Neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreas

To examine the histopathologic effect of neoadjuvant therapy and its impact on survival in patients with carcinoma of the pancreas, we retrospectively reviewed the records of 116 patients who underwent resections for pancreatic cancer from 1987 to 2000. Median follow-up of surviving patients was 19 mo (range 4–150 mo). Preoperative chemotherapy was administered in 61 patients (53%) and consisted of 5-fluorouracil/mitomycin C in 35 patients and gemcitabine in 26 patients, given concurrently with external beam radiation (5040 cGy). All resections were performed with curative intent (98 Whipples, 11 total, 6 distal, and 1 central pancreatectomy). Histopathologic examination included an estimation of the amount of fibrosis present in the tumor specimen (expressed as the percentage of fibrosis identified relative to the amount of neoplastic cells present). The mean fibrosis level for the series was 56% (range 5% to 100%). The administration of neoadjuvant therapy resulted in greater fibrosis (73%) than no preoperative treatment (38%) (p=0.0001). Higher mean fibrosis levels were observed in patients with negative lymph nodes (p=0.0006) and negative margins (p=0.05). Factors associated with improved survival (log rank test) included: negative margins (p=0.001), negative lymph nodes (p=0.03), and use of neoadjuvant therapy (p=0.03). Median survival in the neoadjuvant group was 23 mo vs 16 mo without preoperative therapy (p=0.03). In conclusion, the use of neoadjuvant therapy resulted in a greater degree of fibrosis in the specimen. Patients with negative margins and negative lymph nodes had a greater amount of fibrosis present, and these were significant predictors of improved outcome. Although retrospective, this series suggests an improvement in survival in patients treated with neoadjuvant therapy.     

Loco-recurrence after resection for ductal adenocarcinoma of the pancreas: predictors and implications for adjuvant chemoradiotherapy

Purpose

Loco (regional)-recurrence rate after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remains high, and the efficiency of adjuvant chemoradiotherapy is still debated. We aimed to assess predictors of loco-recurrence in order to tailor the indications for adjuvant chemoradiotherapy.

Methods

Patients who underwent PD for PDAC between January 2001 and December 2010 were retrieved from a prospective database. Tumor recurrence was categorized as either loco-recurrence or distant recurrence. Clinicopathological characteristics and survivals were compared between patients with different recurrence patterns. The predictors for loco-recurrence were assessed.

Results

Seventy-nine patients were included. Loco-recurrence alone was identified in 22 patients (27.8%), distant recurrence alone in 33 (41.8%), both loco- and distant recurrences in 17 (21.5%) and no recurrence in 7 (8.9%). Median survival after recurrence (SAR) was significantly better in patients with loco-recurrence alone than in those with distant recurrence alone (10.4 vs. 5.0?months, P?=?0.002) or in those with both loco- and distant recurrences (10.4 vs. 5.8?months, P?=?0.044); the survival for patients with distant recurrence alone and those with both patterns was identical. Patients with early recurrence had a significantly poorer SAR than those with late recurrence (median, 5.5 vs. 9.0?months, P?=?0.001). Logistic regression analysis revealed that positive resection margin (P?=?0.001, HR?=?14.532; 95% CI 7.399–38.466), early T stage (P?=?0.018, HR?=?0.014; 95% CI 0.000–0.475) and large tumor size (P?=?0.030, HR?=?4.345; 95% CI 1.152–16.391) were the determinant factors directly related to loco-recurrence alone.

Conclusions

Patients with PDAC loco-recurrence alone had a significantly better SAR than those with distant recurrence. Adjuvant chemoradiotherapy should be considered to reduce loco-recurrence further and improve long-term survival.     

Rectal cancer: Neoadjuvant chemoradiotherapy

The monolithic approach to apply the same schedule of preoperative 5-fluorouracil (5-FU)- or capecitabine-based chemoradiotherapy (CRT) to all patients with clinically staged TNM stage II/III rectal cancer need to be questioned. Five randomized trials have been completed to determine if the addition of oxaliplatin to preoperative 5-FU/capecitabine-based CRT offers an advantage compared with single-agent CRT. In contrast to the German CAO/ARO/AIO-04 trial, results from the ACCORD 12, STAR-01, PETACC-6 and NSAPB R-04 trials failed to demonstrate a significant improvement of early or late efficacy endpoints with the addition of oxaliplatin. Most of the phase II trials incorporating cetuximab into CRT reported disappointingly low rates of pCR; the combination of CRT with VEGF inhibition showed encouraging pCR rates but at the cost of increased surgical complications. Novel clinical trials currently address (1) the role of induction and consolidation chemotherapy before or after CRT, (2) minimal or omitted surgery following complete response to CRT, or (3) the omission of radiotherapy for selected patients with response to neoadjuvant chemotherapy. The notion of different multimodal treatment concepts according to tumor stage, location, mesorectal fascia margin status, molecular profiles, tumor response, and patients' preferences becomes increasingly popular and will render the multimodal treatment approach of rectal cancer more risk-adapted.     

