follow up. Patient 1 died of lung metastasis 34 months after EMR. Patient 2 underwent chemotherapy because of an abnormally high value of squamous cell carcinoma (SCC) antigen. Patient 3 died of upper mediastinal lymph node metastasis 62 months after EMR. Patient 4 underwent total gastrectomy because of gastric wall metastasis 41 months after EMR and underwent chemoradiotherapy because of upper mediastinal lymph node metastasis 87 months after EMR. Patient 5 was found to have cardiac lymph node metastasis by follow‐up endoscopic ultrasonography examination 42 months after EMR and underwent curative lymph node dissection. Conclusion: It is unlikely that patient 1 and patient 2, both with probable distant metastasis, received inadequate treatment. Surgery with lymph node dissection usually cannot prevent distant metastasis. The patients with lymph node recurrence (patient 3 and patient 4) should have been followed up more carefully. We believe that patients with early lymph node metastasis, such as patient 5 in this study, should undergo curative surgical resection. Patients undergoing extended EMR should be carefully followed up for a long period to enable early detection and treatment of lymph node metastasis.     

Prognostic Impact of Perineural Invasion Following Pancreatoduodenectomy With Lymphadenectomy for Ampullary Carcinoma

The aim of this study was to identify prognostic factors in patients undergoing pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma. The records of 46 consecutive patients with ampullary carcinoma who underwent pancreatoduodenectomy from 1988 through 2006 were retrospectively reviewed. A 98% rate of potentially curative (R0) resection was achieved. There was no 30-day mortality. Overall 5-year survival rate was 64%. Univariate analysis revealed that T3 and T4 tumor (i.e., pancreatic parenchymal invasion) (P < 0.001), lymph node metastasis (P = 0.01), and perineural invasion (P < 0.001) were significant predictors of poor prognosis. Furthermore, perineural invasion was found to be a significant independent predictor of poor prognosis by multivariate analysis (P = 0.024). Pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma is a safe surgical procedure with an acceptable cure rate. The presence of perineural invasion may be useful for predicting poor prognosis in patients with ampullary carcinoma who undergo potentially curative resection.     

Pylorus-preserving pancreatoduodenectomy is applicable to patients with carcinoma of the head of the pancreas: Studies of lymph node metastasis and quality of life

Metastases to the regional lymph nodes of the stomach were studied in patients in whom carcinoma of the head of the pancreas had been resected (51 standard pancreatoduodenectomy and 26 total pancreatectomy). Involvement of gastric lymph nodes was rare (1.3%–3.9%), except of the subpyloric lymph nodes (9.1%). Carcinoma in the five patients with positive gastric lymph nodes, with the exception of the subpyloric nodes, was clinically far advanced: four of the five had liver metastasis or peritoneal dissemination. This suggests that, in terms of preservation of the regional gastric lymph nodes, only subpyloric node involvement has any significance with respect to surgical treatment of carcinoma of the head of the pancreas. There was no significant difference in survival rates after curative resection between standard pancreatoduodenectomy (n=44) and pylorus-preserving pancreatoduodenectomy (n=17). In the patients who underwent the pylorus-preserving pancreatoduodenectomy for various kinds of periampullary diseases (n=47), postoperative recovery of gastric and small bowel function was temporarily prolonged compared to that after shandard pancreatoduodenectomy (n=44). However, the former group were able to take significantly more calories 6 weeks after the operation. Our study indicates that the pylorus-preserving pancreatoduodenectomy with subpyloric lymph node dissection is applicable to the treatment of patients with carcinoma of the head of the pancreas from the viewpoints of both extent of operation and quality of life.     

