Objective:To investigate the safety and efficacy of the artery-first approach pancreaticoduo-denectomy (PD) combined with portal vein/superior mesenteric vein (PV/SMV) resection and reconstruction for pancreatic head malignancies.Methods:A retrospective analysis was conducted on 322 patients who underwent PD with PV/SMV resection and reconstruction at the Hepatobiliary Pancreatic Surgery Department of the First Hospital Affiliated to Naval Medical University between January 2016 and December 2022. Patients were divided into the artery-first approach PD group (AFA-PD group, n=165) and standard PD group (SPD group, n=157) based on surgical approach. Baseline characteristics, surgical outcomes, postoperative outcomes, pathological results and survival data were compared between two groups. Results:Compared to the SPD group, the AFA-PD group exhibited significantly reduced intraoperative blood loss (500 ml vs 600 ml), lower rates of obvious intraoperative blood loss (≥1 000 ml: 25.45% vs 40.13%), and decreased transfusion requirements (26.67% vs 52.87%). Postoperatively, the AFA-PD group demonstrated lower incidence of grade B/C pancreatic fistula (10.30% vs 19.75%) and higher textbook outcome achievement (78.79% vs 66.24%). Pathologically, the AFA-PD group achieved superior lymph node yield (20 nodes vs 18 nodes) and higher R 0 resection rates (79.39% vs 64.33%), particularly at the posterior pancreatic margin (96.97% vs 91.72%, P=0.040), SMA margin (92.07% vs 82.17%), and SMV margin (88.48% vs 78.98%). Multivariate logistic regression identified arterial invasion >180°, venous invasion >180°, lymph node metastasis, and the artery-first approach as independent predictors of R 0 resection. The AFA-PD group showed prolonged median survival (19.17 month vs 15.73 month). All aforementioned differences were statistically significant (all P value <0.05). Conclusions:The artery-first approach PD combined with PV/SMV resection and reconstruction is safe and effective for pancreatic head malignancies, significantly improving R 0 resection rates and patients' survival outcomes.

Objective:To investigate the safety and efficacy of the artery-first approach pancreaticoduo-denectomy (PD) combined with portal vein/superior mesenteric vein (PV/SMV) resection and reconstruction for pancreatic head malignancies.Methods:A retrospective analysis was conducted on 322 patients who underwent PD with PV/SMV resection and reconstruction at the Hepatobiliary Pancreatic Surgery Department of the First Hospital Affiliated to Naval Medical University between January 2016 and December 2022. Patients were divided into the artery-first approach PD group (AFA-PD group, n=165) and standard PD group (SPD group, n=157) based on surgical approach. Baseline characteristics, surgical outcomes, postoperative outcomes, pathological results and survival data were compared between two groups. Results:Compared to the SPD group, the AFA-PD group exhibited significantly reduced intraoperative blood loss (500 ml vs 600 ml), lower rates of obvious intraoperative blood loss (≥1 000 ml: 25.45% vs 40.13%), and decreased transfusion requirements (26.67% vs 52.87%). Postoperatively, the AFA-PD group demonstrated lower incidence of grade B/C pancreatic fistula (10.30% vs 19.75%) and higher textbook outcome achievement (78.79% vs 66.24%). Pathologically, the AFA-PD group achieved superior lymph node yield (20 nodes vs 18 nodes) and higher R 0 resection rates (79.39% vs 64.33%), particularly at the posterior pancreatic margin (96.97% vs 91.72%, P=0.040), SMA margin (92.07% vs 82.17%), and SMV margin (88.48% vs 78.98%). Multivariate logistic regression identified arterial invasion >180°, venous invasion >180°, lymph node metastasis, and the artery-first approach as independent predictors of R 0 resection. The AFA-PD group showed prolonged median survival (19.17 month vs 15.73 month). All aforementioned differences were statistically significant (all P value <0.05). Conclusions:The artery-first approach PD combined with PV/SMV resection and reconstruction is safe and effective for pancreatic head malignancies, significantly improving R 0 resection rates and patients' survival outcomes.