Neoadjuvant chemoradiotherapy for esophageal carcinoma

SUMMARY. Neoadjuvant chemoradiotherapy is often administered to patients with esophageal carcinoma in the belief that this will improve survival. However, its role in the management of esophageal carcinoma remains controversial. In this study we evaluated our experience with neoadjuvant chemoradiotherapy for the treatment of esophageal carcinoma. The study group was 115 patients who underwent esophagectomies between January 1999 and January 2004. Eighty-nine patients had adenocarcinoma and 26 had squamous cell carcinoma. Fifty-six patients underwent neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil with 45 Gy radiation) followed by esophagectomy. The other 59 patients proceeded directly to esophagectomy. Outcomes were determined prospectively, and follow-up was available for all patients. Neoadjuvant chemoradiotherapy achieved down-staging of the esophageal cancer in 43%, 43% and 46% of patients, according to T, N and TNM classifications, respectively. Neoadjuvant chemoradiotherapy resulted in a complete pathological response in seven (13%) patients. The surgical morbidity rate was 37% (42/115), and in-hospital mortality was 5% (6/115). There were no differences between patients who did and did not undergo neoadjuvant chemoradiotherapy in regard to completeness of resection, perioperative mortality and postoperative morbidity. Four-year survival was 33% following neoadjuvant chemoradiotherapy, compared with 19% for patients undergoing surgery alone. The administration of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma down-staged nearly 50% of tumors, and a complete pathological response occurred in some of these patients. It was not associated with any increase in postoperative morbidity or perioperative mortality. In this non-randomized study, it was also associated with a trend towards a better survival outcome.     

Preoperative chemotherapy of chemoradiotherapy for the treatment of adenocarcinoma of the pancreas and ampulla of Vater

Much has been written about preoperative strategies in the treatment of pancreatic adenocarcinoma, yet there has been very little comment concerning other periampullary malignancies. This review discusses current issues relevant to the further development of preoperative adjuvant treatment of pancreatic adenocarcinoma. A small series of patients with ampullary adenocarcinomas treated with preoperative adjuvant chemoradiotherapy is also described.     

Neoadjuvant chemoradiotherapy for locally advanced pancreas cancer rarely leads to radiological evidence of tumour regression

Background: Neo-adjuvant chemo-radiotherapy has been proposed to improve resectability of locally-advanced pancreatic cancer (LAPC). However, the ability of neo-adjuvant therapy to induce radiological tumour regression has not been reported.Methods: Pre-and post-treatment computed tomography (CT) scans of patients undergoing neo-adjuvant chemo-radiotherapy for LAPC were reviewed. LAPC was sub-classified into borderline resectable disease [≤180° involvement of the superior mesenteric artery (SMA); short-segment encasement/abutment of the common hepatic artery; or tumour-associated deformity, abutment or short-segment occlusion of the superior mesenteric vein (SMV)/ portal vein (PV) that was amenable to vascular resection and reconstruction] and locally advanced un-resectable pancreatic cancer (vascular involvement more than that described for borderline resectable pancreatic cancer). The radiological response and surgical resection rates were assessed.Results: Sixteen patients received neo-adjuvant therapy for LAPC during 2005–2008. Regression of major vascular involvement, i.e. un-encasement or regression of abutment of any involved vessels was not observed in any patient. Pre-and post-treatment tumour densities were not statistically different. Fifty per cent of patients with borderline resectable disease and none of the patients with locally advanced un-resectable pancreatic cancer eventually underwent surgical resection.Conclusion: Neo-adjuvant treatment does not induce radiological tumour regression of LAPC with major vascular involvement. Patient selection for neo-adjuvant trial enrolment should remain focused on borderline disease which may have a potential for surgical resection.     

