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The clinical impact of margin status on recurrence and survival after curative intent surgery for pancreatic ductal adenocarcinoma
Abstracts / Pancreatology 16 (2016) S1eS192
Background: The treatment for so-called borderline resectable pancreatic cancer is a hot topic all over the world. In this time of a revision of the pancreatic cancer classification from Japan Pancreas Society, it is expected to add newly ‘resectability classification’. But the clinical significance of this classification has not been well evaluated. Objective: To elucidate the relationship between the image findings around superior mesenteric artery (SMA) and the pathological findings or surgical outcomes. Methods: Thirty-eight patients, (male:female¼23:15, the median of age:71 years-old (range:47-86), the average observation period:30.9 months) who underwent pancreatoduodenectomy for invasive ductal carcinoma of pancreas with no contact to portal vein or superior mesenteric vein, during from 2009 to 2014, were reviewed the preoperative image of dynamic CT retrospectively with blind from the pathological findings. The degree of the contacted angle of soft tissue density with SMA was measured, and the comparison between it and the surgical or pathological factors was done. Results: Six cases had some contacted soft tissue density, which degree of the contacted angle around SMA was less than 180 (BR-A), and 32 patients had none (R). The ratio of the cases who had any plexus invasion in the pathological findings, were 50% of BR-A and 3.1% of R (P¼0.001); and who were performed margin-negative-surgery, were 16.7% of BR-A and 87.5% of R (P<0.001). The median overall survivals and disease free survivals of BR-A or R were 11 or 48 months (P<0.01), and 6 or 20 months (P¼0.01) respectively. Conclusion: For the correlation the resectability classification by soft tissue density surround SMA and pathological extension, this new classification could be suggested to be a prognostic factor.
F-144. Immunohistochemical analysis of perineural invasion to common hepatic artery plexus in resected pancreatic head cancer Kazuhide Urabe, Yoshiaki Murakami, Kenichiro Uemura, Naru Kondo, Naoya Nakagawa, Takumi Harada, Taijiro Sueda
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F-145. Main pancreatic duct spread in resected invasive ductal adenocarcinoma: A clinicopathological study with propensity score-matched patients Yasutoshi Kimura 1, Masayuki Ishii 1, Shintaro Sugita 2, Masafumi Imamura 1, Tatsuya Ito 1, Daiske Kyuno 1, Tsuyoshi Kono 1, Makoto Meguro 1, Toru Mizuguchi 1, Ichiro Takemasa 1 1 Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Japan 2 Department of Surgical Pathology, Sapporo Medical University Hospital, Japan
Objectives: This study examined main pancreatic ductal spread in invasive ductal adenocarcinoma (IDC) of the pancreas. Methods: Data from IDC patients who underwent radical surgery from 1990 to 2013 in our hospital were examined retrospectively. Incidence of intraductal spread of pancreatic cancer (IS), distance from the tumor edge, direction of IS and clinicopathological factors associated with the presence of IS were examined. Results: Among 184 eligible cases, IS was identified in 42 patients (22.8%) and mean length of IS was 18.7±21.6 mm. Mean distances on the ampullary and distal sides of IS were 11.1 mm and 11.6 mm. IS was significantly more frequent in localized tumors (UICC T1-2 vs. 3-4, p¼0.007), with tumor diameter 2 cm (p¼0.034) and in cases with scarce microscopic perineural invasion (p¼0.047). Among patients who underwent pancreaticoduodenectomy and distal pancreatectomy, IS presence (11.6 vs. 21.8%), mean distance to the contralateral side (11.4 vs. 11.6 mm), and IS2 cm (3.3 vs. 4.7%) showed no significant differences. Overall survival did not differ significantly between IS-positive and -negative patients in the full analysis set or propensity score-matched patients (42 matched pairs). Conclusions: In setting resectional margins at 2 cm, a small proportion of cases (3.8%) showed positive surgical margins. Localized tumor (UICC:T1-2, or <2 cm in diameter) requires more care with surgical margins, warranting intraoperative frozen sections.
