101
|
Yang SH, Guo JC, Yeh KH, Tien YW, Cheng AL, Kuo SH. Association of radiotherapy with favorable prognosis in daily clinical practice for treatment of locally advanced and metastatic pancreatic cancer. J Gastroenterol Hepatol 2016; 31:2004-2012. [PMID: 27059987 DOI: 10.1111/jgh.13395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 03/23/2016] [Accepted: 03/24/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Radiotherapy (RT) with or without chemotherapy is currently used in definitive therapy for advanced pancreatic cancer. We sought to evaluate the prognostic significance, pattern of care, and use of RT in locally advanced and metastatic pancreatic cancer. METHODS Between 2002 and 2011, patients with invasive pancreatic carcinoma and prior exposure to systemic chemotherapy were included. We used Cox regression model and propensity score matching for prognostic analyses and logistic regression for analyzing the factors impacting the use of RT. RESULTS We identified 217 pancreatic cancer patients (74 with unresectable stage II or III and 143 with stage IV). Of all patients, 90.8% had adenocarcinoma, and only 19.2% (42/217) received RT with doses ranging from 50 to 55 Gy in 25 to 28 fractions using modern RT techniques. Logistic regression showed stage (P < 0.001) and initial CA 19-9 level (P = 0.026) were significantly predictive of the choice of RT as a first-line treatment, whereas the second-line use of RT was associated with the response to first-line chemotherapy and longer progression-free survival. Patients with RT had a better median survival than those without it (14.6 vs 8.1 months, P < 0.001). In the multivariate analysis and propensity score matching, RT remained a good prognostic factor for overall survival. CONCLUSION The use of RT might be associated with a favorable clinical outcome in patients with locally advanced and metastatic pancreatic cancer. Further exploration of RT as a first-line therapy or second-line therapy for locally advanced or even metastatic pancreatic cancer is warranted.
Collapse
Affiliation(s)
- Shih-Hung Yang
- Department of Oncology, Taipei, Taiwan.,Internal Medicine, National Taiwan University Hospital and National Taiwan University Cancer Center, Taipei, Taiwan.,Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jhe-Cyuan Guo
- Department of Oncology, Taipei, Taiwan.,Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kun-Huei Yeh
- Department of Oncology, Taipei, Taiwan.,Cancer Research Center, Taipei, Taiwan.,Graduate Institute of Oncology, Taipei, Taiwan.,Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | | | - Ann-Lii Cheng
- Department of Oncology, Taipei, Taiwan.,Internal Medicine, National Taiwan University Hospital and National Taiwan University Cancer Center, Taipei, Taiwan.,Cancer Research Center, Taipei, Taiwan.,Graduate Institute of Oncology, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Department of Oncology, Taipei, Taiwan.,Cancer Research Center, Taipei, Taiwan.,Graduate Institute of Oncology, Taipei, Taiwan
| |
Collapse
|
102
|
Kagedan DJ, Dixon ME, Raju RS, Li Q, Elmi M, Shin E, Liu N, El-Sedfy A, Paszat L, Kiss A, Earle CC, Mittmann N, Coburn NG. Predictors of adjuvant treatment for pancreatic adenocarcinoma at the population level. ACTA ACUST UNITED AC 2016; 23:334-342. [PMID: 27803598 DOI: 10.3747/co.23.3205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use. METHODS In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005-2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt. RESULTS Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 (p = 0.002), multivariate analysis revealed widespread variation between the treating hospitals (p = 0.001), and even between high-volume hepatopancreatobiliary hospitals (p = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx. CONCLUSIONS Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.
Collapse
Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - M E Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, U.S.A
| | - R S Raju
- Sunnybrook Health Sciences Centre
| | - Q Li
- Institute for Clinical Evaluative Sciences and
| | - M Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - E Shin
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - N Liu
- Institute for Clinical Evaluative Sciences and
| | - A El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, U.S.A
| | - L Paszat
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | - A Kiss
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Institute of Health Policy, Management and Evaluation, University of Toronto and
| | - C C Earle
- Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON
| | | | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON;; Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences and; Faculty of Medicine, University of Toronto, Toronto, ON;; Institute of Health Policy, Management and Evaluation, University of Toronto and
| |
Collapse
|
103
|
Tamburrino D, Riviere D, Yaghoobi M, Davidson BR, Gurusamy KS. Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 9:CD011515. [PMID: 27631326 PMCID: PMC6457597 DOI: 10.1002/14651858.cd011515.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Periampullary cancer includes cancer of the head and neck of the pancreas, cancer of the distal end of the bile duct, cancer of the ampulla of Vater, and cancer of the second part of the duodenum. Surgical resection is the only established potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Other imaging methods such as magnetic resonance imaging (MRI), positron emission tomography (PET), PET-CT, and endoscopic ultrasound (EUS) have been used to detect local invasion or distant metastases not visualised on CT scanning which could prevent unnecessary laparotomy. No systematic review or meta-analysis has examined the role of different imaging modalities in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer. OBJECTIVES To determine the diagnostic accuracy of MRI, PET scan, and EUS performed as an add-on test or PET-CT as a replacement test to CT scanning in detecting curative resectability in pancreatic and periampullary cancer. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, and Health Technology Assessment (HTA) databases up to 5 November 2015. Two review authors independently screened the references and selected the studies for inclusion. We also searched for articles related to the included studies by performing the "related search" function in MEDLINE (OvidSP) and Embase (OvidSP) and a "citing reference" search (by searching the articles that cite the included articles). SELECTION CRITERIA We included diagnostic accuracy studies of MRI, PET scan, PET-CT, and EUS in patients with potentially resectable pancreatic and periampullary cancer on CT scan. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and quality assessment using the QUADAS-2 (quality assessment of diagnostic accuracy studies - 2) tool. Although we planned to use bivariate methods for analysis of sensitivities and specificities, we were able to fit only the univariate fixed-effect models for both sensitivity and specificity because of the paucity of data. We calculated the probability of unresectability in patients who had a positive index test (post-test probability of unresectability in people with a positive test result) and in those with negative index test (post-test probability of unresectability in people with a positive test result) using the mean probability of unresectability (pre-test probability) from the included studies and the positive and negative likelihood ratios derived from the model. The difference between the pre-test and post-test probabilities gave the overall added value of the index test compared to the standard practice of CT scan staging alone. MAIN RESULTS Only two studies (34 participants) met the inclusion criteria of this systematic review. Both studies evaluated the diagnostic test accuracy of EUS in assessing the resectability with curative intent in pancreatic cancers. There was low concerns about applicability for most domains in both studies. The overall risk of bias was low in one study and unclear or high in the second study. The mean probability of unresectable disease after CT scan across studies was 60.5% (that is 61 out of 100 patients who had resectable cancer after CT scan had unresectable disease on laparotomy). The summary estimate of sensitivity of EUS for unresectability was 0.87 (95% confidence interval (CI) 0.54 to 0.97) and the summary estimate of specificity for unresectability was 0.80 (95% CI 0.40 to 0.96). The positive likelihood ratio and negative likelihood ratio were 4.3 (95% CI 1.0 to 18.6) and 0.2 (95% CI 0.0 to 0.8) respectively. At the mean pre-test probability of 60.5%, the post-test probability of unresectable disease for people with a positive EUS (EUS indicating unresectability) was 86.9% (95% CI 60.9% to 96.6%) and the post-test probability of unresectable disease for people with a negative EUS (EUS indicating resectability) was 20.0% (5.1% to 53.7%). This means that 13% of people (95% CI 3% to 39%) with positive EUS have potentially resectable cancer and 20% (5% to 53%) of people with negative EUS have unresectable cancer. AUTHORS' CONCLUSIONS Based on two small studies, there is significant uncertainty in the utility of EUS in people with pancreatic cancer found to have resectable disease on CT scan. No studies have assessed the utility of EUS in people with periampullary cancer.There is no evidence to suggest that it should be performed routinely in people with pancreatic cancer or periampullary cancer found to have resectable disease on CT scan.
Collapse
Affiliation(s)
| | - Deniece Riviere
- Radboud University Medical Center NijmegenDepartment of SurgeryGeert Grooteplein Zuid 10route 618Nijmegen6500 HBNetherlandsP.O. Box 9101
| | - Mohammad Yaghoobi
- McMaster University and McMaster University Health Sciences CentreDivision of Gastroenterology1200 Main Street WestHamiltonONCanada
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | | | | |
Collapse
|
104
|
Ter Veer E, Haj Mohammad N, van Valkenhoef G, Ngai LL, Mali RMA, Anderegg MC, van Oijen MGH, van Laarhoven HWM. The Efficacy and Safety of First-line Chemotherapy in Advanced Esophagogastric Cancer: A Network Meta-analysis. J Natl Cancer Inst 2016; 108:djw166. [PMID: 27576566 DOI: 10.1093/jnci/djw166] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/27/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A globally accepted standard first-line chemotherapy regimen in advanced esophagogastric cancer (AEGC) is not clearly established. We conducted a systematic review to investigate the efficacy and safety of first-line chemotherapy using Network meta-analysis (NMA). METHODS Medline, EMBASE, CENTRAL, and conferences were searched until June 2015 for randomized controlled trials that compared regimens containing: fluoropyrimidine (F), platinum (cisplatin [C] and oxaliplatin [Ox]), taxane (T), anthracycline (A), irinotecan (I), or methotrexate (M). Direct and indirect evidence for overall survival (OS) and progression-free-survival (PFS) were combined using random-effects NMA on the hazard ratio (HR) scale and calculated as combined hazard ratios and 95% credible intervals (CrIs). RESULTS The NMA incorporated 17 chemotherapy regimens with 37 direct comparisons between regimens for OS (50 studies, n = 10 249) and 29 direct comparisons for PFS (34 studies, n = 7795). Combining direct and indirect effects showed increased efficacy for fluoropyrimidine noncisplatin doublets (F-doublets) over cisplatin doublets (C-doublets): FI vs CF (combined HR = 0.85, 95% CrI = 0.71 to 0.99), FOx vs CF (combined HR = 0.83, 95% CrI = 0.71 to 0.98) in OS and FOx vs CF (combined HR = 0.82, 95% CrI = 0.66 to 0.99) in PFS. Anthracycline-containing triplets (A-triplets: ACF, AFOx, AFM) and TCF triplet showed no benefit over F-doublets in OS and PFS. The triplet FOxT showed increased PFS vs F-doublets FT (combined HR = 0.61, 95% CrI = 0.38 to 0.99), FI (combined HR = 0.62, 95% CrI = 0.38 to 0.99), and FOx (combined HR = 0.67, 95% CrI = 0.44 to 0.99). Increased grade 3 to 4 toxicity was found for CF vs F-doublets, for ACF vs FI for TCF vs CF, and for FOxT vs FOx. CONCLUSIONS Based on efficacy and toxicity, F-doublets FOx, FI, and FT are preferred as first-line treatment for AEGC compared with C-doublets, A-triplets, and TCF. FOxT is the most promising triplet.
