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Page 6 of 9                          Makuuchi et al. J Cancer Metastasis Treat 2018;4:26  I  http://dx.doi.org/10.20517/2394-4722.2018.15

                                 A  Survival rate (%)
                                   100

                                    80                        Pancreatic invasion
                                                              (n = 11)

                                    60

                                    40                         Duodenum invasion
                                                               (n = 6)
                                    20
                                                                           P = 0.048
                                     0
                                                1                    2                   3                    4                    5
                                                           Survival time (years)

                                 B  Survival rate (%)
                                   100                    Differentiated type
                                                          (n = 10)
                                    80

                                    60


                                    40
                                                               Undifferentiated type
                                                               (n = 7)
                                    20
                                                                               P = 0.004
                                     0
                                                 1                   2                    3                   4                    5
                                                          Survival time (years)
               Figure 2. OS curves of 17 patients who underwent R0 resection. The 5-year OS rate was significantly better (A) in patients with
               pancreatic invasion than in those with duodenal invasion (54.5% vs. 0%; P = 0.048) and (B) in patients with differentiated tumors than
               in those with undifferentiated tumors (68.6% vs. 0%; P = 0.004). OS: overall survival

               invasion (n = 11, 54.5% vs. n = 6, 0%; P = 0.048) [Figure 2A]. Likewise, the 5-year OS rate was significantly
               higher in patients with differentiated tumors than in those with undifferentiated tumors (n = 10, 68.6% vs. n
               = 7, 0%; P = 0.004) [Figure 2B]. The univariate analysis of patients who underwent R0 resection is shown in
               Table 2.

               Although conclusive results are difficult to obtain from previous studies, which had limited number of
               patients and heterogeneous data, it appeared that R0 resection is the minimum requirement for cure and that
               PD should not be performed in cases of CY1. In addition, tumors with duodenal invasion have little chance
               for cure; therefore, in cases with a positive resection margin, palliative surgery followed by chemotherapy or
               radiotherapy may be an alternative to PD. However, evidence proving this hypothesis is lacking.


               DIAGNOSIS OF PANCREATIC INVASION BEFORE OR DURING OPERATION
               Intraoperative diagnosis of tumor invasion to the pancreas has been reported to be difficult, with an
               accuracy rate ranging from 39% to 56.7% [5,6,22] . Adhesions secondary to desmoplastic reaction or tumor
                                                            [23]
               inflammation can be mistaken for local invasion , which could lead to patients being subjected to
               unnecessary multivisceral resection and result in increased morbidity and mortality without oncological
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