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Preoperative anaemia adversely impacts overall survival following resection for pancreatic ductal adenocarcinoma
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Electronic Poster Abstracts
pancreatobiliary depending on their histomolecular profiles. While KRAS mutation occurs in a majority of pancreatic cancers, KRAS mutation occurs in up to one half of ampullary cancers and a third of duodenal cancers. Ampullary cancers of intestinal subtype and duodenal cancers have been shown to respond well to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin and behave more like colorectal cancers. Anti-EGFR treatment may also have a more important role in these cancers unlike pancreatic cancer. Conclusion: Ampullary cancers may form a larger proportion of cancers resected with a PD in the East compared to the West and this requires further study. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given they share similar genomic and molecular alterations.
EP02C-051 FROM PARENCHYMAL PRESERVATION TO MULTIORGAN RESECTION IN PANCREATIC NEUROENDOCRINE TUMORS (PNET), A TAILORED RESECTION BASED IN TUMOR BIOLOGY O. A. Guevara1, R. Pinilla2, M. E. Manrique3, F. Fierro4, A. Romero5, B. Escobar6, R. Oliveros3 and Neuroendocrine Tumors Group 1 Department of Surgery HPB, Universidad Nacional de Colombia, Instituto Nacional de Cancerologia, 2Gastroenterology, Instituto Nacional de Cirugia, 3Gastroenterology, 4Endocrinology, 5Pathology, Instituto Nacional de Cancerologia, and 6Anesthesiology, Universidad Nacional de Colombia, Instituto Nacional de Cancerologia, Colombia Introduction: The biology spectrum of pNETs ranges from small and incidentally discovered tumors to aggressive tumors able to involve adjacent organs and metastasize. So a careful decision about the radicality of surgery depends of multiple reasons. We present a Latin-American institution experience in a multidisciplinary group of Neuroendocrine Tumors (NET), regarding factors related to magnitude of surgery. Methods: In a oncologic institution with a multidisciplinary board discussing NETs, we reviewed patients with resection of pNETs between 2010 and 2015. Perioperative and follow up variables were registered. We looked for characteristics related with preserving parenchyma surgery and with multiorgan resection. Results: Thirty five patients with pNET were resected. Median age was 49 years (IQR 38-62). Some characteristics: 60% females, 17% genetic syndromes, 45% functional tumors. Resection performed were pancreaticoduodenectomy or distal pancreatectomy in 68%, enucleation 20% and central pancreatectomy 12%. Tumor was Grade 1 in 65% and Grade 2/3 in 35%. N1 29% and M1 22%. In total, 32% had parenchymal preserving surgery and 34% had organ associated resection. Lympho-vascular invasion in pathology was correlated with ENETS tumor (T classification) p = 0.03. With a mean follow up of 22.3 months (1e65), 83% of patients are live and free of disease, 14% patients are live with disease and 1 patient deceased.
Conclusion: With a multidisciplinary board decision, choice of radicality of surgery in pNETs are based specially in size of tumor and adjacent organ invasion or resectable metastasis. When biopsy is available Grade tumor helps to decision. Acceptable survival is achieved with tailored surgery.
EP02C-052 SURGICAL OUTCOMES OF UNCINATE PROCESS CARCINOMA AFTER PANCREATICODUODENECTOMY A. Abdelrafee1, A. El Nakeeb2 and T. Elshehawy2 1 General Surgery, and 2Gastroenterology Surgical Center, Mansoura University, Gastroenterology Surgical Center, Egypt Background: Pancreatic head cancer (PHC) is considered to have the worst prognosis of the periampullary carcinomas. The resectability rate of uncinate process pancreatic carcinoma (UPC) is low and have poorer prognosis than equivalent pancreatic head cancer. Methods: This study included three groups of patients from January 2008 to February 2015. Group A patients with PHC, group B patients with combined head and uncinate process carcinoma (CC) and group C patients with UPC. Results: The study included 257 patients. Group A patients was 185 (72%) patients), group B was 37 (14.4%) patients and group C was 35 (13.6%) patients. Jaundice was the most common presenting symptoms in PHC and CC. Abdominal pain was the most common presentation in UPC. The mean common bile duct (CBD) and pancreatic duct diameters were significantly smallest in UPC group (P = 0.0001). The venous invasion was significantly observed more in UPC group and vascular resection was done in 50% of cases. The number of patients with microscopically residual tumor was significantly highest in UPC group after PD than in other two groups (P = 0.001). Recurrence rate occurred in 55% in UPC group, 35% in CC group and 23% in PHC group after PD (P = 0.007). The median survival was 19 months in PHC groups, 16 months in CC group, and 14 months in UPC group (P = 0.02). Conclusion: UPC presented with abdominal pain with more vascular infiltration. The recurrence rate was common after PD for UPC especially locoregional recurrence and the overall survival rate was found to be lower.
