Effect of a Structured Teaching Module Including Intensive Prophylactic Measures on Reducing the Incidence of Capecitabine-Induced Hand-Foot Syndrome: Results of a Prospective Randomized Phase III Study

LESSONS LEARNED

A structured teaching module including intensive prophylactic measures to alleviate hand-foot syndrome (HFS) during capecitabine therapy is feasible but ineffective at protecting patients from HFS. Pharmacologic therapeutic interventions should be investigated for the management of this complication.

BACKGROUND

Capecitabine-induced hand-foot syndrome (HFS) has a detrimental effect on quality of life. The effect of a structured teaching module including intensive prophylactic measures was evaluated.

METHODS

This non-crossover phase III double-blinded clinical trial randomized patients in a 1:1 ratio to either a control group or to a group administered a structured teaching model including intensive prophylactic measures on HFS administered by a trained oncology nurse at regular intervals (case) versus standard information on HFS care administered by treating clinician (control). The primary endpoint was comparison of fraction of patients in both arms developing at least grade 2 HFS.

RESULTS

Between June 15, 2016, and April 4, 2018, 280 patients (140 to case and 140 to control) were enrolled. The median number of capecitabine chemotherapy cycles was eight; 269 patients (96%) were evaluable for HFS, of whom 89 patients (33.08%) developed at least grade 2 HFS (grade 2 HFS, 73 patients [26.1%]; grade 3 HFS, 16 patients (5.7%}). There was no difference in at least grade 2 HFS between evaluable case and control arms of the study (control group, 45/135 [33.3%]; case, 44/134 [32.8%]; p = .93).

CONCLUSION

The use of a structured teaching module including intensive prophylactic measures was feasible, but this did not reduce the incidence and severity of capecitabine-induced HFS.

Real-World Long-Term Outcomes with Perioperative EOX in D2 Gastrectomy: a Meaningful Look While We Switch to FLOT-4

INTRODUCTION

Data regarding long-term survival and prognosis in loco-regionally advanced, non-metastatic gastric cancers (GC) using perioperative chemotherapy and D2 lymphadenectomies from India is scarce.

MATERIALS AND METHODS

The study is a retrospective evaluation of locally advanced gastric cancers who received epirubicin-oxaliplatin-capecitabine (EOX) as perioperative therapy from May 2013 to December 2015 at Tata Memorial Hospital, Mumbai. The report concentrates on long-term survival outcomes and prognostic factors. Event-free survival (EFS) and overall survival (OS) were calculated using Kaplan-Meier method.

RESULTS

Two hundred and sixty-eight patients were started on EOX regimen, of which 200 patients (74.6%) underwent definitive resection with D2 lymphadenectomy. With a median follow-up of 52.7 months, the estimated median 3-year and 5-year EFS were 38.5% and 36.3% respectively. The estimated median 3-year and 5-year OS were 41.7% and 37.6% respectively. Patients younger than age 40 years [HR 1.55 (1.034-2.321); p = 0.034] and with poorly differentiated histology [HR 0.65 (0.446-0.944); p = 0.024] had inferior OS compared to their counterparts.

CONCLUSIONS

Long-term OS in Indian patients in non-metastatic GC with EOX chemotherapy and D2 lymphadenectomy is similar to previously published Western data. Younger Indian patients fare worse than their older counterparts and this needs further evaluation.

Clinical Utility of Staging Laparoscopy for Advanced Obstructing Rectal Adenocarcinoma: Emerging Tool

The multimodal treatment for advanced rectal adenocarcinoma mandates accurate preoperative staging with contrast-enhanced computed tomography (CECT) of the thorax, abdomen, and pelvis, and magnetic resonance imaging (MRI) of the pelvis. Unlike gastric cancer, the role of staging laparoscopy (SL) in advanced colorectal cancer has not been evaluated. This study aims to evaluate the clinical value of SL in treatment decision-making for advanced rectal cancer (RC) with near or complete obstructing tumors. Observational review of colorectal database at Tata Memorial Hospital from January 2013 to December 2016 identified 562 patients diagnosed and treated for advanced RC. Of the 562 cases, 48.7% (274) were clinically and radiologically diagnosed of near or complete obstructing advanced RC. Medical records of 34% (94/274) who underwent SL with diversion stoma (DS) were analyzed. In the absence of ascites, extensive peritoneal deposits, and unresectable liver metastases on SL, a curative treatment was offered, which entailed neoadjuvant chemoradiation (NACTRT), whereas the cohort of patients with extensive peritoneal disease received palliative therapy. Of the 94 patients with advanced RC, conventional imaging studies staged 73.5% (69/94) cohort as non-metastatic locally advanced and 26.5% (25/94) had potentially resectable metastatic RC. Pre-therapeutic SL upstaged the disease by 26% (18/69) and 8% (2/25) in locally advanced and potentially resectable metastatic RC cohorts, respectively. Treatment decision changed in 21.2% (20/94) of the patients, and midline laparotomy was thus avoided. In our observational study, SL was found to be a safe and effective staging modality in RC; it detected occult peritoneal disease and prevented midline laparotomy in 21.2% of the cohort, which was of value to determine treatment strategy in patients with advanced RC before initiating NACTRT. SL and laparoscopic-assisted de-functioning stoma were associated with minimal morbidity and led to early initiation of NACTRT.