Neoadjuvant chemoradiotherapy for resectable esophageal carcinoma： A meta-analysis

AIM: To compare neoadjuvant chemoradiotherapy and surgery with surgery alone for resectable esophageal carcinoma.METHODS: We used MEDLINE and EMBASE databases to identify eligible studies and manual searches were done to ensure no studies were missed. Trial validity assessment was performed and a trial quality score was assigned. RESULTS: Eleven randomized controlled trials (RCTs) including 1308 patients were selected. Neoadjuvant chemoradiotherapy significantly improved the overall survival compared with surgery alone. Odds ratio (OR) [95% confidence interval (CI), P value], expressed as neoadjuvant chemoradiotherapy and surgery vs surgery alone, was 1.28 (1.01-1.64, P = 0.05) for 1-year survival, 1.78 (1.20-2.66, P = 0.004) for 3-year survival, and 1.46 (1.07-1.99, P = 0.02) for 5-year survival. Postoperative mortality increased in patients treated by neoadjuvant chemoradiotherapy (OR:1.68, 95% CI: 1.03-2.73, P = 0.04), but incidence of postoperative complications was similar in two groups (OR: 1.14, 95% CI: 0.88-1.49, P = 0.32). Neoadjuvant chemoradiotherapy lowered the local-regional cancer recurrence (OR: 0.64, 95% CI: 0.41-0.99, P = 0.04),but incidence of distant cancer recurrence was similar (OR: 0.94, 95% CI: 0.68-1.31, P = 0.73). Histological subgroup analysis indicated that esophageal squamous cell carcinoma did not benefit from neoadjuvant chemoradiotherapy, OR (95% CI, P value) was 1.16 (0.85-1.57, P = 0.34) for 1-year survival, 1.34(0.98-1.82, P = 0.07) for 3-year survival and 1.41(0.98-2.02, P = 0.06) for 5-year survival.CONCLUSION: Neoadjuvant chemoradiotherapy can raise the survival rate of patients with esophageal adenocarcinoma.     

Solid-papillary tumors of the pancreas: histopathology

A solid-pseudopapillary tumor is an uncommon and "enigmatic" pancreatic neoplasm, and the term encompasses the two most conspicuous histological features: solid and pseudopapillary areas. Grossly, it appears as a large solid, cystic or solid-cystic mass frequently having necrotic and hemorrhagic zones. Histologically, solid-pseudopapillary tumors are generally characterized by solid areas alternating with a pseudopapillary pattern, and cystic spaces which are the results of degenerative changes occurring in the solid neoplasm. Its immunohistochemical pattern is very distinctive and neoplastic cells are consistently vimentin-, CD10- and CD56-positive. Some cases express focal positivity for alpha-1-antitrypsin, alpha-1-antichymotrypsin, neuron-specific enolase and synaptophysin. Progesterone receptors are frequently present. Keratins are not expressed or are found only focally. Endocrine and pancreatic enzyme markers are absent; the origin of solid-pseudopapillary tumors has not yet been clarified. Many investigators favor the theory that solid-pseudopapillary tumors originate from multipotent primordial cells while others suggest an extra-pancreatic origin from genital ridge angle-related cells. Some controversy exists for both hypotheses. Solid-pseudopapillary tumors appear as a low malignancy tumor and only a small number of cases recur or develop metastases after resection. No pathological factors were found to correlate with the prognosis. Some histological features have recently been suggested to be associated with aggressive behavior.     

Neoadjuvant therapy and major arterial resection for potentially reconstructable arterial involvement by stage 3 adenocarcinoma of the pancreas

BackgroundStage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR).MethodsThis study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date.Results87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41).ConclusionsAR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.     

Neoadjuvant therapy for pancreas cancer: Past lessons and future therapies

Pancreatic adenocarcinoma remains a most deadly malignancy, with an overall 5-year survival of 5%. A subset of patients will be diagnosed with potentially resectable disease, and while complete surgical resection provides the only chance at cure, data from trials of postoperative chemoradiation and/or chemotherapy demonstrate a modest survival advantage over those patients who undergo resection alone. As such, most practitioners believe that completion of multimodality therapy is the optimal treatment. However, the sequence of surgery, chemotherapy and radiation therapy is frequently debated, as patients may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to resection. Here we review the rationale for neoadjuvant therapy, which includes a higher rate of completion of multimodality therapy, minimizing the risk of unnecessary surgical resection for patients who develop early metastatic disease, improved surgical outcomes and the potential for longer overall survival. However, there are no prospective, randomized studies of the neoadjuvant approach compared to a surgery-first strategy; the established and ongoing investigations of neoadjuvant therapy for pancreatic cancer are discussed in detail. Lastly, as the future of therapeutic regimens is likely to entail patient-specific genetic and molecular analyses, and the treatment that is best applied based on those data, a review of clinically relevant biomarkers in pancreatic cancer is also presented.     