EP02C-053 PREOPERATIVE ANAEMIA ADVERSELY IMPACTS OVERALL SURVIVAL FOLLOWING RESECTION FOR PANCREATIC DUCTAL ADENOCARCINOMA J. Campbell1,2, L. Palani Velu2, N. Jamieson2, C. McKay2, R. Carter2 and E. Dickson2 1 West of Scotland School of Anaesthesia, and 2West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, United Kingdom Introduction: A significant proportion of patients undergoing surgery for pancreatic cancer will be anaemic at the time of resection. Controversy exists as to whether the
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts administration of perioperative blood transfusions negatively impacts overall survival. We aimed to assess the impact of preoperative anaemia on overall survival in patients undergoing potentially curative resection for pancreatic ductal adenocarcinoma (PDAC). Methods: In a single-centre cohort of 156consecutive patients who underwent pancreaticoduodenectomy for PDAC with curative intent, between 2009 and 2013, the prognostic significance of preoperative haemoglobin was investigated along with perioperative blood transfusion. Anaemia was defined according to the WHO classification (haemoglobin <130 g/L in men and <120 g/L in women) and assessed within one week before surgical intervention. Multivariate Cox-regression analysis was used to establish independent prognostic factors. Results: For the 89patients (57%) with preoperative anaemia, there was a significantly reduced overall median survival (16.0 months; 95% confidence interval, 12.0e 19.1) compared to 67 non-anaemic patients (43%) (29.0 months; 95% confidence interval, 19.7e38.3; P < 0.0001, log-rank test). However, preoperative anaemia was not related to 90day survival (P > 0.5). In a Cox-regression analysis, preoperative anaemia was a predictor of overall survival (P < 0.05) independent of established pathological prognostic factors, including tumour stage, size and lymph node status, and administration of perioperative blood transfusion. Conclusion: Preoperative anaemia is commonly present in resectable PDAC and negatively influences overall survival independent not only of established pathological factors but also of perioperative blood transfusion. These data have implications for the optimization of patients in the perioperative period in addition to longer-term risk stratification.
EP02C-054 STEREOTACTIC BODY HYPOFRACTIONATED RADIOTHERAPY FOR INOPERABLE PANCREATIC CANCER, WITH OR WITHOUT METASTASES A. J. Oar1, W. Wong1, C. Chen1, K. S. Haghighi1,2, S. Thompson1 and D. Goldstein1 1 Prince of Wales Hospital, and 2HPB & Transplant Surgery, University of New South Wales, Australia Introduction: Curative resection of pancreatic cancer may not always be possible due to patient and disease factors. Biological dose escalation through stereotactic body radiotherapy (SBRT) is emerging as a treatment option to achieve long term control for those patients who are not surgical candidates. Methods: We present our case series of patients who underwent SBRT to pancreatic primary lesions. Patients were identified retrospectively through electronic medical records. All patients were deemed unresectable on basis of imaging or laparoscopic findings and/or had progressed on chemotherapy.
HPB 2016, 18 (S1), e1ee384
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Results: From September 2013 to December 2014, twelve patients were treated with SBRT. Patients were aged between 50 and 84 years. Median CA-19.9 at time of diagnosis was 383 (range 50e15,179). Primary tumour size ranged from 2.4 to 7 cm at time of SBRT. All patients had locally advanced disease with five having synchronous metastases at time of SBRT. The median dose was 48 Gy (Range 35e 48 Gy) in 8 fractions (range 5e8 fractions). Median followup was 70 days. Four patients achieved local control, six failed locally and for two patients local control was unknown. Median progression free survival was 32 days (range 0e133 days) and median overall survival was 84 days (range 7e449 days) from completion of radiotherapy. Conclusion: From the limited data available we do not recommend SBRT for patients with inoperable pancreatic cancer who had progressed on palliative chemotherapy. These patients have very short survival despite SBRT. However, further information on symptom control, toxicity and quality of life in patients receiving SBRT is needed.