Nontrial, real-world outcomes in unresectable locally advanced pancreatic cancer: Chemotherapy and chemoradiation is the standard while surgery is uncommon

BACKGROUND

Outcomes and survival of truly unresectable locally advanced pancreatic cancers (LAPC) is often reported along with borderline resectable pancreatic cancers especially from a real world cohort.

METHODS

The audit of LAPC patients, diagnosed based on the NCCN criteria between February 2013 and January 2016 was used to identify patients starting and continuing treatment in our institution. Practice patterns, outcomes and prognostic factors for overall survival were evaluated.

RESULTS

Of the 83 patients, 52 were available for inclusion in the analysis. Median age was 56 years (range 30- 77), with males constituting 75% of patients. Baseline comorbidities seen were diabetes mellitus, hypertension and cardiac dysfunction in 46.1%, 69.1% and 52% of patients respectively. 84.6% of patients had arterial vascular involvement as criteria for unresectable LAPC. 50% of patients received chemotherapy only, while the remainder received chemotherapy and concurrent chemoradiation. One patient was able to undergo curative R0 resection. FOLFIRINOX was the most commonly used chemotherapy regimen (53.8%). With a median follow up of 15.9 months, median progression free survival (mPFS) was 7.26 months (95% CI: 5.75-8.76) and median OS was 11.8 months (95% CI: 9.96 - 13.61). None of the potential prognostic factors evaluated, i.e., age, gender, nodal status, pre-treatment CA 19.9 levels, showed correlation with OS.

CONCLUSION

This analysis shows outcomes in unresectable LAPC comparable to existing literature. Surgery in unresectable LAPC patients is less common than seen in previously published studies, more likely due to this cohort being truly 'unresectable' in terms of major arterial involvement.

Under-representation of older Indian persons with cancer in clinical trials

OBJECTIVE

Older patients with cancer have traditionally been under-represented in global clinical trials. There are no data from India regarding this issue.

METHODS AND ANALYSIS

This was a retrospective analysis done at our institute on interventional studies conducted between 2003 and 2023 in adult patients with malignancies. We excluded studies done exclusively in the paediatric population and observational studies.

RESULTS

We included 21 894 patients enrolled in 150 interventional trials from the departments of surgical, medical, and radiation oncology, anaesthesia, and clinical pharmacology; 110 (73.3%) were investigator initiated. There were 38 trials (25.3%) in breast cancer (6141 patients, 28%), and 33 (22%) in head and neck cancer (6975 patients, 31.9%). Studies were predominantly phase III (97 trials (64.7%)). Multicentric studies comprised approximately one-third (48, 32%). The median age of enrolled patients was 51 years (IQR 43-59). There were 5132 (23.4%) participants aged ≥60 years, 2678 (12.2%) ≥65 years and 1045 (4.8%) ≥70 years. Data from the hospital registry revealed that 30% of adult registrations were ≥60 years. There was a significant increase in the proportion of older patients enrolled in clinical trials from 2003 (8%) to 2019 (22%) compared with their proportion in the hospital registry (stable at 28%-29%); p<0.001.

CONCLUSION

There is a gap between the proportion of older Indian adults with cancer in the hospital registry and those enrolled in interventional clinical trials, however, this gap has shrunk over time. Various factors that limit the recruitment of this vulnerable cohort like age-specific eligibility criteria are immediately actionable to make clinical trials more inclusive.

Red Cell Distribution Width and Gallbladder Cancer: Is It Really Useful?