Collapse
Affiliation(s)
- Emil Ter Veer
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Nadia Haj Mohammad
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Gert van Valkenhoef
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Lok Lam Ngai
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Rosa M A Mali
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Maarten C Anderegg
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Martijn G H van Oijen
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| | - Hanneke W M van Laarhoven
- Affiliations of author: Department of Medical Oncology (EtV, NHM, LLN, RM, MGHvO, HWMvL) and Department of Surgery (MCA), Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands (GvV)
| |
Collapse
|
105
|
Yang SH, Kuo TC, Wu H, Guo JC, Hsu C, Hsu CH, Tien YW, Yeh KH, Cheng AL, Kuo SH. Perspectives on the combination of radiotherapy and targeted therapy with DNA repair inhibitors in the treatment of pancreatic cancer. World J Gastroenterol 2016; 22:7275-7288. [PMID: 27621574 PMCID: PMC4997635 DOI: 10.3748/wjg.v22.i32.7275] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/20/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is highly lethal. Current research that combines radiation with targeted therapy may dramatically improve prognosis. Cancerous cells are characterized by unstable genomes and activation of DNA repair pathways, which are indicated by increased phosphorylation of numerous factors, including H2AX, ATM, ATR, Chk1, Chk2, DNA-PKcs, Rad51, and Ku70/Ku80 heterodimers. Radiotherapy causes DNA damage. Cancer cells can be made more sensitive to the effects of radiation (radiosensitization) through inhibition of DNA repair pathways. The synergistic effects, of two or more combined non-lethal treatments, led to co-administration of chemotherapy and radiosensitization in BRCA-defective cells and patients, with promising results. ATM/Chk2 and ATR/Chk1 pathways are principal regulators of cell cycle arrest, following DNA double-strand or single-strand breaks. DNA double-stranded breaks activate DNA-dependent protein kinase, catalytic subunit (DNA-PKcs). It forms a holoenzyme with Ku70/Ku80 heterodimers, called DNA-PK, which catalyzes the joining of nonhomologous ends. This is the primary repair pathway utilized in human cells after exposure to ionizing radiation. Radiosensitization, induced by inhibitors of ATM, ATR, Chk1, Chk2, Wee1, PP2A, or DNA-PK, has been demonstrated in preclinical pancreatic cancer studies. Clinical trials are underway. Development of agents that inhibit DNA repair pathways to be clinically used in combination with radiotherapy is warranted for the treatment of pancreatic cancer.
Collapse
|
106
|
Gürlevik E, Fleischmann-Mundt B, Brooks J, Demir IE, Steiger K, Ribback S, Yevsa T, Woller N, Kloos A, Ostroumov D, Armbrecht N, Manns MP, Dombrowski F, Saborowski M, Kleine M, Wirth TC, Oettle H, Ceyhan GO, Esposito I, Calvisi DF, Kubicka S, Kühnel F. Administration of Gemcitabine After Pancreatic Tumor Resection in Mice Induces an Antitumor Immune Response Mediated by Natural Killer Cells. Gastroenterology 2016; 151:338-350.e7. [PMID: 27210037 DOI: 10.1053/j.gastro.2016.05.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 05/02/2016] [Accepted: 05/12/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Even after potentially curative R0 resection, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis owing to high rates of local recurrence and metastasis to distant organs. However, we have no suitable transgenic animal models for surgical interventions. METHODS To induce formation of pancreatic tumor foci, we electroporated oncogenic plasmids into pancreata of LSL-KrasG12D × p53fl/fl mice; mutant Kras was expressed in p53fl/fl mice using a sleeping beauty transposon. We co-delivered a transposon encoding a constitutively active form of Akt2 (myrAkt2). Carcinogenesis and histopathologic features of tumors were examined. Metastasis was monitored by bioluminescence imaging. Tumors were resected and mice were given gemcitabine, and tumor recurrence patterns and survival were determined. Immune cells were collected from resection sites and analyzed by flow cytometry and in depletion experiments. RESULTS After electroporation of oncogenic plasmids, mice developed a single pancreatic tumor nodule with histopathologic features of human PDAC. Pancreatic tumors that expressed myrAkt2 infiltrated the surrounding pancreatic tissue and neurons and became widely metastatic, reflecting the aggressive clinical features of PDAC in patients. Despite early tumor resection, mice died from locally recurring and distant tumors, but adjuvant administration of gemcitabine after tumor resection prolonged survival. In mice given adjuvant gemcitabine or vehicle, gemcitabine significantly inhibited local recurrence of tumors, but not metastasis to distant organs, similar to observations in clinical trials. Gemcitabine inhibited accumulation of CD11b+Gr1intF4/80int myeloid-derived suppressor cells at the resection margin and increased the number of natural killer (NK) cells at this location. NK cells but not T cells were required for gemcitabine-mediated antitumor responses. CONCLUSIONS Gemcitabine administration after resection of pancreatic tumors in mice activates NK cell-mediated antitumor responses and inhibits local recurrence of tumors, consistent with observations from patients with PDAC. Transgenic mice with resectable pancreatic tumors might be promising tools to study adjuvant therapy strategies for patients.
Collapse
Affiliation(s)
- Engin Gürlevik
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Bettina Fleischmann-Mundt
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jennifer Brooks
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Katja Steiger
- Institute of Pathology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Silvia Ribback
- Institute of Pathology, University Medicine of Greifswald, Greifswald, Germany
| | - Tetyana Yevsa
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Norman Woller
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Arnold Kloos
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Dmitrij Ostroumov
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Nina Armbrecht
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank Dombrowski
- Institute of Pathology, University Medicine of Greifswald, Greifswald, Germany
| | - Michael Saborowski
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- Department of Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas C Wirth
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | | | - Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Irene Esposito
- Institute of Pathology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany; Institute of Pathology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Diego F Calvisi
- Institute of Pathology, University Medicine of Greifswald, Greifswald, Germany
| | - Stefan Kubicka
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany; Cancer Center Reutlingen, District Hospital, Reutlingen, Germany
| | - Florian Kühnel
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany.
| |
Collapse
|
107
|
Freeman K, Connock M, Cummins E, Gurung T, Taylor-Phillips S, Court R, Saunders M, Clarke A, Sutcliffe P. Fluorouracil plasma monitoring: systematic review and economic evaluation of the My5-FU assay for guiding dose adjustment in patients receiving fluorouracil chemotherapy by continuous infusion. Health Technol Assess 2016; 19:1-321, v-vi. [PMID: 26542268 DOI: 10.3310/hta19910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND 5-Fluorouracil (5-FU) is a chemotherapy used in colorectal, head and neck (H&N) and other cancers. Dose adjustment is based on body surface area (BSA) but wide variations occur. Pharmacokinetic (PK) dosing is suggested to bring plasma levels into the therapeutic range to promote fewer side effects and better patient outcomes. We investigated the clinical effectiveness and cost-effectiveness of the My5-FU assay for PK dose adjustment to 5-FU therapy. OBJECTIVES To systematically review the evidence on the accuracy of the My5-FU assay compared with gold standard methods [high-performance liquid chromatography (HPLC) and liquid chromatography-mass spectrometry (LC-MS)]; the effectiveness of My5-FU PK dosing compared with BSA; the effectiveness of HPLC and/or LC-MS compared with BSA; the generalisability of published My5-FU and PK studies; costs of using My5-FU; to develop a cost-effectiveness model. DATA SOURCES We searched MEDLINE, EMBASE, Science Citation Index and other databases between January and April 2014. METHODS Two reviewers independently screened titles and abstracts with arbitration and consensus agreement. We undertook quality assessment. We reconstructed Kaplan-Meier plots for progression-free survival (PFS) and overall survival (OS) for comparison of BSA and PK dosing. We developed a Markov model to compare My5-FU with BSA dosing which modelled PFS, OS and adverse events, using a 2-week cycle over a 20 year time horizon with a 3.5% discount rate. Health impacts were evaluated from the patient perspective, while costs were evaluated from the NHS and Personal Social Services perspective. RESULTS A total of 8341 records were identified through electronic searches and 35 and 54 studies were included in the clinical effectiveness and cost-effectiveness reviews respectively. There was a high apparent correlation between My5-FU, HPLC and LC-MS/mass spectrometer but upper and lower limits of agreement were -18% to 30%. Median OS were estimated as 19.6 [95% confidence interval (CI) 17.0 to 21.0] months for PK versus 14.6 (95% CI 14.1 to 15.3) months for BSA for 5-FU+folinic acid (FA); and 27.4 (95% CI 23.2 to 38.8) months for PK versus 20.6 (95% CI 18.4 to 22.9) months for BSA for FOLFOX6 in metastatic colorectal cancer (mCRC). PK versus BSA studies were generalisable to the relevant populations. We developed cost-effectiveness models for mCRC and H&N cancer. The base case assumed a cost per My5-FU assay of £ 61.03. For mCRC for 12 cycles of a oxaliplatin in combination with 5-fluorouracil and FA (FOLFOX) regimen, there was a quality-adjusted life-year (QALY) gain of 0.599 with an incremental cost-effectiveness ratio of £ 4148 per QALY. Probabilistic and scenario analyses gave similar results. The cost-effectiveness acceptability curve showed My5-FU to be 100% cost-effective at a threshold of £ 20,000 per QALY. For H&N cancer, again, given caveats about the poor evidence base, we also estimated that My5-FU is likely to be cost-effective at a threshold of £ 20,000 per QALY. LIMITATIONS Quality and quantity of evidence were very weak for PK versus BSA dosing for all cancers with no randomised controlled trials (RCTs) using current regimens. For H&N cancer, two studies of regimens no longer in use were identified. CONCLUSIONS Using a linked evidence approach, My5-FU appears to be cost-effective at a willingness to pay of £ 20,000 per QALY for both mCRC and H&N cancer. Considerable uncertainties remain about evidence quality and practical implementation. RCTs are needed of PK versus BSA dosing in relevant cancers.
Collapse
Affiliation(s)
| | - Martin Connock
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Tara Gurung
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mark Saunders
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - Aileen Clarke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
108
|
Chemoradiotherapy for locally advanced pancreatic cancer patients: is it still an open question? Contemp Oncol (Pozn) 2016; 20:102-8. [PMID: 27358587 PMCID: PMC4925731 DOI: 10.5114/wo.2016.60066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 03/19/2015] [Indexed: 12/15/2022] Open
Abstract
Operable pancreatic cancer is characterized by a high risk of recurrence. Efforts are made to incorporate new therapies. Throughout the world there is a lack of uniform recommendations concerning the adjuvant treatment of pancreatic cancer patients, due to confusing evidence-based data. The patients recruited to clinical trials differ from the population of patients treated in everyday practice. These differences have an influence on tolerance of treatment, toxicity and results of therapy. The decision on administration of adjuvant treatment is made individually and differs from center to center. A review of the literature concerning both results and tolerance of postoperative chemoradiotherapy of pancreatic cancer patients is presented.
Collapse
|
109
|
Bassi C, Balzano G, Zerbi A, Ramera M. Pancreatic surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it. Updates Surg 2016; 68:117-22. [PMID: 27272682 DOI: 10.1007/s13304-016-0371-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/17/2016] [Indexed: 12/18/2022]
Abstract
Indicators of effectiveness and quality of care are urgently needed to improve the surgical outcomes. This is particularly felt in the field of complex surgical fields, such as the HPB one. International and national studies have documented an association between the large number of pancreatic surgical procedures and the outcome quality. The aim of this paper is to suggest reliable structural requirements and surgical volume to support pancreatic surgical accreditation, preserving patient's safety. Moreover, an accreditation program is outlined.
Collapse
Affiliation(s)
- Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, P.Le L.A. Scuro 10, 37134, Verona, Italy.
| | - Giampaolo Balzano
- Pancreas Unit, Department of Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Zerbi
- Section of Pancreatic Surgery, Humanitas Research Hospital, Milano, Rozzano, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, P.Le L.A. Scuro 10, 37134, Verona, Italy
| |
Collapse
|
110
|
Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016; 34:2541-56. [PMID: 27247221 DOI: 10.1200/jco.2016.67.5553] [Citation(s) in RCA: 259] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to oncologists and others on potentially curative therapy for patients with localized pancreatic cancer. METHODS ASCO convened a panel of medical oncology, radiation oncology, surgical oncology, palliative care, and advocacy experts and conducted a systematic review of literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events. RESULTS Nine randomized controlled trials met the systematic review criteria. RECOMMENDATIONS A multiphase computed tomography scan of the abdomen and pelvis or magnetic resonance imaging should be performed for all patients to assess the anatomic relationships of the primary tumor and for the presence of intra-abdominal metastases. Baseline performance status, comorbidity profile, and goals of care should be evaluated and established. Primary surgical resection is recommended for all patients who have no metastases, appropriate performance and comorbidity profiles, and no radiographic interface between primary tumor and mesenteric vasculature. Preoperative therapy is recommended for patients who meet specific characteristics. All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of contraindications. Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy with microscopically positive margins (R1) after resection and/or who had node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy. Patients should have a full assessment of symptoms, psychological status, and social supports and should receive palliative care early. Patients who have completed treatment and have no evidence of disease should be monitored. Additional information is available at www.asco.org/guidelines/PCPC and www.asco.org/guidelineswiki.
