151
|
Formica V, Morelli C, Ferroni P, Nardecchia A, Tesauro M, Pellicori S, Cereda V, Russo A, Riondino S, Guadagni F, Roselli M. Neutrophil/lymphocyte ratio helps select metastatic pancreatic cancer patients benefitting from oxaliplatin. Cancer Biomark 2017; 17:335-345. [PMID: 27434293 DOI: 10.3233/cbm-160645] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND High Neutrophil/Lymphocyte ratio (NLR), as a measure of enhanced inflammatory response, has been negatively associated with prognosis in patients with localized pancreatic ductal adenocarcinoma (PDA). OBJECTIVE In the present study, we aimed at investigating the prognostic value of NLR in two homogeneous groups of chemotherapy-naïve metastatic PDA patients. Patients were treated with either gemcitabine (GEM) or gemcitabine/oxaliplatin (GEMOXA). We also assessed whether NLR could identify patients benefiting from the use of oxaliplatin. METHODS Consecutive PDA patients treated at the Medical Oncology Unit of Tor Vergata University Hospital of Rome with either GEM or GEMOXA were included (n= 103). NLR was assessed before and during chemotherapy and correlated with outcome together with common clinical and biochemical variables. RESULTS Among 17 analyzed variables NLR, Karhofsky Perfomance Status (KPS), d-dimer and erythrocyte sedimentation rate were found to be significantly associated with median Overall Survival (mOS) at the univariate analysis. Only NLR and KPS were independent prognosticator at multivariate analysis, with NLR displaying the highest statistical significance. NLR was also predictive of oxaliplatin activity, as only patients with NLR > 2.5 (cutoff determined upon ROC analysis) derived benefit from GEMOXA over GEM. CONCLUSIONS NLR is both an independent prognostic and predictive factor in metastatic PDA, since only patients with high NLR seem to benefit from the addition of oxaliplatin. NLR may help select patients for whom a particularly poor prognosis might justify more intensive, yet less tolerable, combination regimens.
Collapse
Affiliation(s)
- Vincenzo Formica
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Cristina Morelli
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Patrizia Ferroni
- San Raffaele Roma Open University, Rome, Italy.,Interinstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele Pisana, Rome, Italy
| | - Antonella Nardecchia
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Manfredi Tesauro
- Department of Systems Medicine, Internal Medicine, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Stefania Pellicori
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Vittore Cereda
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| | - Antonio Russo
- Section of Medical Oncology, Department of Surgical and Oncology Sciences, University of Palermo, Italy
| | - Silvia Riondino
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy.,Interinstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele Pisana, Rome, Italy
| | - Fiorella Guadagni
- San Raffaele Roma Open University, Rome, Italy.,Interinstitutional Multidisciplinary Biobank (BioBIM), IRCCS San Raffaele Pisana, Rome, Italy
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, Tor Vergata Clinical Center, Tor Vergata University of Rome, Rome, Italy
| |
Collapse
|
152
|
Podda M, Thompson J, Kulli CTG, Tait IS. Vascular resection in pancreaticoduodenectomy for periampullary cancers. A 10 year retrospective cohort study. Int J Surg 2017; 39:37-44. [PMID: 28110027 DOI: 10.1016/j.ijsu.2017.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is the only chance of cure for periampullary cancers. This study aims to evaluate survival and complication rates for PD with additional vascular resection performed for local vascular involvement and compare to standard PD. MATERIALS AND METHODS A retrospective cohort analysis of a departmental hepato-pancreatobiliary database from 2004 to 2014 was performed. All patients (n = 92) who underwent PD without vascular resection (n = 72), with venous resection (n = 16), with both arterial and venous resection (n = 4) were included in the study. Patients who received palliative double bypass (n = 6) were also included for survival analysis. Survival and post-operative complications were assessed. RESULTS Median survival for standard PD and PD with venous resection was 21 months and 18 months respectively (P = 0.588). Patients who received PD with venous and arterial resection had a median survival of 7 months, significantly less than standard PD (P = 0.044). Median survival in the palliative bypass group was 4 months, comparable to PD with venous and arterial resection (P = 0.191). There was a significant survival advantage in patients who received an R0 resection (median survival 24 months) compared to those who received an R1 resection (median survival 18 months) (P < 0.02). Patients with a lymph node ratio <0.2 had a median survival of 25 months, which was significantly higher than that of patients who had a lymph node ratio ≥0.2 (9 months) (P < 0.005). CONCLUSION PD with venous resection has similar survival to standard PD with no increased risk of procedure specific post-operative complications. On the other hand, PD with venous resection and additional arterial resection has no survival benefit and may be a step too far in our experience.
