Advertisement

Feasibility and safety of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) combined with neoadjuvant therapy for borderline resectable and unresectable pancreatic body/tail cancer

  • Hideyuki Yoshitomi
  • Nozomu Sakai
  • Shingo Kagawa
  • Shigetsugu Takano
  • Atsuhiko Ueda
  • Atsushi Kato
  • Katsunori Furukawa
  • Tsukasa Takayashiki
  • Satoshi Kuboki
  • Masaru Miyzaki
  • Masayuki OhtsukaEmail author
Original Article

Abstract

Purpose

Pancreatic body/tail cancer commonly invades the hepatic artery or celiac artery, making surgical resection difficult. Distal pancreatectomy with celiac axis resection (DP-CAR) has recently been performed to achieve curative resection of these tumors. However, the safety and efficacy remain unclear. This study aimed to clarify the efficacy and safety of DP-CAR, mainly focusing on the combination with neoadjuvant therapy (NAT).

Methods

We retrospectively reviewed 31 consecutive patients with pancreatic ductal adenocarcinoma who underwent DP-CAR between 2010 and 2016. Data from 7 patients who underwent DP-CAR without NAT were used as a reference (upfront surgery, US).

Results

Gemcitabine + S-1 (GS) (n = 17) and gemcitabine + albumin-bound paclitaxel (GnP) (n = 8) were frequently used as NAT. DP-CAR following NAT was performed safely with 1 death, resulting in a mortality rate of 3%. The median survival time (MST) in the NAT group was 38.6 months, while that in the US group was 15.6 months. The NAT group had a high R0 resection rate (74%), while only 1 of 7 cases in the US group achieved R0 resection. Within the NAT group, patients treated with GS showed favorable overall survival with 39.5 months of MST, while that of patients treated with GnP was 19.8 months.

Conclusion

The combination of NAT and DP-CAR was feasible and safe for pancreatic body/tail cancer invading the celiac artery and/or hepatic artery. This strategy should be further assessed for the optimal regimen and duration of NAT in prospective studies.

Keywords

Pancreatic cancer Distal pancreatectomy with en bloc celiac axis resection Neoadjuvant therapy Gemcitabine S-1 Albumin-bound paclitaxel 

Notes

Acknowledgements

The authors thank the members of the Department of General Surgery, Chiba University Hospital, Chiba, Japan, for helping this study.

Authors’ contributions

Study conception and design: HY and MO; acquisition of data: HY, NS, SK, AU, and TT; analysis and interpretation of data: HY, KF, SK, and AK; drafting of the manuscript: HY and ST; critical revision of the manuscript: MM and MO.