Collapse
Affiliation(s)
- Alok A Khorana
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Pamela B Mangu
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Jordan Berlin
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anitra Engebretson
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Theodore S Hong
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Anirban Maitra
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Supriya G Mohile
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew Mumber
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Richard Schulick
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Marc Shapiro
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Susan Urba
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Herbert J Zeh
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| | - Matthew H G Katz
- Alok A. Khorana and Marc Shapiro, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Jordan Berlin, Vanderbilt University, Nashville, TN; Anitra Engebretson, Patient Representative, Portland, OR; Theodore S. Hong, Massachusetts General Hospital, Boston, MA; Anirban Maitra and Matthew H.G. Katz, The University of Texas MD Anderson Cancer Center, Houston, TX; Supriya G. Mohile, University of Rochester, Rochester, NY; Matthew Mumber, Harbin Clinic, Rome, GA; Richard Schulick, University of Colorado at Denver, Denver, CO; Susan Urba, University of Michigan, Ann Arbor, MI; and Herbert J. Zeh, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
111
|
Laeseke PF, Chen R, Jeffrey RB, Brentnall TA, Willmann JK. Combining in Vitro Diagnostics with in Vivo Imaging for Earlier Detection of Pancreatic Ductal Adenocarcinoma: Challenges and Solutions. Radiology 2016; 277:644-61. [PMID: 26599925 DOI: 10.1148/radiol.2015141020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth-leading cause of cancer-related death in the United States and is associated with a dismal prognosis, particularly when diagnosed at an advanced stage. Overall survival is significantly improved if PDAC is detected at an early stage prior to the onset of symptoms. At present, there is no suitable screening strategy for the general population. Available diagnostic serum markers are not sensitive or specific enough, and clinically available imaging modalities are inadequate for visualizing early-stage lesions. In this article, the role of currently available blood biomarkers and imaging tests for the early detection of PDAC will be reviewed. Also, the emerging biomarkers and molecularly targeted imaging agents being developed to improve the specificity of current imaging modalities for PDAC will be discussed. A strategy incorporating blood biomarkers and molecularly targeted imaging agents could lead to improved screening and earlier detection of PDAC in the future. (©) RSNA, 2015.
Collapse
Affiliation(s)
- Paul F Laeseke
- From the Department of Radiology, Molecular Imaging Program at Stanford, Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5621 (P.F.L., R.B.J., J.K.W.); and Department of Medicine, University of Washington, Seattle, Wash (R.C., T.A.B.)
| | - Ru Chen
- From the Department of Radiology, Molecular Imaging Program at Stanford, Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5621 (P.F.L., R.B.J., J.K.W.); and Department of Medicine, University of Washington, Seattle, Wash (R.C., T.A.B.)
| | - R Brooke Jeffrey
- From the Department of Radiology, Molecular Imaging Program at Stanford, Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5621 (P.F.L., R.B.J., J.K.W.); and Department of Medicine, University of Washington, Seattle, Wash (R.C., T.A.B.)
| | - Teresa A Brentnall
- From the Department of Radiology, Molecular Imaging Program at Stanford, Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5621 (P.F.L., R.B.J., J.K.W.); and Department of Medicine, University of Washington, Seattle, Wash (R.C., T.A.B.)
| | - Jürgen K Willmann
- From the Department of Radiology, Molecular Imaging Program at Stanford, Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5621 (P.F.L., R.B.J., J.K.W.); and Department of Medicine, University of Washington, Seattle, Wash (R.C., T.A.B.)
| |
Collapse
|
112
|
Riviere D, Gurusamy KS, Kooby DA, Vollmer CM, Besselink MGH, Davidson BR, van Laarhoven CJHM. Laparoscopic versus open distal pancreatectomy for pancreatic cancer. Cochrane Database Syst Rev 2016; 4:CD011391. [PMID: 27043078 PMCID: PMC7083263 DOI: 10.1002/14651858.cd011391.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical resection is currently the only treatment with the potential for long-term survival and cure of pancreatic cancer. Surgical resection is provided as distal pancreatectomy for cancers of the body and tail of the pancreas. It can be performed by laparoscopic or open surgery. In operations on other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay as compared with open surgery. However, concerns remain about the safety of laparoscopic distal pancreatectomy compared with open distal pancreatectomy in terms of postoperative complications and oncological clearance. OBJECTIVES To assess the benefits and harms of laparoscopic distal pancreatectomy versus open distal pancreatectomy for people undergoing distal pancreatectomy for pancreatic ductal adenocarcinoma of the body or tail of the pancreas, or both. SEARCH METHODS We used search strategies to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and trials registers until June 2015 to identify randomised controlled trials (RCTs) and non-randomised studies. We also searched the reference lists of included trials to identify additional studies. SELECTION CRITERIA We considered for inclusion in the review RCTs and non-randomised studies comparing laparoscopic versus open distal pancreatectomy in patients with resectable pancreatic cancer, irrespective of language, blinding or publication status.. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated odds ratios (ORs), mean differences (MDs) or hazard ratios (HRs) along with 95% confidence intervals (CIs) using both fixed-effect and random-effects models with RevMan 5 on the basis of intention-to-treat analysis when possible. MAIN RESULTS We found no RCTs on this topic. We included in this review 12 non-randomised studies that compared laparoscopic versus open distal pancreatectomy (1576 participants: 394 underwent laparoscopic distal pancreatectomy and 1182 underwent open distal pancreatectomy); 11 studies (1506 participants: 353 undergoing laparoscopic distal pancreatectomy and 1153 undergoing open distal pancreatectomy) provided information for one or more outcomes. All of these studies were retrospective cohort-like studies or case-control studies. Most were at unclear or high risk of bias, and the overall quality of evidence was very low for all reported outcomes.Differences in short-term mortality (laparoscopic group: 1/329 (adjusted proportion based on meta-analysis estimate: 0.5%) vs open group: 11/1122 (1%); OR 0.48, 95% CI 0.11 to 2.17; 1451 participants; nine studies; I(2) = 0%), long-term mortality (HR 0.96, 95% CI 0.82 to 1.12; 277 participants; three studies; I(2) = 0%), proportion of people with serious adverse events (laparoscopic group: 7/89 (adjusted proportion: 8.8%) vs open group: 6/117 (5.1%); OR 1.79, 95% CI 0.53 to 6.06; 206 participants; three studies; I(2) = 0%), proportion of people with a clinically significant pancreatic fistula (laparoscopic group: 9/109 (adjusted proportion: 7.7%) vs open group: 9/137 (6.6%); OR 1.19, 95% CI 0.47 to 3.02; 246 participants; four studies; I(2) = 61%) were imprecise. Differences in recurrence at maximal follow-up (laparoscopic group: 37/81 (adjusted proportion based on meta-analysis estimate: 36.3%) vs open group: 59/103 (49.5%); OR 0.58, 95% CI 0.32 to 1.05; 184 participants; two studies; I(2) = 13%), adverse events of any severity (laparoscopic group: 33/109 (adjusted proportion: 31.7%) vs open group: 45/137 (32.8%); OR 0.95, 95% CI 0.54 to 1.66; 246 participants; four studies; I(2) = 18%) and proportion of participants with positive resection margins (laparoscopic group: 49/333 (adjusted proportion based on meta-analysis estimate: 14.3%) vs open group: 208/1133 (18.4%); OR 0.74, 95% CI 0.49 to 1.10; 1466 participants; 10 studies; I(2) = 6%) were also imprecise. Mean length of hospital stay was shorter by 2.43 days in the laparoscopic group than in the open group (MD -2.43 days, 95% CI -3.13 to -1.73; 1068 participants; five studies; I(2) = 0%). None of the included studies reported quality of life at any point in time, recurrence within six months, time to return to normal activity and time to return to work or blood transfusion requirements. AUTHORS' CONCLUSIONS Currently, no randomised controlled trials have compared laparoscopic distal pancreatectomy versus open distal pancreatectomy for patients with pancreatic cancers. In observational studies, laparoscopic distal pancreatectomy has been associated with shorter hospital stay as compared with open distal pancreatectomy. Currently, no information is available to determine a causal association in the differences between laparoscopic versus open distal pancreatectomy. Observed differences may be a result of confounding due to laparoscopic operation on less extensive cancer and open surgery on more extensive cancer. In addition, differences in length of hospital stay are relevant only if laparoscopic and open surgery procedures are equivalent oncologically. This information is not available currently. Thus, randomised controlled trials are needed to compare laparoscopic distal pancreatectomy versus open distal pancreatectomy with at least two to three years of follow-up. Such studies should include patient-oriented outcomes such as short-term mortality and long-term mortality (at least two to three years); health-related quality of life; complications and the sequelae of complications; resection margins; measures of earlier postoperative recovery such as length of hospital stay, time to return to normal activity and time to return to work (in those who are employed); and recurrence of cancer.
Collapse
Affiliation(s)
- Deniece Riviere
- Radboud University Nijmegen Medical CenterDepartment of SurgeryNijmegenNetherlands
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - David A Kooby
- Emory University School of MedicineDepartment of SurgeryAtlantaGAUSA
| | - Charles M Vollmer
- University of PennsylvaniaDepartment of Gastrointestinal SurgeryPerelman School of MedicinePhiladelphiaPAUSA
| | - Marc GH Besselink
- AMC AmsterdamDepartment of Surgery, G4‐196PO Box 22660AmsterdamAMCNetherlands1100 DD
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | | | | |
Collapse
|
113
|
Kagedan DJ, Raju RS, Dixon ME, Shin E, Li Q, Liu N, Elmi M, El-Sedfy A, Paszat L, Kiss A, Earle CC, Mittmann N, Coburn NG. The association of adjuvant therapy with survival at the population level following pancreatic adenocarcinoma resection. HPB (Oxford) 2016; 18:339-47. [PMID: 27037203 PMCID: PMC4814617 DOI: 10.1016/j.hpb.2015.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Using a retrospective observational cohort approach, the overall survival (OS) following curative-intent resection of pancreatic adenocarcinoma (PC) was defined at the population level according to adjuvant treatment, and predictors of OS were identified. METHODS Patients undergoing resection of PC in the province of Ontario between 2005 and 2010 were identified using the provincial cancer registry, and linked to databases that include all treatments received and outcomes experienced in the province. Pathology reports were abstracted for staging and margin status. Patients were identified as having received chemotherapy (CT), chemoradiation therapy (CRT), or no adjuvant treatment (NAT). Kaplan-Meier survival analysis of patients surviving ≥ 6 months was performed, and predictors of OS identified by log-rank test. Cox multivariable analysis was used to define independent predictors of OS. RESULTS Among the 473 patients undergoing PC resection, the median survival was 17.8 months; for the 397 who survived ≥ 6 months following surgery, the 5-year OS for the CT, CRT, and NAT groups was 21%, 16%, and 17%, respectively (p = 0.584). Lymph node-negative patients demonstrated improved OS associated with chemotherapy on multivariable analysis (HR = 2.20, 95% CI = 1.25-3.83 for NAT vs. CT). CONCLUSIONS Following PC resection, only patients with negative lymph nodes demonstrated improved OS associated with adjuvant chemotherapy.