Objective:To investigate the clinical value of adjuvant therapy after conversion resection for pancreatic cancer.Methods:The retrospective cohort study was conducted. The clinicopathological data of 173 patients with pancreatic cancer who underwent surgical resection after neoadjuvant and/or induction therapy in The First Affiliated Hospital of Naval Medical University from January 2019 to December 2021 were collected. There were 107 males and 66 females, aged (59±9)years. Observation indicators: (1) comparison of clinicopathological data between patients with and without adjuvant therapy after conversion resection for pancreatic cancer; (2) analysis of influencing factors for prognosis of pancreatic cancer after conversion resection; (3) follow-up and prognosis; (4) survival benefit of adjuvant therapy in subgroup populations. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the non-parameter rank sum test. The Graphpad prism 8 software was used to draw survival curves, the Kaplan-Meier method was used to calculate survival time and survival rates, and the Log-Rank test was used for survival analysis. The COX proportional hazards regression model was used for univariate and multivariate analyses. Interaction analysis was used to determine the benefit of adjuvant therapy in subgroup populations. Results:(1) Comparison of clinicopathological data between patients with and without adjuvant therapy after conversion resection for pancreatic cancer. Of the 173 pancreatic cancer patients, there were 108 cases with adjuvant therapy after conversion resection and 65 cases without adjuvant therapy after conversion resection, respectively. Age and body mass index were (58±9)years and (23.2±2.8)kg/m 2 in patients with adjuvant therapy, versus (61±8)years and (22.2±2.8)kg/m 2 in patients without adjuvant therapy, showing significant differences in the above indicators between them ( t=-2.036, 2.200, P<0.05). (2) Analysis of influencing factors for prognosis of pancreatic cancer after conversion resection. Results of multivariate analysis showed that CA19-9 normalization, pathological N staging, degree of tumor differentiation and postoperative adjuvant therapy were independent factors influencing overall survival time in pancreatic cancer patients receiving conversion resection ( hazard ratio=1.598, 1.541, 2.004, 2.571, 95% confidence interval as 1.041-2.453, 1.021-2.327, 1.288-3.118, 1.721-3.843, P<0.05). (3) Follow-up and prognosis. All 173 patients were followed up for 24.5(5.0,52.0)months. The postoperative median overall survival time of 173 patients was 28.9(5.7,51.9)months, and the 1-, 2-, 3-year overall survival rates were 90%, 59%, 40%, respectively. Of 2019, 2020, 2021, the proportions of patients receiving adjuvant therapy after conversion resection were 62.8%(27/43), 57.7%(30/52) and 65.4%(51/78) respectively. The postoperative median overall survival time was 42.2(8.8,49.7)months in patients with adjuvant therapy after conversion resection, versus 20.4(5.7,51.9)months in patients without adjuvant therapy after conversion resection, showing a significant difference between them ( χ2=29.893, P<0.05). (4) Survival benefit of adjuvant therapy in subgroup populations. Results of interaction analysis showed that in subgroup populations with CA19-9 normalization, pathological stage N0, pathological stage N1-2, moderate to well differentiated tumors, adjuvant therapy after conversion resection can bring a better survival benefit for patients with pancreatic cancer ( adjustment hazard ratio=0.220, 0.300, 0.410, 0.340, 95% confidence interval as 0.120-0.400, 0.170-0.560, 0.240-0.690, 0.210-0.690). Conclusions:Postoperative adjuvant therapy is an independent factor influencing overall survival time in pancreatic cancer patients receiving conversion resection. Adjuvant therapy after conversion resection can bring additional survival benefits for pancreatic cancer, particularly for patients who respond favorably to neoadjuvant and/or induction therapy.

