Faculty Bibliography

OBJECTIVE:The aim of the study was to identify the survival of patients with locally advanced pancreatic cancer (LAPC) and assess the effect of surgical resection after neoadjuvant therapy on patient outcomes. BACKGROUND:An increasing number of LAPC patients who respond favorably to neoadjuvant therapy undergo surgical resection. The impact of surgery on patient survival is largely unknown. MATERIALS AND METHODS:All LAPC patients who presented to the institutional pancreatic multidisciplinary clinic (PMDC) from January 2013 to September 2017 were included in the study. Demographics and clinical data on neoadjuvant treatment and surgical resection were documented. Primary tumor resection rates after neoadjuvant therapy and overall survival (OS) were the primary study endpoints. RESULTS:A total of 415 LAPC patients were included in the study. Stratification of neoadjuvant therapy in FOLFIRINOX-based, gemcitabine-based, and combination of the two, and subsequent outcome comparison did not demonstrate significant differences in OS of 331 non-resected LAPC patients (P = 0.134). Eighty-four patients underwent resection of the primary tumor (20%), after a median duration of 5 months of neoadjuvant therapy. FOLFIRINOX-based therapy and stereotactic body radiation therapy correlated with increased probability of resection (P = 0.006). Resected patients had better performance status, smaller median tumor size (P = 0.029), and lower median CA19-9 values (P < 0.001) at PMDC. Patients who underwent surgical resection had significant higher median OS compared with those who did not (35.3 vs 16.3 mo, P < 0.001). The difference remained significant when non-resected patients were matched for time of neoadjuvant therapy (19.9 mo, P < 0.001). CONCLUSIONS:Surgical resection of LAPC after neoadjuvant therapy is feasible in a highly selected cohort of patients (20%) and is associated with significantly longer median overall survival.

Background: Intraductal papillary mucinous neoplasm (IPMN) is premalig-nant pancreatic lesion. International guidelines suggest several treatments and malignancy predictors but offer limited predictors of individual risk. A nomo-gram to predict individual IPMN malignancy risk was released with good diagnostic performance, basedona cohort of2258 Korean or Japanese patients with IPMN. This study validated a nomogram to predict malignancy risk and inva-siveness of IPMN, using Eastern and Western cohorts.
Method(s): We collected clinicopathological and radiological data of patients who underwent pancreas resection for IPMN at 4 centers each in Eastern and Western countries. After excluding patients with >=1 missing malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum CEA and CA 19-9 levels, and age), we analyzed data of the remaining 393 patients (Eastern: n = 265; Western: n = 128).
Result(s): Although mean age, sex, log value of serum CA 19-9, tumor location, main duct diameter, cyst size and presence of mural nodule differed between the Korea/Japan, Eastern and Western cohorts, rates of malignancy and invasive cancer did not significantly differ. Areas under the receiver operating characteristics curve (AUC) values using the nomogram to predict malignancy were Eastern: 0.745, Western: 0.856, and combined cohorts: 0.776; and to predict in-vasiveness were Eastern: 0.736, Western: 0.891, and combined cohorts: 0.788.
Conclusion(s): External validation of the nomogram showed good performance in predicting malignancy and invasive cancer in both Eastern and Western IPMN patients. The nomogram could be globally applicable to decide customized treatment options for patients with IPMN

Background and Objectives: We previously proposed a nomogram predicting individual risks of malignancy and invasiveness of intraductal papillary mucinous neoplasms and validated it in an external cohort. However, it is difficult to apply if data on tumor marker are lacking. The aim of the current study was to develop a new nomogram based on radiologic findings using previous nomogram development and an external validation cohort.
Material(s) and Method(s): A total of 3049 patients who underwent surgical resection at 30 tertiary institutes in 7 countries were enrolled and clinicopathologic data were retrospectively analyzed. Based on fitted model, area under the receiver operating characteristics curve (AUC) was calculated using 10-fold cross validation by exhaustive search.
Result(s): The study consisted of 1914 (62.8%) patients for previous nomogram development and 1135 patients (37.2%) in the external validation cohort. Among patients, 1898 (62.3%) had low, 577 (18.9%) had high grade dysplasia, and 574 (18.8%) had invasive carcinoma. Patients were allocated randomly into model development and test sets to construct the nomogram, with fixed ratios according to malignancy and invasiveness. Exhaustive search resulted in three variables (cyst size, duct dilatation, and mural nodule) for malignancy and four variables (cyst size, duct dilatation, mural nodule, and location) for invasiveness being selected to construct the nomogram, and AUC was 0.742 and 0.741, respectively. AUC for test set was 0.727 and 0.704, respectively, and Hosmer-Lemeshow goodness of fit test showed good discrimination power (p = 0.066 and 0.067, respectively).
Conclusion(s): The new nomogram based on radiologic findings is accurate and helpful in identifying patients at risk of malignancy and invasiveness and selecting treatment options in clinical settings.
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