Neoadjuvant Treatment (NAT) is indicated in locally advanced tumors and improves the results of subsequent surgery. In borderline tumors, the place of this preoperative treatment is more controversial, probably because borderline tumors are a heterogeneous group. We focused on the tumors with venous involvement without any arterial involvement and studied the results of neoadjuvant treatment in this particular group.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
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Pancreatic Adenocarcinoma with Isolated Venous Involvement: Is Neoadjuvant Tr...EditorSara
Neoadjuvant Treatment (NAT) is indicated in locally advanced tumors and improves the results of subsequent surgery. In borderline tumors, the place of this preoperative treatment is more controversial, probably because borderline tumors are a heterogeneous group. We focused on the tumors with venous involvement without any arterial involvement and studied the results of neoadjuvant treatment in this particular group.
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Neulasta Onpro kit eliminates need for additional clinic visit after chemotherapy. Given the racially diverse population in our institution, we investigated acceptance of Onpro kit among patients on chemotherapy.Single-institution, retrospective review conducted in patients with GI tumors who received Onpro kit within 1 hour of completion of systemic chemotherapy from Jan 2014 through Jan 2018...
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Acute promyelocytic leukemia(APL),a specific characteristic of t(15;17) chromosomal translocation,molecular gene analyses are conclusive in vivo evidence that oncogenic pml/RARa fusion plays a crucial role in APL leukemogenesis [1-3]. Since the introduction of initial 13-cis retinoic acid(13-cis RA)[4],and currently all-trans RA(ATRA) [5] and tamibarotene [6],RA plus chemotherapy or RA plus As2O3 regimen is currently the standard of care [7]...
Hairy Cell Leukemia (HCL) is a rare subtype of B-cell chronic lymphoid leukemia which was first described by Bertha Bouroncle in 1958 [1]. The annual incidence of HCL is approximately 0.3 cases per 100,000 and the disease comprises 2-3% of all leukaemia?s in the Western world [2,3]...
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Classical Hodgkin Lymphoma (cHL), consists of rare neoplastic Hodgkin and Reed-Sternberg cells (HRS) residing in a prominent inflammatory background. HRS show deregulated activation of multiple signaling pathways and transcription factors. The activation of these pathways and factors is partly mediated through interactions of HRS with various other types of cells in the microenvironment, but also through genetic lesions...
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Lipocalin 2 (LCN2) is a 25 kDa secreted protein, initially purified from neutrophil granules, and mainly expressed in immune cells, hepatocytes, renal cells, prostate, cells of the respiratory tract and cardiomyocytes. LCN2 belongs to the family of lipocalins known for their ability to traffic small hydrophobic molecules such as lipids and retinoids...
As an Obstetrics & Gynaecology, member of National Breast Cancer Foundation and a woman I find it very important to raise awareness about the importance of early detection of Breast Cancer. Make a difference! Spread the word about mammograms and encourage communities, organisations, your friends and family memebrs to get involved! Your help matters...
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Peripheral T-Cell Lymphomas (PTCL) arises from mature T-cells and they represent an extremely heterogeneous group. They are sub-classified into three major groups based on clinical presentation and localization, namely the nodal, extra nodal and leukemic PTCL. This review focuses on nodal PTCL which are the most frequently encountered entities...
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Prostate Cancer (PC) is the common tumor in men, which represents one of leading cause of cancer death throughout the world. Most patients were diagnosed too late for curative treatment. So, it is necessary to develop a minimal invasive method to identify novel biomarkers. Currently, plasma DNA has attracted increasing attention as a potential tumor marker..
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Approaches are limited for treating advanced Non-Small-Cell Lung Cancer (NSCLC) with multidrug resistance but without ALK and EGFR mutations. Pembrolizumab (KEYTRUDA) brings on unprecedented clinical benefit in various cancer types..