Department of Surgery, Institute of Biomedical and Health, Hiroshima University, Japan F-146. Background: Perineural invasion has been recognized as one of the risk factors of poor prognosis in resectable pancreatic cancer, however, few studies have reported the benefit of dissection of the common hepatic artery plexus during radical pancreatectomy for pancreatic head cancer. The aim of this study is to investigate the significance of dissection common hepatic artery plexus (PL-cha) for pancreatic cancer. Materials & methods: Total 194 patients with pancreatic head cancer who underwent surgical resection between October 2008 and January 2015 at Hiroshima university hospital. 29 patients underwent radical pancreatectomy with hepatic artery resection or dissection of common hepatic nerve plexus without hepatic artery resection were enrolled into this study. Twelve (41%) patients were underwent hepatic artery resection (HAR) because of suspicion of PL-cha invasion. In the other 17 patients, PL-cha was separately dissected from common hepatic artery. To detect a micro-perineural invasion to PL-cha, immunohistochemistry using anti-cytokeratin 7/8 antibody were performed for all patients. Results: Of the 29 patients, PL-cha perineural invasion was found in 7 (24%) patients. These 7 patients underwent HAR. In contrast, PL-cha perineural invasion was not found in patients without HAR. Conclusion: The current results suggested that suspicious cases of invasion to hepatic artery by preoperative findings could have PL-cha perineural invasion and dissecting plexus with artery may contribute to curative resection. However, dissection of plexus may be saved for non-evidence of hepatic arterial invasion in pancreatic head cancer.
The clinical impact of margin status on recurrence and survival after curative intent surgery for pancreatic ductal adenocarcinoma Hiroaki Terajima 1, Akira Kurita 2, Yasushi Kudo 2, Shujiro Yazumi 2, Akira Mori 1 1 Division of Gastroenterological Surgery and Oncology, Digestive Disease Center, Kitano Hospital, Japan 2 Division of Gastroenterology and Hepatology, Digestive Disease Center, Kitano Hospital, Japan
Background: Curative intent surgery and the consequent margin status is one of key factors influencing recurrence and survival of pancreatic ductal adenocarcinoma (PDAC) patients. Objects: To determine the clinical impact of microscopically positive resection margin within 1mm from any resection margin on recurrence and survival following pancreatectomy for PDAC. Methods: Retrospective analysis of 100 consecutive resections for PDAC except for IPMN-derived carcinoma from 2001 to 2015 was performed. The microscopic evidence of tumor just at any resection margin was defined as R1 (0mm), and that within 1mm from any resection margin as R1 (1mm). Results: The R1 (1mm) ratio was significantly higher than the R1 (0mm) ratio (49% vs. 18%, p<0.0001). The median disease free survival time of R1 (1mm) cases was significantly shorter than that of R0 (1mm) cases (11.7mo. vs 16.0mo., p¼0.007). The pathohistological risk factors predicting postoperative recurrence estimated by the univariate analysis using Kaplan-Meyer method included R1 (1mm) as well as tumor size (>3cm),
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ly+, v+, ne+, pDU+, pPV+, pOO+, and pN+, but the multivariate analysis did not demonstrate that R1 (1mm) was an independent recurrence predicting factor. The median overall survival time was not significantly different between R1 (1mm) and R0 (1mm) (25.6mo. vs. 35.9mo.) or between R1 (0mm) and R0 (0mm) (24.6mo. vs. 31.6mo.). The local recurrence and peritoneal dissemination rates were significantly higher in R1 (1mm) compared with R0 (1mm) (42.9% vs. 23.5%, p¼0.04, and 32.7% vs. 11.8%, p¼0.012, respectively), but no differences were found between R1 (0mm) and R0 (0mm). Conclusions: The margin status, even if R1 (1mm), cannot be used as a surrogate marker of survival after pancreatectomy for PDAC, possibly because R1 status is underestimated by the current non-standardized pathology examination technique. However, R1 (1mm), not R1 (0mm), might be one of pathohistological factors predicting postoperative recurrence and its pattern (local recurrence and peritoneal dissemination).