Collapse
Affiliation(s)
- Mauro Podda
- San Francesco Hospital, General, Minimally Invasive and Robotic Surgery Unit, 08100 Nuoro, Italy; Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
| | - Jessica Thompson
- Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
| | | | - Iain Stephen Tait
- Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
| |
Collapse
|
153
|
Bouvier AM, Bossard N, Colonna M, Garcia-Velasco A, Carulla M, Manfredi S. Trends in net survival from pancreatic cancer in six European Latin countries: results from the SUDCAN population-based study. Eur J Cancer Prev 2017; 26 Trends in cancer net survival in six European Latin Countries: the SUDCAN study:S63-S69. [PMID: 28005607 DOI: 10.1097/cej.0000000000000303] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pancreatic cancer represents a real clinical challenge. The aim of the SUDCAN collaborative study was to compare the net survival from pancreatic cancer between six European Latin countries (Belgium, France, Italy, Portugal, Spain and Switzerland) and provide trends in net survival and dynamics of excess mortality rates up to 5 years after diagnosis. The data were extracted from the EUROCARE-5 database. First, net survival was studied over the period 2000-2004 using the Pohar-Perme estimator. For trend analyses, the study period was specific to each country. Results were reported from 1992 to 2004 in France, Italy, Spain and Switzerland and from 2000 to 2004 in Belgium and Portugal. These analyses were carried out using a flexible excess rate modelling strategy. There were little differences between countries in age-standardized net survivals (2000-2004). The 5-year net survival was poor (range: 6-10%). The changes in net survival from 1992 to 2004 were mostly related to early survival and patients aged 60 years. A slight decrease in the excess mortality rate between 1992 and 2004 was observed, limited to the 18 months after diagnosis. This study confirmed that, despite some improvement, survival from pancreatic cancer is still poor throughout European Latin countries. The major improvements in clinical imaging did not result in improvements in prognosis. Development of truly innovative treatments is highly needed to improve prognosis.
Collapse
Affiliation(s)
- Anne-Marie Bouvier
- aDigestive Cancer Registry of Burgundy F-21079; INSERM U866; CHU Dijon; University of Burgundy, Dijon bDepartment of Biostatistics, University Hospital of Lyon cUniversity of Lyon, Lyon dUniversity of Lyon 1 eCNRS, UMR5558, Biometry and Evolutionary Biology Laboratory (LBBE), BioMaths-Health Department Villeurbanne fIsère Cancer Registry, University Hospital of Grenoble, Grenoble, France gCatalan Institute of Oncology, University Hospital of Girona Doctor Josep Trueta, Unit of Epidemiology and Cancer Registry of Girona, University of Girona, Girona hTarragona Cancer Registry, Foundation for Research and Cancer Prevention, Reus, Spain
| | | | | | | | | | | |
Collapse
|
154
|
Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A. Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning. Radiographics 2017; 37:93-112. [DOI: 10.1148/rg.2017160054] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
155
|
Dietrich CF, Burmester E. Contrast-enhanced ultrasound of small focal solid pancreatic lesions: A must! Endosc Ultrasound 2017; 6:S106-S110. [PMID: 29387704 PMCID: PMC5774065 DOI: 10.4103/eus.eus_73_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Christoph F Dietrich
- Medical Department, Caritas Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, 23560 Luebeck, Germany.,Ultrasound Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan province, China
| | - Eike Burmester
- Medical Department I, Sana Hospital Luebeck, Kronsforder Allee 71-73, 23560 Luebeck, Germany
| |
Collapse
|
156
|
Dietrich CF. The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, introduction. Endosc Ultrasound 2017; 6:S69-S70. [PMID: 29387693 PMCID: PMC5774076 DOI: 10.4103/eus.eus_63_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Christoph F Dietrich
- Medical Department, Caritas Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, Germany.,Ultrasound Department, First Affiliated Hospital of Zhengzhou University Zhengzhou, Henan Province, China
| |
Collapse
|
157
|
|
158
|
Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc 2016; 84:933-940. [PMID: 27155592 DOI: 10.1016/j.gie.2016.04.034] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/25/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at a late stage. Little is known about the incidental finding of early-stage PDAC. The aim of the current study was to determine the etiology of small solid pancreatic lesions (≤15 mm) to optimize clinical management. METHODS Inclusion criterion for the retrospective study analysis was the incidental finding of primarily undetermined small solid pancreatic lesions ≤15 mm in 394 asymptomatic patients. Final diagnoses were based on histology or cytology obtained by imaging-guided biopsy (and at least 12-month follow-up) and/or surgery. Contrast-enhanced US or contrast-enhanced EUS was performed in 219 patients. RESULTS The final diagnoses of 394 patients were as follows: 146 PDACs, 156 neuroendocrine tumors, 28 metastases into the pancreas from other primary sites, and 64 various other etiologies. Contrast-enhanced US allowed differential diagnosis of PDAC and non-PDAC in 189 of 219 patients (86%). CONCLUSIONS Approximately 40% of patients with small solid pancreatic lesions had very early stage PDAC. Approximately 60% of small solid pancreatic lesions ≤15 mm are not PDAC and, therefore, do not require radical surgery. Without preoperative diagnosis, an unacceptably large proportion of patients would be exposed to radical surgery with significant morbidity and mortality.