Objective:To investigate and compare the clinical outcomes of the arterial pre-occlusion technique(APOT) and the traditional technique in the surgery of locally advanced pancreatic cancer with arterial involvement after conversion therapy.Methods:This is a retrospective cohort study. The clinical data of 145 patients with locally advanced pancreatic cancer with arterial involvement admitted to the Department of Hepato-Biliary-Pancreatic Surgery of the First Hospital Affiliated to Naval Medical University,from January 2020 to December 2022 were retrospectively analyzed. All patients completed neoadjuvant therapy for tumors, and the feasibility of radical surgical treatment was determined by a multidisciplinary collaborative team evaluation before surgery. According to whether the intraoperative artery was pre-occluded, 145 patients were divided into two groups, including 28 cases in the APOT group(16 males, 12 females, aged (59.0±9.4) years), and 117 cases in the routine surgery group(76 males, 41 females, aged (55.1±8.2) years). To ensure comparability of baseline data between the APOT group and the routine surgery group, a 1∶2 match was performed using the propensity score matching method, and the caliper value was 0.006 45. The t-test,the Mann-Whitney U test, χ2 test or Fisher′s exact test were used to compare the data between the two groups,respectively. Results:After matching the propensity score,there were 28 cases in the APOT group and 56 cases in the routine surgery group. There were no significant differences in gender,age,preoperative comorbidities,preoperative body mass index,surgical approaches,chemotherapy regimen,stereotactic body radiation therapy ratio,tumor markers,and type of invaded artery between the two groups (all P>0.05).The arterial occlusion time M(IQR) in the APOT group was 7.0(3.8)minutes(range:3 to 15 minutes),and no ischemic manifestations were observed in the distal target organs that blocked blood vessels after surgery. The operation time was (170.3±57.7)minutes in the APOT group and (235.0±80.2)minutes in the routine surgery group,and the difference was statistically significant ( t=-3.800, P<0.01). The APOT group also experienced less intraoperative blood loss(650(588)ml vs. 800(600)ml; U=1 026.500, P=0.021). No significant differences were found between the groups in combined vein resection and reconstruction,celiac trunk resection,early postoperative complications, readmission rates at 30 days,and postoperative length of stay(all P>0.05). Extra-arterial dissection was performed in all patients,with arterial resection and reconstruction in 3 cases: 2 cases in the APOT group(1 case involving the superior mesenteric artery and 1 case involving the common hepatic artery) and 1 case in the routine group(involving the common hepatic artery). Postoperative abdominal bleeding occurred in 4 cases,with 3 cases in the routine group,1 case in the routine group. The R0 resection rate was 85.7%(24/28) in the APOT group and 80.4%(45/56) in the routine group,without significant differences between the groups( P=0.763). The median overall survival time was 27.6 months for the APOT group and 22.5 months for the routine group,while the median disease-free survival was 11.7 months and 16.8 months,respectively,with no significant differences between the two groups( P=0.532, P=0.927). Conclusion:The arterial pre-occlusion technique can be used for extra-arterial dissection in patients with locally advanced pancreatic cancer involving the arteries,reducing surgery time and intraoperative blood loss.