F-147. The impact of the location of the tumor and UICC resectability criteria for prognosis after surgery in pancreatic cancer Isamu Makino 1, Hisatoshi Nakagawara 1, Tomoharu Miyashita 1, Hidehiro Tajima 1, Yoshinao Obatake 1, Shinichi Nakanuma 1, Hironori Hayashi 1, Hiroyuki Takamura 1, Sachio Fushida 1, Tetsuo Ohta 1, Hirohisa Kitagawa 2 1 2
Department of Gastroenterologic Surgery, Kanazawa University, Japan Department of Surgery, Toyama City Hospital, Japan
Background: We have advocated that pancreatic cancer spreads in different direction by the location of the tumor. Recently, we usually establish treatment strategy for pancreatic cancer on the basis of the resectability criteria in UICC guideline. We studied the impact of the location of the tumor and detailed pattern of resectability criteria for prognosis after surgery in pancreatic cancer. Patients and methods: We retrospectively investigated 166 patients who received surgical resection for pancreatic cancer in 2002 to 2015 at Kanazawa University Hospital. The patients were divided into 5 groups according to the location of the tumor; V:the tumor located in ventral pancreas, D:dorsal pancreas, VD:both ventral and dorsal pancreas, B:pancreatic body, and T:pancreatic tail. The resectability was categorized into resectable (R), borderline resectable by PV factor (BR-PV), SMA factor (BR-SMA), CHA factor (BR-CHA), CA factor (BR-CA), and unresectable (UR). We performed clinicopathological analysis concerning about prognosis and the significance of R0 resection according to the tumor location and the resectability criteria. Results: V, D, VD, B, T group consisted of 39, 18, 48, 28, 33 patients, and the survival of V and T group was significantly better than others. R, BR-PV, BR-SMA, BR-CHA, BR-CA, UR group consisted of 93, 24, 25, 14, 8, 2 patients, and R0 resection rate was 71, 83, 60, 43, 63, 0%, respectively. The survival of BR-CHA and UR was significantly worse than others. Survival benefit of R0 resection was revealed in V, VD, and T group;however there was no benefit in D and B group. Conclusion: The surgical result for pancreatic cancer derived from dorsal portion in pancreas head or pancreatic body, especially when the tumor attached to CHA was worse than that derived from other site. We must investigate the reason of poor prognosis in these patients.
F-148. Remnant pancreatic cancer following radial pancreatectomy for invasive ductal carcinoma Takumi Harada, Yoshiaki Murakami, Kenichiro Uemura, Naru Kondo, Naoya Nakagawa, Kazuhide Urabe, Hiroki Ohge, Taijiro Sueda Department of Surgery, Applied Life Sciences Institute of Biomedical ＆ Health Sciences, Hiroshima University, Japan
Background: Recently, patients treated with radical pancreatectomy for Pancreatic ductal adenocarcinoma (PDAC) sometimes experience recurrent PDAC in remnant pancreas owing to development of several perioperative therapeutic modalities. However, survival benefit of pancreatectomy for these cancers is still controversial. Purpose: To investigate the short term and long term outcomes of surgical resection for remnant PDAC following radical pancreatectomy for PDAC. Methods: Seven patients who underwent surgical resection for remnant PDAC between November 2004 and November 2015were eligible for this study. All of these 7 patients were treated with radical pancreatectomy for prior PDAC. Clinicopathological features and prognosis of these 7 patients were retrospectively evaluated in the current study. Results: Of the 7 patients with remnant pancreatic cancers, 2 were female and 5 were male with median age of 67. As for prior radical pancreatectomy for initial PDAC, pancreatoduodenectomy and distal pancreatectomy have performed in 3 and 4 patients, respectively. All 7 patients have underwent R0 resection, and 4 patients had lymph node metastasis. All 7 patients received adjuvant chemotherapy (Gemcitabine plus S-1) after initial pancreatectomy. The median time from first operation to diagnosis of remnant PDAC is 45 month. (range: 6-89month) Seven cases were detected by contrast-enhanced computed tomography, 1 case was accompanied with increase in tumor marker and 1 case with obstructive jaundice. Six patients underwent radical pancreatectomy for remnant PDAC, and 1 is going to underwent soon. The median operation time was 199 minutes, the median estimated blood loss was 405 ml. No postoperative complication was found. The median survival time from first operation and from second operation are 70 month and 14 month. Conclusion: Radical pancreatectomy for remnant PDAC was safely performed without increasing morbidity and mortality. Although some patients experienced prolonged survival after, larger number of patients and longer follow-up will be needed to evaluate survival benefit of radical pancreatectomy for remnant PDAC.
