501
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Boone BA, Steve J, Krasinskas AM, Zureikat AH, Lembersky BC, Gibson MK, Stoller RG, Zeh HJ, Bahary N. Outcomes with FOLFIRINOX for borderline resectable and locally unresectable pancreatic cancer. J Surg Oncol 2013; 108:236-41. [PMID: 23955427 DOI: 10.1002/jso.23392] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/12/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Trials examining FOLFIRINOX in metastatic pancreatic cancer demonstrate higher response rates compared to gemcitabine-based regimens. There is currently limited experience with neoadjuvant FOLFIRINOX in pancreatic cancer. METHODS Retrospective review of outcomes of patients with borderline resectable or locally unresectable pancreatic cancer who were recommended to undergo neoadjuvant treatment with FOLFIRINOX. RESULTS FOLFIRINOX was recommended for 25 patients with pancreatic cancer, 13 (52%) unresectable and 12 (48%) borderline resectable. Four patients (16%) refused treatment or were lost to follow-up. Twenty-one patients (84%) were treated with a median of 4.7 cycles. Six patients (29%) required dose reductions secondary to toxicity. Two patients (9%) were unable to tolerate treatment and three patients (14%) had disease progression on treatment. Seven patients (33%) underwent surgical resection following treatment with FOLFIRINOX alone, 2 (10%) of which were initially unresectable. Two patients underwent resection following FOLFIRINOX + stereotactic body radiation therapy (SBRT). The R0 resection rate for patients treated with FOLFIRINOX ± SBRT was 33% (55% borderline resectable, 10% unresectable). A total of five patients (24%) demonstrated a significant pathologic response. CONCLUSIONS FOLFIRINOX is a biologically active regimen in borderline resectable and locally unresectable pancreatic cancer with encouraging R0 resection and pathologic response rates.
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Affiliation(s)
- Brian A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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502
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Jin P, Ren H, Sun W, Xin W, Zhang H, Hao J. Circulating IL-35 in pancreatic ductal adenocarcinoma patients. Hum Immunol 2013; 75:29-33. [PMID: 24121041 DOI: 10.1016/j.humimm.2013.09.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/20/2013] [Accepted: 09/27/2013] [Indexed: 11/16/2022]
Abstract
IL-35 is a novel inhibitory cytokine that is mainly produced by regulatory T-cells (Tregs) and is required for Treg-mediated immunosuppression. However, the plasma levels of IL-35 in patients with pancreatic ductal adenocarcinoma (PDAC) have never been investigated. In this study, we found that plasma IL-35 levels more significantly increased in PDAC patients than in normal controls (134.53 ± 92.45 pg/mL vs. 14.26 ± 6.56 pg/mL). IL-35 mRNA levels were positively correlated with plasma IL-35 levels (EBI3, R = 0.925, p<0.01; p35, R = 0.916, p<0.01). Furthermore, IL-35 expression levels were associated with lymph node metastasis (p = 0.001) and late tumor stage (p = 0.002). For the resected patients, high IL-35 expression levels were associated with large tumor size (p<0.01), higher TNM classification T staging (p<0.05), and late tumor stage (p<0.05). In conclusion, circulating IL-35 in PDAC patients significantly increased, suggesting that regulating the expression of IL-35 may provide a new possible target for the treatment of PDAC patients, especially for the resectable ones.
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Affiliation(s)
- Peng Jin
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China
| | - He Ren
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China
| | - Wei Sun
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China
| | - Wen Xin
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China
| | - Huan Zhang
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China
| | - Jihui Hao
- Department of Pancreatic Cancer, Key Lab of Cancer Treatment and Prevention, Tianjin Cancer Hospital, Tianjin Medical University, Tianjin 300060, China.
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503
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Chen Y, Tan C, Mai G, Ke N, Liu X. Resection of Pancreatic Tumors Involving the Anterior Surface of the Superior Mesenteric/Portal Veins Axis: An Alternative Procedure to Pancreaticoduodenectomy with Vein Resection. J Am Coll Surg 2013; 217:e21-8. [PMID: 24054418 DOI: 10.1016/j.jamcollsurg.2013.07.383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/24/2013] [Accepted: 07/09/2013] [Indexed: 02/05/2023]
Affiliation(s)
- Yonghua Chen
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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504
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Hartwig W, Werner J, Jäger D, Debus J, Büchler MW. Improvement of surgical results for pancreatic cancer. Lancet Oncol 2013; 14:e476-e485. [DOI: 10.1016/s1470-2045(13)70172-4] [Citation(s) in RCA: 260] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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505
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Heinemann V, Haas M, Boeck S. Neoadjuvant treatment of borderline resectable and non-resectable pancreatic cancer. Ann Oncol 2013; 24:2484-2492. [PMID: 23852311 DOI: 10.1093/annonc/mdt239] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neoadjuvant therapy is increasingly becoming a valid treatment option for patients with locally advanced pancreatic cancer (LAPC). In borderline resectable disease, neoadjuvant therapy is employed to improve the probability of margin-clear resections. In non-metastatic, non-resectable pancreatic cancer, treatment primarily aims to induce disease control, but may achieve conversion to surgical resectability in some patients. Several treatment modalities including chemotherapy, chemoradiotherapy (CRT) or the sequential use of both have been investigated in numerous, mostly small and non-randomized studies. Nevertheless, there is a consistent finding that neoadjuvant therapy can induce resectability in up to 30%-40% of LAPC patients. Once resection has been achieved, overall survival appears to be comparable to that observed for primarily resectable patients. Thus, patient selection evolves as an important aspect of neoadjuvant therapy; retrospective analyses identified induction chemotherapy as an appropriate tool to define LAPC patients who may benefit most from subsequent treatment with CRT. The clinical importance of induction chemotherapy may further increase once highly active protocols such as the FOLFIRINOX or the gemcitabine plus nab-paclitaxel regimen are introduced into novel multimodality treatment concepts.
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Affiliation(s)
- V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig-Maximilians-University of Munich, Munich, Germany.
| | - M Haas
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - S Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig-Maximilians-University of Munich, Munich, Germany
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506
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507
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Irreversible electroporation of locally advanced pancreatic head adenocarcinoma. J Gastrointest Surg 2013; 17:1850-6. [PMID: 23929188 DOI: 10.1007/s11605-013-2309-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 07/30/2013] [Indexed: 01/31/2023]
Abstract
Irreversible electroporation of locally advanced pancreatic adenocarcinoma has been used to palliate appropriate patients with locally advanced pancreatic adenocarcinoma. The setting was at a university tertiary care center. Subjects are patients with locally advanced pancreatic adenocarcinoma who have undergone appropriate induction chemotherapy for at least 3 to 4 months in duration. Technique of open irreversible electroporation of locally advanced pancreatic adenocarcinoma is described. The technique of open irreversible electroporation with continuous intraoperative ultrasound imaging and consideration of intraoperative navigational system is described. Irreversible electroporation of locally advanced pancreatic adenocarcinoma is feasible for locally advanced unresectable pancreatic cancer.
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508
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Dholakia AS, Hacker-Prietz A, Wild AT, Raman SP, Wood LD, Huang P, Laheru DA, Zheng L, De Jesus-Acosta A, Le DT, Schulick R, Edil B, Ellsworth S, Pawlik TM, Iacobuzio-Donahue CA, Hruban RH, Cameron JL, Fishman EK, Wolfgang CL, Herman JM. Resection of borderline resectable pancreatic cancer after neoadjuvant chemoradiation does not depend on improved radiographic appearance of tumor-vessel relationships. ACTA ACUST UNITED AC 2013; 2:413-425. [PMID: 25755849 DOI: 10.1007/s13566-013-0115-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Neoadjuvant therapy increases rates of margin-negative resection of borderline resectable pancreatic ductal adenocarcinoma (BL-PDAC). Criteria for BL-PDAC resection following neoadjuvant chemotherapy and radiation therapy (NCRT) have not been clearly defined. METHODS Fifty consecutive patients with BL-PDAC who received NCRT from 2007 to 2012 were identified. Computed tomography (CT) scans pre- and post-treatment were centrally reviewed. RESULTS Twenty-nine patients (58 %) underwent resection following NCRT, while 21 (42 %) remained unresected. Patients selected for and successfully undergoing resection were more likely to have better performance status and absence of the following features on pre- and post-treatment CT: superior mesenteric vein/portal vein encasement, superior mesenteric artery involvement, tumor involvement of two or more vessels, and questionable/overt metastases (all p <0.05). Tumor volume and degree of tumor-vessel involvement did not significantly change in both groups after NCRT (all p > 0.05). The median overall survival was 22.9 months in resected versus 13.0 months in unresected patients (p < 0.001). Of patients undergoing resection, 93 % were margin-negative, 72 % were node-negative, and 54 % demonstrated moderate pathologic response to NCRT. CONCLUSION Apparent radiographic extent of vascular involvement does not change significantly after NCRT. Patients without metastatic disease should be chosen for surgical exploration based on adequate performance status and lack of disease progression.