Does direct invasion of peripancreatic lymph nodes impact survival in patients with pancreatic ductal adenocarcinoma? A retrospective dual-center study

BackgroundPancreatic ductal adenocarcinoma can directly invade the peripancreatic lymph nodes; however, the significance of direct lymph node invasion is controversial, and it is currently classified as lymph node metastasis. This study aimed to identify the impact of direct invasion of peripancreatic lymph nodes on survival in patients with pancreatic ductal adenocarcinoma.MethodsA total of 411 patients with resectable/borderline resectable pancreatic ductal adenocarcinoma who underwent pancreatic resection at two high-volume centers from 2006 to 2016 were evaluated retrospectively.ResultsSixty (14.6%) patients had direct invasion of the peripancreatic lymph nodes without isolated lymph node metastasis (N-direct group), 189 (46.0%) had isolated lymph node metastasis (N-met group), and 162 (39.4%) had neither direct invasion nor isolated metastasis (N0 group). There was no significant difference in median overall survival between the N-direct group (35.0 months) and the N0 group (45.6 month) (p = 0.409), but survival was significantly longer in the N-direct compared with the N-met group (25.0 months) (p = 0.003). Similarly, median disease-free survival was similar in the N-direct (21.0 months) and N0 groups (22.7 months) (p = 0.151), but was significantly longer in the N-direct compared with the N-met group (14.0 months) (p < 0.001). Multivariate analysis identified resectability, adjuvant chemotherapy, and isolated lymph node metastasis as independent predictors of overall survival. However, direct lymph node invasion was not a predictor of survival.ConclusionDirect invasion of the peripancreatic lymph nodes had no effect on survival in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma, and should therefore not be classified as lymph node metastasis.     

Size of the Tumor and Other Factors Influencing Prognosis of Carcinoma of the Head of the Pancreas

Extent of the tumor in carcinoma of the pancreas seems an important factor in stage classification. The purpose of this report is to present the results of studies on the relationship between the size of the tumor (T) and prognosis, and the correlation between the size and the other factors influencing prognosis such as invasion to the pancreatic capsule, invasion to the retroperitoneal tissue, metastasis to the regional lymph node, and so on. T was divided into four groups: T1, T2, T3, T4. Tumor diameter of 2 cm or less was designated as T1, 2.1-4 cm as T2, 4.1-6 cm as T3, and 6.1 cm or more as T4. Case reports of 163 patients who underwent resection of carcinoma of the pancreatic head were submitted by 10 major institutions and retrospectively analyzed. There was significant differences in 1-year cumulative survival rates between T1 and T3, T1 and T4, and T1 and T2 + T3 + T4, but no significant difference in 3- or 5-year survival rates among the T groups. The incidence of no capsular invasion, no retroperitoneal invasion, and no lymph node metastasis had a tendency to decrease along with increase in tumor size and the incidence of definite capsular invasion, and lymph node metastases increase with increase in the size. Attempts to diagnose tumors of less than 2 cm should be made to ameliorate the poor surgical results. However, it should be stressed that even in the T1 group regional lymph node metastases were seen in about half of the cases.     

Clinicopathological features of small nonfunctioning pancreatic neuroendocrine tumors

AIM: To present our experiences in studying the clinicopathological features of small nonfunctioning pancreatic neuroendocrine tumors (NF-pNETs).METHODS: The subjects included 9 patients with NF-pNETs who underwent pancreatectomy between April 1996 and September 2012. The surgical procedure, histopathological findings, and prognosis were assessed.RESULTS: All tumors were incidentally detected by computed tomography. The median diameter was 10 mm (5-32 mm). One patient was diagnosed with von Hippel-Lindau disease, and the others were sporadic cases. For the histopathological findings, 7 patients were G1; 1 patient was G2; and 1 patient, whose tumor was 22 mm, had neuroendocrine carcinoma (NEC). One patient who had a tumor that was 32 mm had direct invasion to a regional lymph node and 1 patient with NEC, had regional lymph node metastases. Six of the 7 patients with sporadic NF-pNETs, excluding the patient with NEC, had tumors that were smaller than 10 mm. Tumors smaller than 10 mm showed no malignancy and lacked lymph node metastasis.CONCLUSION: Sporadic NF-pNETs smaller than 10 mm tend to have less malignant potential. These findings suggest that lymphadenectomy may be omitted for small NF-pNETs after further investigation.