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Lung cancer is the second common malignancy and the most aggressive cancer worldwide with late diagnosis and poor prognosis. The search for biomarkers that promote early diagnosis and improve therapeutic strategies focuses to the understanding of the mechanisms underlying cancer development and progression. The deregulation of gene expression is one of the cancer hallmarks reflected to the stability..
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In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
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Neoadjuvant Treatment (NAT) is indicated in locally advanced tumors and improves the results of subsequent surgery. In borderline tumors, the place of this preoperative treatment is more controversial, probably because borderline tumors are a heterogeneous group. We focused on the tumors with venous involvement without any arterial involvement and studied the results of neoadjuvant treatment in this particular group.
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Hairy Cell Leukemia (HCL) is a rare subtype of B-cell chronic lymphoid leukemia which was first described by Bertha Bouroncle in 1958 [1]. The annual incidence of HCL is approximately 0.3 cases per 100,000 and the disease comprises 2-3% of all leukaemia?s in the Western world [2,3]...
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As an Obstetrics & Gynaecology, member of National Breast Cancer Foundation and a woman I find it very important to raise awareness about the importance of early detection of Breast Cancer. Make a difference! Spread the word about mammograms and encourage communities, organisations, your friends and family memebrs to get involved! Your help matters...
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
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O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. Complete surgical resection is the only curative treatment; howev-
er, R0 resection rates are still low (10-22%) [4, 5]. Many studies
reported that adjuvant therapy after pancreatic surgery increased
patient survival [6-8]. This adjuvant therapy has to be initiated as
soon as possible [9], but may be delayed or even cancelled be-
cause of surgical complication and delayed recovery [10]. NAT
on the contrary is always feasible and moreover, a lot of studies
demonstrated that it increases the resection rate [11-15]. In partic-
ular, neoadjuvant chemo-radiotherapy can increased resection rate
and R0 resection rates with a better median survival [12, 15, 16].
Today, pancreatic cancer 5-year survival rate have risen to a record
high, 7.9%, in the UK [17].
Non metastatic pancreatic tumors are often divided in 3 groups:
potentially resectable, borderline resectable and locally advanced
[18]. NAT is undisputable for locally advanced tumors [19-23],
and increased R0 resection rates for borderline tumors [19, 24,
25]. But the question remains open for tu-mors with isolated ve-
nous involvement. Indeed, tumors with venous contact are either
resectable (if contact <180°) or borderline (if involvement ≥180°)
and neoadjuvant treatment is not a paradigm for resectable tumors,
especially because venous resection is safe. In fact, surgical mor-
tality is not in-creased with venous resection and is not predictive
of disease-free or overall survival [26, 27]. Howev-er, recent study
seems to suggest favorable oncologic benefits for this kind of tu-
mors [28].
In this retrospective observational study, we focused on patients
with isolated venous involvement or abutment who had Whipple
procedure following NAT.
3. Methods
For this observational retrospective study, we included all patients
who underwent a Whipple procedure in our center (Bordeaux Uni-
versity Hospital, Department of digestive surgery) for Pancreatic
Adenocarcinoma (PA) from January 2004 to December 2016. A
total of 287 patients had a Whipple procedure for PA. 169 had
surgery first, 112 had a neoadjuvant treatment.
Preoperative contrast-enhanced Computerized Tomography (CT)
or Magnetic Resonance Imaging (MRI) was performed for all the
patients allowing a precise staging.
In order to specify the vascular contacts of the tumor, we used a
local classification of vascular involvement. All tumors were clas-
sified 0 (no involvement), 1 (abutment or involvement between 0
and 180°) or 2 (involvement >180° or vascular stenosis), for su-
perior mesenteric vein or portal vein (MV), superior Mesenteric
Artery (MA), Hepatic Artery (HA) and coeliac artery (C). Every
patient was classified MV x, MA x, HA x and C x, depending on
diagnostic CT-scan.