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Affiliation(s)
- Avani S Dholakia
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
| | - Aaron T Wild
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
| | - Siva P Raman
- Department of Radiology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 601 N. Broadway, Baltimore, MD 21231, USA
| | - Laura D Wood
- Department of Pathology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 2242, Baltimore, MD 21231, USA
| | - Peng Huang
- Department of Oncology Biostatistics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 1103, Baltimore, MD 21205, USA
| | - Daniel A Laheru
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St., Baltimore, MD 21287, USA
| | - Lei Zheng
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St., Baltimore, MD 21287, USA
| | - Ana De Jesus-Acosta
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St., Baltimore, MD 21287, USA
| | - Dung T Le
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St., Baltimore, MD 21287, USA
| | - Richard Schulick
- Department of Surgery, University of Colorado, 12631 E. 17th Avenue, Suite 6117, Aurora, CO 80045, USA
| | - Barish Edil
- Department of Surgery, University of Colorado, 12631 E. 17th Avenue, Suite 6117, Aurora, CO 80045, USA
| | - Susannah Ellsworth
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
| | - Timothy M Pawlik
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Christine A Iacobuzio-Donahue
- Department of Pathology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 2242, Baltimore, MD 21231, USA
| | - Ralph H Hruban
- Department of Pathology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 2242, Baltimore, MD 21231, USA
| | - John L Cameron
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Elliot K Fishman
- Department of Radiology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 601 N. Broadway, Baltimore, MD 21231, USA
| | - Christopher L Wolfgang
- Department of Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Joseph M Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 401 N. Broadway, Weinberg Suite 1440, Baltimore, MD 21231, USA
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509
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Neoadjuvant therapy for potentially resectable pancreatic cancer: an emerging paradigm? Curr Oncol Rep 2013; 15:162-9. [PMID: 23325567 DOI: 10.1007/s11912-012-0291-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although neoadjuvant chemoradiotherapy has been tested for more than two decades and can be safely delivered to patients with non-metastatic pancreatic cancer, no randomised trials have been reported until now. Here we provide an overview of the first randomised trial in patients with potentially resectable cancer and of the latest developments in neoadjuvant therapy for this group of patients. It is necessary to continue to perform clinical trials in this field to accurately identify the effect on survival and quality of life in patients with potentially resectable, borderline resectable and unresectable pancreatic cancer. Aspects of imaging for restaging and clinical prognostic factors are also discussed given they will be useful instruments for future trials.
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510
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Conroy T, Gavoille C, Samalin E, Ychou M, Ducreux M. The role of the FOLFIRINOX regimen for advanced pancreatic cancer. Curr Oncol Rep 2013; 15:182-9. [PMID: 23341367 DOI: 10.1007/s11912-012-0290-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2010, the FOLFIRINOX regimen (bolus and infusional 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) emerged as a new option in patients with metastatic pancreatic cancer and a good performance status. However, at that time, some doubts were raised regarding safety issues. Similarly, no data on FOLFIRINOX were published in patients with unresectable/locally advanced or borderline resectable pancreatic cancer. This article presents the available experience with FOLFIRINOX outside clinical trials in metastatic and locally advanced pancreatic cancer patients. The safety of the regimen in patients with biliary stents and in previously treated patients is also described. FOLFIRINOX usage in clinical practice, including modification of the regimen (omission of bolus 5-fluorouracil; FOLFOXIRI regimen), is also presented. These data suggest that a phase III randomized study is warranted to further explore the role of FOLFIRINOX in locally advanced pancreatic cancer.
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Affiliation(s)
- Thierry Conroy
- EA 4360 and Department of Medical Oncology, Centre Alexis Vautrin, Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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511
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Dudeja V, Greeno EW, Walker SP, Jensen EH. Neoadjuvant chemoradiotherapy for locally advanced pancreas cancer rarely leads to radiological evidence of tumour regression. HPB (Oxford) 2013; 15:661-7. [PMID: 23458352 PMCID: PMC3948532 DOI: 10.1111/hpb.12015] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/18/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neo-adjuvant chemo-radiotherapy has been proposed to improve resectability of locally-advanced pancreatic cancer (LAPC). However, the ability of neo-adjuvant therapy to induce radiological tumour regression has not been reported. METHODS Pre- and post-treatment computed tomography (CT) scans of patients undergoing neo-adjuvant chemo-radiotherapy for LAPC were reviewed. LAPC was sub-classified into borderline resectable disease [≤ 180° involvement of the superior mesenteric artery (SMA); short-segment encasement/abutment of the common hepatic artery; or tumour-associated deformity, abutment or short-segment occlusion of the superior mesenteric vein (SMV)/ portal vein (PV) that was amenable to vascular resection and reconstruction] and locally advanced un-resectable pancreatic cancer (vascular involvement more than that described for borderline resectable pancreatic cancer). The radiological response and surgical resection rates were assessed. RESULTS Sixteen patients received neo-adjuvant therapy for LAPC during 2005-2008. Regression of major vascular involvement, i.e. un-encasement or regression of abutment of any involved vessels was not observed in any patient. Pre- and post-treatment tumour densities were not statistically different. Fifty per cent of patients with borderline resectable disease and none of the patients with locally advanced un-resectable pancreatic cancer eventually underwent surgical resection. CONCLUSION Neo-adjuvant treatment does not induce radiological tumour regression of LAPC with major vascular involvement. Patient selection for neo-adjuvant trial enrollment should remain focused on borderline disease which may have a potential for surgical resection.
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Affiliation(s)
- Vikas Dudeja
- Department of Surgery, University of MinnesotaMinneapolis, MN, USA
| | - Edward W Greeno
- Department of Medical Oncology, University of MinnesotaMinneapolis, MN, USA
| | - Sidney P Walker
- Department of Radiology, University of MinnesotaMinneapolis, MN, USA
| | - Eric H Jensen
- Department of Surgery, University of MinnesotaMinneapolis, MN, USA,Correspondence Eric H. Jensen, Department of Surgery, University of Minnesota., Mayo Mail Code 195 Mayo, 420 Delaware Street SE, Minneapolis, MN 55455, USA. Tel: +1 612 625 2991. Fax: +1 612 625 4406. E-mail:
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512
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Hartwig W, Büchler MW. Pancreatic Cancer: Current Options for Diagnosis, Staging and Therapeutic Management. Gastrointest Tumors 2013; 1:41-52. [PMID: 26673950 DOI: 10.1159/000354992] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pancreatic cancer is characterized by frequently delayed diagnosis and aggressive tumor growth which hampers most of the current treatment modalities. This review aims to summarize the available evidence about the diagnostic and therapeutic aspects of resectable and non-resectable pancreatic cancer therapy. SUMMARY Embedded in the concept of multimodal therapy, surgery plays the central role in the treatment of pancreatic cancer. With advantageous tumor characteristics and complete tumor resection as the most relevant positive prognostic factors, the detection of premalignant or early invasive lesions combined with safe and oncologic adequate surgery is the major therapeutic aim. Most pancreatic adenocarcinomas are locally advanced or metastatic when diagnosed and need to be treated by the combination of surgery and (radio)chemotherapy or by palliative chemotherapy.
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Affiliation(s)
- Werner Hartwig
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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513
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Denost Q, Laurent C, Adam JP, Capdepont M, Vendrely V, Collet D, Sa Cunha A. Pancreaticoduodenectomy following chemoradiotherapy for locally advanced adenocarcinoma of the pancreatic head. HPB (Oxford) 2013; 15:716-23. [PMID: 23458326 PMCID: PMC3948540 DOI: 10.1111/hpb.12039] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone. METHODS From 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group). RESULTS A total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow-up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease-free (35% and 37%, respectively) survival (P = 0.10). CONCLUSIONS In patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.