PURPOSE

The data on the prognostic significance of red cell distribution width (RDW) in gallbladder cancers is sparse, especially in the potentially resectable cohort of patients. The aim was to assess the prognostic significance of RDW in gallbladder cancer patients undergoing surgery.

METHODS

Retrospective analysis of prospectively maintained database of gallbladder cancer patients undergoing surgery at a tertiary cancer institute from 2010 till 2018. Baseline values were collected. Patients were grouped as per the median RDW value and compared. Survival analysis was done using the Kaplan Meier method.

RESULTS

A total of 605 patients were included. The median follow up period was 23 months (range: 6-120 months). The median value of RDW was 14. Comparison between RDW > 14 and RDW < 14 groups showed no difference in outcomes. RDW did not predict overall survival or recurrences. However, in combined stages II and III, a statistically significant improvement in OS and DFS (p < 0.001) was noted in the RDW < 14 group.

CONCLUSION

RDW did not predict recurrence or survival in potentially resectable gallbladder cancer patients. However, in the subset of stages II and III in combination, lower RDW value was associated with better outcomes. More prospective studies are needed to conclusively establish the prognostic value of RDW.

Chemotherapy-Induced Nausea and Vomiting (CINV) with GI Cancer Chemotherapy: Do We Need CINV Risk Score Over and Above Antiemetic Guidelines in Prescribing Antiemetic Regime?

Background  Various predictive models have been developed which incorporates patient risk factors into the selection of optimal antiemetic therapy, one of which is chemotherapy-induced nausea and vomiting (CINV) risk scoring system developed by Multinational Association of Supportive Care in Cancer (MASCC). Patients and Methods  Consecutive patients with gastrointestinal malignancy who had not received previous chemotherapy were eligible for enrollment in the study if they were scheduled to receive at least one cycle of chemotherapy. The CINV risk assessment tool was used to collect the study data and to assess CINV risk score. Results  Ninety-eight patients fulfilling the eligibility criteria were included in this study, out of which 57% were males, median age was 48 years (range: 28-77). Colorectal cancer (32.7%) was the most common diagnosis followed by gastric cancer (27.6%). Gemcitabine/cisplatin and CAPOX regimen were the most common regimen being administered in 19.4% each. As per MASCC guidelines, 19.4% patients received highly emetogenic chemotherapy, 69.4% moderately emetogenic chemotherapy, while 11.2% received regimen with low emetogenicity. CINV risk module characterized 52% patients to have high risk for CINV, while 48% to have low risk of CINV, thus, 52% had the discrepancy in risk assigned by two methods, and this was statistically significant ( p = 0.025). In subgroup analysis, although patient cohort with acute nausea had no statistically significant discrepancy ( p = 0.123), but statistically significant discrepancy was found in patient cohort with delayed nausea ( p = 0.001), acute ( p = 0.038), and delayed ( p < 0.001) vomiting. Conclusion  A significant percentage of patients who receive chemotherapy continue to experience nausea and vomiting despite receiving antiemetic treatment as per standard guidelines. The study generates a hypothesis for future large randomized studies looking at change in antiemetic prophylaxis based on CINV risk tool, leading to improvement in complete response rates of acute and delayed CINV.

Chemotherapy-Induced Nausea and Vomiting in Gastrointestinal Cancer Patients: Do We Need to Revisit Guidelines?

Purpose  The objective of this study was to assess the proportion of patients developing chemotherapy-induced nausea and vomiting (CINV) after receiving chemotherapy for gastrointestinal (GI) cancers, despite receiving antiemetic prophylaxis (AEP) as per the standard guidelines. Patients and Methods  Between April 2019 and March 2020, all patients planned for chemotherapy were eligible for enrolment in the study. The primary endpoint of the study was the assessment of complete response (CR) rates. Results  Overall, 1,276 consecutive patients were screened for this study, while 738 patients fulfilling the eligibility criteria were included. A total of 23.2% of the whole cohort failed to achieve CR. Also, 28.2, 16.9, and 16.6% of patients receiving moderately emetogenic chemotherapy (MEC), low emetogenic chemotherapy (LEC), and high emetogenic chemotherapy (HEC), respectively, failed to achieve CR. The differences in failure to achieve CR was statistically significant between MEC and HEC ( p < 0.001) groups. Among MEC group, there was no difference between those who received oxaliplatin (27.8%) versus nonoxaliplatin regimens (25.8%) in terms of failure rates ( p = 0.613). Conclusion  Approximately one-fourth of patients failed to achieve a complete response from CINV in GI cancers despite using guideline-based AEP. Patients receiving MEC had the highest failure rates suggesting a need to improve AEP in these patients.