We included all patients who had just on CT-scanner or MRI, a
venous involvement, i.e., MV 1 or 2, MA 0, HA 0, C 0. All patients
who had no pancreatic ductal adenocarcinoma on histologic analy-
sis were excluded from our study.
We divided patients in two groups:
- NA group for patients who had surgery following neoad-
juvant treatment
- R group for patients who had surgery without neoadju-
vant treatment, i.e. our control group
Every decision of NAT or first-line resection were decided in mul-
tidisciplinary meeting, depending on ongoing clinical trials, trials
result and medical experience.
Eighty-five patients had a venous abutment or involvement (MV1
or MV2) without any arterial abutment (MA0, HA0, and C0). Pa-
thology exam was not possible for one surgical specimen because
of a bad formalin fixation. The patient was excluded from the
study. 50 (59.5%) had surgery after NAT (NA group, n= 50), 34
(40.5%) had surgery first (R group, n =34).
NAT consisted in exclusive chemotherapy (CT) for 9 patients, or
an association of radiotherapy and chemotherapy (RCT) for 41 pa-
tients, protocols of chemotherapy were FOLFIRINOX [25], gem-
citabine-based CT [13], Cisplatin LV5 FU2 (4). For patients who
had radiotherapy (41/50), radiation doses were applied with daily
fractions of 1.8 Gy, 5 days a week, for a total of 45, 50,5 or 59 Gy.
Four weeks after completion of first and second rounds of neoad-
juvant treatment, CT-scan was con-ducted.
Pancreaticoduodenectomies were conducted with en-bloc re-
section. During procedure, vascular resection was decided by sur-
geon, with regards to the adhesion between pancreatic tumor and
the vein. Tangential or segmental vein resections were conducted
according to the importance of the adherence and the feasibility of
reconstruction in-order to achieve R0 resection.
Neoadjuvant treatment, when performed (17 (34%) in NA-group,
24 (70.96%) in R-group), was FOLFOX (or FOLFIRINOX) or
gemcitabine-based CT.
Statistical analyses were performed using Prism 6® software pro-
gram for Mac OS.
Minimal follow-up was 12 months. Overall survival was calcu-
lated from the time of surgery to death or the last follow-up day.
Disease-free survival was calculated from the time of surgery to
recur-rence diagnosis or last follow-up day. Overall survival from
diagnosis was calculated from the time of diagnosis to death or
last-follow-up day. Disease-free survival was calculated from
the time of diag-nostic to recurrence diagnostic or last follow-up
day. Survival time was analyzed using Kaplan-Meier method.
Differences in survival were compared using log-rank test. Pa-
tient’s characteristics, periopera-tive outcomes and pathological
results among the 2 groups were compared with non-parametrical
Mann-Whitney test for continuous variable and Fischer test for
categorical variables. Repeated measures data between same pa-
clinicsofoncology.com 2
Volume 5 Issue 5 -2021 Research Article
3. tients were compared with Wilcoxon matched-pairs signed rank
test. P-value < 0.05 was considered statistically significant.
Primary endpoint was disease-free survival.
Secondary endpoints were overall survival, complete resection ra-
tio, positive nodes ratio, and tu-mor size.
4. Results
Forty-three patients were male, 41 were female. Median age was
65.7 (59.2-71) years. Thirty-four patients belong to R group, 50
patients to NA group. Patients were older in the R group (68.9
years) than in the NA group (62.2). At diagnosis tumors were big-
ger in NA group (median = 30 mm) than in R group (median = 25
mm). Tumor characteristics were similar except for uncus tumors,
more fre-quents in NA group (18% vs 2.9%). Venous involvement
>180° were more important in the NA group (46% vs 17.6%).