F-149. Diagnostic strategy for TS1a PDAC using EUS-FNA Susumu Hijioka 1, Yasuhiro Shimizu 2, Kazuo Hara 2 1 2
Department of Gastroenterology, Aichi Cancer Center Hospital, Japan Department of Surgery, Aichi Cancer Center Hospital, Japan
Background/purpose: Although early detection of pancreatic adenocarcinoma (PDAC) is essential to improve prognosis, it is presently challenging. We aimed to determine the clinicopathological features of TS1a (10 mm) PDAC to help early PDAC diagnosis. Patients and results: We operated on 383 patients with PDAC between 1996 and 2015. Among them, 12 (3.1%) who had TS1a comprised six males (mean age, 64 years; mean tumor invasion, 7 [2-10] mm). The UICC stages were 1A, 1B and 2A in six, five and one patient, respectively. None of the patients had carcinoma in situ (CIS). PDAC was discovered as a result of abdominal pain (n¼6), aggravated diabetes (n¼1), periodical medical checks, (n¼5) and periodical follow-up for IPMN (n¼2). The detection rates of US, CT and EUS were 4 (33.3%), 7 (58%) and 12 (100%), respectively. Pathological assessment revealed fibrosis, 12 (8-20) mm and the range of CIS was 21.7 (10-40) mm. All TS1a was detected by EUS as low echoic areas, although invasion sites and fibrosis and/or CIS sites were difficult to discriminate using EUS. All patients with T1a tumors also had CIS and fibrosis that was larger than the amount of invasion. Nine of 12 patients underwent EUS-FNA a total of 10 times. We diagnosed PDAC in 9 (90%) of 10 patients by EUS-FNA combined with cytological and pathological analyses. Conclusions: Since about 40% of patients with TS1a present with abdominal pain, PDAC should be suspected even when abdominal pain is minimal. Evaluation by EUS should be mandatory due to the low (58%) detection rate of tumors by CT. Low echo on EUS reflects fibrosis and/or CIS with an invasive component, but discriminating invasion from fibrosis and/ or CIS was challenging. However, EUS-FNA could distinguish TS1a PDAC.
Background: The treatment for so-called borderline resectable pancreatic cancer is a hot topic all over the world. In this time of a revision of the pancreatic cancer classification from Japan Pancreas Society, it is expected to add newly ‘resectability classification’. But the clinical significance of this classification has not been well evaluated. Objective: To elucidate the relationship between the image findings around superior mesenteric artery (SMA) and the pathological findings or surgical outcomes. Methods: Thirty-eight patients, (male:female¼23:15, the median of age:71 years-old (range:47-86), the average observation period:30.9 months) who underwent pancreatoduodenectomy for invasive ductal carcinoma of pancreas with no contact to portal vein or superior mesenteric vein, during from 2009 to 2014, were reviewed the preoperative image of dynamic CT retrospectively with blind from the pathological findings. The degree of the contacted angle of soft tissue density with SMA was measured, and the comparison between it and the surgical or pathological factors was done. Results: Six cases had some contacted soft tissue density, which degree of the contacted angle around SMA was less than 180 (BR-A), and 32 patients had none (R). The ratio of the cases who had any plexus invasion in the pathological findings, were 50% of BR-A and 3.1% of R (P¼0.001); and who were performed margin-negative-surgery, were 16.7% of BR-A and 87.5% of R (P<0.001). The median overall survivals and disease free survivals of BR-A or R were 11 or 48 months (P<0.01), and 6 or 20 months (P¼0.01) respectively. Conclusion: For the correlation the resectability classification by soft tissue density surround SMA and pathological extension, this new classification could be suggested to be a prognostic factor.