Chicken pox infection in patients undergoing chemotherapy: A retrospective analysis from a tertiary care center in India

There is paucity of data on the incidence, severity and management of chicken pox in patients receiving active chemotherapy for cancer. From October 2010 to October 2011, patients were included in this study if they developed a chicken pox infection during their chemotherapy. The details of patients' cancer diagnosis and treatment along with clinical and epidemiological data of the chicken pox infections were assessed from a prospectively maintained database. Twenty-four patients had a chicken pox infection while receiving chemotherapy and/or radiotherapy. The median age of the patients was 21 years, and two-thirds of the patients had solid tumor malignancies. Overall, eight (33%) patients had complications, six (25%) patients had febrile neutropenia, four (17%) had diarrhea/mucositis, and four (17%) had pneumonia. The median time for recovery of the infection and complications in the patients was 9.5 days (5-29 days), whereas for neutropenic patients, it was 6.5 days (3-14 days). The median time for recovery from chicken pox infections in neutropenic patients was 10 days (5-21 days), compared with 8.5 days (0-29 days) in non-neutropenic patients (P=0.84). The median time for recovery from infections was 8.5 days in patients with comorbidities (N=4), which was the same for patients with no comorbidities. The clinical presentation and complication rates of chicken pox in cancer patients, who were on active chemotherapy, are similar to the normal population. The recovery from a varicella infection and complications may be delayed in patients with neutropenia. The varicella infection causes a therapy delay in 70% of patients. Aggressive antiviral therapy, supportive care and isolation of the index cases remain the backbone of treatment.

Chemo-Radiation After Upfront Rectal Resections-a Clinical Dilemma

To compare the impact of adjuvant chemo-radiotherapy (ACRT) versus adjuvant chemotherapy (ACT) alone on recurrence and survival in patients with stage II and III rectal adenocarcinoma undergoing upfront curative resection. Prospective observational review of colorectal database at Tata Memorial Hospital from July 2010 to March 2015 identified 84 patients who underwent upfront curative resection for stage II or III rectal cancer. None of the patient received preoperative chemo-radiation. Of these, adjuvant chemo-radiotherapy was administered to 29 patients (ACRT group) and 55 patients received CAPEOX/FOLFOX-based adjuvant chemotherapy (ACT group) alone. At a median follow-up of 20 months, there were 10 recurrences (3 local recurrence) in the ACRT group and 15 (2 local recurrence) in ACT group. The estimated disease-free survival at 3 years in the ACRT group was 62.7% and in ACT group was 49.7% (p = 0.417) with an estimated 3-year overall survival of 74 and 78% in the ACRT and ACT group, respectively (p = 0.241). Subgroup analysis was performed after risk stratifying prognostic features (pT4, pN2, poor differentiation, involved resection margin). Our study does not show any benefit of ACRT over ACT on local control, disease-free and overall survival after upfront rectal cancer resection for low-risk stage II-III. In the subgroup analysis, local recurrence did not occur in patients who did not have poor prognostic features irrespective whether they received ACRT or ACT. Adjuvant chemo-radiation can be avoided in low-risk stage II-III rectal cancer after upfront resection.

Realizing Textbook Outcomes Following Liver Resection for Hepatic Neoplasms with Development and Validation of a Predictive Nomogram

BACKGROUND

'Textbook Outcome' (TO) represents an effort to define a standardized, composite quality benchmark based on intraoperative and postoperative endpoints. This study aimed to assess the applicability of TO as an outcome measure following liver resection for hepatic neoplasms from a low- to middle-income economy and determine its impact on long-term survival. Based on identified perioperative predictors, we developed and validated a nomogram-based scoring and risk stratification system.

METHODS

We retrospectively analyzed patients undergoing curative resections for hepatic neoplasms between 2012 and 2023. Rates of TO were assessed over time and factors associated with achieving a TO were evaluated. Using stepwise regression, a prediction nomogram for achieving TO was established based on perioperative risk factors.