Neoadjuvant chemoradiotherapy for esophageal cancer:Impact on extracapsular lymph node involvement

AIM:To assess the effects of neoadjuvant chemoradiotherapy(CRT) on the presence of extracapsular lymph node involvement(LNI) and its prognostic value in patients with resected esophageal cancer.METHODS:Two hundred and ninety-eight patients with advanced esophageal cancer underwent esophagectomy between 1997 and 2006.One hundred and ninety patients(63.8%) were treated with neoadjuvant CRT prior to resection.A total of 986 metastatic LNs were examined.Survival of the patients was analyzed according to intra-a...     

Neoadjuvant therapy for adenocarcinoma of the rectum: Tumor response and acute toxicity

PURPOSE: This study was designed to evaluate the down-staging effect and acute toxicity of preoperative radiation and chemoradiation for primary adenocarcinoma of the rectum. METHODS: The results of pretreatment staging with transrectal ultrasound and computed tomography were compared with final histologic stage in 260 consecutive patients who underwent neoadjuvant therapy and proctectomy for primary adenocarcinoma of the rectum. Patients underwent short-course radiation (2,000 cGy in five fractions), long-course radiation (4,500 cGy in 25 fractions), or chemoradiation (4,500 cGy in 25 fractions with concurrent chemotherapy). RESULTS: Down-staging of one or more T stages occurred in 116 of 260 (45 percent) patients overall (short-course radiation 34/82 (42 percent), long-course radiation 55/122 (45 percent), chemoradiation 27/56 (48 percent),P = not significant). Down-staging of one or more N stages occurred in 85 of 178 (48 percent) patients overall (short-course radiation 12/45 (27 percent), long-course radiation 49/86 (57 percent), chemoradiation 24/47 (51 percent),P=0.003). Complete pathologic response was observed in 16 of 260 (6 percent) patients overall (short-course radiation 4/82 (5 percent), long-course radiation 5/122 (4 percent), chemoradiation 7/56 (13 percent),P=0.08). Resection with negative margins (distal, proximal, and radial) was achieved in 211 of 227 patients (93 percent) in whom complete radial margin data were available. Permanent stomas were created in 35 percent of patients; temporary stomas were created in 15 percent. Thirty-three Grade 3 or 4 toxicities occurred in 22 of 260 (8 percent) patients overall during neoadjuvant therapy. Toxicity was more frequent in patients receiving chemoradiation (14/56; 25 percent) and long-course radiation (8/122; 7 percent) than in those receiving short-course radiation (0/82; 0 percent),P<0.0001. Perioperative complications occurred in 93 patients overall (36 percent). The postoperative mortality rate was 0.4 percent (1/260). There was no significant difference in the complication rate between patients treated with short-course radiation (26/82; 32 percent), long-course radiation (46/122; 36 percent), and chemoradiation (21/56; 38 percent). CONCLUSION: Neoadjuvant therapy for adenocarcinoma of the rectum is well tolerated and can produce substantial down-staging and a high curative resection rate. Chemoradiation can achieve high complete pathologic response rates, although toxicity during neoadjuvant therapy is greater than for radiation alone. Short-course radiation can achieve down-staging of both T stage and N stage.Heather Whiteford, M.D. was supported by the Wallace R. Ruwitch Family Research Fund.The colorectal cancer database is supported in part by the St. Louis Men's Group Against Cancer.     

