background The effect of adjuvant treatment on survival in pancreatic cancer is unclear. We report the final results of the European Study Group for Pancreatic Cancer 1 Trial and update the interim results. methods In a multicenter trial using a two-by-two factorial design, we randomly assigned 73 patients with resected pancreatic ductal adenocarcinoma to treatment with chemoradiotherapy alone (20 Gy over a two-week period plus fluorouracil), 75 patients to chemotherapy alone (fluorouracil), 72 patients to both chemoradiotherapy and chemotherapy, and 69 patients to observation. results The analysis was based on 237 deaths among the 289 patients (82 percent) and a median follow-up of 47 months (interquartile range, 33 to 62). The estimated five-year survival rate was 10 percent among patients assigned to receive chemoradiotherapy and 20 percent among patients who did not receive chemoradiotherapy (P=0.05). The five-year survival rate was 21 percent among patients who received chemotherapy and 8 percent among patients who did not receive chemotherapy (P=0.009). The benefit of chemotherapy persisted after adjustment for major prognostic factors. conclusions Adjuvant chemotherapy has a significant survival benefit in patients with resected pancreatic cancer, whereas adjuvant chemoradiotherapy has a deleterious effect on survival.

https://pancreaticcanceraction.org/wp-content/uploads/2010/09/ESPAC1.pdf

A Randomized Trial of Chemoradiotherapy and Chemotherapy after Resection of Pancreatic Cancer

OBJECTIVE: In 1986 a prospective multicenter observation trial in patients with resected gastric cancer was initiated in Germany. An analysis of prognostic factors based on the 10-year survival data is now presented. PATIENTS AND METHODS: A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included. The resected specimen were evaluated histopathologically according to a standardized protocol. The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment (25 or fewer removed nodes, D1 or standard lymphadenectomy; >25 removed nodes, D2 or extended lymphadenectomy). Endpoint of the study was death. Follow-up is complete for 97% of the included patients (median follow-up of the surviving patients is 8.4 years). Prognostic factors were assessed by multivariate analysis. RESULTS: A complete macroscopic and microscopic tumor resection (R0 resection according to the UICC 1997) could be achieved in 1182 of the 1654 patients (71.5%). The calculated 10-year survival rate in the entire patient population was 26.3% +/- 4.7%; it was 36.1% +/- 1.6% after an R0 resection. In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes, the residual tumor (R) category, the pT category, the presence of postsurgical complications, and the presence of distant metastases. Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status, the pT category, and the presence of postsurgical complications as the major independent prognostic factors. The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors. This effect was present in the subgroups with (pT2N1) and without (pT3N0) lymph node metastases on standard histopathologic assessment. The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection (<15 nodes) were excluded from the analysis. There was no difference in the postsurgical morbidity and mortality rates between patients with standard and extended lymph node dissection. CONCLUSIONS: Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer. In experienced centers, extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II tumors. This effect appears to be independent of the phenomenon of stage migration.

Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(01)06651-X.pdf

Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial.

Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial

Background:

Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma.



Methods:

Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models.



Results:

Fifty-eight patients (15·8 per cent) underwent surgical exploration only, 97 patients (26·5 per cent) underwent palliative bypass surgery and 211 patients (57·7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9·0 per cent, stage II in 18·0 per cent, stage III in 68·7 per cent and stage IV in 4·3 per cent of patients who underwent resection. Resection was curative (R0) in 75·8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41·2 per cent), classical Whipple resection (37·0 per cent), left pancreatic resection (13·7 per cent) and total pancreatectomy (8·1 per cent). The in-hospital mortality and cumulative morbidity rates were 2·8 and 44·1 per cent respectively. The overall actuarial 5-year survival rate was 19·8 per cent after resection. Survival was better after curative resection (R0) (24·2 per cent) and in lymph-node negative patients (31·6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival.



Conclusion:

Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma.

The trends in treatment and outcome of 13560 patients with pancreatic cancer, and in incidence of the disease, in the West Midlands health region were determined between 1957 and 1986 using data from the West Midlands Region Cancer Registry. Patients were divided into those diagnosed in the first 20 years (19570–1976, n = 7888) and the most recent 10 years (1977–1986, n = 5672). The disease was more common in men and the incidence increased up to 1970 after which it levelled off. In the 1977–1986 period a lower proportion of patients had laparotomy alone (825 (14·5 per cent) versus 1552 (19·7 per cent)), a similar proportion had bypass surgery (2010 (35·4 per cent) versus 2760 (35·0 per cent)), while a greater proportion had supportive care (2710 (47·8 per cent) versus 3368 (42·7 per cent)) but the resection rates were the same (145 (2·6 per cent) versus 208 (2·6 per cent)). The 30-day mortality rates between the two periods unproved for resection (40 (27·6 per cent) versus 94 (45·2 per cent)), bypass surgery (436 (21·7 percent) versus 691 (25·0 per cent)) and laparotomy (372 (45·1 per cent) versus 873 (56·3 per cent)). The 12-month survival rate for bypass did not significantly differ during the study (14·9 per cent versus 12·4 per cent) but there was a significant improvement in the 5-year survival for resection (9·7 per cent versus 2·6 per cent, P < 0·015). The resection rates were low and 30-day mortality rates for surgery were high compared with those of other published series.

Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study.

Between 1957 and 1981, 31,716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17.42 per 100,000 population during the first quinquennium to 15.30 per 100,000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.

Gastric cancer: a 25-year review.

How do we ensure that surgical care practitioners are supported and developed? 

W. H. Allum

Papers

Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study.

Gastric cancer: a 25-year review.

The role of surgical care practitioners in the extended surgical team