Objective:To investigate and compare the clinical outcomes of the arterial pre-occlusion technique(APOT) and the traditional technique in the surgery of locally advanced pancreatic cancer with arterial involvement after conversion therapy.Methods:This is a retrospective cohort study. The clinical data of 145 patients with locally advanced pancreatic cancer with arterial involvement admitted to the Department of Hepato-Biliary-Pancreatic Surgery of the First Hospital Affiliated to Naval Medical University,from January 2020 to December 2022 were retrospectively analyzed. All patients completed neoadjuvant therapy for tumors, and the feasibility of radical surgical treatment was determined by a multidisciplinary collaborative team evaluation before surgery. According to whether the intraoperative artery was pre-occluded, 145 patients were divided into two groups, including 28 cases in the APOT group(16 males, 12 females, aged (59.0±9.4) years), and 117 cases in the routine surgery group(76 males, 41 females, aged (55.1±8.2) years). To ensure comparability of baseline data between the APOT group and the routine surgery group, a 1∶2 match was performed using the propensity score matching method, and the caliper value was 0.006 45. The t-test,the Mann-Whitney U test, χ2 test or Fisher′s exact test were used to compare the data between the two groups,respectively. Results:After matching the propensity score,there were 28 cases in the APOT group and 56 cases in the routine surgery group. There were no significant differences in gender,age,preoperative comorbidities,preoperative body mass index,surgical approaches,chemotherapy regimen,stereotactic body radiation therapy ratio,tumor markers,and type of invaded artery between the two groups (all P>0.05).The arterial occlusion time M(IQR) in the APOT group was 7.0(3.8)minutes(range:3 to 15 minutes),and no ischemic manifestations were observed in the distal target organs that blocked blood vessels after surgery. The operation time was (170.3±57.7)minutes in the APOT group and (235.0±80.2)minutes in the routine surgery group,and the difference was statistically significant ( t=-3.800, P<0.01). The APOT group also experienced less intraoperative blood loss(650(588)ml vs. 800(600)ml; U=1 026.500, P=0.021). No significant differences were found between the groups in combined vein resection and reconstruction,celiac trunk resection,early postoperative complications, readmission rates at 30 days,and postoperative length of stay(all P>0.05). Extra-arterial dissection was performed in all patients,with arterial resection and reconstruction in 3 cases: 2 cases in the APOT group(1 case involving the superior mesenteric artery and 1 case involving the common hepatic artery) and 1 case in the routine group(involving the common hepatic artery). Postoperative abdominal bleeding occurred in 4 cases,with 3 cases in the routine group,1 case in the routine group. The R0 resection rate was 85.7%(24/28) in the APOT group and 80.4%(45/56) in the routine group,without significant differences between the groups( P=0.763). The median overall survival time was 27.6 months for the APOT group and 22.5 months for the routine group,while the median disease-free survival was 11.7 months and 16.8 months,respectively,with no significant differences between the two groups( P=0.532, P=0.927). Conclusion:The arterial pre-occlusion technique can be used for extra-arterial dissection in patients with locally advanced pancreatic cancer involving the arteries,reducing surgery time and intraoperative blood loss.

Objective:To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN).Methods:A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤ acyst diameter ≥40 mm,⑤ bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results:Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly ( P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail, OR=3.284,95% CI:1.268-8.503, P=0.014),thickened/enhancement cyst wall (with vs.without, OR=2.713,95% CI:1.177-6.252, P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95% CI:2.05-12.62, P<0.01) and NLR(≥2 vs.<2, OR=2.380,95% CI:1.043-5.434, P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤ b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤ a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤ b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions:Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