F-144. Immunohistochemical analysis of perineural invasion to common hepatic artery plexus in resected pancreatic head cancer Kazuhide Urabe, Yoshiaki Murakami, Kenichiro Uemura, Naru Kondo, Naoya Nakagawa, Takumi Harada, Taijiro Sueda
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F-145. Main pancreatic duct spread in resected invasive ductal adenocarcinoma: A clinicopathological study with propensity score-matched patients Yasutoshi Kimura 1, Masayuki Ishii 1, Shintaro Sugita 2, Masafumi Imamura 1, Tatsuya Ito 1, Daiske Kyuno 1, Tsuyoshi Kono 1, Makoto Meguro 1, Toru Mizuguchi 1, Ichiro Takemasa 1 1 Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Japan 2 Department of Surgical Pathology, Sapporo Medical University Hospital, Japan
Objectives: This study examined main pancreatic ductal spread in invasive ductal adenocarcinoma (IDC) of the pancreas. Methods: Data from IDC patients who underwent radical surgery from 1990 to 2013 in our hospital were examined retrospectively. Incidence of intraductal spread of pancreatic cancer (IS), distance from the tumor edge, direction of IS and clinicopathological factors associated with the presence of IS were examined. Results: Among 184 eligible cases, IS was identified in 42 patients (22.8%) and mean length of IS was 18.7±21.6 mm. Mean distances on the ampullary and distal sides of IS were 11.1 mm and 11.6 mm. IS was significantly more frequent in localized tumors (UICC T1-2 vs. 3-4, p¼0.007), with tumor diameter 2 cm (p¼0.034) and in cases with scarce microscopic perineural invasion (p¼0.047). Among patients who underwent pancreaticoduodenectomy and distal pancreatectomy, IS presence (11.6 vs. 21.8%), mean distance to the contralateral side (11.4 vs. 11.6 mm), and IS2 cm (3.3 vs. 4.7%) showed no significant differences. Overall survival did not differ significantly between IS-positive and -negative patients in the full analysis set or propensity score-matched patients (42 matched pairs). Conclusions: In setting resectional margins at 2 cm, a small proportion of cases (3.8%) showed positive surgical margins. Localized tumor (UICC:T1-2, or <2 cm in diameter) requires more care with surgical margins, warranting intraoperative frozen sections.
Department of Surgery, Institute of Biomedical and Health, Hiroshima University, Japan F-146. Background: Perineural invasion has been recognized as one of the risk factors of poor prognosis in resectable pancreatic cancer, however, few studies have reported the benefit of dissection of the common hepatic artery plexus during radical pancreatectomy for pancreatic head cancer. The aim of this study is to investigate the significance of dissection common hepatic artery plexus (PL-cha) for pancreatic cancer. Materials & methods: Total 194 patients with pancreatic head cancer who underwent surgical resection between October 2008 and January 2015 at Hiroshima university hospital. 29 patients underwent radical pancreatectomy with hepatic artery resection or dissection of common hepatic nerve plexus without hepatic artery resection were enrolled into this study. Twelve (41%) patients were underwent hepatic artery resection (HAR) because of suspicion of PL-cha invasion. In the other 17 patients, PL-cha was separately dissected from common hepatic artery. To detect a micro-perineural invasion to PL-cha, immunohistochemistry using anti-cytokeratin 7/8 antibody were performed for all patients. Results: Of the 29 patients, PL-cha perineural invasion was found in 7 (24%) patients. These 7 patients underwent HAR. In contrast, PL-cha perineural invasion was not found in patients without HAR. Conclusion: The current results suggested that suspicious cases of invasion to hepatic artery by preoperative findings could have PL-cha perineural invasion and dissecting plexus with artery may contribute to curative resection. However, dissection of plexus may be saved for non-evidence of hepatic arterial invasion in pancreatic head cancer.
