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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