RESULTS

Of the 1018 consecutive patients who underwent liver resections, a TO was achieved in 64.9% (661/1018). The factor most responsible for not achieving TO was significant post-hepatectomy liver failure (22%). Realization of TO was independently associated with improved overall and disease-free survival. On logistic regression, American Society of Anesthesiologists score of 2 (p = 0.0002), perihilar cholangiocarcinoma (p = 0.011), major hepatectomy (p = 0.0006), blood loss >1500 mL (p = 0.007), and presence of lymphovascular emboli on pathology (p = 0.026) were associated with the non-realization of TO. These independent risk factors were integrated into a nomogram prediction model with the predictive efficiency for TO (area under the curve 75.21%, 95% confidence interval 70.69-79.72%).

CONCLUSION

TO is a realizable outcome measure and should be adopted. We recommend the use of the nomogram proposed as a convenient tool for patient selection and prognosticating outcomes following hepatectomy.

Evaluation of Metronomic Therapy as a Low-Cost, Sustainable, Standard-of-Care Option in Desmoid Fibromatosis: Real-World Data From a Tertiary Care Center in India

PURPOSE

Desmoid fibromatosis (DF) is a locally aggressive tumor with low mortality but significant morbidity. There is a lack of standard of care, and existing therapies are associated with significant barriers including access, cost, and toxicities. This study aimed to explore the efficacy and safety of the metronomic therapy (MT) in DF in a large, homogenous cohort from India.

PATIENTS AND METHODS

This study involved histologically confirmed DF cases treated with MT comprising vinblastine (6 mg) and methotrexate (15 mg) both once a week, and tamoxifen (40 mg/m2) in two divided doses once daily between 2002 and 2018.

RESULTS

There were 315 patients with a median age of 27 years; the commonest site was extremity (142 of 315; 45.0%). There were 159 (50.1%) male patients. Of the 123 (39.0%) prior treated patients, 119 had surgery. Of 315 patients, 263 (83.5%) received treatment at our institute (MT-151, 77-local treatment, 9-tyrosine kinase inhibitor, and 26 were observed). Among the MT cohort (n = 163, 61.2%), at a median follow-up of 36 (0.5-186) months, the 3-year progression-free and overall survival were 81.1% (95% CI, 74.3 to 88.4) and 99.2% (95% CI, 97.6 to 100), respectively. There were 35% partial responses. Ninety-two patients (56.4%) completed 1-year therapy, which was an independent prognosticator (P < .0001; hazard ratio, 0.177 [95% CI, 0.083 to 0.377]). MT was well tolerated. Predominant grade ≥3 toxicities were febrile neutropenia, 12 (7.4%) without any chemotoxicity-related death. The annual cost of MT was $130 US dollars.

CONCLUSION

The novel, low-cost MT qualifies as one of the effective, less toxic, sustainable, standard-of-care options for the treatment of DF with global reach and merits wide recognition.

Radiotherapy for locally advanced unresectable gallbladder cancer - A way forward: Comparative study of chemotherapy versus chemoradiotherapy

BACKGROUND

For nonmetastatic locally advanced gallbladder cancer (LAGBC) which remains unresectable and nonmetastatic after chemotherapy, there is no consensus on whether to continue chemotherapy or add local radiotherapy (RT) for improving outcomes.

MATERIALS AND METHODS

Forty-five patients of surgically unresectable nonmetastatic LAGBC were analyzed. Twenty patients did not receive RT (no RT cohort) and received only chemotherapy, while 25 patients received RT (RT cohort) with conformal techniques along with concurrent gemcitabine-based chemotherapy. No RT and RT cohorts were compared for disease-related outcomes and toxicities.

RESULTS

Median follow-up of the entire cohort was 11.5 months. Two-year progression-free survival (18.6% vs. 0%, P = 0.0001) and overall survival (37.3% vs. 5%, P = 0.0001) were significantly better in the RT cohort as compared to a no RT cohort. More number of patients had locoregional progression in the no RT cohort (85% vs. 32%, P = 0.0002). Radiation-induced acute and late gastrointestinal toxicity ≥ RTOG Grade 3 were seen in one and two patients, respectively.

CONCLUSION

Addition of local RT to chemotherapy improves the survival outcomes and can be considered as a definite treatment modality for nonmetastatic LAGBC patients not amenable to surgery who have responded to chemotherapy.