The clinical impact of margin status on recurrence and survival after curative intent surgery for pancreatic ductal adenocarcinoma Hiroaki Terajima 1, Akira Kurita 2, Yasushi Kudo 2, Shujiro Yazumi 2, Akira Mori 1 1 Division of Gastroenterological Surgery and Oncology, Digestive Disease Center, Kitano Hospital, Japan 2 Division of Gastroenterology and Hepatology, Digestive Disease Center, Kitano Hospital, Japan
Background: Curative intent surgery and the consequent margin status is one of key factors influencing recurrence and survival of pancreatic ductal adenocarcinoma (PDAC) patients. Objects: To determine the clinical impact of microscopically positive resection margin within 1mm from any resection margin on recurrence and survival following pancreatectomy for PDAC. Methods: Retrospective analysis of 100 consecutive resections for PDAC except for IPMN-derived carcinoma from 2001 to 2015 was performed. The microscopic evidence of tumor just at any resection margin was defined as R1 (0mm), and that within 1mm from any resection margin as R1 (1mm). Results: The R1 (1mm) ratio was significantly higher than the R1 (0mm) ratio (49% vs. 18%, p<0.0001). The median disease free survival time of R1 (1mm) cases was significantly shorter than that of R0 (1mm) cases (11.7mo. vs 16.0mo., p¼0.007). The pathohistological risk factors predicting postoperative recurrence estimated by the univariate analysis using Kaplan-Meyer method included R1 (1mm) as well as tumor size (>3cm),
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ly+, v+, ne+, pDU+, pPV+, pOO+, and pN+, but the multivariate analysis did not demonstrate that R1 (1mm) was an independent recurrence predicting factor. The median overall survival time was not significantly different between R1 (1mm) and R0 (1mm) (25.6mo. vs. 35.9mo.) or between R1 (0mm) and R0 (0mm) (24.6mo. vs. 31.6mo.). The local recurrence and peritoneal dissemination rates were significantly higher in R1 (1mm) compared with R0 (1mm) (42.9% vs. 23.5%, p¼0.04, and 32.7% vs. 11.8%, p¼0.012, respectively), but no differences were found between R1 (0mm) and R0 (0mm). Conclusions: The margin status, even if R1 (1mm), cannot be used as a surrogate marker of survival after pancreatectomy for PDAC, possibly because R1 status is underestimated by the current non-standardized pathology examination technique. However, R1 (1mm), not R1 (0mm), might be one of pathohistological factors predicting postoperative recurrence and its pattern (local recurrence and peritoneal dissemination).
F-147. The impact of the location of the tumor and UICC resectability criteria for prognosis after surgery in pancreatic cancer Isamu Makino 1, Hisatoshi Nakagawara 1, Tomoharu Miyashita 1, Hidehiro Tajima 1, Yoshinao Obatake 1, Shinichi Nakanuma 1, Hironori Hayashi 1, Hiroyuki Takamura 1, Sachio Fushida 1, Tetsuo Ohta 1, Hirohisa Kitagawa 2 1 2
Department of Gastroenterologic Surgery, Kanazawa University, Japan Department of Surgery, Toyama City Hospital, Japan
Background: We have advocated that pancreatic cancer spreads in different direction by the location of the tumor. Recently, we usually establish treatment strategy for pancreatic cancer on the basis of the resectability criteria in UICC guideline. We studied the impact of the location of the tumor and detailed pattern of resectability criteria for prognosis after surgery in pancreatic cancer. Patients and methods: We retrospectively investigated 166 patients who received surgical resection for pancreatic cancer in 2002 to 2015 at Kanazawa University Hospital. The patients were divided into 5 groups according to the location of the tumor; V:the tumor located in ventral pancreas, D:dorsal pancreas, VD:both ventral and dorsal pancreas, B:pancreatic body, and T:pancreatic tail. The resectability was categorized into resectable (R), borderline resectable by PV factor (BR-PV), SMA factor (BR-SMA), CHA factor (BR-CHA), CA factor (BR-CA), and unresectable (UR). We performed clinicopathological analysis concerning about prognosis and the significance of R0 resection according to the tumor location and the resectability criteria. Results: V, D, VD, B, T group consisted of 39, 18, 48, 28, 33 patients, and the survival of V and T group was significantly better than others. R, BR-PV, BR-SMA, BR-CHA, BR-CA, UR group consisted of 93, 24, 25, 14, 8, 2 patients, and R0 resection rate was 71, 83, 60, 43, 63, 0%, respectively. The survival of BR-CHA and UR was significantly worse than others. Survival benefit of R0 resection was revealed in V, VD, and T group;however there was no benefit in D and B group. Conclusion: The surgical result for pancreatic cancer derived from dorsal portion in pancreas head or pancreatic body, especially when the tumor attached to CHA was worse than that derived from other site. We must investigate the reason of poor prognosis in these patients.