Collapse
Affiliation(s)
- Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ravish S Raju
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Matthew E Dixon
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Elizabeth Shin
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ning Liu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Maryam Elmi
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Abraham El-Sedfy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Lawrence Paszat
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
114
|
Huang SG, Chen B, Lv D, Zhang Y, Nie FF, Li W, Lv Y, Zhao HL, Liu HM. Evaluation of shoulder function in clavicular fracture patients after six surgical procedures based on a network meta-analysis. Disabil Rehabil 2016; 39:105-112. [PMID: 26984590 DOI: 10.3109/09638288.2016.1140827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpose Using a network meta-analysis approach, our study aims to develop a ranking of the six surgical procedures, that is, Plate, titanium elastic nail (TEN), tension band wire (TBW), hook plate (HP), reconstruction plate (RP) and Knowles pin, by comparing the post-surgery constant shoulder scores in patients with clavicular fracture (CF). Methods A comprehensive search of electronic scientific literature databases was performed to retrieve publications investigating surgical procedures in CF, with the stringent eligible criteria, and clinical experimental studies of high quality and relevance to our area of interest were selected for network meta-analysis. Statistical analyses were conducted using Stata 12.0. Results A total of 19 studies met our inclusion criteria were eventually enrolled into our network meta-analysis, representing 1164 patients who had undergone surgical procedures for CF (TEN group = 240; Plate group = 164; TBW group = 180; RP group = 168; HP group = 245; Knowles pin group = 167). The network meta-analysis results revealed that RP significantly improved constant shoulder score in patients with CF when compared with TEN, and the post-operative constant shoulder scores in patients with CF after Plate, TBW, HP, Knowles pin and TEN were similar with no statistically significant differences. The treatment relative ranking of predictive probabilities of constant shoulder scores in patients with CF after surgery revealed the surface under the cumulative ranking curves (SUCRA) value is the highest in RP. Conclusion The current network meta-analysis suggests that RP may be the optimum surgical treatment among six inventions for patients with CF, and it can improve the shoulder score of patients with CF. Implications for Rehabilitation RP improves shoulder joint function after surgical procedure. RP achieves stability with minimal complications after surgery. RP may be the optimum surgical treatment for rehabilitation of patients with CF.
Collapse
Affiliation(s)
- Shou-Guo Huang
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| | - Bo Chen
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| | - Dong Lv
- b Department of Orthopedics , Tengzhou People's Hospital , Tengzhou , China
| | - Yong Zhang
- c Department of General Surgery , Affiliated Hospital of Taishan Medical University , Tai'an , China
| | - Feng-Feng Nie
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| | - Wei Li
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| | - Yao Lv
- d Department of Orthopedic Surgery , Affiliated Hospital of Taishan Medical University , Tai'an , China
| | - Huan-Li Zhao
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| | - Hong-Mei Liu
- a Department of Orthopedics , Linyi Second People's Hospital , Linyi , China
| |
Collapse
|
115
|
GONG JUN, TULI RICHARD, SHINDE ARVIND, HENDIFAR ANDREWE. Meta-analyses of treatment standards for pancreatic cancer. Mol Clin Oncol 2016; 4:315-325. [PMID: 26998283 PMCID: PMC4774516 DOI: 10.3892/mco.2015.716] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 11/23/2015] [Indexed: 01/05/2023] Open
Abstract
Pancreatic cancer is the most lethal common cancer with an estimated 5-year survival rate of 6-7% (across all stages). The only potential curative therapy is surgical resection in those with localized disease. Adjuvant (postoperative) therapy confers a survival advantage over postoperative observation alone. Neoadjuvant (preoperative) therapy offers the potential to downstage initially unresectable tumors for resection, sterilize resection margins and decrease locoregional recurrence, and identify a subset of patients with aggressive disease for whom surgery will not be beneficial. Induction chemotherapy followed by consolidation chemoradiation is another recommended approach in those with locally advanced disease. For those who cannot be downstaged, cannot tolerate surgery, or were diagnosed with metastatic disease, treatment remains palliative with chemotherapy being a critical component of this approach. Recently, intensive combination chemotherapy has been shown to improve survival rates in comparison to gemcitabine alone in advanced disease. The past few decades have afforded an accumulation of high-level evidence regarding neoadjuvant, adjuvant and palliative therapies in pancreatic cancer. There are numerous reviews discussing recent retrospective studies, prospective studies and randomized controlled trials in each of these areas. However, reviews of optimal and recommended treatment strategies across all stages of pancreatic cancer that focus on the highest levels of hierarchical evidence, such as meta-analyses, are limited. The discussion of novel therapeutics is beyond the scope of this review. However, an extensive and the most current collection of meta-analyses of first-line systemic and locoregional treatment options for all stages of pancreatic cancer to date has been accumulated.
Collapse
Affiliation(s)
- JUN GONG
- Department of Internal Medicine, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - RICHARD TULI
- Department of Radiation Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ARVIND SHINDE
- Department of Hematology and Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ANDREW E. HENDIFAR
- Gastrointestinal and Neuroendocrine Malignancies, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| |
Collapse
|
116
|
Hartley ML, Bade NA, Prins PA, Ampie L, Marshall JL. Pancreatic cancer, treatment options, and GI-4000. Hum Vaccin Immunother 2016; 11:931-7. [PMID: 25933185 DOI: 10.1080/21645515.2015.1011017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although pancreatic cancer is but the eleventh most prevalent cancer in the US, it is predicted that of all the patients newly diagnosed with this disease in 2014, only 27% will still be alive at the end of the first year, which is reduced to 6% after 5 years. The choice of chemotherapy in the treatment of pancreatic cancer is dependent on disease stage and patient performance status but, in general, the most widely used approved regimens include 5-fluorouracil (5-FU) combinations and gemcitabine combinations. Recent therapeutic strategies have resulted in an improvement in survival of patients with pancreatic cancer but the magnitude of change is disappointing and vast improvements are still needed. The goal of immunotherapy is to enhance and guide the body's immune system to recognize tumor-specific antigens and mount an attack against the disease. Among newer immune therapies, GI-4000 consists of 4 different targeted molecular immunogens, each containing a different Ras protein (antigen) encoded by the most commonly found mutant RAS genes in solid tumors-RAS mutations exist in over 90% of pancreatic ductal adenocarcinomas. We will review pancreatic cancer epidemiology and its current treatment options, and consider the prospects of immunotherapy, focusing on GI-4000. We discuss the potential mechanism of action of GI-4000, and the performance of this vaccination series thus far in early phase clinical trials.
Collapse
Affiliation(s)
- Marion L Hartley
- a The Ruesch Center for the Cure of GI Cancers at the Georgetown Lombardi Comprehensive Cancer Center ; Georgetown University ; Washington , DC USA
| | | | | | | | | |
Collapse
|
117
|
Conroy T, Bachet JB, Ayav A, Huguet F, Lambert A, Caramella C, Maréchal R, Van Laethem JL, Ducreux M. Current standards and new innovative approaches for treatment of pancreatic cancer. Eur J Cancer 2016; 57:10-22. [PMID: 26851397 DOI: 10.1016/j.ejca.2015.12.026] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022]
Abstract
Pancreatic adenocarcinoma remains a devastating disease with a 5-year survival rate not exceeding 6%. Treatment of this disease remains a major challenge. This article reviews the state-of-the-art in the management of this disease and the new innovative approaches that may help to accelerate progress in treating its victims. After careful pre-therapeutic evaluation, only 15-20% of patients diagnosed with a pancreatic cancer (PC) are eligible for upfront radical surgery. After R0 or R1 resection in such patients, evidence suggests a significantly positive impact on survival of adjuvant chemotherapy comprising 6 months of gemcitabine or fluorouracil/folinic acid. Delayed adjuvant chemoradiation is considered as an option in cases of positive margins. Borderline resectable pancreatic cancer (BRPC) is defined as a tumour involving the mesenteric vasculature to a limited extend. Resection of these tumours is technically feasible, yet runs the high risk of a R1 resection. Neoadjuvant treatment probably offers the best chance of achieving successful R0 resection and long-term survival, but the best treatment options should be determined in prospective randomised studies. Gemcitabine has for 15 years been the only validated therapy for advanced PC. Following decades of negative phase III studies, increasing evidence now suggests that further significant improvements to overall survival can be achieved via either Folfirinox or gemcitabine + nab-paclitaxel regimens. Progress in systemic therapy may improve the chances of resection in borderline resectable pancreatic cancer (BRPC) or locally advanced PC. This requires first enhancing knowledge of the genetic events driving carcinogenesis, which may then be translated into clinical studies.
Collapse
Affiliation(s)
- Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Lorraine University, 6 avenue de Bourgogne, CS 30519, 54519, Vandoeuvre-lès-Nancy, France.
| | - Jean-Baptiste Bachet
- Department of Hepato-Gastroenterology, Pitié-Salpétrière University Hospital, 47-83 boulevard de l'hôpital, 75651, Paris Cedex 13, France
| | - Ahmet Ayav
- Department of Surgery, Nancy University Hospital Lorraine and Lorraine University, rue du Morvan, 54511, Vandoeuvre-lès Nancy, France
| | - Florence Huguet
- Department of Radiation Therapy, Tenon Hospital, Paris Est University Hospitals, 4 rue de la Chine, 75020, Paris, France
| | - Aurélien Lambert
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Lorraine University, 6 avenue de Bourgogne, CS 30519, 54519, Vandoeuvre-lès-Nancy, France
| | - Caroline Caramella
- Gustave Roussy Cancer Campus Grand Paris, 114 rue Edouard-Vaillant, 94805, Villejuif Cedex, France
| | - Raphaël Maréchal
- Department of Gastroenterology, Erasme University Hospital-ULB-Brussels, Lennikstreet 808, 1070, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Erasme University Hospital-ULB-Brussels, Lennikstreet 808, 1070, Brussels, Belgium
| | - Michel Ducreux
- Gustave Roussy Cancer Campus Grand Paris, 114 rue Edouard-Vaillant, 94805, Villejuif Cedex, France
| |
Collapse
|
118
|
Higuera O, Ghanem I, Nasimi R, Prieto I, Koren L, Feliu J. Management of pancreatic cancer in the elderly. World J Gastroenterol 2016; 22:764-75. [PMID: 26811623 PMCID: PMC4716075 DOI: 10.3748/wjg.v22.i2.764] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/03/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Currently, pancreatic adenocarcinoma mainly occurs after 60 years of age, and its prognosis remains poor despite modest improvements in recent decades. The aging of the population will result in a rise in the incidence of pancreatic adenocarcinoma within the next years. Thus, the management of pancreatic cancer in the elderly population is gaining increasing relevance. Older cancer patients represent a heterogeneous group with different biological, functional and psychosocial characteristics that can modify the usual management of this disease, including pharmacokinetic and pharmacodynamic changes, polypharmacy, performance status, comorbidities and organ dysfunction. However, the biological age, not the chronological age, of the patient should be the limiting factor in determining the most appropriate treatment for these patients. Unfortunately, despite the increased incidence of this pathology in older patients, there is an underrepresentation of these patients in clinical trials, and the management of older patients is thus determined by extrapolation from the results of studies performed in younger patients. In this review, the special characteristics of the elderly, the multidisciplinary management of localized and advanced ductal adenocarcinoma of the pancreas and the most recent advances in the management of this condition will be discussed, focusing on surgery, chemotherapy, radiation and palliative care.
Collapse
|
119
|
Coveler AL, Herman JM, Simeone DM, Chiorean EG. Localized Pancreatic Cancer: Multidisciplinary Management. Am Soc Clin Oncol Educ Book 2016; 35:e217-26. [PMID: 27249726 DOI: 10.1200/edbk_160827] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Pancreatic cancer is an aggressive cancer that continues to have single-digit 5-year mortality rates despite advancements in the field. Surgery remains the only curative treatment; however, most patients present with late-stage disease deemed unresectable, either due to extensive local vascular involvement or the presence of distant metastasis. Resection guidelines that include a borderline resectable group, as well as advancements in neoadjuvant chemotherapy and radiation that improve resectability of locally advanced disease, may improve outcomes for patients with more invasive disease. Multi-agent chemotherapy regimens fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) and nab-paclitaxel with gemcitabine improved response rates and survival in metastatic pancreatic cancer and are now being used in earlier stages for patients with localized potentially resectable and unresectable disease, with goals of downstaging tumors to allow margin-negative resection and reducing systemic recurrence. Chemoradiotherapy, although still controversial for both resectable and unresectable pancreatic cancer, is being used in the context of contemporary chemotherapy backbone regimens, and novel radiation techniques such as stereotactic body frame radiation therapy (SBRT) are studied on the premise of maintaining or improving efficacy and reducing treatment duration. Patient selection for optimal treatment designation is currently provided by multidisciplinary tumor boards, but biomarker discovery, in blood, tumors, or through novel imaging, is an area of intense research. Results to date suggest that some patients with unresectable disease at the outset have survival rates as good as those with initially resectable disease if able to undergo surgical resection. Long-term follow-up and improved clinical trials options are needed to determine optimal treatment modalities for patients with localized pancreatic cancer.