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Affiliation(s)
- Quentin Denost
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France,Correspondence Quentin Denost, Service de Chirurgie Digestive, Hôpital Haut-Lévêque, Avenue Magellan, 33600 Pessac, France. Tel: + 33 5 57 65 60 19. Fax: + 33 5 57 65 60 28. E-mail:
| | | | - Jean-Philippe Adam
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Maylis Capdepont
- CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Veronique Vendrely
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Denis Collet
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France
| | - Antonio Sa Cunha
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France
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514
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Rossi M, Orgera G, Hatzidakis A, Krokidis M. Minimally invasive ablation treatment for locally advanced pancreatic adenocarcinoma. Cardiovasc Intervent Radiol 2013; 37:586-91. [PMID: 23989503 DOI: 10.1007/s00270-013-0724-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/06/2013] [Indexed: 12/15/2022]
Abstract
Pancreatic adenocarcinoma is an aggressive tumour with an extremely poor prognosis, which has not changed significantly during the last 30 years. Prolonged survival is achieved only by R0 resection with macroscopic tumour clearance. However, the majority of the cases are considered inoperable at diagnosis due to local spread or presence of metastatic disease. Chemoradiotherapy is not tolerated by all patients and still fails to prolong survival significantly; neoadjuvant treatment also has limited results on pain control or tumour downstaging. In recent years, there has been a growing interest in the use of ablation therapy for the treatment of nonresectable tumours in various organs. Ablation techniques are based on direct application of chemical, thermal, or electrical energy to a tumour, which leads to cellular necrosis. With ablation, tumour cytoreduction, local control, and relief from symptoms are obtained in the majority of the patients. Inoperable cases of pancreatic adenocarcinoma have been treated by various ablation techniques in the last few years with promising results. The purpose of this review is to present the current status of local ablative therapies in the treatment of pancreatic adenocarcinoma and to investigate on the efficiency and the future trends.
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Affiliation(s)
- Michele Rossi
- Unit of Interventional Radiology, S. Andrea University Hospital "Sapienza", Rome, Italy
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515
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Abstract
Patients with pancreatic cancer have a dismal prognosis. This article reviews the role that interventional radiology can play in managing postoperative complications and in patient palliation, particularly with an obstructed biliary system. In addition, options for cytoreduction are discussed, including chemoembolization, radioembolization, and thermal ablation. The final option reviewed is irreversible electroporation, which is being explored as a technique to allow patients with locally advanced pancreatic cancer to be converted to surgical candidates.
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516
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Tinchon C, Hubmann E, Pichler A, Keil F, Pichler M, Rabl H, Uggowitzer M, Jilek K, Leitner G, Bauernhofer T. Safety and efficacy of neoadjuvant FOLFIRINOX treatment in a series of patients with borderline resectable pancreatic ductal adenocarcinoma. Acta Oncol 2013; 52:1231-3. [PMID: 23445338 DOI: 10.3109/0284186x.2013.771821] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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517
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Van Buren G, Ramanathan RK, Krasinskas AM, Smith RP, Abood GJ, Bahary N, Lembersky BC, Shuai Y, Potter DM, Bartlett DL, Zureikat AH, Zeh HJ, Moser AJ. Phase II study of induction fixed-dose rate gemcitabine and bevacizumab followed by 30 Gy radiotherapy as preoperative treatment for potentially resectable pancreatic adenocarcinoma. Ann Surg Oncol 2013; 20:3787-93. [PMID: 23904005 DOI: 10.1245/s10434-013-3161-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND Eighty percent of patients with resected pancreatic ductal carcinoma (PDC) experience treatment failure within 2 years. We hypothesized that preoperative fixed-dose rate (FDR) gemcitabine (GEM) combined with the angiogenesis inhibitor bevacizumab (BEV) and accelerated 30 Gy radiotherapy (RT) would improve outcomes among patients with potentially resectable PDC. METHODS This phase II trial tested induction FDR GEM (1,500 mg/m(2)) plus BEV (10 mg/kg IV) every 2 weeks for three cycles followed by accelerated RT (30 Gy in 10 fractions) plus BEV directed at gross tumor volume plus a 1-2 cm vascular margin. Subjects underwent laparoscopy and resection after day 85. Therapy was considered effective if the complete pathologic response rate exceeded 10 % and the margin-negative resection rate exceeded 80%. RESULTS Fifty-nine subjects were enrolled; 29 had potential portal vein involvement. Two grade 4 (3.4%) and 19 grade 3 toxicities (32.8%) occurred. Four subjects manifested radiographic progression, and 10 had undetected carcinomatosis. Forty-three pancreatic resections (73%) were performed, including 19 portal vein resections (44%). Margin-negative outcomes were observed in 38 (88%, 95% confidence interval [CI] 75-96), with one complete pathologic response (2.3%; 95% CI 0.1-12). There were seven (6 grade 3; 1 grade 4) wound complications (13%). Median overall survival for the entire cohort was 16.8 months (95% CI 14.9-21.3) and 19.7 months (95% CI 16.5-28.2) after resection. CONCLUSIONS Induction therapy with FDR GEM and BEV, followed by accelerated BEV/RT to 30 Gy, was well tolerated. Although both effectiveness criteria were achieved, survival outcomes were equivalent to published regimens.
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Affiliation(s)
- George Van Buren
- Division of Surgical Oncology, UPMC Pancreatic Cancer Center, Pittsburgh, PA, USA
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518
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Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines. Pancreas 2013; 42:1004-10. [PMID: 23532000 DOI: 10.1097/mpa.0b013e31827b2d7c] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the relevance of defining borderline resectable (BR) pancreatic cancer as a distinct entity in the treatment scheme of pancreatic cancer as proposed by the National Comprehensive Cancer Network. METHODS Among 375 patients with pancreatic cancer, 137 patients were deemed to have resectable disease (R) by preoperative imaging studies, whereas 96 were found to have an unresectable disease during surgery. The remaining 142 patients fulfilled the definition of BR and were further classified into 3 subgroups based on the National Comprehensive Cancer Network guidelines: portal vein invasion (PV[+]), common hepatic artery invasion (CHA[+]), and superior mesenteric artery invasion (SMA[+]). PV(+) was subdivided into types B, C, and D according to the degree of portal vein invasion. RESULTS Patients in the R group had significantly better survival than those in the PV(+) group (P = 0.0038), who in turn survived significantly longer than those classified as SMA(+) (P = 0.041). Type B patients survived significantly longer than did types C and D patients (P = 0.013 and P = 0.030, respectively). In PV(+) patients, compliance with postoperative chemotherapy at 3 and 6 months was 56.9% and 44.6%, respectively, substantially inferior to patients with resectable disease (72.6% and 54.7%, respectively). CONCLUSIONS The optimal treatment strategy may differ among various subgroups within the BR category.
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519
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Splenic vein thrombosis is associated with an increase in pancreas-specific complications and reduced survival in patients undergoing distal pancreatectomy for pancreatic exocrine cancer. J Gastrointest Surg 2013; 17:1392-8. [PMID: 23797883 DOI: 10.1007/s11605-013-2260-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 06/11/2013] [Indexed: 01/31/2023]
Abstract
Distal pancreatectomy and splenectomy (DPS) is the procedure of choice for the surgical treatment of pancreatic exocrine cancer localized to the body and tail of the pancreas. Splenic vein thrombosis (SVT) can occur in patients with malignant pancreatic exocrine tumors secondary to direct tumor invasion or compression of the splenic vein by mass effect. This study examines the effect of preoperative SVT on postoperative outcomes. In this retrospective cohort study, we queried our pancreatic surgery database to identify patients who underwent DPS from October 2005 to June 2011. These cases were evaluated for evidence of preoperative SVT on clinical records and cross-sectional imaging (CT,MRI, endoscopic US). Outcomes for patients with and without SVT were compared. From an overall cohort of 285 consecutive patients who underwent DPS during the study period, data were evaluated for 70 subjects who underwent surgery for pancreatic exocrine cancer (27 with SVT, 43 without SVT). The preoperative demographics and co-morbidities were similar between the groups, except the average age was higher for those without SVT (p<0.05). The median estimated blood loss was significantly higher in the SVT group (675 versus 250 ml, p=<0.001).While the overall morbidity rates were similar between the two groups (48 % SVT versus 56% no SVT, p=NS), the group with SVT had a significantly higher rate of pancreas-specific complications, including pancreatic fistula (33 versus 7 %,p<0.01) and delayed gastric emptying (15 versus 0%, p<0.02). Hospital readmission rates were similar between the groups(30 versus 28 %, p=NS). Patients without SVT had a trend toward longer median survival (40 versus 20.8 months),although the difference was not statistically significant (p=0.1). DPS for pancreatic ductal adenocarcinoma can be performed safely in patients with SVT, but with higher intraoperative blood loss, increased pancreas-specific complications, and a trend towards lower long-term survival rates. This paper was presented as a poster at the 53rd annual meeting of the Society for Surgery of the Alimentary Tract and at the 46th annual meeting of the Pancreas Club, San Diego, CA, May 2012.