Table 1: Demographic and tumor characteristics of 84 patients with venous involvement
NA group (n=50) R group (n=34) Total (n=84) p
Age (years) (median) 62.8 (54.2-68.4) 68.9 (57.1-71.3) 65.7 (59.25-71) 0.009
Male 28 (56%) 15 (44.1%) 43 (51.2%) ns
Tobacco use 16 (32%) 6 (17.6%) 22 (26.2%) ns
- PA (median) 20 (15-30) 17.5 (11.25-23.75) 20 (10-30)
ASA (median) 2 (1-2) 2 (2-2) 2 (2-2) ns
Weight loss (kg) (median) 5 (0-8) 5 (0-7.75) 4.75 (0-8) ns
BMI (kg/m²) (median) 23.4 (21.1-25.5) 23.2 (21.5-24.6) 23.3 (21.1-25.4) ns
Tumor size (mm) (median) 30 (25-38) 25 (22-30) 30 (23-34.3) 0,01
Tumor site
- Head 39 (78%) 32 (94.1%) 71 (84.5%)
- Uncus 9 (18%) 1 (2.9%) 10 (11.9%)
- Isthmus 2 (4%) 1 (2.9%) 3 (3.6%) ns
Dilatation
- bile duct system 36 (72%) 26 (76.5%) 62 (73.8%) ns
- pancreatic duct 36 (72%) 26 (76.5%) 59 (70.2%) ns
Lymph nodes 19 (38%) 11 (32.35%) 30 (35.7%) ns
MV1 27 (54%) 28 (82.4%) 55 (65.5%) 0.01
MV2 23 (46%) 6 (17.6%) 29 (34.5%) 0.01
Median time from diagnostic to surgery was 1.07 month in R group
and 8.38 month in the NA group. Median operating time was lon-
ger in NA group (318 min) than in R group (260 min). Venous
resection frequency was similar in the two groups. Kind, severity
and frequency of complications were similar in the 2 groups, in
particular pancreatic fistula (20.6 % in R group vs 19.6 % in NA
group). 3 patients had grade C fistula, 1 in NA group, 2 in R group.
In postoperative time, 1 patient died in NA group from hemor-
rhage, no patients in R group.
Table 2: Operative characteristics and post-operative time of the 84 patients
NA group (n=50) R group (n=34) p
Time from diagnostic to surgery (month) (median) 8.47 (7.54-9.56) 1.07 (0.69-2.34) 0.0001001
Operating time (min) (median) 318 (258-403) 260 (227-325) 0.024
Venous resection 25 (50%) 15 (44.1%) ns
Arterial resection 1 (2%) 0 ns
Pancreatic duct size (mm) (median) 5 (3-7) 5 (3-6) ns
Anastomosis
- pancreaticojejunostomy 28 (56%) 17 (50%) ns
- pancreaticogastrostomy 17 (34%) 16 (47.1%) ns
- wirsungostomy 2 (4%) 0 ns
- total pancreatectomy 3 (6%) 1 (2.9%) ns
Length of hospital stay (median) 15 (13-20.5) 17 (13-21) ns
DINDO
- I 17 (34%) 10 (29.4%) ns
- II 25 (50%) 15 (44.1%) ns
- IIIa 1 (2%) 2 (5.9%) ns
- IIIb 2 (4%) 1 (2.9%) ns
- IVa 1 (2%) 1 (2.9%) ns
- IVb 0 0 ns
- V 1 (2%) 0 ns
Complications
- Pancreatic fistula 9 (18%) 7 (20.6%) ns
- Delay gastric emptying 6 (12%) 4 (11.8%) ns
- Hemorrhage 2 (4%) 1 (2.9%) ns
- Other 5 (10%) 3 (8.8%) ns
Rehospitalization 6 (12%) 5 (14.7%) ns
clinicsofoncology.com 3
Volume 5 Issue 5 -2021 Research Article
4. There were no pT4. There were more pT3 in the R group (91.1%)
than in the NA group (68%). Tumor size was not significantly big-
ger in the R group (p=0.058). Tumoral nodes were more frequent
in R group (73.5%) than in the NA group (46%).