Collapse
Affiliation(s)
- Andrew L Coveler
- From the Division of Hematology-Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD; University of Michigan, Ann Arbor, MI
| | - Joseph M Herman
- From the Division of Hematology-Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD; University of Michigan, Ann Arbor, MI
| | - Diane M Simeone
- From the Division of Hematology-Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD; University of Michigan, Ann Arbor, MI
| | - E Gabriela Chiorean
- From the Division of Hematology-Oncology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD; University of Michigan, Ann Arbor, MI
| |
Collapse
|
120
|
Takaori K, Bassi C, Biankin A, Brunner TB, Cataldo I, Campbell F, Cunningham D, Falconi M, Frampton AE, Furuse J, Giovannini M, Jackson R, Nakamura A, Nealon W, Neoptolemos JP, Real FX, Scarpa A, Sclafani F, Windsor JA, Yamaguchi K, Wolfgang C, Johnson CD. International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer. Pancreatology 2016; 16:14-27. [PMID: 26699808 DOI: 10.1016/j.pan.2015.10.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/25/2015] [Accepted: 10/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cancer is one of the most devastating diseases with an extremely high mortality. Medical organizations and scientific societies have published a number of guidelines to address active treatment of pancreatic cancer. The aim of this consensus review was to identify where there is agreement or disagreement among the existing guidelines and to help define the gaps for future studies. METHODS A panel of expert pancreatologists gathered at the 46th European Pancreatic Club Meeting combined with the 18th International Association of Pancreatology Meeting and collaborated on critical reviews of eight English language guidelines for the clinical management of pancreatic cancer. Clinical questions (CQs) of interest were proposed by specialists in each of nine areas. The recommendations for the CQs in existing guidelines, as well as the evidence on which these were based, were reviewed and compared. The evidence was graded as sufficient, mediocre or poor/absent. RESULTS Only 4 of the 36 CQs, had sufficient evidence for agreement. There was also agreement in five additional CQs despite the lack of sufficient evidence. In 22 CQs, there was disagreement regardless of the presence or absence of evidence. There were five CQs that were not addressed adequately by existing guidelines. CONCLUSION The existing guidelines provide both evidence- and consensus-based recommendations. There is also considerable disagreement about the recommendations in part due to the lack of high level evidence. Improving the clinical management of patients with pancreatic cancer, will require continuing efforts to undertake research that will provide sufficient evidence to allow agreement.
Collapse
Affiliation(s)
- Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy
| | - Andrew Biankin
- Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospitals Freiburg, Germany
| | - Ivana Cataldo
- Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Fiona Campbell
- Department of Pathology, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - Massimo Falconi
- Pancreatic Surgery Unit, Università Vita e Salute, Milano, Italy
| | - Adam E Frampton
- HPB Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital, London, United Kingdom
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University School of Medicine, Tokyo, Japan
| | - Marc Giovannini
- Endoscopic Unit, Paoli-Calmettes Institute, Marseille, France
| | - Richard Jackson
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Akira Nakamura
- Department of Radiation Oncology and Image-applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - William Nealon
- Division of General Surgery, Yale University, New Haven, CT, United States of America
| | - John P Neoptolemos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Francisco X Real
- Epithelial Carcinogenesis Group, CNIO-Spanish National Cancer Research Centre, Madrid, Spain
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - John A Windsor
- Department of Surgery, University of Auckland, HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand
| | - Koji Yamaguchi
- Department of Advanced Treatment of Pancreatic Disease, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Christopher Wolfgang
- Department of Surgery, The Johns Hopkins University, Baltimore, MD, United States of America
| | - Colin D Johnson
- University Surgical Unit, Southampton General Hospital, Southampton, United Kingdom
| |
Collapse
|
121
|
Kluger MD, Epelboym I, Schrope BA, Mahendraraj K, Hecht EM, Susman J, Weintraub JL, Chabot JA. Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients. Ann Surg Oncol 2015; 23:1736-43. [PMID: 26714959 DOI: 10.1245/s10434-015-5034-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.
Collapse
Affiliation(s)
- Michael D Kluger
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
| | - Irene Epelboym
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Krishnaraj Mahendraraj
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth M Hecht
- Division of Abdominal Imaging, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Jonathan Susman
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Joshua L Weintraub
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
122
|
Qiu WJ, Li YF, Ji YH, Xu W, Zhu XD, Tang XZ, Zhao HL, Wang GB, Jia YQ, Zhu SC, Zhang FF, Liu HM. The comparative risk of developing postoperative complications in patients with distal radius fractures following different treatment modalities. Sci Rep 2015; 5:15318. [PMID: 26549312 PMCID: PMC4637827 DOI: 10.1038/srep15318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 09/21/2015] [Indexed: 11/25/2022] Open
Abstract
In this study, we performed a network meta-analysis to compare the outcomes of seven most common surgical procedures to fix DRF, including bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. Published studies were retrieved through PubMed, Embase and Cochrane Library databases. The database search terms used were the following keywords and MeSH terms: DRF, bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating. The network meta-analysis was performed to rank the probabilities of postoperative complication risks for the seven surgical modalities in DRF patients. This network meta-analysis included data obtained from a total of 19 RCTs. Our results revealed that compared to DRF patients treated with bridging external fixation, marked differences in pin-track infection (PTI) rate were found in patients treated with plaster fixation, volar plating, and dorsal and volar plating. Cluster analysis showed that plaster fixation is associated with the lowest probability of postoperative complication in DRF patients. Plaster fixation is associated with the lowest risk for postoperative complications in DRF patients, when compared to six other common DRF surgical methods examined.
Collapse
Affiliation(s)
- Wen-Jun Qiu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Yi-Fan Li
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Yun-Han Ji
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Wei Xu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Xiao-Dong Zhu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Xian-Zhong Tang
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Huan-Li Zhao
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Gui-Bin Wang
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Yue-Qing Jia
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Shi-Cai Zhu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Feng-Fang Zhang
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| | - Hong-Mei Liu
- Department of Orthopedic Surgery, Tongren Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200336, P.R. China
| |
Collapse
|
123
|
Yu P, Artz D, Warner J. Electronic health records (EHRs): supporting ASCO's vision of cancer care. Am Soc Clin Oncol Educ Book 2015:225-31. [PMID: 24857080 DOI: 10.14694/edbook_am.2014.34.225] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
ASCO's vision for cancer care in 2030 is built on the expanding importance of panomics and big data, and envisions enabling better health for patients with cancer by the rapid transformation of systems biology knowledge into cancer care advances. This vision will be heavily dependent on the use of health information technology for computational biology and clinical decision support systems (CDSS). Computational biology will allow us to construct models of cancer biology that encompass the complexity of cancer panomics data and provide us with better understanding of the mechanisms governing cancer behavior. The Agency for Healthcare Research and Quality promotes CDSS based on clinical practice guidelines, which are knowledge bases that grow too slowly to match the rate of panomic-derived knowledge. CDSS that are based on systems biology models will be more easily adaptable to rapid advancements and translational medicine. We describe the characteristics of health data representation, a model for representing molecular data that supports data extraction and use for panomic-based clinical research, and argue for CDSS that are based on systems biology and are algorithm-based.
Collapse
Affiliation(s)
- Peter Yu
- From the Department of Hematology and Department of Oncology, Palo Alto Medical Foundation, Mountain View, CA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - David Artz
- From the Department of Hematology and Department of Oncology, Palo Alto Medical Foundation, Mountain View, CA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Jeremy Warner
- From the Department of Hematology and Department of Oncology, Palo Alto Medical Foundation, Mountain View, CA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
124
|
Quel traitement adjuvant de l’adénocarcinome du pancréas aujourd’hui : quelles perspectives ? ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2558-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
125
|
Kumachev A, Yan M, Berry S, Ko YJ, Martinez MCR, Shah K, Chan KKW. A Systematic Review and Network Meta-Analysis of Biologic Agents in the First Line Setting for Advanced Colorectal Cancer. PLoS One 2015; 10:e0140187. [PMID: 26474403 PMCID: PMC4608731 DOI: 10.1371/journal.pone.0140187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/22/2015] [Indexed: 12/20/2022] Open
Abstract
Background Epithelial growth factor receptor inhibitors (EGFRis) and bevacizumab (BEV) are used in combination with chemotherapy for the treatment of metastatic colorectal cancer (mCRC). However, few randomized controlled trials (RCTs) have directly compared their relative efficacy on progression-free survival (PFS) and overall survival (OS). Methods We conducted a systematic review of first-line RCTs comparing (1) EGFRis vs. BEV, with chemotherapy in both arms (2) EGFRis + chemotherapy vs. chemotherapy alone, or (3) BEV + chemotherapy vs. chemotherapy alone, using Cochrane methodology. Data on and PFS and OS were extracted using the Parmar method. Pairwise meta-analyses and Bayesian network meta-analyses (NMA) were conducted to estimate the direct, indirect and combined PFS and OS hazard ratios (HRs) comparing EGFRis to BEV. Results Seventeen RCTs contained extractable data for quantitative analysis. Combining direct and indirect data using an NMA did not show a statistical difference between EGFRis versus BEV (PFS HR = 1.11 (95% CR: 0.92–1.36) and OS HR = 0.91 (95% CR: 0.75–1.09)). Direct meta-analysis (3 RCTs), indirect (14 RCTs) and combined (17 RCTs) NMA of PFS HRs were concordant and did not show a difference between EGFRis and BEV. Meta-analysis of OS using direct evidence, largely influenced by one trial, showed an improvement with EGFRis therapy (HR = 0.79 (95% CR: 0.65–0.98)), while indirect and combined NMA of OS did not show a difference between EGFRis and BEV Successive inclusions of trials over time in the combined NMA did not show superiority of EGFRis over BEV. Conclusions Our findings did not support OS or PFS benefits of EGFRis over BEV in first-line mCRC.