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520
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Cho IR, Chung MJ, Bang S, Park SW, Chung JB, Song SY, Seong J, Hwang HK, Kang CM, Lee WJ, Park JY. Gemcitabine based neoadjuvant chemoradiotherapy therapy in patients with borderline resectable pancreatic cancer. Pancreatology 2013; 13:539-43. [PMID: 24075521 DOI: 10.1016/j.pan.2013.07.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/09/2013] [Accepted: 07/10/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical resection is the only curative treatment for pancreatic cancer, but surgical outcomes for borderline resectable pancreatic cancer (BRPC) are generally poor because of the complexity of the surgery and the advanced nature of the tumor. The aim of this study was to evaluate whether neoadjuvant concurrent chemoradiation therapy (CCRT) in BRPC patients could improve surgical outcome. METHODS Baseline characteristics and treatment outcomes for patients who underwent surgery for BRPC with (CCRT (+) group) and without neoadjuvant treatment (CCRT (-) group) were retrospectively compared. Treatment outcomes measured included overall survival, recurrence-free survival, and perioperative complications. RESULTS A total of 30 patients were included in the CCRT (+) group and 21 patients in the CCRT (-) group. Baseline characteristics were not different before CCRT, but pathological examination after resection revealed reduced tumor size and a lower neurovascular invasion rate in the CCRT (+) group. Overall median survival time was 45.0 months in the CCRT (+) group and 23.5 months in the CCRT (-) group (p = 0.045). The CCRT (+) group had a lower recurrence rate (50.0% vs. 81.0%; p = 0.024) and a longer median disease-free survival period (21.0 months vs. 10.6 months; p = 0.004) than the CCRT (-) group. Perioperative complication rates were not different between the two groups. CONCLUSIONS Neoadjuvant chemoradiation therapy combined with surgical resection yielded better treatment outcomes in patients with BRPC compared with surgery alone. Further larger prospective clinical trials with well defined enrollment criteria and treatment plan are needed.
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Affiliation(s)
- In Rae Cho
- Division of Gastroenterology, Department of Internal Medicine and Yonsei Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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521
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Kelly KJ, Winslow E, Kooby D, Lad NL, Parikh AA, Scoggins CR, Ahmad S, Martin RC, Maithel SK, Kim HJ, Merchant NB, Cho CS, Weber SM. Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of "borderline resectable disease"? J Gastrointest Surg 2013; 17:1209-17; discussion 1217. [PMID: 23620151 DOI: 10.1007/s11605-013-2178-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 02/20/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Current National Comprehensive Cancer Network guidelines recommend neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma to increase the likelihood of achieving R0 resection. A consensus has not been reached on the degree of venous involvement that constitutes borderline resectability. This study compares the outcome of patients who underwent pancreaticoduodenectomy with or without vein resection without neoadjuvant therapy. METHODS A multi-institutional database of patients who underwent pancreaticoduodenectomy was reviewed. Patients who required vein resection due to gross vein involvement by tumor were compared to those without evidence of vein involvement. RESULTS Of 492 patients undergoing pancreaticoduodenectomy, 70 (14 %) had vein resection and 422 (86 %) did not. There was no difference in R0 resection (66 vs. 75 %, p = NS). On multivariate analysis, vein involvement was not predictive of disease-free or overall survival. CONCLUSION This is the largest modern series examining patients with or without isolated vein involvement by pancreas cancer, none of whom received neoadjuvant therapy. Oncological outcome was not different between the two groups. These data suggest that up-front surgical resection is an appropriate option and call into question the inclusion of isolated vein involvement in the definition of "borderline resectable disease."
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Affiliation(s)
- Kaitlyn J Kelly
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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522
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Nagrial A, Chantrill L, Chin V, Sjoquist K, O'Connor CA, Yip D. Pharmacologic and radiotherapeutic interventions for advanced pancreatic cancer. Hippokratia 2013. [DOI: 10.1002/14651858.cd010584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Adnan Nagrial
- Garvan Institute of Medical Research; Department of Pancreatic Cancer; 384 Victoria Street Darlinghurst Sydney NSW Australia 2010
| | - Lorraine Chantrill
- Garvan Institute of Medical Research; Department of Pancreatic Cancer; 384 Victoria Street Darlinghurst Sydney NSW Australia 2010
| | - Venessa Chin
- Garvan Institute of Medical Research; Pancreatic Research Program; 384 Victoria Street Darlinghurst Sydney NSW Australia 2010
| | - Katrin Sjoquist
- University of Sydney; NHMRC Clinical Trials Centre; K25 - Medical Foundation Building Sydney NSW Australia 2006
| | - Chelsie A O'Connor
- Garvan Institute of Medical Research; Department of Pancreatic Cancer; 384 Victoria Street Darlinghurst Sydney NSW Australia 2010
| | - Desmond Yip
- The Canberra Hospital; Medical Oncology Unit; Yamba Drive Garran ACT Australia 2605
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523
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Sahora K, Schindl M, Kuehrer I, Werba G, Fitzal F, Goetzinger P, Gnant M. Gemcitabine-based neoadjuvant chemotherapy for locally advanced pancreatic cancer does not affect mortality and morbidity after pancreatic resection. Eur Surg 2013. [DOI: 10.1007/s10353-013-0213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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524
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Narayanan G, Hosein PJ, Arora G, Barbery KJ, Froud T, Livingstone AS, Franceschi D, Rocha Lima CM, Yrizarry J. Percutaneous irreversible electroporation for downstaging and control of unresectable pancreatic adenocarcinoma. J Vasc Interv Radiol 2013. [PMID: 23177107 DOI: 10.1016/j.jvir.2012.09.012] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Treatment of unresectable locally advanced pancreatic cancer (LAPC) usually includes chemotherapy and/or radiation therapy in an attempt to downstage these tumors to the extent of resectability, but outcomes remain poor. Irreversible electroporation (IRE) is an ablative modality that may be useful in this population. The aim of this study was to evaluate the safety of percutaneous IRE in patients with pancreatic adenocarcinoma. MATERIALS AND METHODS IRE was performed in patients with pancreatic cancer whose tumors remained unresectable after, or who were intolerant of, standard therapy. The procedures were all done percutaneously under general anesthesia. Patients were then followed for adverse events, tumor response, and survival. RESULTS Fifteen IRE procedures were performed in 14 patients (one was treated twice). Three patients had metastatic disease and 11 had LAPC. All patients had received chemotherapy previously, and 11 had received radiation. The median tumor size was 3.3 cm (range, 2.5-7 cm). Immediate and 24-hour postprocedural scans demonstrated patent vasculature in the treatment zone in all patients. Two patients underwent surgery 4 and 5 months after IRE, respectively. Both had margin-negative resections, and one had a pathologic complete response; both remain disease-free after 11 and 14 months, respectively. Complications included spontaneous pneumothorax during anesthesia (n = 1) and pancreatitis (n = 1), and both patients recovered completely. There were no deaths directly related to the procedure. All three patients with metastatic disease at IRE died from progression of their disease. CONCLUSIONS Percutaneous IRE for pancreatic adenocarcinoma is feasible and safe. A prospective trial is being planned.
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Affiliation(s)
- Govindarajan Narayanan
- Department of Radiology, Division of Vascular/Interventional Radiology, University of Miami Miller School of Medicine, 1475 NW 12th Ave., Miami, FL 33136, USA.
