Background: The clinical course of complete pathologic response (cPR) in pancreatic cancer after neoadjuvant chemotherapy is not well known. The aim of this study was to investigate the clinical course of patients according to pathological response, including cPR, who received only FOLIFIRNOX in advanced pancreatic cancer. Methods: Patients who underwent pancreatectomy after FOLFIRINOX for pancreatic ductal adenocarcinoma (PDAC) from 2017 to 2019 were retrospectively reviewed. cPR was defined as an absence of residual tumor on pathologic report. A nearly complete pathologic response (ncPR) was defined as a tumor confined to pancreas parenchyma, less than 1 cm without lymph-node metastasis. cPR and ncPR were assigned into a favorable pathologic response group (fPR). Kaplan–Meier method and Cox proportional hazard models were used for analysis. Results: Of a total 64 patients, 8 (12.5%) had a cPR and 8 (12.5%) had a ncPR. In the fPR group, median OS and DFS were superior to those of non-pathologic response group (more than 60 months vs. 38 months, p < 0.001; more than 42 months vs. 10 months, p < 0.001). On multivariable analyses, fPR and adjuvant therapy were independent prognostic factors for OS (HR: 0.12; 95% CI: 0.02–0.96, p = 0.05; HR: 0.26; 95% CI: 0.09–0.74, p = 0.01) and DFS (HR: 0.31; 95% CI: 0.12–0.86, p = 0.02; HR:0.31; 95% CI: 0.13–0.72, p = 0.01). Conclusions: pathologic response predicts survival after pancreatectomy following neoadjuvant FOLFIRINOX for pancreatic cancer, and adjuvant chemotherapy following neoadjuvant treatment might be beneficial for OS and DFS.

Importance: Although tumor-infiltrating lymphocytes (TILs) have been implicated as prognostic biomarkers across various malignancies, the clinical application remains challenging. This study evaluated the applicability of artificial intelligence (AI)–powered spatial mapping of TIL density for prognostic assessment in resected pancreatic ductal adenocarcinoma (PDAC).Objective: To evaluate the prognostic significance of AI-powered spatial TIL analysis in resected PDAC and its clinical applicability.Design, Setting, and Participants: This cohort study included patients with PDAC who underwent up-front R0 resection at a tertiary referral center between January 2017 and December 2020. Whole-slide images of retrospectively enrolled patients with PDAC and up-front R0 resection were analyzed. An AI-powered whole-slide image analyzer was used for spatial TIL quantification, segmentation of tumor and stroma, and immune phenotype classification as immune-inflamed phenotype, immune-excluded phenotype, or immune-desert phenotype. Study data were analyzed from January 2017 to August 2023.Exposure: Use of AI-powered spatial analysis of the tumor microenvironment in resected PDACs.Main Outcomes and Measures: Tumor microenvironment–related risk factors and their associations with overall survival (OS) and recurrence-free survival (RFS) outcomes were identified.Results: Among 304 patients, the mean (SD) age was 66.8 (9.4) years with 171 male patients (56.3%), and preoperative clinical stages I and II were represented by 54.3% patients (165 of 304) and 45.7% patients (139 of 304), respectively. The TILs in the tumor microenvironment were predominantly concentrated in the stroma, and the median intratumoral TIL and stromal TIL densities were 100.64/mm² (IQR, 53.25-121.39/mm²) and 734.88/mm² (IQR, 443.10-911.16/mm²), respectively. Overall, 9.9% of tumors (30 of 304) were immune inflamed, 85.2% (259 of 304) were immune excluded, and 4.9% (15 of 304) were immune desert. The immune-inflamed phenotype was associated with the most prolonged OS (median not reached; P < .001) and RFS (median not reached; P = .001), followed by immune-excluded phenotype and immune-desert phenotype. High intratumoral TIL density was associated with longer OS (median, 52.47 months; 95% CI, 41.98-62.96; P = .004) and RFS (median, 21.67 months; 95% CI, 14.43-28.91; P = .02). A combined analysis of the pathologic stage with immune phenotype predicted better survival of stage II PDAC stratified as immune-inflamed phenotype than stage I PDAC stratified as non–immune-inflamed phenotype.Conclusions and Relevance: Results of this cohort study suggest that the use of AI has markedly condensed the labor-intensive process of TIL assessment, potentially rendering the process more feasible and practical in clinical application. Importantly, the IP may be one of the most important prognostic biomarkers in resected PDACs.