Treatment of Metastatic Colorectal Cancers in Resource-Constrained Low- and Middle-Income Countries (LMICS) Scenario-Outcomes, Practice Patterns, and Commentary on Treatment Costs

Anant RamaswamyIntroduction  The overall survival (OS) of metastatic colorectal cancers (mCRCs) in clinical practice and resource-constrained low- and middle-income countries (LMICS) like India is not known. Materials and Methods  Data of patients with mCRC treated between January 2013 and August 2017 were accessed from a prospectively maintained database. Demographics, disease characteristics, chemotherapeutic regimens, use of monoclonal antibodies, and survival outcomes in treated patients were collected and analyzed. Costs of treatment options as off 2017 were also interpreted. Results  The data of 403 patients satisfied prespecified inclusion criteria and were included for analysis. The median age of the cohort was 48 years (range: 17-86) with a predominance of rectal cancers (63.3%), liver alone metastases (47.1%), and resected primary (69.7%). Signet ring histology was present in 82 patients (20.3%). The most commonly used first-line regimen (CT1) was modified capecitabine-oxaliplatin (53.3%). Two hundred and nineteen patients (54.3%) received second-line systemic therapy (CT2). Patients received a median of two lines of therapy (range: 1-6). MoAbs were used by 48 patients (13.4%) with CT1 and 34 patients (15.5%) with CT2. Median OS of the entire cohort was 17.61 months (95% confidence interval: 15.48-19.74), which was within the predicted range, as per investigator hypothesis. The presence of signet ring histology ( p <0.001), raised carcinoembryonic antigen at baseline ( p =0.017), and the absence of a resected primary ( p <0.001) predicted inferior median OS. Conclusions  Survival of patients with mCRC in a resource-constrained LMIC scenario like India is approximately 12 to 15 months lower than published trial data. Limited access to targeted therapy and newer expensive treatment options due to financial constraints may contribute to this disparity.

Lessons learnt from 1300 consecutive gallbladder cancer surgeries: Evolving role of peri-operative chemotherapy in the treatment paradigm

BACKGROUND

Level I evidence for multi-modality management of gallbladder cancers (GBC) is evolving.

METHODS

Prospectively maintained operative GBC database of 1307 patients (year 2010-2019) was analysed to study the impact of peri-operative chemotherapy (PCT) on survival outcomes.

RESULTS

1040 patients had pathologically confirmed GBC. Stage distribution showed: Stage I(85,8.2%), II(247,23.8%), III(460,44.2%), IV(248, 23.8%). PCT was used as follows: in stage II, 164 patients received adjuvant chemotherapy(ACT); in stage III, ACT was given to 444 patients, either operated upfront(244 patients) or after neoadjuvant chemotherapy (NACT)(216 patients); in stage IV, 32 patients (11 received NACT) underwent radical surgery followed by ACT and 216 patients had inoperable disease (77 received NACT) upon exploration. With a median follow-up of 30 months, the 3-year OS for stage I, II and III was 94.1%, 82.6% and 48.2% respectively. Corresponding DFS was 93.8%, 67.3% and 38.3%. Upon reassessment for surgery after NACT (n = 332), patients who underwent radical surgery (n = 235) had superior OS (p = 0.000) and DFS (p = 0.000) in comparison to those who had inoperable disease (n = 97). Amongst stage III and IV patients with operable disease (n = 492), those who were operated upfront (n = 238) had equivalent survival as those operated after NACT (n = 254). This was also confirmed by a 1:1 propensity matched analysis (118 patients each), matching for T and N stage.

CONCLUSION

The role of peri-operative chemotherapy in management of GBC is evolving. While the role of NACT for locally advanced GBC is unsettled and merits testing prospectively, it helps in selection of patients with favourable disease biology for radical surgery.

Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers

BACKGROUND

Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC.

METHODS

A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared.

RESULTS

Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections.

CONCLUSION

In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.

An evaluation of early-onset fatigue and the related coping strategies in patients with gastrointestinal cancer: A prospective pilot study

BACKGROUND

Cancer related fatigue (CRF) has been studied extensively and it has the worse impact as compared to pain on quality of life (QOL) of cancer patients.

MATERIAL AND METHODS

Prospective study was conducted at Tata Memorial center in Gastrointestinal (GI) cancer patients to assess fatigue with FACIT and PIPER scales. This was also to assess qualitative data on coping strategies in these patients.

RESULTS

Severe to moderate fatigue was commonly associated with sedentary to moderate activities (P = 0.049) whereas it was less common as education level increases (P = 0.031). Baseline pain was significantly associated with increase in fatigue (P = 0.033). This study also suggests that fatigue increases with as number of chemotherapy cycles increase. Qualitative data analysis revealed that majority of the patients used resting and energy conservation in the form of sitting, lying down. Most of them were following high protein diet (with or without supplementary protein powder) and little exercise such as walking.