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525
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Papavasiliou P, Chun YS, Hoffman JP. How to Define and Manage Borderline Resectable Pancreatic Cancer. Surg Clin North Am 2013; 93:663-74. [DOI: 10.1016/j.suc.2013.02.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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526
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Fong ZV, Tan WP, Lavu H, Kennedy EP, Mitchell DG, Koniaris LG, Sauter PK, Rosato EL, Yeo CJ, Winter JM. Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings. J Gastrointest Surg 2013; 17:1098-106. [PMID: 23553385 DOI: 10.1007/s11605-013-2181-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 03/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. METHODS We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. RESULTS There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). DISCUSSION While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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527
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Paulson AS, Tran Cao HS, Tempero MA, Lowy AM. Therapeutic advances in pancreatic cancer. Gastroenterology 2013; 144:1316-26. [PMID: 23622141 DOI: 10.1053/j.gastro.2013.01.078] [Citation(s) in RCA: 220] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/12/2012] [Accepted: 01/02/2013] [Indexed: 02/07/2023]
Abstract
Despite our improved understanding of pancreatic cancer biology and ability to perform more complex pancreatic cancer surgeries that produce better short-term outcomes, major progress toward increasing survival times has been painstakingly slow. Through the often-repeated, dismal survival statistics, it is easy to lose sight of real progress that has been made in pancreatic cancer therapy. It is particularly interesting to observe the extent to which these advances are interdependent and the effects they have had on practice. For example, during the past 5-10 years, we have seen widespread adoption of pancreatic imaging protocols that allow for objectively defined criteria of resectability. This has led to the definition of "borderline resectable pancreatic cancer"--a new clinical category that has affected the design of clinical trials. A major change in our surgical approach has been the move to minimally invasive pancreatectomy, which continues to gain broader acceptance and use, particularly for left-sided lesions. Although many new agents have been developed aimed at putative molecular targets, recent breakthroughs in therapy for advanced disease have arisen from our ability to safely give patients combination cytotoxic chemotherapy. We are now faced with the challenge of combining multidrug, cytotoxic chemotherapies with newer-generation agents. Ultimately, the hope is that drug combinations will be selected based on biomarkers, and strategies for pancreatic cancer therapy will be personalized, which could prolong patients' lives and reduce toxicity. We review the major advances in pancreatic cancer therapy during the last 5 years, and discuss how these have set the stage for greater progress in the near future.
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Affiliation(s)
- Andrew Scott Paulson
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, California 94115, USA
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528
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Kim EJ, Ben-Josef E, Herman JM, Bekaii-Saab T, Dawson LA, Griffith KA, Francis IR, Greenson JK, Simeone DM, Lawrence TS, Laheru D, Wolfgang CL, Williams T, Bloomston M, Moore MJ, Wei A, Zalupski MM. A multi-institutional phase 2 study of neoadjuvant gemcitabine and oxaliplatin with radiation therapy in patients with pancreatic cancer. Cancer 2013; 119:2692-700. [PMID: 23720019 DOI: 10.1002/cncr.28117] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 03/18/2013] [Accepted: 03/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate preoperative treatment with full-dose gemcitabine, oxaliplatin, and radiation therapy (RT) in patients with localized pancreatic cancer. METHODS Eligibility included confirmation of adenocarcinoma, resectable or borderline resectable disease, a performance status ≤2, and adequate organ function. Treatment consisted of two 28-day cycles of gemcitabine (1 g/m(2) over 30 minutes on days 1, 8, and 15) and oxaliplatin (85 mg/m(2) on days 1 and 15) with RT during cycle 1 (30 Gray [Gy] in 2-Gy fractions). Patients were evaluated for surgery after cycle 2. Patients who underwent resection received 2 cycles of adjuvant chemotherapy. RESULTS Sixty-eight evaluable patients received treatment at 4 centers. By central radiology review, 23 patients had resectable disease, 39 patients had borderline resectable disease, and 6 patients had unresectable disease. Sixty-six patients (97%) completed cycle 1 with RT, and 61 patients (90%) completed cycle 2. Grade ≥3 adverse events during preoperative therapy included neutropenia (32%), thrombocytopenia (25%), and biliary obstruction/cholangitis (14%). Forty-three patients underwent resection (63%), and complete (R0) resection was achieved in 36 of those 43 patients (84%). The median overall survival was 18.2 months (95% confidence interval, 13-26.9 months) for all patients, 27.1 months (95% confidence interval, 21.2-47.1 months) for those who underwent resection, and 10.9 months (95% confidence interval, 6.1-12.6 months) for those who did not undergo resection. A decrease in CA 19-9 level after neoadjuvant therapy was associated with R0 resection (P = .02), which resulted in a median survival of 34.6 months (95% confidence interval, 20.3-47.1 months). Fourteen patients (21%) are alive and disease free at a median follow-up of 31.4 months (range, 24-47.6 months). CONCLUSIONS Preoperative therapy with full-dose gemcitabine, oxaliplatin, and RT was feasible and resulted in a high percentage of R0 resections. The current results are particularly encouraging, because the majority of patients had borderline resectable disease.
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Affiliation(s)
- Edward J Kim
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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529
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Warsame R, Grothey A. Treatment options for advanced pancreatic cancer: a review. Expert Rev Anticancer Ther 2013; 12:1327-36. [PMID: 23176620 DOI: 10.1586/era.12.115] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Advanced pancreatic adenocarcinoma historically has a poor prognosis and the mortality rate has remained unchanged for over a decade. Common treatment options for patients with advanced pancreatic cancer include chemoradiation and/or chemotherapy. Single-agent gemcitabine has been considered the standard of care since 1997. Recently published findings indicate that the oxaliplatin, irinotecan, fluorouracil and leucovorin (FOLFIRINOX) treatment regimen significantly improves overall survival compared with gemcitabine. Research has shifted to focus on understanding the causes the resistance of pancreatic cancer to chemotherapy and potential methods to overcome it. This review will focus on the current treatment options, the evolution of targeted therapy, novel agents on the horizon and potential options to ameliorate chemoresistance.
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Affiliation(s)
- Rahma Warsame
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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530
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Werner J, Combs SE, Springfeld C, Hartwig W, Hackert T, Büchler MW. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 2013; 10:323-33. [PMID: 23629472 DOI: 10.1038/nrclinonc.2013.66] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most aggressive cancers, and surgical resection is a requirement for a potential cure. However, the majority of patients are diagnosed with advanced-stage disease, either metastatic (50%) or locally advanced cancer (30%). Although palliative chemotherapy is the standard of care for patients with metastatic disease, management of locally advanced adenocarcinoma is controversial. Several treatment options, including extended surgical resections, neoadjuvant therapy with subsequent resections, as well as palliative radiotherapy and/or chemotherapy, should be considered. However, there is little evidence available to support treatment options for locally advanced disease. As valid predictive biomarkers for stratification of therapy are not available today, future trials need to define the role of the different treatment options. This Review summarizes the current evidence and discusses available treatment options for both locally advanced and metastatic pancreatic adenocarcinoma.
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Affiliation(s)
- Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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531
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La Gamma N, Nandakumar G. The management of gastrointestinal tract malignancies. Hosp Pract (1995) 2013; 41:7-15. [PMID: 23545755 DOI: 10.3810/hp.2013.04.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgery is the mainstay of treatment for many patients with malignancies of the gastrointestinal (GI) tract. The coordination of patient care and timing of surgical intervention require a multidisciplinary approach. It is not unusual for GI malignancies to be discovered in a hospital setting; patients with these malignancies are frequently admitted and discharged from nonsurgical services. Therefore, it is imperative that all physicians involved in the care of patients with GI malignancies have knowledge regarding the workup and surgical treatment of GI tract lesions. This article is a brief overview of the workup and surgical management of malignancies of the GI tract.
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Affiliation(s)
- Nicholas La Gamma
- Weill Cornell Medical College, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA.
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532
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Gunderson LL, Ashman JB, Haddock MG, Petersen IA, Moss A, Heppell J, Gray RJ, Pockaj BA, Nelson H, Beauchamp C. Integration of radiation oncology with surgery as combined-modality treatment. Surg Oncol Clin N Am 2013; 22:405-32. [PMID: 23622071 DOI: 10.1016/j.soc.2013.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Integration of surgery and radiation (external beam, EBRT; intraoperative, IORT) has become more routine for patients with locally advanced primary cancers and those with local-regional relapse. This article discusses patient selection and treatment from a more general perspective, followed by a discussion of patient selection and treatment factors in select disease sites (pancreas cancer, colorectal cancer, retroperitoneal soft-tissue sarcomas). Outcomes with combined modality treatment (surgery, EBRT alone or with concurrent chemotherapy, IORT) are discussed. The ultimate in contemporary integration of radiation and surgery is found in patients who are candidates for surgery plus both EBRT and IORT.