EP02C-055 FROZEN SECTION OF THE PANCREATIC NECK MARGIN IN PANCREATICODUODENECTOMY FOR PANCREATIC ADENOCARCINOMA IS IMPORTANT OR NOT FOR SURVIVAL M. Kerem1, K. Dikmen2, H. Bostanci2, M. Sare2 and O. Ekinci3 1 General Surgery, Gazi University, School of Medicine, 2 General Surgery, and 3Department of Pathology, Gazi University, Turkey The aim of the study was to assess the overall survival (OS) benefit of taking additional neck margin at the time of pancreatico-duodenectomy (PD) in patients with pancreatic adenocarcinoma (PAC). Patients and methods: 437 patients underwent PD for pancreatic adenocarcinoma between 2008 and 2015 at Gazi University Hospital, a tertiary referral center in Ankara, Turkey, were analyzed. FS was taken out 237 of these patients and they were included to study. FS assessment of the neck and common bile duct (CBD) margin was requested at the surgeons’ discretion after resection and prior to reconstruction. Hereby FS assessment was negative in 209 (88 %), and positive in 28 (12 %) patients. Re-resections were carried out to all patients had R1 for getting of R0 resection margin. While OS was 14.1 months on patients (n = 16) who to be achieved R0 margin after reresection to result of positive FS, otherwise, its 11.5 months on patients who had not been achieved R0 (p < 0.05). Patients (n = 17, %7), who had final R1 pancreatic neck margin, have 12.5 months OS, there was no significantly difference between first of two groups. On the other hand, on its 22.3 months in patients had final R0 and whom had statistically significantly higher survival than the others (p < 0.05). Results: FS assessment for achieving resection margin during PD, allows us to be perform re-resection and consequently improve survival, but final R0 resection margin is most important for survival in patients have PAC.
Electronic Poster Abstracts
pancreatobiliary depending on their histomolecular profiles. While KRAS mutation occurs in a majority of pancreatic cancers, KRAS mutation occurs in up to one half of ampullary cancers and a third of duodenal cancers. Ampullary cancers of intestinal subtype and duodenal cancers have been shown to respond well to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin and behave more like colorectal cancers. Anti-EGFR treatment may also have a more important role in these cancers unlike pancreatic cancer. Conclusion: Ampullary cancers may form a larger proportion of cancers resected with a PD in the East compared to the West and this requires further study. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given they share similar genomic and molecular alterations.
EP02C-051 FROM PARENCHYMAL PRESERVATION TO MULTIORGAN RESECTION IN PANCREATIC NEUROENDOCRINE TUMORS (PNET), A TAILORED RESECTION BASED IN TUMOR BIOLOGY O. A. Guevara1, R. Pinilla2, M. E. Manrique3, F. Fierro4, A. Romero5, B. Escobar6, R. Oliveros3 and Neuroendocrine Tumors Group 1 Department of Surgery HPB, Universidad Nacional de Colombia, Instituto Nacional de Cancerologia, 2Gastroenterology, Instituto Nacional de Cirugia, 3Gastroenterology, 4Endocrinology, 5Pathology, Instituto Nacional de Cancerologia, and 6Anesthesiology, Universidad Nacional de Colombia, Instituto Nacional de Cancerologia, Colombia Introduction: The biology spectrum of pNETs ranges from small and incidentally discovered tumors to aggressive tumors able to involve adjacent organs and metastasize. So a careful decision about the radicality of surgery depends of multiple reasons. We present a Latin-American institution experience in a multidisciplinary group of Neuroendocrine Tumors (NET), regarding factors related to magnitude of surgery. Methods: In a oncologic institution with a multidisciplinary board discussing NETs, we reviewed patients with resection of pNETs between 2010 and 2015. Perioperative and follow up variables were registered. We looked for characteristics related with preserving parenchyma surgery and with multiorgan resection. Results: Thirty five patients with pNET were resected. Median age was 49 years (IQR 38-62). Some characteristics: 60% females, 17% genetic syndromes, 45% functional tumors. Resection performed were pancreaticoduodenectomy or distal pancreatectomy in 68%, enucleation 20% and central pancreatectomy 12%. Tumor was Grade 1 in 65% and Grade 2/3 in 35%. N1 29% and M1 22%. In total, 32% had parenchymal preserving surgery and 34% had organ associated resection. Lympho-vascular invasion in pathology was correlated with ENETS tumor (T classification) p = 0.03. With a mean follow up of 22.3 months (1e65), 83% of patients are live and free of disease, 14% patients are live with disease and 1 patient deceased.