F-148. Remnant pancreatic cancer following radial pancreatectomy for invasive ductal carcinoma Takumi Harada, Yoshiaki Murakami, Kenichiro Uemura, Naru Kondo, Naoya Nakagawa, Kazuhide Urabe, Hiroki Ohge, Taijiro Sueda Department of Surgery, Applied Life Sciences Institute of Biomedical ＆ Health Sciences, Hiroshima University, Japan
Background: Recently, patients treated with radical pancreatectomy for Pancreatic ductal adenocarcinoma (PDAC) sometimes experience recurrent PDAC in remnant pancreas owing to development of several perioperative therapeutic modalities. However, survival benefit of pancreatectomy for these cancers is still controversial. Purpose: To investigate the short term and long term outcomes of surgical resection for remnant PDAC following radical pancreatectomy for PDAC. Methods: Seven patients who underwent surgical resection for remnant PDAC between November 2004 and November 2015were eligible for this study. All of these 7 patients were treated with radical pancreatectomy for prior PDAC. Clinicopathological features and prognosis of these 7 patients were retrospectively evaluated in the current study. Results: Of the 7 patients with remnant pancreatic cancers, 2 were female and 5 were male with median age of 67. As for prior radical pancreatectomy for initial PDAC, pancreatoduodenectomy and distal pancreatectomy have performed in 3 and 4 patients, respectively. All 7 patients have underwent R0 resection, and 4 patients had lymph node metastasis. All 7 patients received adjuvant chemotherapy (Gemcitabine plus S-1) after initial pancreatectomy. The median time from first operation to diagnosis of remnant PDAC is 45 month. (range: 6-89month) Seven cases were detected by contrast-enhanced computed tomography, 1 case was accompanied with increase in tumor marker and 1 case with obstructive jaundice. Six patients underwent radical pancreatectomy for remnant PDAC, and 1 is going to underwent soon. The median operation time was 199 minutes, the median estimated blood loss was 405 ml. No postoperative complication was found. The median survival time from first operation and from second operation are 70 month and 14 month. Conclusion: Radical pancreatectomy for remnant PDAC was safely performed without increasing morbidity and mortality. Although some patients experienced prolonged survival after, larger number of patients and longer follow-up will be needed to evaluate survival benefit of radical pancreatectomy for remnant PDAC.
F-149. Diagnostic strategy for TS1a PDAC using EUS-FNA Susumu Hijioka 1, Yasuhiro Shimizu 2, Kazuo Hara 2 1 2
Department of Gastroenterology, Aichi Cancer Center Hospital, Japan Department of Surgery, Aichi Cancer Center Hospital, Japan
Background/purpose: Although early detection of pancreatic adenocarcinoma (PDAC) is essential to improve prognosis, it is presently challenging. We aimed to determine the clinicopathological features of TS1a (10 mm) PDAC to help early PDAC diagnosis. Patients and results: We operated on 383 patients with PDAC between 1996 and 2015. Among them, 12 (3.1%) who had TS1a comprised six males (mean age, 64 years; mean tumor invasion, 7 [2-10] mm). The UICC stages were 1A, 1B and 2A in six, five and one patient, respectively. None of the patients had carcinoma in situ (CIS). PDAC was discovered as a result of abdominal pain (n¼6), aggravated diabetes (n¼1), periodical medical checks, (n¼5) and periodical follow-up for IPMN (n¼2). The detection rates of US, CT and EUS were 4 (33.3%), 7 (58%) and 12 (100%), respectively. Pathological assessment revealed fibrosis, 12 (8-20) mm and the range of CIS was 21.7 (10-40) mm. All TS1a was detected by EUS as low echoic areas, although invasion sites and fibrosis and/or CIS sites were difficult to discriminate using EUS. All patients with T1a tumors also had CIS and fibrosis that was larger than the amount of invasion. Nine of 12 patients underwent EUS-FNA a total of 10 times. We diagnosed PDAC in 9 (90%) of 10 patients by EUS-FNA combined with cytological and pathological analyses. Conclusions: Since about 40% of patients with TS1a present with abdominal pain, PDAC should be suspected even when abdominal pain is minimal. Evaluation by EUS should be mandatory due to the low (58%) detection rate of tumors by CT. Low echo on EUS reflects fibrosis and/or CIS with an invasive component, but discriminating invasion from fibrosis and/ or CIS was challenging. However, EUS-FNA could distinguish TS1a PDAC.