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Affiliation(s)
- Leonard L Gunderson
- Department of Radiation Oncology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA.
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533
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Kang CM, Hwang HK, Lee WJ. Pancreas club international joint symposium on pancreatic cancer 2012, Kyoto: down staging chemo±radiotherapy for borderline resectable pancreatic cancer. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2013; 17:8-13. [PMID: 26155207 PMCID: PMC4304507 DOI: 10.14701/kjhbps.2013.17.1.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/02/2013] [Accepted: 02/08/2013] [Indexed: 11/17/2022]
Abstract
This manuscript summarized one section out of the international symposium, Pancreatic Cancer 2012, which was held last October 4th through 6th in Kyoto (Japan) under the theme, "We are the Team: Opening the Door to the Next Step for Pancreatic Cancer Therapy." Borderline resectable pancreatic cancer (BRPC) is a specific clinical presentation with features in between those of resectable and locally advanced pancreatic cancers. The classification of pancreatic cancer is an important issue given that a cancer may look resectable but be high-risk for R1 or R2 resection. Considering that margin-negative resection is a fundamental requirement for curing pancreatic cancer, this issue is one of the most interesting to pancreatic surgeons. At Pancreatic Cancer 2012 in Kyoto, BRPC was also discussed at the Pancreatic Club International Joint Symposium. In this manuscript, the contents of the presented topics are briefly summarized to facilitate understanding of recent issues in managing BRPC.
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Affiliation(s)
- Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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534
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Tosolini C, Michalski CW, Kleeff J. Response evaluation following neoadjuvant treatment of pancreatic cancer patients. World J Gastrointest Surg 2013; 5:12-15. [PMID: 23515366 PMCID: PMC3600566 DOI: 10.4240/wjgs.v5.i2.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 10/09/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive human neoplastic entities, with a very poor prognosis characterized by a high mortality rate and short survival. This is due both to its aggressive biological behaviour and the high incidence of locally advanced stages at the time of the initial diagnosis. The limits of resectability and the role of neoadjuvant (radio) chemotherapy for PDAC management are still unclear. A recently published article by Kats et al compared the radiological, surgical and histopathological results of 129 patients with borderline resectable tumors undergoing neoadjuvant treatment followed by surgery. Although post-neoadjuvant treatment imaging implied a low response rate, a high rate of complete resections was achieved. This seems to confirm that, though radiology has made a significant progress in defining locally advanced PDAC, there is place for further improvement. In particular, the differentiation between radiotherapy-induced scarring/fibrosis and cancer-associated desmoplasia remains a clinical/radiological challenge. Though selection of patients with occult systemic disease is possible with neoadjuvant treatment, downstaging does not seem to occur frequently. Thus, development of novel, more aggressive (radio) chemotherapy regimens is required to improve prognosis of patients with locally unresectable but not systemically micro-metastasized tumors.
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535
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Katz MHG, Marsh R, Herman JM, Shi Q, Collison E, Venook AP, Kindler HL, Alberts SR, Philip P, Lowy AM, Pisters PWT, Posner MC, Berlin JD, Ahmad SA. Borderline resectable pancreatic cancer: need for standardization and methods for optimal clinical trial design. Ann Surg Oncol 2013; 20:2787-95. [PMID: 23435609 DOI: 10.1245/s10434-013-2886-9] [Citation(s) in RCA: 240] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Methodological limitations of prior studies have prevented progress in the treatment of patients with borderline resectable pancreatic adenocarcinoma. Shortcomings have included an absence of staging and treatment standards and pre-existing biases with regard to the use of neoadjuvant therapy and the role of vascular resection at pancreatectomy. METHODS In this manuscript, we review limitations of studies of borderline resectable PDAC reported to date, highlight important controversies related to this disease stage, emphasize the research infrastructure necessary for its future study, and present a recently-approved Intergroup pilot study (Alliance A021101) that will provide a foundation upon which subsequent well-designed clinical trials can be performed. RESULTS We identified twenty-three studies published since 2001 which report outcomes of patients with tumors labeled as borderline resectable and who were treated with neoadjuvant therapy prior to planned pancreatectomy. These studies were heterogeneous in terms of the populations studied, the metrics used to characterize therapeutic response, and the indications used to select patients for surgery. Mechanisms used to standardize these and other issues that are incorporated into Alliance A021101 are reviewed. CONCLUSIONS Rigorous standards of clinical trial design incorporated into trials of other disease stages must be adopted in all future studies of borderline resectable pancreatic cancer. The Intergroup trial should serve as a paradigm for such investigations.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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536
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Leone F, Gatti M, Massucco P, Colombi F, Sperti E, Campanella D, Regge D, Gabriele P, Capussotti L, Aglietta M. Induction gemcitabine and oxaliplatin therapy followed by a twice-weekly infusion of gemcitabine and concurrent external-beam radiation for neoadjuvant treatment of locally advanced pancreatic cancer. Cancer 2013; 119:277-284. [DOI: 10.1002/cncr.27736] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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537
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Kumar R, Herman JM, Wolfgang CL, Zheng L. Multidisciplinary management of pancreatic cancer. Surg Oncol Clin N Am 2013; 22:265-87. [PMID: 23453334 DOI: 10.1016/j.soc.2012.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreatic cancer (pancreatic adenocarcinoma) remains one of the deadliest malignancies in the western hemisphere despite improved surgical technique, chemotherapy, and radiation therapy. The appropriate management of this malignancy should incorporate multiple treatment modalities for optimal opportunity for cure. Recent trials with a variety of treatment techniques confer improved survival of patients with pancreatic cancer, even in the metastatic setting. In this review, the importance of multidisciplinary management of pancreatic cancer based on disease stage is discussed.
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Affiliation(s)
- Rachit Kumar
- Department of Radiation Oncology & Molecular Radiation Sciences, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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538
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An evaluation of the accuracy of CT when determining resectability of pancreatic head adenocarcinoma after neoadjuvant treatment. Eur J Radiol 2012; 82:589-93. [PMID: 23287712 DOI: 10.1016/j.ejrad.2012.12.002] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 12/03/2012] [Accepted: 12/04/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND To evaluate the accuracy of MDCT for determination of resectability R0 after neoadjuvant therapy in patients with pancreatic head adenocarcinoma locally advanced. METHODS From January 2005 to December 2010, 80 patients with pancreatic head adenocarcinoma underwent multidetector CT before surgery. Of these, 38 patients received neoadjuvant therapy because tumor was considered locally advanced on baseline CT scan. We retrospectively correlated imaging interpretations with operative and histological data and compared results in patients without (control group) or with (neoadjuvant group) preoperative treatment. RESULTS 41/42 patients in control group and 31/38 patients in neoadjuvant group finally had curative resection. While resection R0 is similar in both groups (83% and 81%), CT accuracy in determining resectability R0 was significantly decreased in neoadjuvant group (58% versus 83%; p=0.039). CT scan specificity was significantly lower after neoadjuvant therapy (52% versus 88% in control group) due to an overestimation of vascular invasion: 12/31 patients with complete resection in neoadjuvant group were evaluated at high risk of incomplete resection on CT scan. Tumor size tends to be underestimated in control group (-2mm) and overestimated in neoadjuvant group (+10mm). T-staging accuracy was decreased in neoadjuvant group (39% versus 78% in control group; p=0.002). CONCLUSION Neoadjuvant therapy significantly decreases the accuracy of CT scan in determining operability, T-staging, and resectability R0 of pancreatic head carcinoma. Overestimation of tumor size and vascular invasion significantly reduces CT scan specificity after preoperative treatment.