Collapse
|
159
|
Schawkat K, Kühn W, Inderbitzin D, Gloor B, Heverhagen JT, Runge VM, Christe A. Diagnostic Value and Interreader Agreement of the Pancreaticolienal Gap in Pancreatic Cancer on MDCT. PLoS One 2016; 11:e0166003. [PMID: 27893776 PMCID: PMC5125578 DOI: 10.1371/journal.pone.0166003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/21/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The aim of this retrospective study was to evaluate the diagnostic value and measure interreader agreement of the pancreaticolienal gap (PLG) in the assessment of imaging features of pancreatic carcinoma (PC) on contrast-enhanced multi-detector computed tomography (CE-MDCT). MATERIALS AND METHODS CE-MDCT studies in the portal venous phase were retrospectively reviewed for 66 patients with PC. The age- and gender-matched control group comprised 103 healthy individuals. Three radiologists with different levels of experience independently measured the PLG (the minimum distance of the pancreatic tail to the nearest border of the spleen) in the axial plane. The interreader agreement of the PLG and the receiver operating characteristic (ROC) curve was used to calculate the accuracy of the technique. RESULTS While the control group (n = 103) showed a median PLG of 3 mm (Range: 0 - 39mm) the PC patients had a significantly larger PLG of 15mm (Range: 0 - 53mm)(p < 0.0001). A ROC curve demonstrated a cutoff-value of >12 mm for PC, with a sensitivity of 58.2% (95% CI = 45.5-70.1), specificity of 84.0% (95% CI = 75.6-90.4) and an area under the ROC curve of 0.714 (95% CI = 0.641 to 0.780). The mean interreader agreement showed correlation coefficient r of 0.9159. The extent of the PLG did not correlate with tumor stage but did correlate with pancreatic density (fatty involution) and age, the density decreased by 4.1 HU and the PLG increased by 0.8 mm within every 10 y. CONCLUSION The significant interreader agreement supports the use of the PLG as a characterizing feature of pancreatic cancer independent of the tumor stage on an axial plane. The increase in the PLG with age may represent physiological atrophy of the pancreatic tail.
Collapse
Affiliation(s)
- Khoschy Schawkat
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Wolfgang Kühn
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Daniel Inderbitzin
- Department of Visceral and Transplantion Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Surgery, Tiefenau Hospital, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral and Transplantion Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Johannes T. Heverhagen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Val Murray Runge
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Andreas Christe
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Radiology, Tiefenau Hospital, Bern, Switzerland
| |
Collapse
|
160
|
Gostimir M, Bennett S, Moyana T, Sekhon H, Martel G. Complete pathological response following neoadjuvant FOLFIRINOX in borderline resectable pancreatic cancer - a case report and review. BMC Cancer 2016; 16:786. [PMID: 27724927 PMCID: PMC5057443 DOI: 10.1186/s12885-016-2821-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 09/29/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic cancer is among the top 5 most common cancers worldwide, but is particularly devastating due to its insidious nature. Complete surgical resection remains the only potential curative treatment, although only 20 % of patients present with a resectable tumor. Patients may alternatively present with borderline resectable pancreatic cancer or locally advanced pancreatic cancer and can be offered treatment with neoadjuvant intent. The effectiveness of these treatments is unclear and there is a paucity of data to suggest one optimal treatment approach. CASE PRESENTATION We describe a 61-year-old female who presented with a two-week history of obstructive jaundice in the context of vague abdominal pain that had been ongoing for years prior to her visit. CT scan of the abdomen confirmed a hypovascular mass in the uncinate process consistent with borderline resectable pancreatic cancer. Pancreatic adenocarcinoma was confirmed with endoscopic ultrasound guided fine-needle aspiration cytology. Following multidisciplinary discussion, it was recommended that she undergo treatment with FOLFIRINOX. After a total of 13 cycles, follow up CT revealed that the lesion had decreased in size and she was offered resection as a potentially curative treatment. She underwent pancreaticoduodenectomy. Final pathology report revealed no evidence of residual adenocarcinoma (ypT0 ypN0 (0/23)). The patient remains disease-free 15 months following surgery. CONCLUSION To date, there have been very few reports of a complete pathological response following neoadjuvant therapy in borderline resectable or locally advanced pancreatic cancer. This report describes a unique case of a complete pathological remission in a patient with borderline resectable pancreatic cancer following FOLFIRINOX therapy alone and adds to the growing base of evidence meriting the initiation of clinical trials to assess the efficacy of FOLFIRINOX in these subsets of pancreatic cancer.