Collapse
Affiliation(s)
| | - Marie Yan
- Faculty of Medicine, University of Toronto, Toronto Canada
| | - Scott Berry
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Yoo-Joung Ko
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | | | - Keya Shah
- Faculty of Medicine, Queens University, Kingston, Canada
| | - Kelvin K. W. Chan
- Faculty of Medicine, University of Toronto, Toronto Canada
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- * E-mail:
| |
Collapse
|
126
|
Zhang L, Cao HY, Zhao S, Yuan LJ, Han D, Jiang H, Wu S, Wu HM. Effect of exogenous pulmonary surfactants on mortality rate in neonatal respiratory distress syndrome: A network meta-analysis of randomized controlled trials. Pulm Pharmacol Ther 2015; 34:46-54. [DOI: 10.1016/j.pupt.2015.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/15/2015] [Accepted: 08/17/2015] [Indexed: 01/01/2023]
|
127
|
Mai R, Zhou S, Zhong W, Rong S, Cong Z, Li Y, Xie Q, Chen H, Li X, Liu S, Cheng Y, Huang Y, Zhou Y, Zhang G. Therapeutic efficacy of combined BRAF and MEK inhibition in metastatic melanoma: a comprehensive network meta-analysis of randomized controlled trials. Oncotarget 2015; 6:28502-12. [PMID: 26143635 PMCID: PMC4695075 DOI: 10.18632/oncotarget.4375] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/03/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Several recent randomized clinical trials have preliminarily demonstrated that initial targeted therapy with combined BRAF and MEK inhibition is more effective in metastatic melanoma (MM) than single agent. To guide therapeutic decisions, we did a comprehensive network meta-analysis to identify evidence to robustly support whether combined BRAF and MEK inhibition is the best initial targeted therapeutic strategy for patients with MM. METHODS The databases of PubMed and trial registries were researched for randomized clinical trials of targeted therapy. Data of outcome were extracted on progression-free survival (PFS), objective response rate (ORR), and overall survival (OS). Network meta-analysis using a Bayesian statistical model was performed to evaluate relative hazard ratio (HR) for PFS and OS, odds ratio (OR) for ORR. RESULTS Finally, 16 eligible trials comprising 5976 participants were included in this meta-analysis. PFS were significantly prolonged in patients who received combined BRAF-MEK inhibition compared with those who received BRAF inhibition (HR: 0.58, 95%CI: 0.51-0.67, P < 0.0001) or MEK inhibition alone (HR: 0.29, 95%CI: 0.22-0.37, P < 0.0001). Combined BRAF-MEK inhibition also improved the OS over BRAF inhibition (HR: 0.67, 95%CI: 0.56-0.81, P < 0.0001) or MEK inhibition alone (HR: 0.48, 95%CI: 0.36-0.65, P < 0.0001). The ORR was superior in combined BRAF and MEK inhibition comparing with BRAF inhibition (OR: 2.00, 95%CI: 1.66-2.44, P < 0.0001) or MEK inhibition alone (OR: 20.66, 95%CI: 12.22-35.47, P < 0.0001). CONCLUSIONS This study indicates that concurrent inhibition of BRAF and MEK improved the most effective therapeutic modality as compared as single BRAF or MEK inhibition for patients with MM.
Collapse
Affiliation(s)
- Ruiqin Mai
- Department of Laboratory Medicine, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Songxia Zhou
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Weixiang Zhong
- Department of Pathology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Siming Rong
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Zhichao Cong
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Yunxian Li
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Qizhi Xie
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Huanming Chen
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaoyun Li
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Shuhui Liu
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Yabin Cheng
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yuanshen Huang
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Youwen Zhou
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Guohong Zhang
- Department of Pathology, Shantou University Medical College, Shantou, Guangdong, China
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
128
|
Gurusamy K, Toon C, Virendrakumar B, Morris S, Davidson B. Feasibility of Comparing the Results of Pancreatic Resections between Surgeons: A Systematic Review and Meta-Analysis of Pancreatic Resections. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2015; 2015:896875. [PMID: 26351405 PMCID: PMC4553327 DOI: 10.1155/2015/896875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/15/2015] [Indexed: 02/06/2023]
Abstract
Background. Indicators of operative outcomes could be used to identify underperforming surgeons for support and training. The feasibility of identifying HPB surgeons with poor operative performance ("outliers") based on the results of pancreatic resections is not known. Methods. A systematic review of Medline, Embase, and the Cochrane library was performed to identify studies on pancreatic resection including at least 100 patients and published between 2004 and 2014. Proportions that lay outside the upper 95% and 99.8% confidence intervals based on results of the systematic reviews were considered as "outliers." Results. In total, 30 studies reporting on 10712 patients were eligible for inclusion in this review. The average short-term mortality after pancreatic resections was 3.1% and proportion of patients with procedure-related complications was 47.0%. None of the classification systems assessed the long-term impact of the complications on patients. The surgeon-specific mortality should be 5 times the average mortality before he or she can be identified as an outlier with 0.1% false positive rate if he or she performs 50 surgeries a year. Conclusions. A valid risk prognostic model and a classification system of surgical complications are necessary before meaningful comparisons of the operative performance between pancreatic surgeons can be made.
Collapse
Affiliation(s)
- Kurinchi Gurusamy
- Department of Surgery, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
| | - Clare Toon
- Public Health Research Unit, West Sussex County Council, County Hall Campus, West Sussex PO19 1QT, UK
| | - Bhavisha Virendrakumar
- Evidence Synthesis, Sightsavers, 35 Perrymount Road, Haywards Heath, West Sussex RH16 3BW, UK
| | - Steve Morris
- Department of Applied Health Research, UCL, London WC1E 7HB, UK
| | - Brian Davidson
- Department of Surgery, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
| |
Collapse
|
129
|
Prognostic Fifteen-Gene Signature for Early Stage Pancreatic Ductal Adenocarcinoma. PLoS One 2015; 10:e0133562. [PMID: 26247463 PMCID: PMC4527782 DOI: 10.1371/journal.pone.0133562] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/28/2015] [Indexed: 01/22/2023] Open
Abstract
The outcomes of patients treated with surgery for early stage pancreatic ductal adenocarcinoma (PDAC) are variable with median survival ranging from 6 months to more than 5 years. This challenge underscores an unmet need for developing personalized medicine strategies to refine the current treatment decision-making process. To derive a prognostic gene signature for patients with early stage PDAC, a PDAC cohort from Moffitt Cancer Center (n = 63) was used with overall survival (OS) as the primary endpoint. This was further evaluated using an independent microarray cohort dataset (Stratford et al: n = 102). Technical validation was performed by NanoString platform. A prognostic 15-gene signature was developed and showed a statistically significant association with OS in the Moffitt cohort (hazard ratio [HR] = 3.26; p<0.001) and Stratford et al cohort (HR = 2.07; p = 0.02), and was independent of other prognostic variables. Moreover, integration of the signature with the TNM staging system improved risk prediction (p<0.01 in both cohorts). In addition, NanoString validation showed that the signature was robust with a high degree of reproducibility and the association with OS remained significant in the two cohorts. The gene signature could be a potential prognostic tool to allow risk-adapted stratification of PDAC patients into personalized treatment protocols; possibly improving the currently poor clinical outcomes of these patients.
Collapse
|
130
|
Abstract
OBJECTIVES It has been suggested that statins exert potential anti-tumor effects. The relationship between statin use and outcomes in pancreatic cancer is controversial. We hypothesized that statin use at baseline would impact survival among patients with early-stage pancreatic cancer and that the effect might vary by individual statin agent. METHODS We conducted a retrospective cohort study on data from an integrated healthcare system. We included patients with pancreatic cancer stage I-IIb who underwent resection for curative intent between January 2005 and January 2011. Baseline statin use was characterized as any prior use as well as active use of either simvastatin or lovastatin. Intensity of exposure was calculated as average daily dose prior to surgery. Overall and disease-free survival was assessed from surgery until the end of study (April 2014). We used the Kaplan-Meier method and Cox proportional hazards regression to evaluate the impact of baseline statin use on survival, adjusting for age, sex, Charlson comorbidity score, resection margin, disease stage, and receipt of adjuvant chemotherapy. RESULTS Among 226 patients, 71 (31.4%) had prior simvastatin use and 27 (11.9%) had prior lovastatin use at baseline. Prior simvastatin but not lovastatin use was associated with improved survival (median 28.5 months (95% confidence limit (CL) 20.8, 38.4) for simvastatin vs. 12.9 months (9.6, 15.5) for lovastatin vs. 16.5 months (14.1, 18.9) for non-statin users; log-rank P=0.0035). In Cox regression, active simvastatin use was independently associated with reduced risk for mortality (adjusted hazard ratio (HR) 0.56 (95% CL 0.38, 0.83), P=0.004) and risk for recurrence (adjusted HR 0.61 (0.41, 0.89), P=0.01). Survival improved significantly among patients who received moderate-high-intensity (median 42.1 months (24.0,52.7)) doses compared with those who received low-intensity doses of simvastatin (median 14.1 months (8.6, 23.8), log-rank P=0.03). CONCLUSIONS The effects of statins varied by agent and dose. Active use of moderate-high-dose simvastatin at baseline was associated with improved overall and disease-free survival among patients undergoing resection for pancreatic cancer.
Collapse
|
131
|
Yang J, Huang Q, Wang C. Postoperative drain amylase predicts pancreatic fistula in pancreatic surgery: A systematic review and meta-analysis. Int J Surg 2015. [PMID: 26211439 DOI: 10.1016/j.ijsu.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES This study to evaluate the utility of drain fluid amylase as a predictor of PF in patients undergoing pancreatic surgery based on the International Study Group of Pancreatic Fistula definitions of pancreatic fistula. METHODS A comprehensive search was carried out using Pubmed (Medline), Embase, Web of science and Cochrane database for clinical trials, which studied DFA as a diagnostic marker for pancreatic fistula after pancreatic surgery. Sensitivity, specificity and the diagnostic odds ratios with 95% confidence interval were calculated for each study. Summary receiver-operating curves were conducted and the area under the curve was evaluated. RESULTS A total of 10 studies were included. The pooled sensitivity and specificity of drain fluid amylase Day 1 for the diagnosis of postoperative pancreatic fistula were 81% and 87%, respectively (area under the curve was 0.897, diagnostic odds ratios was 16.83 and 95%CI was 12.66-22.36), the pooled sensitivity and specificity of drain fluid amylase Day 3 for the diagnosis of postoperative pancreatic fistula were 56% and 79%, respectively (area under the curve was 0.668, diagnostic odds ratios was 3.26 and 95%CI was 1.83-5.82) CONCLUSIONS: The drain fluid amylase Day 1, instead of drain fluid amylase Day 3, may be a useful criterion for the early identification of postoperative pancreatic fistula, and a value of drain fluid amylase Day 1 over than 1300 U/L was a risk factor of pancreatic fistula. And the diagnostic accuracy and the proposed cut-off levels of drain fluid amylase Day 1 in predicting the postoperative pancreatic fistula will have to be validated by multicenter prospective studies.
Collapse
Affiliation(s)
- Ji Yang
- Department of General Surgery, Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China; Hepatobiliary and Pancreatic Laboratory of Anhui Province, Hefei 230001, China.
| | - Qiang Huang
- Department of General Surgery, Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China; Hepatobiliary and Pancreatic Laboratory of Anhui Province, Hefei 230001, China.
| | - Chao Wang
- Department of General Surgery, Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China; Hepatobiliary and Pancreatic Laboratory of Anhui Province, Hefei 230001, China
| |
Collapse
|
132
|
Alemi F, Alseidi A, Scott Helton W, Rocha FG. Multidisciplinary management of locally advanced pancreatic ductal adenocarcinoma. Curr Probl Surg 2015; 52:362-98. [PMID: 26363649 DOI: 10.1067/j.cpsurg.2015.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/13/2015] [Indexed: 12/13/2022]
|
133
|
Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JPA, Straus S, Thorlund K, Jansen JP, Mulrow C, Catalá-López F, Gøtzsche PC, Dickersin K, Boutron I, Altman DG, Moher D. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015; 162:777-84. [PMID: 26030634 DOI: 10.7326/m14-2385] [Citation(s) in RCA: 4388] [Impact Index Per Article: 487.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The PRISMA statement is a reporting guideline designed to improve the completeness of reporting of systematic reviews and meta-analyses. Authors have used this guideline worldwide to prepare their reviews for publication. In the past, these reports typically compared 2 treatment alternatives. With the evolution of systematic reviews that compare multiple treatments, some of them only indirectly, authors face novel challenges for conducting and reporting their reviews. This extension of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement was developed specifically to improve the reporting of systematic reviews incorporating network meta-analyses. A group of experts participated in a systematic review, Delphi survey, and face-to-face discussion and consensus meeting to establish new checklist items for this extension statement. Current PRISMA items were also clarified. A modified, 32-item PRISMA extension checklist was developed to address what the group considered to be immediately relevant to the reporting of network meta-analyses. This document presents the extension and provides examples of good reporting, as well as elaborations regarding the rationale for new checklist items and the modification of previously existing items from the PRISMA statement. It also highlights educational information related to key considerations in the practice of network meta-analysis. The target audience includes authors and readers of network meta-analyses, as well as journal editors and peer reviewers.