Neoadjuvant external beam radiation and proctectomy for adenocarcinoma of the rectum

PURPOSE: The aim of this study was to determine the survival rate, local failure, and perioperative morbidity in patients with adenocarcinoma of the rectum undergoing curative proctectomy who were felt to have transmural disease on preoperative assessment. Eighty-nine percent of these patients were treated with preoperative external beam radiotherapy. METHODS: The records of 191 consecutive patients undergoing abdominal surgical procedures for primary treatment of rectal cancer were reviewed. The product-limit method (Kaplan-Meier) was used to analyze survival rate and tumor recurrence. RESULTS: One patient was excluded from survival analysis because of incomplete record of tumor stage. The study population comprised 109 males and 81 females, median age 64 (range, 33–91) years. Curative resection was performed in 152 of these 190 patients (80 percent), including low anterior resection with coloproctostomy or coloanal anastomosis (n=103), abdominoperineal resection (n=44), Hartmann's procedure (n = 4), and pelvic exenteration (n=1). Mean follow-up of patients undergoing curative resection was 96±48 months. Palliative procedures were performed in 38 of 190 patients (20 percent). Perioperative mortality was 0.5 percent (1/190). Complications occurred in 64 patients (34 percent). The anastomotic leak rate was 4 percent (5/128). Disease-free five-year survival rate by pathologic stage was as follows: Stage I, 90 percent; Stage II, 85 percent; Stage III, 54 percent; Stage IV, 0 percent; and no residual tumor, 90 percent. Of the 152 patients treated with curative resection, disease-free survival rate was 80 percent at five years. Preoperative external beam radiation was administered to 135 of these 152 patients (89 percent). Tumor recurred in 32 of 152 patients (21 percent) treated with curative resection. The predominant pattern of recurrence was distant failure only. Kaplan-Meier overall local recurrence (local and local plus distant) at five years was 6.6 percent. The local recurrence rate paralleled tumor stage: Stage I, 0 percent; Stage II, 6 percent; Stage III, 20 percent; and no residual tumor, 0 percent. CONCLUSION: Preoperative external beam radiotherapy and attention to mesorectal dissection can achieve low local recurrence and excellent long-term survival rate in patients with adenocarcinoma of the rectum. Moreover, these goals can be obtained with low morbidity and mortality.Dr. Ogunbiyi was supported in part by grants from the Ronald Raven Traveling Fellowship of the British Association of Surgical Oncology, the American Society of Colon and Rectal Surgeons Research Foundation International Traveling Fellowship, and the Royal College of Surgeons of England Ethicon Foundation Traveling Fellowship.Presented at the meeting of the Missouri Chapter of the American College of Surgeons, Lake of the Ozarks, Missouri, June 18 to 19, 1999.     

Second pancreatectomy for recurrent pancreatic ductal adenocarcinoma in the remnant pancreas: A pooled analysis

ObjectivesThe aim of this study was to examine the outcomes of second pancreatectomy for the treatment of recurrent pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas.MethodSearch of the PubMed database was undertaken to identify relevant English language studies. Pooled individually data were examined for clinical outcomes after second pancreatectomy for recurrent PDAC.ResultsA total of 19 articles involving 55 patients were eligible for inclusion. The median disease-free interval after initial resection was 33 (range 7–143) months. Of the 55 patients reported, 52 (94.5%) patients underwent completion total pancreatectomy in the second operation for recurrences, including 15 patients who developed recurrences more than 5 years after the initial operation. There was no perioperative death. The 1-, 3- and 5-year overall survival rate after the second pancreatectomy was 82.2%, 49.2% and 40.6% respectively.ConclusionSecond pancreatectomy for recurrent PDAC can be performed safely with long-term survival in selected patients.     

Clinicopathological analysis and survival outcome of duodenal adenocarcinoma

Duodenal adenocarcinoma is a rare cancer, contributing <10 % of periampullary carcinoma. This study reviews the single center experience of duodenal adenocarcinoma and analyzes the clinical and pathological factors to predict survival and recurrence. The records of 50 patients with duodenal adenocarcinoma who underwent surgical exploration or resection from 1995 to 2010 were reviewed retrospectively. Univariate and multivariate analyses were performed to identify the clinicopathological factors associated with survival and recurrence. There were 35 men and 15 women, with a mean age of 61 years. In multivariate analysis of 50 patients, R0 resection [p = 0.041, hazard ratio (HR) = 3.569, 95% confidence interval (CI) = 1.057–12.054] and symptom at initial admission (p = 0.025, HR = 11.210, 95% CI = 1.354–92.812) were independent prognostic factors for overall survival. Thirty-six patients underwent curative resection (resectability 72%). The 5-year survival rates for curative and noncurative resections were 46.4% and 0%, respectively. Univariate analysis of 36 patients who underwent R0 resection revealed that symptoms at initial admission (p = 0.023), presence of lymph node metastasis (p = 0.034), and perineural invasion (p = 0.025) were significant prognostic factors after curative resection. There was no significant factor for overall survival in the multivariate analysis. There was recurrence in 15 patients, mainly as liver metastasis. Multivariate analysis revealed that presence of symptom (p = 0.047, HR = 5.362, 95% CI = 1.021–28.149) and ulcerative tumor (p = 0.036, HR = 5.668, 95% CI = 1.123–28.619) were independent factors for disease free survival. An aggressive surgical approach to achieve R0 resection was important to enhance survival. Most of the recurrence occurred within 1 year after surgery. Close follow-up is necessary after surgical resection.     