Conclusion: With a multidisciplinary board decision, choice of radicality of surgery in pNETs are based specially in size of tumor and adjacent organ invasion or resectable metastasis. When biopsy is available Grade tumor helps to decision. Acceptable survival is achieved with tailored surgery.
EP02C-052 SURGICAL OUTCOMES OF UNCINATE PROCESS CARCINOMA AFTER PANCREATICODUODENECTOMY A. Abdelrafee1, A. El Nakeeb2 and T. Elshehawy2 1 General Surgery, and 2Gastroenterology Surgical Center, Mansoura University, Gastroenterology Surgical Center, Egypt Background: Pancreatic head cancer (PHC) is considered to have the worst prognosis of the periampullary carcinomas. The resectability rate of uncinate process pancreatic carcinoma (UPC) is low and have poorer prognosis than equivalent pancreatic head cancer. Methods: This study included three groups of patients from January 2008 to February 2015. Group A patients with PHC, group B patients with combined head and uncinate process carcinoma (CC) and group C patients with UPC. Results: The study included 257 patients. Group A patients was 185 (72%) patients), group B was 37 (14.4%) patients and group C was 35 (13.6%) patients. Jaundice was the most common presenting symptoms in PHC and CC. Abdominal pain was the most common presentation in UPC. The mean common bile duct (CBD) and pancreatic duct diameters were significantly smallest in UPC group (P = 0.0001). The venous invasion was significantly observed more in UPC group and vascular resection was done in 50% of cases. The number of patients with microscopically residual tumor was significantly highest in UPC group after PD than in other two groups (P = 0.001). Recurrence rate occurred in 55% in UPC group, 35% in CC group and 23% in PHC group after PD (P = 0.007). The median survival was 19 months in PHC groups, 16 months in CC group, and 14 months in UPC group (P = 0.02). Conclusion: UPC presented with abdominal pain with more vascular infiltration. The recurrence rate was common after PD for UPC especially locoregional recurrence and the overall survival rate was found to be lower.
EP02C-053 PREOPERATIVE ANAEMIA ADVERSELY IMPACTS OVERALL SURVIVAL FOLLOWING RESECTION FOR PANCREATIC DUCTAL ADENOCARCINOMA J. Campbell1,2, L. Palani Velu2, N. Jamieson2, C. McKay2, R. Carter2 and E. Dickson2 1 West of Scotland School of Anaesthesia, and 2West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, United Kingdom Introduction: A significant proportion of patients undergoing surgery for pancreatic cancer will be anaemic at the time of resection. Controversy exists as to whether the
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts administration of perioperative blood transfusions negatively impacts overall survival. We aimed to assess the impact of preoperative anaemia on overall survival in patients undergoing potentially curative resection for pancreatic ductal adenocarcinoma (PDAC). Methods: In a single-centre cohort of 156consecutive patients who underwent pancreaticoduodenectomy for PDAC with curative intent, between 2009 and 2013, the prognostic significance of preoperative haemoglobin was investigated along with perioperative blood transfusion. Anaemia was defined according to the WHO classification (haemoglobin <130 g/L in men and <120 g/L in women) and assessed within one week before surgical intervention. Multivariate Cox-regression analysis was used to establish independent prognostic factors. Results: For the 89patients (57%) with preoperative anaemia, there was a significantly reduced overall median survival (16.0 months; 95% confidence interval, 12.0e 19.1) compared to 67 non-anaemic patients (43%) (29.0 months; 95% confidence interval, 19.7e38.3; P < 0.0001, log-rank test). However, preoperative anaemia was not related to 90day survival (P > 0.5). In a Cox-regression analysis, preoperative anaemia was a predictor of overall survival (P < 0.05) independent of established pathological prognostic factors, including tumour stage, size and lymph node status, and administration of perioperative blood transfusion. Conclusion: Preoperative anaemia is commonly present in resectable PDAC and negatively influences overall survival independent not only of established pathological factors but also of perioperative blood transfusion. These data have implications for the optimization of patients in the perioperative period in addition to longer-term risk stratification.