Collapse
|
134
|
Yan M, Kumachev A, Siu LL, Chan KKW. Chemoradiotherapy regimens for locoregionally advanced nasopharyngeal carcinoma: A Bayesian network meta-analysis. Eur J Cancer 2015; 51:1570-9. [PMID: 26044925 DOI: 10.1016/j.ejca.2015.04.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Concurrent chemoradiotherapy followed by adjuvant chemotherapy (CRT-A) is often the regimen of choice in locoregionally advanced nasopharyngeal carcinoma (NPC). Many alternative regimens have been reported in the literature, however, it is unknown how effective these regimens are compared to each other due to the lack of direct comparisons. Our objective was to perform a network meta-analysis (NMA) to determine the relative survival benefits of these treatments for locoregionally advanced NPC. METHODS We performed a systematic review following the Cochrane methodology, using MEDLINE, EMBASE and CENTRAL to identify all randomised controlled trials (RCTs) that compared different chemoradiotherapy regimens for locoregionally advanced NPC. Overall survival (OS) was the primary outcome of interest, and hazard ratios (HRs) were extracted using the Parmar method. Bayesian NMAs with random effects were conducted using WinBUGS. RESULTS Twenty-five RCTs (5576 patients) were included in this review. All together, these trials compared seven different regimens: radiotherapy (RT), concurrent chemoradiotherapy (CRT), neoadjuvant followed by CRT (N-CRT), CRT-A, RT-A, N-RT and N-RT-A. All regimens that contained CRT performed significantly better than RT. CRT-A did not improve survival compared to CRT alone (0.98; 95% credible regions: 0.71-1.34). For N-CRT versus CRT, the HR was 1.03 (0.69-1.47). When CRT-A was compared against N-CRT, the resulting HR was 0.96 (0.64-1.48). CONCLUSIONS Adjuvant chemotherapy does not appear to improve survival following CRT. The efficacies of CRT, CRT-A and N-CRT all appeared to be similar. Further studies are warranted to determine the value of additional chemotherapy phases in specific patient subgroups.
Collapse
Affiliation(s)
- Marie Yan
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Alexander Kumachev
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Lillian L Siu
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Division of Medical Oncology, Princess Margaret Cancer Centre, 610 University Ave, Toronto, Ontario M5G 2M9, Canada
| | - Kelvin K W Chan
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Division of Medical Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
| |
Collapse
|
135
|
The anticancer effect of Huaier (Review). Oncol Rep 2015; 34:12-21. [PMID: 25955759 DOI: 10.3892/or.2015.3950] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/24/2015] [Indexed: 12/18/2022] Open
Abstract
Trametes robiniophila Murr. (Huaier) is a sandy beige mushroom found on the trunks of trees and has been widely used in traditional Chinese medicine (TCM) for ~1,600 years. The anticancer effects of Huaier have attracted increasing worldwide interest in recent years. Accumulating evidence suggests that the anticancer mechanism of Huaier may be associated with various biological activities, such as inhibition of cell proliferation, anti-metastasis, interference with tumor angiogenesis and tumor-specific immunomodulatory effect. Animal and experimental studies suggest that Huaier is a promising anticancer agent. Further clinical research is warranted to illustrate the untapped chemopreventive and therapeutic potential of Huaier either alone or in conjunction with existing therapies.
Collapse
|
136
|
Patel AA, Nagarajan S, Scher ED, Schonewolf CA, Balasubramanian S, Poplin E, Moss R, August D, Carpizo D, Melstrom L, Jabbour SK. Early vs. Late Chemoradiation Therapy and the Postoperative Interval to Adjuvant Therapy Do Not Correspond to Local Recurrence in Resected Pancreatic Cancer. ACTA ACUST UNITED AC 2015; 5. [PMID: 26779392 PMCID: PMC4712931 DOI: 10.4172/2165-7092.1000151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective Standard postoperative therapy for pancreatic cancer consists of both chemotherapy alone and chemoradiation. We sought to investigate whether the sequence of chemotherapy and chemoradiation and overall time to initiation of adjuvant therapy would impact local vs. distant recurrence. Methods After Institutional Review Board approval, resected pancreas cancer patient charts were evaluated for medical background, surgical, pathological, chemoradiation (CRT), and follow-up. Local recurrence (LR) was defined as failures occurring in the postoperative bed and regional lymph nodes. Early vs. late CRT was defined by whether CRT was given early (within 1–2 cycles of adjuvant chemotherapy) or late in the course of adjuvant chemotherapy (after the 3rd cycle of chemotherapy). The postoperative interval variance was compared to LR factors such as progression-free survival (PFS) and overall survival (OS). Results Of the 34 eligible patients, 47% (n=16) underwent early CRT and 41% (n=14) underwent late CRT. 12% (n=14) did not undergo any induction chemotherapy. At median follow-up of 22 months, 53% (n=18) had metastases, 24% (n=8) had LR, and 24% (n=8) were disease free. Kaplan-Meier curves revealed that early vs. late CRT did not appear to significantly impact OS (p=0.63), PFS (p=0.085) or LR (p=0.19). Postoperative interval did not affect PFS (p=0.42) or OS (p=0.93). Conclusions Early vs. late CRT and the time to initiation of adjuvant therapy were not significantly associated with LR in patients with resected pancreatic cancer. Future prospective studies are required to determine if sequencing of chemotherapy, CRT, or the postoperative interval impact survival and patterns of recurrence.
Collapse
Affiliation(s)
- Ajay A Patel
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
| | - Sairaman Nagarajan
- Center on Genomics, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Eli D Scher
- Rowan University School of Osteopathic Medicine, Stratford NJ, USA
| | - Caitlin Ab Schonewolf
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA; Department of Radiation Oncology, University of Pennsylvania, Philadelphia PA, USA
| | - Sairam Balasubramanian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
| | - Elizabeth Poplin
- Department of Medicine, Division of Medical Oncology, Cancer Institute of New Jersey
| | - Rebecca Moss
- Department of Medicine, Division of Medical Oncology, Cancer Institute of New Jersey
| | - David August
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Darren Carpizo
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Laleh Melstrom
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
| |
Collapse
|
137
|
Zhang H, Gao H, Liu C, Kong Y, Wang C, Zhang H. Expression and clinical significance of HSPA2 in pancreatic ductal adenocarcinoma. Diagn Pathol 2015; 10:13. [PMID: 25890028 PMCID: PMC4383074 DOI: 10.1186/s13000-015-0253-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 03/17/2015] [Indexed: 01/22/2023] Open
Abstract
Background It has been shown that heat shock-related 70-kDa protein 2 (HSPA2), a member of the HSP70 family of heat shock proteins, is important for cancer cell growth and metastasis. However, the status of HSPA2 expression and its prognostic significance in pancreatic cancer remain unknown. Methods Quantitative reverse transcriptase ploymerase chain reaction (qRT-PCR) was applied to examine HSPA2 messenger RNA (mRNA) expression in 104 pairs of pancreatic cancer tissues and adjacent noncancerous tissues. Statistical analyses were applied to evaluate the diagnostic value and associations of HSPA2 expression with clinicopathological characteristics. Results HSPA2 mRNA was significantly overexpressed in pancreatic cancer tissues (3.9 ± 0.8) than in adjacent normal tissues (1.1 ± 0.4) (P < 0.001). Clinicopathological analysis showed that HSPA2 expression was significantly correlated with tumor size (P = 0.024), histological differentiation (P = 0.012), TNM stage (P = 0.006), lymph node metastasis (P = 0.043) and serum CA19-9 level (P = 0.046). Moreover, patients with higher HSPA2 expression levels had shorter overall survival time than those with lower HSPA2 expression levels (P = 0.019). Furthermore, Cox regression analyses showed that HSPA2 expression was an independent predictor of overall survival (P = 0.011). Conclusions Our results suggest that overexpression of HSPA2 in pancreatic cancer is associated with aggressive progression and poor prognosis and that HSPA2 may be served as a prognostic marker. Virtual slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5988744821527257.
Collapse
Affiliation(s)
- Hui Zhang
- Department of Hepatobiliary Surgery, Air Force General Hospital of PLA, Beijing, 100142, China.
| | - Hongli Gao
- Department of Oncology, the fourth people's hospital of Jinan, Jinan, 250031, China.
| | - Chengli Liu
- Department of Hepatobiliary Surgery, Air Force General Hospital of PLA, Beijing, 100142, China.
| | - Yalin Kong
- Department of Hepatobiliary Surgery, Air Force General Hospital of PLA, Beijing, 100142, China.
| | - Cheng Wang
- Department of Hepatobiliary Surgery, Air Force General Hospital of PLA, Beijing, 100142, China.
| | - Hongyi Zhang
- Department of Hepatobiliary Surgery, Air Force General Hospital of PLA, Beijing, 100142, China.
| |
Collapse
|
138
|
Morganti AG, Mattiucci GC, Valentini V, van Stiphout RG. In Reply to Yamazaki et al. Int J Radiat Oncol Biol Phys 2015; 91:877-8. [DOI: 10.1016/j.ijrobp.2014.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Indexed: 11/24/2022]
|
139
|
Sirohi B, Singh A, Dawood S, Shrikhande SV. Advances in chemotherapy for pancreatic cancer. Indian J Surg Oncol 2015; 6:47-56. [PMID: 25937764 PMCID: PMC4412866 DOI: 10.1007/s13193-014-0371-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 12/17/2014] [Indexed: 12/26/2022] Open
Abstract
Pancreatic cancer remains challenging to treat. Over the past decade, there have been some major improvements in systemic therapy. Gemcitabine remains the key drug for both early and advanced cancer but combination chemotherapy is emerging as a new paradigm for patients with good performance status. This review focuses on current chemotherapy status for patients with pancreatic cancer.
Collapse
Affiliation(s)
- Bhawna Sirohi
- />Department of Medical Oncology, Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | - Ashish Singh
- />Department of Medical Oncology, CMC, Vellore, India
| | | | | |
Collapse
|
140
|
Puleo F, Maréchal R, Demetter P, Bali MA, Calomme A, Closset J, Bachet JB, Deviere J, Laethem JLV. New challenges in perioperative management of pancreatic cancer. World J Gastroenterol 2015; 21:2281-2293. [PMID: 25741134 PMCID: PMC4342903 DOI: 10.3748/wjg.v21.i8.2281] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/14/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in the industrialized world. Despite progress in the understanding of the molecular and genetic basis of this disease, the 5-year survival rate has remained low and usually does not exceed 5%. Only 20%-25% of patients present with potentially resectable disease and surgery represents the only chance for a cure. After decades of gemcitabine hegemony and limited therapeutic options, more active chemotherapies are emerging in advanced PDAC, like 5-Fluorouracil, folinic acid, irinotecan and oxaliplatin and nab-paclitaxel plus gemcitabine, that have profoundly impacted therapeutic possibilities. PDAC is considered a systemic disease because of the high rate of relapse after curative surgery in patients with resectable disease at diagnosis. Neoadjuvant strategies in resectable, borderline resectable, or locally advanced pancreatic cancer may improve outcomes. Incorporation of tissue biomarker testing and imaging techniques into preoperative strategies should allow clinicians to identify patients who may ultimately achieve curative benefit from surgery. This review summarizes current knowledge of adjuvant and neoadjuvant treatment for PDAC and discusses the rationale for moving from adjuvant to preoperative and perioperative therapeutic strategies in the current era of more active chemotherapies and personalized medicine. We also discuss the integration of good specimen collection, tissue biomarkers, and imaging tools into newly designed preoperative and perioperative strategies.
Collapse
|
141
|
Pancreatic cancer: diagnosis and treatments. Tumour Biol 2015; 36:1375-84. [PMID: 25680410 DOI: 10.1007/s13277-015-3223-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/03/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer is one of the deadliest cancers, with exceptionally high mortality. Despite the relatively low incidence rate (10th), it is the fourth leading cause of cancer-related deaths in most developed countries. To improve the early diagnosis of pancreatic cancer and strengthen the standardized comprehensive treatment are still the main focus of pancreatic cancer research. Here, we summarized the rapid developments in the diagnosis and treatments of pancreatic cancer. Regarding diagnosis, we reviewed advances in medical imaging technology, tumor markers, molecular biology (e.g., gene mutation), and proteomics. Moreover, great progress has also been made in the treatments of this disease, including surgical resection, chemotherapy, targeted radiotherapy, targeted minimally invasive treatment, and molecular targeted therapy. Therefore, we also recapitulated the development, advantages, and disadvantages of each of the treatment methods in this review.