Alpha-fetoprotein-positive adenocarcinoma of the pancreas

A case of a poorly differentiated ductal adenocarcinoma arising in the body and tail of the pancreas with diffuse intraabdominal metastases in an adult is reported. Serum alpha-fetoprotein (AFP) level was markedly elevated in this patient, but fell transiently when a partial tumor response to combination chemotherapy was achieved. Both the occurrence of biochemical and anatomical responses, and the immunohistochemical finding of AFP in the tumor tissue clearly indicate that oncofetal protein is produced by the tumor cells. The patient survived 10.5 mo after the onset of symptoms.     

Neoadjuvant chemoradiotherapy before resection of perihilar cholangiocarcinoma: A systematic review

Background: Treatment with neoadjuvant chemoradiotherapy followed by liver transplantation yields promising results in perihilar cholangiocarcinoma (PH-CCA). This study reviews the literature to assess whether there is evidence to justify modern phase Ⅱ studies of neoadjuvant chemoradiotherapy prior to resection of PH-CCA.Data sources: A systematic review of the literature for reports of patients undergoing resection of PH- CCA after neoadjuvant chemoradiotherapy was performed using MEDLINE and EMBASE databases for the period between 1990 and 2019. The keywords and MeSH headings hilar cholangiocarcinoma, Klatskin, chemoradiotherapy and chemotherapy were used. Data were extracted on demographic profile, dis- ease staging, chemoradiotherapy protocols, complications and outcome. Risks of bias were assessed using Cochrane methodology. Results: There were seven reports on this topic, with median recruitment period of 14 (range 4–31) years. The total number of patients in these studies was 87. Interval from completion of neoadjuvant treatment to surgery varied from 3 days to 6 months. Resection was by hepatectomy with three studies reporting an R0 rate of 100%, 24% and 63%, respectively. Three studies reported histopathological evidence of prior treatment response. There were two treatment related deaths at 90 days. Median survival was 19 (95% CI: 9.9–28) months and 5-year survival 20%. Conclusions: There are potential benefits of treatment on both R0 rate and complete response in resected specimens. Scientific equipoise exists in relation to neoadjuvant chemoradiotherapy for PH-CCA.     

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatec tomy(LDP) appeared in the 1990 s, the procedure ha been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Man earlier publications have shown LDP to be a good alter native to open distal pancreatectomy for benign lesions although this has never been studied in a prospective randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as we established. The purpose of this review is to evaluat the current evidence for LDP in cases of pancreati adenocarcinoma. We conducted a review of English language publications reporting LDP results between1990 and 2013. All studies reporting results in patient with histologically proven pancreatic adenocarcinom were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pan creatic adenocarcinoma(potential double publication were not eliminated). Most LDP procedures are per formed in selected cases and generally involve smalle tumors than open distal pancreatectomy(ODP) proce dures. Some of the papers report unselected cases andinclude procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.     

Neoadjuvant therapy for pancreatic ductal adenocarcinoma: Opportunities for personalized cancer care

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that is best treated in a multidisciplinary fashion using surgery, chemotherapy, and radiation. Adjuvant chemotherapy has shown to have a significant survival benefit in patients with resected PDAC. However, up to 50% of patients fail to receive adjuvant chemotherapy due to postoperative complications, poor patient performance status or early disease progression. In order to ensure the delivery of chemotherapy, an alternative strategy is to administer systemic treatment prior to surgery. Precision oncology refers to the application of diverse strategies to target therapies specific to characteristics of a patient’s cancer. While traditionally emphasized in selecting targeted therapies based on molecular, genetic, and radiographic biomarkers for patients with metastatic disease, the neoadjuvant setting is a prime opportunity to utilize personalized approaches. In this article, we describe the current evidence for the use of neoadjuvant therapy (NT) and highlight unique opportunities for personalized care in patients with PDAC undergoing NT.