Despite the empirical use of human albumin during pancreatectomy to replace intraoperative volume loss while preventing fluid overload and edema, its impact on postoperative outcomes remains unclear. In addition, most previous studies have focused on the effects of therapeutic albumin usage. Here, we investigated whether preemptive administration of human albumin to prevent edema during pancreatectomy could reduce the incidence of moderate postoperative complications. Adult patients undergoing pancreatectomy were assigned to either the albumin group (n = 100) or the control group (n = 100). Regardless of the preoperative albumin level, 200 mL of 20% albumin was administered to the albumin group after induction of anesthesia. The primary outcome was the incidence of moderate postoperative complications as defined by a Clavien–Dindo classification grade ≥ 2 at discharge. Intraoperative net-fluid balance, a known risk factor of postoperative complication after pancreatectomy, was lower in the albumin group than in the control group (p = 0.030), but the incidence of moderate postoperative complications was not different between the albumin and control groups (47/100 vs. 38/100, respectively; risk ratio: 1.24, 95% CI: 0.89 to 1.71; p = 0.198). Therefore, preemptive administration of human albumin to prevent fluid overload and edema during pancreatectomy is not recommended because of its lack of apparent benefit in improving postoperative outcomes.

Given the rare incidence of pancreatic acinar cell carcinoma (PACC), its post-resection clinical outcomes remain unclear. Treatment strategies for PACC have relied on those of pancreatic ductal adenocarcinoma (PDAC). The present study retrospectively investigated clinicopathologic characteristics of resected PACC registered in the Korea Tumor Registry System Biliary Pancreas database. Among 59 patients with a mean age of 59.2 years and a male predominance (83.1%), 43, 5, 7, and 4 had pure PACC, ductal differentiations, mixed neuroendocrine carcinomas, and intraductal and papillary variants, respectively. The mean tumor size was 4.6 cm, consisting of eight at T1, 26 at T2, and 25 at T3 stages. Metastasis to regional lymph node was identified in 15 (25.4%) patients. Thirty-one (52.5%) patients received adjuvant therapy. Five-year survival rate was 57.4%. The median survival was 78.8 months. In survival comparison according to the stage with AJCC system, N stage (lymph node metastasis), but not T stage, showed significant differences (p = 0.027). Resected PACC appeared to have clinical outcomes distinct from those of PDAC in this nationwide study. Therefore, large-scale multinational studies are needed to overcome the rarity of PACC and to establish an appropriate treatment strategies and staging system.

Background/Purpose: This study aimed to evaluate the clinical outcomes of stereotactic body proton beam therapy (SBPT) for pancreatic cancer. Methods: This retrospective study included 49 patients who underwent SBPT for pancreatic cancer between 2017 and 2020. Survival outcomes, bowel-related toxicities, and failure patterns were analysed. SBPT was performed after induction chemotherapy in 44 (89.8%) patients. The dose-fractionation scheme included 60 gray (Gy) relative biological effectiveness (RBE) in five fractions (n = 42, 85.7%) and 50 GyRBE in five fractions (n = 7, 14.3%). The median follow-up was 16.3 months (range, 1.8–45.0 months). Results: During follow-up, the best responses were complete response, partial response, and stable disease in four (8.2%), 13 (26.5%), and 31 (63.3%) patients, respectively. The 2-year overall survival, progression-free survival, and local control (LC) rates were 67.6%, 38.0%, and 73.0%, respectively. Grade ≥ 3 gastroduodenal (GD) toxicity occurred in three (6.1%) patients. Among them, one patient underwent endoscopic haemostasis. The other two patients received surgical management. They were followed up without disease progression for >30 months after SBPT. Overall, there was no significant dosimetric difference between the grade ≥ 2 and lower toxicity groups. Conclusions: SBPT provides relatively high LC rates with acceptable toxicities in pancreatic cancer.

(1) Aim: To evaluate clinicopathological features and postoperative outcomes including survival in patients who underwent pancreaticoduodenectomy (PD) for periampullary diseases. (2) Methods: We retrospectively reviewed 3078 cases of PD performed in our center for 25 years. Periampullary diseases were divided into benign and malignancy groups. All cases were also classified by location. The time of 25 years was divided to different periods (5 years per period) to compare outcomes. Overall survival was compared between subdivided periods. (3) Results: Hospitalization became significantly shorter from 28.0 days in the 1st period to 13.8 days in the 5th period. Overall complication rate was significantly increased since the 3rd period. The rate without postoperative pancreatic fistula (POPF) was high at 98.7% in the 1st period. This might be because drain amylase on the 3rd day after PD was not routinely checked in the past. Thus, POPF was not detected. In survival analysis of adenocarcinoma of pancreas, bile duct, and ampulla, overall survival was found to be improved significantly in recent years. (4) Conclusions: Our study revealed that outcomes were improved with increasing number of PDs performed. Although POPF and overall complications showed increases more recently, those were detected and managed, resulting in shorter hospitalization and improved outcomes.