Objective:To analyze the clinical and pathological features and gene mutations of pancreatic acinar cell carcinoma (PACC).Methods:Clinical data of 34 patients with PACC admitted to the Department of Pancreatic Surgery of the First Affiliated Hospital of Naval Medical University from December 2009 to July 2018 were retrospectively analyzed to summarize its clinical characteristics, and the expressions of α1-ACT, CaM5.2, Syn and CgA in pancreatic tumor tissues were detected by immunohistochemistry. Next-generation gene sequencing technology was used to detect gene mutations in tumor specimens.Results:Among the 34 PACC patients, 23(68%) were males and 11(32%) were females; the age ranged from 25 to 75 years, with an average age of 54 years. The first symptom was abdominal pain or distension in 21 cases (62%), skin or scleral yellow staining in 4 cases(12%), and 9 cases(26%) were found in routine physical examination. BMI was 17.6-34.0 kg/m 2, of which 3 cases (9%) were <18.5 kg/m 2, 23 cases (68%) were 18.5-24.0 kg/m 2, and 8 cases (23%) were >24.0 kg/m 2. Preoperative examination showed elevated CA19-9 in 7 cases (20.6%), elevated CEA in 3 cases (8.8%), and elevated AFP in 7 cases (20.6%). Blood amylase was 16-247 U/L, with an average of 80 U/L. Enhanced CT showed that the lesion was irregular in shape, showing inhomogeneity and slightly low density, with areas of cystic degeneration and necrosis. The tumor was located in the head of the pancreas in 14 cases (41%), the body and tail of the pancreas in 19 cases (56%), and the neck of the pancreas in 1 case (3%). The largest tumor diameter was 1.5-15.5 cm, with an average of 5.4 cm. Postoperative pathologic stage I was confirmed in 4 cases (12%), stage Ⅱ in 14 cases (41%), stage Ⅲ in 14 cases (41%) and stage Ⅳ in 2 cases (6%). Immunohistochemical results showed that both α1-ACT and CaM5.2 were positively expressed (100%). Syn was positive in 8 cases (23.5%) and CgA was positive in 6 cases (17.6%). Ki-67 index was from 9% to 70%, with an average of 41%. Gene sequencing of pancreatic tumor tissue from 6 patients showed BRCA2 mutation in 2 patients (7155C>G), K-ras mutation in 1 patient (35G>T), RET mutation in 1 patient (200G>A), and LKB1 mutation (234G>T) in 1 patient, and one double mutation of K-ras and RET (35G>A, 1 798C>T). 30 patients were followed up, and the median survival was 38.3 months. Conclusions:PACC was a rare pancreatic tumor with no specific clinical manifestations. The positive expression rates of α1-ACT and CAM5.2 in tumor tissues were 100%. BRCA2, K-ras, RET and LKB1 were common gene mutations.

Objective:To evaluate the performance of the European Evidence-based Guidelines on Pancreatic Cystic Neoplasms (EEGPCN)(2018) and International Association of Pancreatology(IAP) Guideline(Version 2017) in predicting high grade dysplasia/invasive carcinoma-intraductal papillary mucinous neoplasm(HGD/INV-IPMN).Methods:A retrospective analysis of 363 patients,who underwent surgical resection in Changhai Hospital affiliated to Navy Medical University from January 2012 to December 2018 and were pathologically identified as (intraductal papillary mucinous neoplasm, IPMN),was performed. The patients,including 230 males and 133 females,aging (61.7±10.1) years(range:19 to 83 years). The proportion of HGD/INV-IPMN who met with the absolute indication(AI) of EEGPCN and high risk stigma(HRS) of IAP were compared. The binary Logistic regression analysis was used to find the independent risk factors of HGD/INV-IPMN.Eight combinations of risk factors derived from relative indication/worrisome feature or risk factors in this study,were made to evaluate the diagnostic efficacy. The area under curve(AUC) of receiver operating characteristics was used to evaluate the the cutoff value of risk factors(①CA19-9≥37 U/ml,②diameter of main pancreatic duct 5.0-9.9 mm,③enhancing mural nodule<5 mm,④(acute) pancreatiti,⑤ acyst diameter ≥40 mm,⑤ bcyst diameter ≥30 mm, ⑥thickened or enhancing cyst walls,⑦neutrophile granulocyte to lymphocyte ratio(NLR)≥2, ⑧cyst located in head, uncinate or neck,⑨carcinoembryonic antigen(CEA) ≥5 μg/L) number for predicting HGD/INV-IPMN.The accuracy,sensitivity,specificity,positive predictive value,negative predictive value,true positive,true negative,false positive,false negative,positive likelihood ratio,negative likelihood ratio,Youden index and F1 score were calculated. Results:Ninety-two patients(49.5%) of 186 ones who met AI and 85 patients(48.3%) of 176 ones who met HRS were respectively confirmed as HGD/INV-IPMN. In those patients who were not met AI,tumor location,thickened/enhancing cyst wall,CA19-9 elevated,NLR≥2 and CEA elevated were significantly ( P<0.05) correlated with HGD/INV-IPMN. And tumor location(head/uncinate/neck vs. body/tail, OR=3.284,95% CI:1.268-8.503, P=0.014),thickened/enhancement cyst wall (with vs.without, OR=2.713,95% CI:1.177-6.252, P=0.019),CA19-9(≥37 U/L vs.