For R group, median tumor size was 25 mm (22-30) at diagnostic
CT-scan and 28.5 mm (22.25-30.5) at pathological exam (p=0.77).
For NA group, median tumor size was 30 mm (25-38) and 23 mm
(18-30) at pathological exam (p=0.0009).
Adjuvant treatment was more frequent in R group (n=24, 70.6%)
than in NA group (n=17, 32.7%).
Follow-up was at least 12 months. 1 patient was lost of follow-up
after 23.7 months because he moved in another country.
Median disease-free survival after surgery was 20.6 months for
NA group vs 13.6 months in R group. Median overall survival af-
ter surgery was 35.2 months in NA group vs 22.3 in R group. Dif-
fer-ences were not significant with log-rank test.
Median disease-free survival from diagnostic was 31 months for
NA group vs 16.7 months in R group (p=0.025). Median overall
survival from diagnostic was 44.6 months for NA group vs 24.9
month in R group (p=0.11).
Because neoadjuvant treatment was different, we made comple-
mentary analysis. Median disease-free survival was 54.4 month
for patients from NA group who had FOLFIRINOX or FOLFOX
vs 10 months for other patients (p=0.09). Median overall survival
was 54.4 months for patients from NA group who had FOLFIRI-
NOX or FOLFOX vs 26.6 months for others patients.
Table 3: Pathological results for 84 patients
NA group (n=50) R group (n=34) p
Median tumor size (mm) 23 (18-30) 28.5 (22.25-30.5) 0.058
TNM
- T0 6 (12%) 0 (0%) 0.08
T1 6 (12%) 1 (2.9%)
T2 4 (8%) 2 (5.9%)
T3 34 (68%) 31 (91.1%) 0.016
- N+ 23 (46%) 25 (73.5%) 0.01
- M+ 1 (2%) 1 (2.9%) ns
Tumoral nodes ratio (median) 0 (0-7.9) 7(0.7-21.7) 0.009
Différenciation
- well 12 (24%) 8 (23.5%) ns
- moderate 25 (50%) 20 (58.8%) ns
- poor 0 (0%) 3 (8.8%) ns
- other 3 (6%) 1 (2.9%) ns
Lymphovascular invasion 19 (38%) 19 (55.9%) ns
Perineural invasion 29 (58 %) 27 (79.4%) 0.059
Complete resection (R0) 43 (86%) 25 (73.5%) ns
Table 4: Survival and recurrence of 85 patients
NA group (n=50) R group (n=34) p
Adjuvant treatment 17 (34%) 24 (70.6%) 0.0008
One year survival 0.78 0.824
Two years suvival 0.608 0.385
Five year survival 0.315 0.292
Median overall survival (month) 35.2 22.3 ns
Recurrence 28 (56%) 24 (70.6%) ns
- local 3 4 ns
- nodes 0 0 ns
- lever 6 7 ns
- peritoneal 8 1 0.02
- lung 3 3 ns
- other 0 0 ns
- diffuse 4 6 ns
Median disease-free survival (month) 20.6 13.6 ns
clinicsofoncology.com 4
Volume 5 Issue 5 -2021 Research Article
5. Figure 1: Tumor size at diagnostic (CT-scan) and after surgery (at patho-
logical exam)
Figure 2: Disease-free and overall survivals
5. Discussion
In pancreatic head adenocarcinoma, vascular and in particular ve-
nous abutment or involvement is a key point of resectability and
the classifications are partially based on it
- Classifications from NCCN and MDACC in resectable/
borderline/ locally advanced are un-clear. According to
NCCN, venous abutment without artery abutment can
be either resectable (if <180° without vein contour irreg-
ularity), either borderline resectable [29]. According to
MDACC (University of Texas D Anderson Cancer Cen-
ter), venous involvement without oc-clusion is potential-
ly resectable [16, 30].