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539
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Sahani DV, Bonaffini PA, Catalano OA, Guimaraes AR, Blake MA. State-of-the-art PET/CT of the pancreas: current role and emerging indications. Radiographics 2012; 32:1133-58; discussion 1158-60. [PMID: 22786999 DOI: 10.1148/rg.324115143] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fused positron emission tomography (PET)/computed tomography (CT) is a recently developed technology that couples the functional information of PET with the anatomic details of CT. Integrated PET/CT scanners produce both PET and contrast material-enhanced CT images of the entire body in one setting. Typically, the amount of fluorine 18 (18F) fluorodeoxyglucose (FDG) uptake in normal pancreatic parenchyma is insignificant compared with that of the liver. However, both malignant (eg, adenocarcinoma) and benign (eg, acute pancreatitis) pancreatic conditions may demonstrate intense FDG uptake. PET/CT provides an opportunity to depict pancreatic tumors and distant metastases, perform preoperative staging, and monitor response to treatment, and it has proved useful in distinguishing postoperative fibrosis from recurrence. In selected cases, PET/CT findings may be used to help diagnose autoimmune pancreatitis mimicking a mass by depicting systemic involvement. PET/CT may also be used to direct biopsy to sites more likely to yield representative tumor tissue. Novel radiolabeled molecules, such as sigma-receptor ligands and 18F-3'-fluoro-3'-deoxy-l-thymidine (FLT), may play an even greater role in distinguishing tumor recurrence from postoperative fibrosis or inflammation.
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Affiliation(s)
- Dushyant V Sahani
- Department of Radiology, Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114, USA.
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540
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Katz MHG, Fleming JB, Bhosale P, Varadhachary G, Lee JE, Wolff R, Wang H, Abbruzzese J, Pisters PWT, Vauthey JN, Charnsangavej C, Tamm E, Crane CH, Balachandran A. Response of borderline resectable pancreatic cancer to neoadjuvant therapy is not reflected by radiographic indicators. Cancer 2012; 118:5749-56. [PMID: 22605518 DOI: 10.1002/cncr.27636] [Citation(s) in RCA: 375] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/06/2012] [Accepted: 04/09/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Experience with preoperative therapy for other cancers has led to an assumption that borderline resectable pancreatic cancers can be converted to resectable cancers with preoperative therapy. In this study, the authors sought to determine the rate at which neoadjuvant therapy is associated with a reduction in the size or stage of borderline resectable tumors. METHODS Patients who had borderline resectable pancreatic cancer and received neoadjuvant therapy before potentially undergoing surgery at the authors' institution between 2005 and 2010 were identified. The patients' pretreatment and post-treatment pancreatic protocol computed tomography images were rereviewed to determine changes in tumor size or stage using modified Response Evaluation Criteria in Solid Tumors (RECIST) (version 1.1) and standardized anatomic criteria. RESULTS The authors identified 129 patients who met inclusion criteria. Of the 122 patients who had their disease restaged after receiving preoperative therapy, 84 patients (69%) had stable disease, 15 patients (12%) had a partial response to therapy, and 23 patients (19%) had progressive disease. Although only 1 patient (0.8%) had their disease downstaged to resectable status after receiving neoadjuvant therapy, 85 patients (66%) underwent pancreatectomy. The median overall survival duration for all 129 patients was 22 months (95% confidence interval, 14-30 months). The median overall survival duration for the patients who underwent pancreatectomy was 33 months (95% confidence interval, 25-41 months) and was not associated with RECIST response (P = .78). CONCLUSIONS Radiographic downstaging was rare after neoadjuvant therapy, and RECIST response was not an effective treatment endpoint for patients with borderline resectable pancreatic cancer. The authors concluded that these patients should undergo pancreatectomy after initial therapy in the absence of metastases.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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541
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Kim JH, Lee JM, Park JH, Kim SC, Joo I, Han JK, Choi BI. Solid pancreatic lesions: characterization by using timing bolus dynamic contrast-enhanced MR imaging assessment--a preliminary study. Radiology 2012. [PMID: 23192779 DOI: 10.1148/radiol.12120111] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess the feasibility of postprocessing dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging timing bolus data by using a three-dimensional radial gradient-echo technique with k-space-weighted image contrast (KWIC) for the characterization of solid pancreatic diseases. MATERIALS AND METHODS This retrospective study was approved by the institutional review board, and informed consent was waived. A total of 45 patients suspected of having biliary or pancreatic disease underwent pancreatic MR examination with a 3.0-T imager with a low-dose (2 mL gadopentetate dimeglumine) timing bolus by using the radial KWIC technique. There were 24 patients with pancreatic cancers, eight with pancreatic neuroendocrine tumors (PNETs), three with chronic pancreatitis, and 10 with a normal pancreas. By using a dedicated postprocessing software program for DCE MR imaging, the following perfusion parameters were measured for tumor and nontumorous parenchyma: volume transfer coefficient (K(trans)) and extracellular extravascular volume fraction; the rate constant (k(ep)) and initial area under the concentration curve in 60 seconds (iAUC) were then generated. The perfusion parameters acquired on DCE MR images were compared among the groups by using the analysis of variance test. RESULTS K(trans), k(ep), and iAUC values in patients with pancreatic cancer (0.042 min(-1) ± 0.023 [standard deviation], 0.761 min(-1) ± 0.529, and 2.841 mmol/sec ± 1.811, respectively) were significantly lower than in patients with a normal pancreas (0.387 min(-1) ± 0.176, 6.376 min(-1) ± 2.529, and 7.156 mmol/sec ± 3.414, respectively) (P < .05 for all). In addition, k(ep) values of PNETs and normal pancreas also differed (P < .0001), and K(trans), k(ep), and iAUC values of pancreatic cancers and PNETs differed significantly (P < .0001, P = .038, and P < .0001, respectively). CONCLUSION Results of timing bolus DCE MR imaging with the radial KWIC sequence from routine examinations can be postprocessed to yield potentially useful perfusion parameters for the characterization of pancreatic diseases.
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Affiliation(s)
- Jae Hyun Kim
- Seoul National University College of Medicine, Seoul, Korea
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542
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Calvo F, Guillen Ponce C, Muñoz Beltran M, Sanjuanbenito Dehesa A. Multidisciplinary management of locally advanced–borderline resectable adenocarcinoma of the head of the pancreas. Clin Transl Oncol 2012. [DOI: 10.1007/s12094-012-0962-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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543
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Kato A, Shimizu H, Ohtsuka M, Yoshidome H, Yoshitomi H, Furukawa K, Takeuchi D, Takayashiki T, Kimura F, Miyazaki M. Surgical resection after downsizing chemotherapy for initially unresectable locally advanced biliary tract cancer: a retrospective single-center study. Ann Surg Oncol 2012; 20:318-24. [PMID: 23149849 DOI: 10.1245/s10434-012-2312-8] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection is the only method for curative treatment of biliary tract cancer (BTC). Recently, an improved efficacy has been revealed in patients with initially unresectable locally advanced BTC to improve the prognosis by the advent of useful cancer chemotherapy. The aim of this study was to evaluate the effect of downsizing chemotherapy in patients with initially unresectable locally advanced BTC. METHODS Initially unresectable locally advanced cases were defined as those in which therapeutic resection could not be achieved even by proactive surgical resection. Gemcitabine was administered intravenously once a week for 3 weeks followed by 1 week's respite. Patients whose disease responded to chemotherapy were reevaluated to determine whether their tumor was resectable. RESULTS Chemotherapy with gemcitabine was provided to 22 patients with initially unresectable locally advanced BTC. Tumor was significantly downsized in nine patients, and surgical resection was performed in 8 (36.4%) of 22 patients. Surgical resection resulted in R0 resection in four patients and R1 resection in four patients. Patients who underwent surgical resection had a significantly longer survival compared with those unable to undergo surgery. CONCLUSIONS Preoperative chemotherapy enables the downsizing of initially unresectable locally advanced BTC, with radical resection made possible in a certain proportion of patients. Downsizing chemotherapy should be proactively carried out as a multidisciplinary treatment strategy for patients with initially unresectable locally advanced BTC with the aim of expanding the surgical indication.