Funding

This research was partly supported by the Grant-in-Aid for scientific research (B:Grant No.: JP17H04287 and C: Grant No.: JP15K10180) of JSPS (Japan Society for the Promotion of Science) KAKENHI.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Tempero MA, et al. (2018) NCCN clinical practice guideline in oncology Pancreatic adenocarcinoma ver. 2.2018. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Accessed 6 Aug 2018
  2. 2.
    Appleby LH (1953) The coeliac axis in the expansion of the operation for gastric carcinoma. Cancer 6:704–707CrossRefGoogle Scholar
  3. 3.
    Mayumi T, Nimura Y, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M, Hamaguchi K, Hayakawa N (1997) Distal pancreatectomy with en bloc resection of the celiac artery for carcinoma of the body and tail of the pancreas. Int J Surg 22:15–21.  https://doi.org/10.1007/BF02803900 Google Scholar
  4. 4.
    Gagandeep S, Artinyan A, Jabbour N, Mateo R, Matsuoka L, Sher L, Genyk Y, Selby R (2006) Extended pancreatectomy with resection of the celiac axis: the modified Appleby operation. Am J Surg 192:330–335.  https://doi.org/10.1016/j.amjsurg.2006.05.010 CrossRefGoogle Scholar
  5. 5.
    Hishinuma S, Ogata Y, Tomikawa M, Ozawa I (2007) Stomach-preserving distal pancreatectomy with combined resection of the celiac artery: radical procedure for locally advanced cancer of the pancreatic body. J Gastrointest Surg 11:743–749.  https://doi.org/10.1007/s11605-007-0143-x CrossRefGoogle Scholar
  6. 6.
    Hirano S, Kondo S, Hara T, Ambo Y, Tanaka E, Shichinohe T, Suzuki O, Hazama K (2007) Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg 246:46–51.  https://doi.org/10.1097/01.sla.0000258608.52615.5a CrossRefGoogle Scholar
  7. 7.
    Baumgartner JM, Krasinskas A, Daouadi M, Zureikat A, Marsh W, Lee K, Bartlett D, Moser AJ, Zeh HJ 3rd (2012) Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy. J Gastrointest Surg 16:1152–1159.  https://doi.org/10.1007/s11605-012-1839-0 CrossRefGoogle Scholar
  8. 8.
    Yamamoto Y, Sakamoto Y, Ban D, Shimada K, Esaki M, Nara S, Kosuge T (2012) Is celiac axis resection justified for T4 pancreatic body cancer? Surgery 151:61–69.  https://doi.org/10.1016/j.surg.2011.06.030 CrossRefGoogle Scholar
  9. 9.
    Okada K, Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H (2014) Preservation of the left gastric artery on the basis of anatomical features in patients undergoing distal pancreatectomy with celiac axis en-bloc resection (DP-CAR). World J Surg 38:2980–2985.  https://doi.org/10.1007/s00268-014-2702-0 CrossRefGoogle Scholar
  10. 10.
    Gong H, Ma R, Gong J, Cai C, Song Z, Xu B (2016) Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer: a systematic review and meta-analysis. Medicine (Baltimore) 95:e3061.  https://doi.org/10.1097/MD.0000000000003061 CrossRefGoogle Scholar
  11. 11.
    Klompmaker S, de Rooij T, Korteweg JJ, van Dieren S, van Lienden KP, van Gulik TM, Busch OR, Besselink MG (2016) Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer. Br J Surg 103:941–949.  https://doi.org/10.1002/bjs.10148 CrossRefGoogle Scholar
  12. 12.
    Nakamura T, Hirano S, Noji T, Asano T, Okamura K, Tsuchikawa T, Murakami S, Kurashima Y, Ebihara Y, Nakanishi Y, Tanaka K, Shichinohe T (2016) Distal pancreatectomy with en bloc celiac axis resection (modified Appleby procedure) for locally advanced pancreatic body CANCER: a single-center review of 80 consecutive patients. Ann Surg Oncol 23:969–975.  https://doi.org/10.1245/s10434-016-5493-8 CrossRefGoogle Scholar
  13. 13.
    Bockhorn M, Uzunoglu FG, Adham M, Imrie C, Milicevic M, Sandberg AA, Asbun HJ, Bassi C, Büchler M, Charnley RM, Conlon K, Cruz LF, Dervenis C, Fingerhutt A, Friess H, Gouma DJ, Hartwig W, Lillemoe KD, Montorsi M, Neoptolemos JP, Shrikhande SV, Takaori K, Traverso W, Vashist YK, Vollmer C, Yeo CJ, Izbicki JR, International Study Group of Pancreatic S (2014) Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 155:977–988.  https://doi.org/10.1016/j.surg.2014.02.001 CrossRefGoogle Scholar
  14. 14.
    Lutz MP, Zalcberg JR, Ducreux M, Aust D, Bruno MJ, Büchler MW, Delpero JR, Gloor B, Glynne-Jones R, Hartwig W, Huguet F, Laurent-Puig P, Lordick F, Maisonneuve P, Mayerle J, Martignoni M, Neoptolemos J, Rhim AD, Schmied BM, Seufferlein T, Werner J, van Laethem JL, Otto F (2017) 3rd St. Gallen EORTC Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of pancreatic cancer. Eur J Cancer 79:41–49.  https://doi.org/10.1016/j.ejca.2017.03.022 CrossRefGoogle Scholar