- From oncological point of view, the question about neo-
adjuvant treatment has not been solved yet, especially in
resectable tumors but also for borderline tumors. Homog-
enous group of pa-tients are difficult to obtain because of
unclear classification (Groups of borderline patients can
include patients with just venous involvement but arteri-
al abutment too, venous abutment or involvement can be
classified in two kind of group, depending of the classifi-
cation choice made by medical staff). This question about
classification increases the difficulty to interpret studies
and metanalyses about neoadjuvant treatment [31, 32].
- From a technical point of view, contrary to arterial resec-
tion [33-35], venous resection is con-sidered as safe and
useful to achieve complete resection [34, 36, 37]. Lots of
questions are still open: is it necessary to do systematic
resection [32]? Which kind of resection (lateral, resec-
tion, end-to-end anastomosis) is the best [32, 33]?
In our center, every patient’s treatment is discussed weekly in mul-
tidisciplinary meeting with on-cologists, gastroenterologists, ra-
diologists and specialized digestive surgeons. Tumors and vascu-
lar abutment were analyzed for each patient with our simple clas-
sification MVx, MAx, HAx and Cx and classified in resectable/
borderline/locally advanced. NAT or not were decided depending
on several studies protocols or depending on subjective criteria
when no studies protocols were on progress. NAT has been criti-
cized as a loss of chance because some patients progressed in the
meantime and did not reach surgery. We believe that one interest
of NAT is the selection of patients allowing the exclusion of pro-
gressive patients with aggressive tumors which anyway wouldn’t
be good candidates to surgery.
That’s why in our center, the frequency of NAT was high in the
group of patients with only ve-nous involment or abutment. As
a matter of fact, the decision in our multidisciplinary staff was to
per-form the NAT when the tumor seemed aggressive (size, CA19
9). We are aware that the characteristics of the patients from NA
group and R group are different: tumors were bigger and median
age lower. A case-control study would have been preferable but it
was impossible considering the size of the groups.
Moreover, our long-term results need to be examined with pre-
caution because it is not an inten-tion-to-treat study. The period
between diagnostic and surgery is significantly longer in NA group
be-cause of the pre-operative treatment (8.47m vs 1.07m). We de-
cide to calculate survival after surgery and not after diagnostic to
avoid a bias.
Median disease-free survival after pancreaticoduodenectomy was
20.6 month in NA group versus 13.6 months in R group. Log-
rank test has found no significant difference between the 2 groups.
About overall-survival, we didn’t find some significant differences
either: median survival was 35.2 months in NA-group and 22.3
months in R-group. It is interesting to note that’s the survival in
the NAT group, encompassing patients with more advanced tu-
mors, was slightly better than in the front line surgery group, even
the statistical difference was not reached, probably because of the
small size of the groups.
Recent meta-analysis about resectable and borderline resectable
pancreatic adenocarcinoma found lower median survival after re-
section (26.1m vs 15.0m) [31] probably because of heterogeneity
in vascular involvement and neoadjuvant treatment. Some recent
study suggests the interest of neoadju-vant treatment for tumors
with venous contact only [28]. But considering our primary end-
point we are not able to demonstrate that NAT is beneficial in term
clinicsofoncology.com 5
Volume 5 Issue 5 -2021 Research Article
6. of survival.
Nevertheless, efficiency of NAT on pancreatic adenocarcinoma is
confirmed in our study:
- Wilcoxon matched-pairs signed rank test found a signif-
icant difference in group NA between tumor size before
and after neoadjuvant treatment. This result confirms effi-
cacy of neoadju-vant treatment on downsizing for tumors
with only venous involvement.
- Concerning downstaging, 6 patients (12%) in NA group
were T0 on pathological analyze. T3 tumors in NA group
was less frequent than in R group (68 % vs 91.1%,
p=0.016). Positive lymph nodes were more frequent in
R group than in NA group (26.5 % vs 54%) with tumoral
nodes ratio significantly different. These data are con-
firmed by other studies [31, 32].