Collapse
|
142
|
Sohal DPS, Shrotriya S, Glass KT, Pelley RJ, McNamara MJ, Estfan B, Shapiro M, Wey J, Chalikonda S, Morris-Stiff G, Walsh RM, Khorana AA. Predicting early mortality in resectable pancreatic adenocarcinoma: A cohort study. Cancer 2015; 121:1779-84. [PMID: 25676016 DOI: 10.1002/cncr.29298] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/22/2015] [Accepted: 01/26/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Survival after surgical resection for pancreatic cancer remains poor. A subgroup of patients die early (<6 months), and understanding factors associated with early mortality may help to identify high-risk patients. The Khorana score has been shown to be associated with early mortality for patients with solid tumors. In the current study, the authors evaluated the role of this score and other prognostic variables in this setting. METHODS The current study was a cohort study of patients who underwent surgical resection for pancreatic cancer from January 2006 through June 2013. Baseline (diagnosis ±30 days) parameters were used to define patients as high risk (Khorana score ≥3). Statistically significant univariable associations and a priori prognostic variables were tested in multivariable models; adjusted hazard ratios (HR) were calculated. RESULTS The study population comprised 334 patients. The median age was 67 years, 50% of the study population was female, and 86% of the patients were white. The pancreatic head was the primary tumor site for 73% of patients; 67% of tumors were T3 and 63% were N1. The median Khorana score was 2; 152 patients (47%) were determined to be high risk. Adjunctive treatment included chemotherapy (70%) and radiotherapy (40%). The postoperative (30-day) mortality rate was 0.9%. The 6-month mortality rate for the entire cohort was 9.4%, with significantly higher rates observed for high-risk patients (13.4% vs 5.6%; P = .02). On multivariable analyses (examining a total of 326 patients), the Khorana score (HR for high risk, 2.31; P = .039) and elevated blood urea nitrogen (HR, 4.34; P<.001) were associated with early mortality. CONCLUSIONS Patients at high risk of early mortality after surgical resection of pancreatic adenocarcinoma can be identified using simple baseline clinical and laboratory parameters. Future studies should address preoperative interventions in these patients at high risk of early mortality.
Collapse
Affiliation(s)
- Davendra P S Sohal
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shiva Shrotriya
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kate Tullio Glass
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert J Pelley
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael J McNamara
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bassam Estfan
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Shapiro
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jane Wey
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sricharan Chalikonda
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gareth Morris-Stiff
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
143
|
Gurusamy KS, Davidson BR. Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
144
|
Tu YK. Linear mixed model approach to network meta-analysis for continuous outcomes in periodontal research. J Clin Periodontol 2015; 42:204-12. [DOI: 10.1111/jcpe.12362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine; College of Public Health; National Taiwan University; Taipei Taiwan
| |
Collapse
|
145
|
Morita S, Onaya H, Kishi Y, Hiraoka N, Arai Y. Multiple Intraglandular Metastases in a Patient with Invasive Ductal Carcinoma of the Pancreas. Intern Med 2015; 54:1753-6. [PMID: 26179530 DOI: 10.2169/internalmedicine.54.3819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old man was admitted to our hospital for an evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the head of the pancreas, with three other tumors detected in the body and tail. Magnetic resonance imaging showed similar enhancement patterns and signal intensities in all four lesions. The patient underwent total pancreatectomy based on a preoperative diagnosis of multiple invasive ductal carcinomas. Histopathologically, the lesion in the pancreatic head was considered to be the primary lesion, while the others were diagnosed as metastases. This is a rare case of pancreatic cancer with intraglandular metastases. The possibility of this differential diagnosis should thus be considered when imaging shows multiple hypovascular lesions in the pancreas.
Collapse
MESH Headings
- Carcinoma, Pancreatic Ductal/complications
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Cholangiopancreatography, Endoscopic Retrograde
- Flank Pain/etiology
- Humans
- Jaundice/etiology
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Neoplasms, Second Primary/complications
- Neoplasms, Second Primary/diagnosis
- Neoplasms, Second Primary/pathology
- Neoplasms, Second Primary/surgery
- Pancreas/pathology
- Pancreatectomy/methods
- Pancreatic Neoplasms/complications
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- Shinichi Morita
- Division of Diagnostic Radiology, National Cancer Center Hospital, Japan
| | | | | | | | | |
Collapse
|
146
|
Hidalgo M, Cascinu S, Kleeff J, Labianca R, Löhr JM, Neoptolemos J, Real FX, Van Laethem JL, Heinemann V. Addressing the challenges of pancreatic cancer: future directions for improving outcomes. Pancreatology 2015; 15:8-18. [PMID: 25547205 DOI: 10.1016/j.pan.2014.10.001] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 10/01/2014] [Accepted: 10/03/2014] [Indexed: 12/11/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC), which accounts for more than 90% of all pancreatic tumours, is a devastating malignancy with an extremely poor prognosis, as shown by a 1-year survival rate of around 18% for all stages of the disease. The low survival rates associated with PDAC primarily reflect the fact that tumours progress rapidly with few specific symptoms and are thus at an advanced stage at diagnosis in most patients. As a result, there is an urgent need to develop accurate markers of pre-invasive pancreatic neoplasms in order to facilitate prediction of cancer risk and to help diagnose the disease at an earlier stage. However, screening for early diagnosis of prostate cancer remains challenging and identifying a highly accurate, low-cost screening test for early PDAC for use in clinical practice remains an important unmet need. More effective therapies are also crucial in PDAC, since progress in identifying novel therapies has been hampered by the genetic complexity of the disease and treatment remains a major challenge. Presently, the greatest step towards improved treatment efficacy has been made in the field of palliative chemotherapy by introducing FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan and oxaliplatin) and gemcitabine/nab-paclitaxel. Strategies designed to raise the profile of PDAC in research and clinical practice are a further requirement in order to ensure the best treatment for patients. This article proposes a number of approaches that may help to accelerate progress in treating patients with PDAC, which, in turn, may be expected to improve the quality of life and survival for those suffering from this devastating disease.
Collapse
Affiliation(s)
- Manuel Hidalgo
- Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid, Spain.
| | - Stefano Cascinu
- Department of Medical Oncology, University of Ancona, Ancona, Italy
| | - Jörg Kleeff
- Department of General Surgery, Technische Universität München, Munich, Germany
| | | | - J-Matthias Löhr
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - John Neoptolemos
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Cancer Research UK Liverpool Clinical Trials Unit Director, University of Liverpool and Royal Liverpool University Hospital, Liverpool, UK
| | - Francisco X Real
- Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid and Universitat Pompeu Fabra, Barcelona, Spain
| | - Jean-Luc Van Laethem
- Department of Gastroenterology-GI Cancer Unit, Erasme University Hospital, Brussels, Belgium
| | - Volker Heinemann
- Comprehensive Cancer Centre Munich, Klinikum der Universität München, Munich, Germany
| |
Collapse
|
147
|
Abstract
The last two decades of research in the adjuvant setting of pancreas adenocarcinoma have established the value of adjuvant systemic therapy as being able to delay recurrence and increase overall survival. International standards of care in the adjuvant setting include either 6 months of gemcitabine or 5-fluorouracil and leucovorin. The added value of additional agents in the adjuvant setting is being evaluated in several large adjuvant studies. The role of a targeted agent in the adjuvant setting remains investigational. Other major areas of exploration include the integration of adjuvant immunotherapeutic approaches, which provide promise in a setting of micrometastatic disease volumes where such approaches may have greatest value.
Collapse
Affiliation(s)
- Daneng Li
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY.
| |
Collapse
|
148
|
Jones OP, Melling JD, Ghaneh P. Adjuvant therapy in pancreatic cancer. World J Gastroenterol 2014; 20:14733-46. [PMID: 25356036 PMCID: PMC4209539 DOI: 10.3748/wjg.v20.i40.14733] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/29/2014] [Accepted: 05/25/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer remains one of the leading causes of cancer related death worldwide with an overall five-year survival of less than 5%. Potentially curative surgery, which alone can improve 5-year survival to 10%, is an option for only 10%-20% of patients at presentation owing to local invasion of the tumour or metastatic disease. Adjuvant chemotherapy has been shown to improve 5-year survival to 20%-25% but conflicting evidence remains with regards to chemoradiation. In this article we review the current evidence available from published randomised trials and discuss ongoing phase III trials in relation to adjuvant therapy in pancreatic cancer.
Collapse
|
149
|
Leong D, Rai R, Nguyen B, Lee A, Yip D. Advances in adjuvant systemic therapy for non-small-cell lung cancer. World J Clin Oncol 2014; 5:633-645. [PMID: 25302167 PMCID: PMC4129528 DOI: 10.5306/wjco.v5.i4.633] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 02/17/2014] [Accepted: 05/14/2014] [Indexed: 02/06/2023] Open
Abstract
Non-small-cell lung cancer remains a leading cause of death around the world. For most cases, the only chance of cure comes from resection for localised disease, however relapse rates remain high following surgery. Data has emerged over recent years regarding the utility of adjuvant chemotherapy for improving disease-free and overall survival of patients following curative resection. This paper reviews the clinical trials that have been conducted in this area along with the studies integrating radiation therapy in the adjuvant setting. The role of prognostic gene signatures are reviewed as well as ongoing clinical trials including those incorporating biological or targeted therapies.
Collapse
|
150
|
Ibrahim AA, Cramer HM, Wu HH. Endoscopic ultrasound-guided fine-needle aspiration of the pancreas: a retrospective study of 1000 cases. J Am Soc Cytopathol 2014; 3:227-235. [PMID: 31051675 DOI: 10.1016/j.jasc.2014.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as a superior method for the diagnosis of pancreatic tumors. Very few large studies have been published. We retrospectively examined 1000 cases to determine the sensitivity and specificity of EUS-guided FNA for solid and cystic lesions. MATERIALS AND METHODS EUS-guided FNA was performed in 1000 patients. Air-dried aspirates were reviewed immediately to ensure adequacy, and ethanol-fixed aspirates were reviewed the following day. The rendered diagnoses were placed into various categories and compared to subsequent histologic and clinical follow-up data. RESULTS Of the 1000 cases, 579 were solid lesions. The FNA diagnoses of the solid lesions were benign (B) 229 (39.5%), atypia (A) 22 (3.8%), suspicious (S) 27 (4.7%), malignant (M) 260 (44.9%), tumor (T) 1 (0.2%), and nondiagnostic (ND) 40 (6.9%). The sensitivity, specificity, positive predictive value, and negative predictive value for solid lesions were 97%, 97%, 99%, and 94%, respectively. There were 421 cystic lesions. The FNAs of the cystic lesions were classified as follows: B 342 (81.2%), A 5 (1.2%), S 4 (1%), M 7 (1.7%), T 46 (10.9%), and ND 17 (4.0%). The sensitivity, specificity, positive predictive value, and negative predictive value to identify mucinous tumors and malignancy for cystic lesions were 46%, 98%, 94%, and 87%, respectively. CONCLUSIONS At our institution, EUS-guided FNA of solid pancreatic lesions is both sensitive and specific for the diagnosis of both primary and metastatic tumors. For cystic lesions, FNA is not as sensitive, but its specificity remains high.
Collapse
Affiliation(s)
- Ashley A Ibrahim
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W. 11th Street, Indianapolis, Indiana.
| | - Harvey M Cramer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W. 11th Street, Indianapolis, Indiana
| | - Howard H Wu
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 W. 11th Street, Indianapolis, Indiana
| |
Collapse
|