EP02C-054 STEREOTACTIC BODY HYPOFRACTIONATED RADIOTHERAPY FOR INOPERABLE PANCREATIC CANCER, WITH OR WITHOUT METASTASES A. J. Oar1, W. Wong1, C. Chen1, K. S. Haghighi1,2, S. Thompson1 and D. Goldstein1 1 Prince of Wales Hospital, and 2HPB & Transplant Surgery, University of New South Wales, Australia Introduction: Curative resection of pancreatic cancer may not always be possible due to patient and disease factors. Biological dose escalation through stereotactic body radiotherapy (SBRT) is emerging as a treatment option to achieve long term control for those patients who are not surgical candidates. Methods: We present our case series of patients who underwent SBRT to pancreatic primary lesions. Patients were identified retrospectively through electronic medical records. All patients were deemed unresectable on basis of imaging or laparoscopic findings and/or had progressed on chemotherapy.
HPB 2016, 18 (S1), e1ee384
e359
Results: From September 2013 to December 2014, twelve patients were treated with SBRT. Patients were aged between 50 and 84 years. Median CA-19.9 at time of diagnosis was 383 (range 50e15,179). Primary tumour size ranged from 2.4 to 7 cm at time of SBRT. All patients had locally advanced disease with five having synchronous metastases at time of SBRT. The median dose was 48 Gy (Range 35e 48 Gy) in 8 fractions (range 5e8 fractions). Median followup was 70 days. Four patients achieved local control, six failed locally and for two patients local control was unknown. Median progression free survival was 32 days (range 0e133 days) and median overall survival was 84 days (range 7e449 days) from completion of radiotherapy. Conclusion: From the limited data available we do not recommend SBRT for patients with inoperable pancreatic cancer who had progressed on palliative chemotherapy. These patients have very short survival despite SBRT. However, further information on symptom control, toxicity and quality of life in patients receiving SBRT is needed.
EP02C-055 FROZEN SECTION OF THE PANCREATIC NECK MARGIN IN PANCREATICODUODENECTOMY FOR PANCREATIC ADENOCARCINOMA IS IMPORTANT OR NOT FOR SURVIVAL M. Kerem1, K. Dikmen2, H. Bostanci2, M. Sare2 and O. Ekinci3 1 General Surgery, Gazi University, School of Medicine, 2 General Surgery, and 3Department of Pathology, Gazi University, Turkey The aim of the study was to assess the overall survival (OS) benefit of taking additional neck margin at the time of pancreatico-duodenectomy (PD) in patients with pancreatic adenocarcinoma (PAC). Patients and methods: 437 patients underwent PD for pancreatic adenocarcinoma between 2008 and 2015 at Gazi University Hospital, a tertiary referral center in Ankara, Turkey, were analyzed. FS was taken out 237 of these patients and they were included to study. FS assessment of the neck and common bile duct (CBD) margin was requested at the surgeons’ discretion after resection and prior to reconstruction. Hereby FS assessment was negative in 209 (88 %), and positive in 28 (12 %) patients. Re-resections were carried out to all patients had R1 for getting of R0 resection margin. While OS was 14.1 months on patients (n = 16) who to be achieved R0 margin after reresection to result of positive FS, otherwise, its 11.5 months on patients who had not been achieved R0 (p < 0.05). Patients (n = 17, %7), who had final R1 pancreatic neck margin, have 12.5 months OS, there was no significantly difference between first of two groups. On the other hand, on its 22.3 months in patients had final R0 and whom had statistically significantly higher survival than the others (p < 0.05). Results: FS assessment for achieving resection margin during PD, allows us to be perform re-resection and consequently improve survival, but final R0 resection margin is most important for survival in patients have PAC.