  15. 15.
    Brierley JD, Gospodarowicz MK, Wittekind C (2016) The TNM classification of malignant tumours, 8th eddition edn. Wiley, HobokenGoogle Scholar
  16. 16.
    Evans DB, Rich TA, Byrd DR, Cleary KR, Connelly JH, Levin B, Charnsangavej C, Fenoglio CJ, Ames FC (1992) Preoperative chemoradiation and pancreaticoduodenectomy for adenocarcinoma of the pancreas. Arch Surg 127:1335–1339.  https://doi.org/10.1001/archsurg.1992.01420110083017 CrossRefGoogle Scholar
  17. 17.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213.  https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefGoogle Scholar
  18. 18.
    Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Büchler M, International Study Group on Pancreatic S (2017) The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 161:584–591.  https://doi.org/10.1016/j.surg.2016.11.014 CrossRefGoogle Scholar
  19. 19.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768.  https://doi.org/10.1016/j.surg.2007.05.005 CrossRefGoogle Scholar
  20. 20.
    Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J, Arbuck S, Gwyther S, Mooney M, Rubinstein L, Shankar L, Dodd L, Kaplan R, Lacombe D, Verweij J (2009) New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228–247.  https://doi.org/10.1016/j.ejca.2008.10.026 CrossRefGoogle Scholar
  21. 21.
    Kondo S, Katoh H, Shimizu T, Omi M, Hirano S, Ambo Y, Okushiba S, Morikawa T (2000) Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer. Hepato-gastroenterology 47:1447–1449Google Scholar
  22. 22.
    Nakamura K, Yamaguchi T, Ishihara T, Sudo K, Kato H, Saisho H (2006) Phase II trial of oral S-1 combined with gemcitabine in metastatic pancreatic cancer. Br J Cancer 94:1575–1579.  https://doi.org/10.1038/sj.bjc.6603168 CrossRefGoogle Scholar
  23. 23.
    Klompmaker S, van Hilst J, Gerritsen SL, Adham M, Teresa Albiol Quer M, Bassi C, Berrevoet F, Boggi U, Busch OR, Cesaretti M, Dalla Valle R, Darnis B, De Pastena M, Del Chiaro M, Grutzmann R, Diener MK, Dumitrascu T, Friess H, Ivanecz A, Karayiannakis A, Fusai GK, Labori KJ, Lombardo C, Lopez-Ben S, Mabrut JY, Niesen W, Pardo F, Perinel J, Popescu I, Roeyen G, Sauvanet A, Prasad R, Sturesson C, Lesurtel M, Kleeff J, Salvia R, Besselink MG, group EAD-Cs (2018) Outcomes after distal pancreatectomy with celiac axis resection for pancreatic cancer: a pan-European retrospective cohort study. Ann Surg Oncol 25:1440–1447.  https://doi.org/10.1245/s10434-018-6391-z CrossRefGoogle Scholar
  24. 24.
    Abo D, Hasegawa Y, Sakuhara Y, Terae S, Shimizu T, Tha KK, Tanaka E, Hirano S, Kondo S, Shirato H (2012) Feasibility of a dual microcatheter-dual interlocking detachable coil technique in preoperative embolization in preparation for distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer. J Hepatobiliary Pancreat Sci 19:431–437.  https://doi.org/10.1007/s00534-011-0455-9 CrossRefGoogle Scholar
  25. 25.
    Ueno H, Ioka T, Ikeda M, Ohkawa S, Yanagimoto H, Boku N, Fukutomi A, Sugimori K, Baba H, Yamao K, Shimamura T, Sho M, Kitano M, Cheng AL, Mizumoto K, Chen JS, Furuse J, Funakoshi A, Hatori T, Yamaguchi T, Egawa S, Sato A, Ohashi Y, Okusaka T, Tanaka M (2013) Randomized phase III study of gemcitabine plus S-1, S-1 alone, or gemcitabine alone in patients with locally advanced and metastatic pancreatic cancer in Japan and Taiwan: GEST study. J Clin Oncol 31:1640–1648.  https://doi.org/10.1200/JCO.2012.43.3680 CrossRefGoogle Scholar
  26. 26.
    Von Hoff DD, Ervin T, Arena FP, Chiorean EG, Infante J, Moore M, Seay T, Tjulandin SA, Ma WW, Saleh MN, Harris M, Reni M, Dowden S, Laheru D, Bahary N, Ramanathan RK, Tabernero J, Hidalgo M, Goldstein D, Van Cutsem E, Wei X, Iglesias J, Renschler MF (2013) Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med 369:1691–1703.  https://doi.org/10.1056/NEJMoa1304369 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Hideyuki Yoshitomi
    • 1
  • Nozomu Sakai
    • 1
  • Shingo Kagawa
    • 1
  • Shigetsugu Takano
    • 1
  • Atsuhiko Ueda
    • 1
  • Atsushi Kato
    • 1
    • 2
  • Katsunori Furukawa
    • 1
  • Tsukasa Takayashiki
    • 1
  • Satoshi Kuboki
    • 1
  • Masaru Miyzaki
    • 1
    • 2
  • Masayuki Ohtsuka
    • 1
    Email author
  1. 1.Department of General Surgery, Graduate School of MedicineChiba UniversityChibaJapan
  2. 2.Digestive Diseases CenterInternational University of Health and Welfare, Mita HospitalTokyoJapan

Personalised recommendations