CONCLUSION

Patients with GI cancer receiving chemotherapy were found to have fatigue, which increased during the subsequent cycles. Patients with sedentary lifestyle and experiencing pain at baseline were found to have more fatigue. Coping strategies adopted by majority of patients were resting and a high-protein diet.

High-Grade Gastrointestinal Neuroendocrine Carcinomas: Multidisciplinary Approach Can Improve Survival Outcomes

Purpose There is limited evidence for the presentation patterns and outcomes of patients with high-grade gastrointestinal neuroendocrine carcinomas (HG-NEC).

Methods Patients diagnosed with HG-NEC, defined as having a pathological diagnosis of neuroendocrine cancer with an epicenter of cancer in the gastrointestinal tract and Molecular Immunology Borstel-1 index ≥ 20% between May 2014 and May 2022 were retrospectively analyzed for demographic variables, survivals, and prognostic parameters. The primary endpoint of the study was the estimation of median overall survival (OS) by the Kaplan–Meier method.

Results A total of 336 patients were included in the analysis, of whom 283 patients (84%) were started on cancer-directed treatment while 53 patients (16%) were planned for best supportive care. The most common sites of the primary were gallbladder (45%), colorectal (19%), and pancreas (13%), with 253 patients (75%) having metastatic NEC. All treated patients received systemic therapy (commonly platinum and etoposide), while 64 patients (23%) underwent resection of the primary. With a median follow-up of 65.4 (45.6 -85.3) months, the median OS of the entire cohort was 15.8 months. The prospective multidisciplinary tumor (MDT) board decision of classifying patients into resectable, unresectable, and metastatic HG-NEC was prognostic for OS (26.8 vs. 21.1 vs. 13.5 months; p = 0.001). Patients who were able to undergo multimodality therapy (resection and systemic therapy) had improved OS compared with patients on systemic therapy alone (23.1 vs. 14.9 months; p = 0.003).

Conclusion A majority of patients with HG-NEC present with advanced disease. An MDT is essential to deciding initial therapeutic strategies in these patients, with patients undergoing resection and systemic therapy having improved OS.

Bevacizumab Erlotinib Switch Maintenance in Chemo-Responsive Advanced Gallbladder and Cholangiocarcinoma (BEER BTC): A Multicenter, Open-Label, Randomized, Phase II Trial

PURPOSE

Patients with chemotherapy-responsive advanced biliary tract cancers (BTCs) are usually observed after 6 months of gemcitabine-based therapy. There is limited prospective evidence for maintenance strategies after chemotherapy.

METHODS

This investigator-initiated, open-label, randomized, integrated phase II-III study enrolled adult patients with advanced BTC from two cancer centers in India. Patients with histologically confirmed advanced biliary tract adenocarcinoma who had at least disease stabilization after 6 months of gemcitabine-based chemotherapy were randomly assigned (1:1) to either active surveillance or switch maintenance, which was a combination of bevacizumab 5 mg/kg intravenous once every 21 days plus erlotinib 100 mg once daily. Both arms were continued until disease progression, unacceptable toxicity, or patient decision to withdraw. The primary end point of the phase II component of the trial was investigator-evaluated progression-free survival. This trial is registered with Clinical Trials Registry of India (CTRI/2019/05/019323I).

RESULTS

From May 2021 to November 2022, 98 patients were randomly assigned to active surveillance (n = 49) or bevacizumab-erlotinib (n = 49). A majority of patients had gallbladder cancer (80%). The median follow-up was 13.4 months. The median progression-free survival was 3.1 months (95% CI, 2.47 to 3.64) in the active surveillance group versus 5.3 months (95% CI, 3.53 to 7.04) in the bevacizumab-erlotinib group (hazard ratio, 0.51 [95% CI, 0.33 to 0·74]; P = .0013). The most common grade 3 class-specific adverse events associated with bevacizumab-erlotinib were acneiform rash 1 (2%) and oral stomatitis 1 (2%) with erlotinib and bleeding 1 (2%) with bevacizumab.

CONCLUSION

The combination of bevacizumab and erlotinib as switch maintenance improves progression-free survival with an acceptable safety profile compared with active surveillance in patients with advanced BTCs in this phase II study. The trial moves on to the phase III component to evaluate improvement in overall survival.

Evolution and improved outcomes in the era of multimodality treatment for extended pancreatectomy

BACKGROUND

The evolution and outcomes of extended pancreatectomies at a single institute over 15 years are presented in this study.