<37 U/L, OR=5.086,95% CI:2.05-12.62, P<0.01) and NLR(≥2 vs.<2, OR=2.380,95% CI:1.043-5.434, P=0.039) were the independent risk factors of HGD/INV-IPMN. Patients with ≥4 risk factors of 9 in combination Ⅷ(①②③④⑤ b⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the moderate accuracy(71.0%),moderate sensitivity (62.0%) and moderate specificity (73.0%). Patients with ≥4 risk factors of 9 in Combination Ⅶ(①②③④⑤ a⑥⑦⑧⑨) were diagnosed as HGD/INV-IPMN with the highest specificity(83.0%) and patients with ≥3 risk factors of 8 in combination Ⅵ(①②③④⑤ b⑥⑧⑨) were diagnosed as HGD/INV-IPMN with the highest sensitivity(74.0%). The AUC for diagnosis of HGD/INV-IPMN in combination Ⅵ,Ⅶ and Ⅷ were 0.72,0.75 and 0.75,respectively. Older patients and younger patients could respectively refer to combination Ⅶ and combination Ⅵ to improve the management of IPMN. Conclusions:Patients who meet AI of EEGPCN should undertake resection, otherwise the method we explored is recommended. The method of improvement for diagnosis of HGD/INV-IPMN is relatively applicable and efficient for decision-making of surgery, especially for younger patients with decreasing of missed diagnosis and elder patients with decreasing of misdiagnosis.

As a new direction of pancreatic cancer treatment, neoadjuvant therapy for pancreatic cancer has been confirmed to be able to improve the prognosis of the patients. Under multidisciplinary treatment (MDT) mode, neoadjuvant therapy combines multidisciplinary advantages to solve patients′ problems of diagnosis and treatment, provides accurate, comprehensive and individual treatments, and maximizes the clinical benefit for patients. In this article, we summarize the present problems of neoadjuvant therapy for pancreatic cancer in patient selection, treatment regimen selection, treatment response evaluation and surgical selection, and explore the direction of clinical research and neoadjuvant therapy for pancreatic cancer under MDT mode.

Objective: To examine the prognostic value of four important driver gene mutations in patients with radical resection of pancreatic cancer. Methods: The clinical data and follow-up data of pancreatic cancer patients undergoing radical pancreatectomy and targeted sequencing from January 2016 to March 2018 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital were retrospectively analyzed.There were 159 males and 88 females,aged of (60.8±8.7)years(range:33-83 years) and preoperative CA19-9 of (492.4±496.6)kU/L(range: 2-1 200 kU/L). One hundred and fifty nine cases of tumors were located in the head and 88 cases in the body and tail of the pancreas. After univariate analysis of clinical pathological factors (including gender, age, preoperative CA19-9, tumor location, tumor differentiation, pathological T and N stage, Micr. perineural invasion, Micr. lympho-vascular invasion, resection margin), the variable whose P<0.1 was included in COX regression model with four important driver gene mutations to find which mutation was related to prognosis independently. The number of gene mutations and KRAS subgroups were analyzed by Kaplan-Meier curve. Results: Among 247 patients,the number of KRAS,TP53, SMAD4 and CDKN2A mutations was 212 cases(85.8%), 160 cases(64.8%), 66 cases(26.7%) and 44 cases(17.8%),respectively.KRAS mutation was correlated with the tumor differentiation and pathological T stage (χ²=24.570/6.690, P=0.000/0.035), TP53 mutation was correlated with the tumor differentiation and the resected margin(χ²=5.500/4.620, P=0.019/0.032), and CDKN2A mutation was correlated with gender(χ²=16.574, P=0.000).COX regression model analysis showed that only KRAS mutation was an independent risk factor for disease free survival and overall survival(HR=1.776, 95%CI: 1.079-2.923, P=0.024; HR=1.923, 95%CI: 1.016-3.639, P=0.045); KRAS^G12D mutation was associated with shorter OS(P=0.007). Conclusion KRAS and its subgroup KRAS^G12D mutation can be used as a prognostic index for patients with radical resection of pancreatic cancer.