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Affiliation(s)
- Atsushi Kato
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
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544
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Martin RCG, McFarland K, Ellis S, Velanovich V. Irreversible electroporation in locally advanced pancreatic cancer: potential improved overall survival. Ann Surg Oncol 2012; 20 Suppl 3:S443-9. [PMID: 23128941 DOI: 10.1245/s10434-012-2736-1] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Locally advanced unresectable pancreatic adenocarcinoma (LAC) is characterized by poor survival despite chemotherapy and conventional radiation therapy. We have recently reported on the safety of using irreversible electroporation (IRE) for the management of LAC. The purpose of this study was to evaluate the overall survival in patients with LAC treated with IRE. METHODS A prospective, multi-institutional evaluation of 54 patients who underwent IRE for unresectable pancreatic cancer from December 2009 to October 2010 was evaluated for overall survival and propensity matched to 85 matched stage III patients treated with standard therapy defined as chemotherapy and radiation therapy alone. RESULTS A total of 54 LAC patients have undergone IRE successfully, with 21 women, 23 men (median age, 61 (range, 45-80) years). Thirty-five patients had pancreatic head primary and 19 had body tumors; 19 patients underwent margin accentuation with IRE and 35 underwent in situ IRE. Forty-nine (90 %) patients had pre-IRE chemotherapy alone or chemoradiation therapy for a median duration 5 months. Forty (73%) patients underwent post-IRE chemotherapy or chemoradiation. The 90 day mortality in the IRE patients was 1 (2 %). In a comparison of IRE patients to standard therapy, we have seen an improvement in local progression-free survival (14 vs. 6 months, p = 0.01), distant progression-free survival (15 vs. 9 months, p = 0.02), and overall survival (20 vs. 13 months, p = 0.03). CONCLUSIONS IRE ablation of locally advanced pancreatic tumors remains safe and in the appropriate patient who has undergone standard induction therapy for a minimum of 4 months can achieve greater local palliation and potential improved overall survival compared with standard chemoradiation-chemotherapy treatments. Validation of these early results will need to be validated in the current multi-institutional Phase 2 IDE study.
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Affiliation(s)
- Robert C G Martin
- Division of Surgical Oncology, Department of Surgery and James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA,
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545
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Pipas JM, Zaki BI, McGowan MM, Tsapakos MJ, Ripple GH, Suriawinata AA, Tsongalis GJ, Colacchio TA, Gordon SR, Sutton JE, Srivastava A, Smith KD, Gardner TB, Korc M, Davis TH, Preis M, Tarczewski SM, MacKenzie TA, Barth RJ. Neoadjuvant cetuximab, twice-weekly gemcitabine, and intensity-modulated radiotherapy (IMRT) in patients with pancreatic adenocarcinoma. Ann Oncol 2012; 23:2820-2827. [PMID: 22571859 PMCID: PMC3577039 DOI: 10.1093/annonc/mds109] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 02/22/2012] [Accepted: 02/23/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy has been investigated for localized and locally advanced pancreatic ductal adenocarcinoma (PDAC) but no standard of care exists. Combination cetuximab/gemcitabine/radiotherapy demonstrates encouraging preclinical activity in PDAC. We investigated cetuximab with twice-weekly gemcitabine and intensity-modulated radiotherapy (IMRT) as neoadjuvant therapy in patients with localized or locally advanced PDAC. EXPERIMENTAL DESIGN Treatment consisted of cetuximab load at 400 mg/m(2) followed by cetuximab 250 mg/m(2) weekly and gemcitabine 50 mg/m(2) twice-weekly given concurrently with IMRT to 54 Gy. Following therapy, patients were considered for resection. RESULTS Thirty-seven patients were enrolled with 33 assessable for response. Ten patients (30%) manifested partial response and 20 (61%) manifested stable disease by RECIST. Twenty-five patients (76%) underwent resection, including 18/23 previously borderline and 3/6 previously unresectable tumors. Twenty-three (92%) of these had negative surgical margins. Pathology revealed that 24% of resected tumors had grade III/IV tumor kill, including two pathological complete responses (8%). Median survival was 24.3 months in resected patients. Outcome did not vary by epidermal growth factor receptor status. CONCLUSIONS Neoadjuvant therapy with cetuximab/gemcitabine/IMRT is tolerable and active in PDAC. Margin-negative resection rates are high and some locally advanced tumors can be downstaged to allow for complete resection with encouraging survival. Pathological complete responses can occur. This combination warrants further investigation.
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Affiliation(s)
- J M Pipas
- Section Hematology/Oncology, Department of Medicine.
| | - B I Zaki
- Section Radiation Oncology, Department of Medicine
| | - M M McGowan
- Section Hematology/Oncology, Department of Medicine
| | | | - G H Ripple
- Section Hematology/Oncology, Department of Medicine
| | | | | | | | - S R Gordon
- Section Gastroenterology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
| | - J E Sutton
- Department of Surgery, Veterans Administration Medical Center, White River Junction
| | - A Srivastava
- Department of Pathology, Brigham & Women's Hospital, Boston
| | - K D Smith
- Section Surgical Oncology, Department of Surgery
| | - T B Gardner
- Section Gastroenterology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
| | - M Korc
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - T H Davis
- Section Hematology/Oncology, Department of Medicine
| | - M Preis
- Section Hematology/Oncology, Department of Medicine
| | - S M Tarczewski
- Office of Clinical Research, Norris Cotton Cancer Center, Lebanon
| | - T A MacKenzie
- Department of Epidemiology & Biostatistics, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - R J Barth
- Section Surgical Oncology, Department of Surgery
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546
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Tempero MA, Arnoletti JP, Behrman SW, Ben-Josef E, Benson AB, Casper ES, Cohen SJ, Czito B, Ellenhorn JDI, Hawkins WG, Herman J, Hoffman JP, Ko A, Komanduri S, Koong A, Ma WW, Malafa MP, Merchant NB, Mulvihill SJ, Muscarella P, Nakakura EK, Obando J, Pitman MB, Sasson AR, Tally A, Thayer SP, Whiting S, Wolff RA, Wolpin BM, Freedman-Cass DA, Shead DA. Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw 2012; 32:e80-4. [PMID: 22679115 DOI: 10.1200/jco.2013.48.7546] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.
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547
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Johnson PT, Fishman EK. Computed tomography dataset postprocessing: from data to knowledge. ACTA ACUST UNITED AC 2012; 79:412-21. [PMID: 22678864 DOI: 10.1002/msj.21316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The introduction of spiral computed tomography from the days of single-slice spiral to today's 64-row multidetector computed tomography and beyond creates datasets with unprecedented spatial and temporal resolution. The key to computed tomography imaging in the big picture is not in the acquisition of data, but in the use of the data acquired. By supplementing traditional axial interpretation with 3-dimensional rendering of the computed tomography volume, the greatest amount of information available is extracted. The information provided by a comprehensive postprocessed study, which includes multiplanar reconstruction in the coronal, sagittal, and oblique plane, as well as 3-dimensional maps of both the arterial and venous phase datasets using volume rendering and maximum intensity projection techniques, allows for key clinical decisions to be made with a high degree of accuracy. Postprocessing of computed tomography data is thus no longer an option, but a true requirement in this era of 64-row multidetector computed tomography and beyond.
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Affiliation(s)
- Pamela T Johnson
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, USA.
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548
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Wang F, Arianayagam R, Gill A, Puttaswamy V, Neale M, Gananadha S, Hugh TJ, Samra JS. Grafts for Mesenterico-Portal Vein Resections Can Be Avoided during Pancreatoduodenectomy. J Am Coll Surg 2012; 215:569-79. [DOI: 10.1016/j.jamcollsurg.2012.05.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 05/29/2012] [Accepted: 05/30/2012] [Indexed: 12/22/2022]
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549
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Katz MHG, Lee JE, Pisters PWT, Skoracki R, Tamm E, Fleming JB. Retroperitoneal dissection in patients with borderline resectable pancreatic cancer: operative principles and techniques. J Am Coll Surg 2012; 215:e11-8. [PMID: 22818108 DOI: 10.1016/j.jamcollsurg.2012.05.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/27/2012] [Accepted: 05/14/2012] [Indexed: 11/28/2022]
Abstract
Pancreatectomy with aggressive vascular resection is increasingly being recognized as an appropriate treatment strategy for patients with borderline resectable PDAC after administration of chemotherapy and/or chemoradiation. Because tumor downstaging is an uncommon event, both venous and hepatic arterial resection and reconstruction might be necessary to achieve negative surgical margins and the favorable short-term and long-term outcomes we have reported previously. The technical approaches we have described here can be used as a basic foundation for operative safety and efficiency during these challenging operations.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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550
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Witkowski ER, Smith JK, Tseng JF. Outcomes following resection of pancreatic cancer. J Surg Oncol 2012; 107:97-103. [PMID: 22991309 DOI: 10.1002/jso.23267] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/27/2012] [Indexed: 12/11/2022]
Abstract
Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long-term survival after resection.
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Affiliation(s)
- Elan R Witkowski
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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