Complete resection was similar in the two groups, 86% in NA
group, 73,5% in R group, despite bigger tumors and more venous
involment on CT-scan in NA group. This result is in favor of neo-
adju-vant treatment. In fact, we know than complete resection is a
good-prognosis criterion [38-40].
NAT does not influence the postoperative course even if surgery
was longer in NA group than in R group. Recent meta-analysis
confirms longer procedure after neoadjuvant therapy but it in-
cludes local-ly advanced tumors or borderline tumors with arterial
involvement [41]. In our series, the prolonged time was mostly
due to difficulties in dissection after radiotherapy. Interestingly
venous involvement doesn’t seem to explain differences for oper-
ative length because venous resection was as frequent in R group
(44.1%) as in NA group (50%).
Concerning post-operative period, complications were similar in
term of frequency, kind or severi-ty. and similar than in other stud-
ies [42]. Median length of stay in the hospital is logically not dif-
ferent for the two groups. Unlike some studies, we didn't find less
pancreatic fistula in NA group (18%) vs in R group (20.6%) [41].
In NA group, only 34% of patients had adjuvant therapy, but log-
ically 100% of them had systemic treatment before surgery. In R
group, 10 patients (29.4%) had no adjuvant therapy after resection
because of delayed recovery, less than in other studies [10, 43].
We know that adjuvant therapy must not be delayed to increase
survival after resection [6, 9], which can be a challenge be-cause
of the morbidity in pancreatocoduodenectomies. That’s why neo-
adjuvant treatment is a better chance for patients to receive a com-
plete treatment (local and systemic). A recent study suggests that
the addition of AT after NT is beneficial for patients with low-risk
pathology. Today adjuvant treat-ment after NAT should be recon-
sidered, especially for patient with good response [44].
About neoadjuvant and adjuvant treatment, protocols evolved
with time. Before FOLFIRINOX, other treatments (5-FU, Gemcit-
abine) were the reference. With FOLFIRINOX, disease-free sur-
vival seemed to be better in our study but we need more follow-up
time to confirm it. This chemotherapy is relatively new in neoad-
juvant treatment. It already proves its interest for locally advanced
pancreatic cancer [19, 20, 24, 45] and for metastatic pancreatic
cancer [46] despite lower quality of life [47]. Some new results in
neoadjuvant treatment for borderline tumors are interesting [48,
49] but we still need more studies. Moreover, in the similar study
of Lee et al., neoadjuvant treatment was based on Gemcitabine
[28]. Literature reports better results for FOLFIRINOX compared
to gemcitabine or cape-citabine in neoadjuvant treatment for local-
ly advanced tumors [50]. Today it should be interesting to consider
FOLFIRINOX in neoadjuvant for tumors with venous involment
alone. Gemcitabine/Nab-Paclitaxel may be a good option for neo-
adjuvant therapy too [51, 52].
In conclusion, pancreaticoduodenectomy after neoadjuvant for ad-
enocarcinoma with venous involvement only is as safe as up-front
surgery. It provides good results in term of downsizing (smaller
tumors) and down staging (more T0, T1 and T2, less N+)., De-
spite bigger tumors with worse venous involvement, frequency of
complete resection is the same after neoadjuvant treatment than
without. De-spite longer surgery, frequency of post-operative
complications is the same. Despite worst prognosis tumors, long-
term survival and disease-free survival are comparable. Despite
post-operative complications or longer recovery, every patient op-
erated after neoadjuvant treatment had complete treatment.
This study confirms that neoadjuvant treatment can be an option
for selected patients with only venous involvement. But insuffi-
cient number of patient, retrospective character and differences in
neoadjuvant protocols are major disadvantages that we share with
other studies. That’s why multicenter series and meta-analyses
would be interesting to study the benefit of NAT in this particular
group. In order to eliminate the biais, a randomized trial, even dif-
ficult to construct, would be indeed the best option.
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Volume 5 Issue 5 -2021 Research Article