METHODS

A retrospective analysis of the institutional database was performed from 2015 to 2022 (period B). Patients undergoing extended pancreatic resections, as defined by the International Study Group for Pancreatic Surgery, were included. Perioperative and survival outcomes were compared with data from 2007-2015 (period A). Regression analyses were used to identify factors affecting postoperative and long-term survival outcomes.

RESULTS

A total of 197 (16.1%) patients underwent an extended resection in period B compared to 63 (9.2%) in period A. Higher proportions of borderline resectable (5 (18.5%) versus 51 (47.7%), P = 0.011) and locally advanced tumours (1 (3.7%) versus 24 (22.4%), P < 0.001) were resected in period B with more frequent use of neoadjuvant therapy (6 (22.2%) versus 79 (73.8%), P < 0.001). Perioperative mortality (4 (6.0%) versus 12 (6.1%), P = 0.81) and morbidity (23 (36.5%) versus 83 (42.1%), P = 0.57) rates were comparable. The overall survival for patients with pancreatic adenocarcinoma was similar in both periods (17.5 (95% c.i. 6.77 to 28.22) versus 18.3 (95% c.i. 7.91 to 28.68) months, P = 0.958). Resectable, node-positive tumours had a longer disease-free survival (DFS) in period B (5.81 (95% c.i. 1.73 to 9.89) versus 14.03 (95% c.i. 5.7 to 22.35) months, P = 0.018).

CONCLUSION

Increasingly complex pancreatic resections were performed with consistent perioperative outcomes and improved DFS compared to the earlier period. A graduated approach to escalating surgical complexity, multimodality treatment, and judicious patient selection enables the resection of advanced pancreatic tumours.

Adjuvant Gemcitabine Plus Cisplatin and Chemoradiation in Patients With Gallbladder Cancer: A Randomized Clinical Trial

IMPORTANCE

There is limited evidence with regard to the benefit of adjuvant chemotherapy chemoradiotherapy in resected gallbladder cancers (GBCs).

OBJECTIVE

To establish a baseline survival rate for operated GBCs in patients receiving either gemcitabine plus cisplatin (GC) or capecitabine and capecitabine concurrent with chemoradiation (CCRT).

DESIGN, SETTING, AND PARTICIPANTS

The GECCOR-GB study was a multicenter, open-label, randomized phase 2 noncomparator "pick the winner" design trial of adjuvant GC and CCRT in patients with resected histologically confirmed adenocarcinoma or adenosquamous carcinoma of the gallbladder, (stage II/III) with no local residual tumor (R0) or microscopic residual tumor (R1). The study was carried out in 3 tertiary cancer institutions in India. Patients 18 years or older with adequate end-organ functions, and Eastern Cooperative Oncology Group Performance Status of 1 or lower between May 2019 and February 2022 were enrolled. The cutoff date for data analysis was February 28, 2023.

INTERVENTIONS

Patients were randomized 1:1 to receive either GC every 3 weeks (maximum of 6 cycles) or CCRT comprising capecitabine with concurrent chemoradiation (capecitabine concurrent with radiotherapy) sandwiched between capecitabine chemotherapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was disease-free survival (DFS) at 1 year in randomized patients. This study was conducted as 2 parallel, single-stage phase 2 clinical trials. Within each treatment arm, a 1-year DFS rate of less than 59% was considered as insufficient activity, whereas a 1-year DFS rate of 77% or higher would be considered as sufficient activity.

RESULTS

With a median follow-up of 23 months, 90 patients were randomized, 45 in each arm. Overall, there were 31 women (69%) and 14 men (31%) in the GC arm with a mean (range) age of 56 (33-72) years and 34 women (76%) and 11 men (24%) in the CCRT group with a mean (range) age of 55 (26-69) years. In the GC and CCRT arms, 1-year DFS and estimated 2-year DFS was 88.9% (95% CI, 79.5-98.3) and 74.8% (95% CI, 60.4-89.2), and 77.8% (95% CI, 65.4-90.2) and 74.8% (95% CI, 59.9-86.3), respectively. Completion rates for planned treatment was 82% in the GC arm and 62% in the CCRT arm.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, GC and CCRT crossed the prespecified trial end points of 1-year DFS in patients with resected stage II/III GBCs. The results set a baseline for a larger phase 3 trial evaluating both regimens in operated GBCs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: CTRI/2019/05/019323I.