Collapse
Affiliation(s)
- Mišo Gostimir
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, K1H 8 M5 Ottawa, Canada
| | - Sean Bennett
- Department of Surgery, Division of General Surgery, University of Ottawa, 451 Smyth Rd, K1H 8 M5 Ottawa, Canada
| | - Terence Moyana
- Department of Pathology and Laboratory Medicine, University of Ottawa, 501 Smyth Rd, K1H 8 L6 Ottawa, Canada
| | - Harman Sekhon
- Department of Pathology and Laboratory Medicine, University of Ottawa, 501 Smyth Rd, K1H 8 L6 Ottawa, Canada
| | - Guillaume Martel
- Department of Surgery, Liver and Pancreas Unit, University of Ottawa, 501 Smyth Rd, K1H 8 L6 Ottawa, Canada
| |
Collapse
|
161
|
Maroni L, Ravaioli M, Pinna AD. Why is pancreatic adenocarcinoma not screened for earlier? Expert Rev Anticancer Ther 2016; 16:1003-4. [PMID: 27552648 DOI: 10.1080/14737140.2016.1224972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Lorenzo Maroni
- a Department of Medical and Surgical Sciences , Alma Mater Studiorum - Università di Bologna , Bologna , Italy
| | - Matteo Ravaioli
- a Department of Medical and Surgical Sciences , Alma Mater Studiorum - Università di Bologna , Bologna , Italy
| | - Antonio Daniele Pinna
- a Department of Medical and Surgical Sciences , Alma Mater Studiorum - Università di Bologna , Bologna , Italy
| |
Collapse
|
162
|
Mirkin KA, Hollenbeak CS, Wong J. Survival impact of neoadjuvant therapy in resected pancreatic cancer: A Prospective Cohort Study involving 18,332 patients from the National Cancer Data Base. Int J Surg 2016; 34:96-102. [DOI: 10.1016/j.ijsu.2016.08.523] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 02/08/2023]
|
163
|
Dalgleish AG, Stebbing J, Adamson DJA, Arif SS, Bidoli P, Chang D, Cheeseman S, Diaz-Beveridge R, Fernandez-Martos C, Glynne-Jones R, Granetto C, Massuti B, McAdam K, McDermott R, Martín AJM, Papamichael D, Pazo-Cid R, Vieitez JM, Zaniboni A, Carroll KJ, Wagle S, Gaya A, Mudan SS. Randomised, open-label, phase II study of gemcitabine with and without IMM-101 for advanced pancreatic cancer. Br J Cancer 2016; 115:789-96. [PMID: 27599039 PMCID: PMC5046215 DOI: 10.1038/bjc.2016.271] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/22/2016] [Accepted: 07/22/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Immune Modulation and Gemcitabine Evaluation-1, a randomised, open-label, phase II, first-line, proof of concept study (NCT01303172), explored safety and tolerability of IMM-101 (heat-killed Mycobacterium obuense; NCTC 13365) with gemcitabine (GEM) in advanced pancreatic ductal adenocarcinoma. METHODS Patients were randomised (2 : 1) to IMM-101 (10 mg ml(-l) intradermally)+GEM (1000 mg m(-2) intravenously; n=75), or GEM alone (n=35). Safety was assessed on frequency and incidence of adverse events (AEs). Overall survival (OS), progression-free survival (PFS) and overall response rate (ORR) were collected. RESULTS IMM-101 was well tolerated with a similar rate of AE and serious adverse event reporting in both groups after allowance for exposure. Median OS in the intent-to-treat population was 6.7 months for IMM-101+GEM v 5.6 months for GEM; while not significant, the hazard ratio (HR) numerically favoured IMM-101+GEM (HR, 0.68 (95% CI, 0.44-1.04, P=0.074). In a pre-defined metastatic subgroup (84%), OS was significantly improved from 4.4 to 7.0 months in favour of IMM-101+GEM (HR, 0.54, 95% CI 0.33-0.87, P=0.01). CONCLUSIONS IMM-101 with GEM was as safe and well tolerated as GEM alone, and there was a suggestion of a beneficial effect on survival in patients with metastatic disease. This warrants further evaluation in an adequately powered confirmatory study.
Collapse
Affiliation(s)
- Angus G Dalgleish
- Cancer Vaccine Institute, St George's University of London, London, UK
| | - Justin Stebbing
- Department of Oncology, Imperial College, Hammersmith Hospital, London, UK
| | | | | | - Paolo Bidoli
- Department of Oncology, Azienda Ospedaliera San Gerardo, Monza, Italy
| | - David Chang
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - Sue Cheeseman
- Department of Oncology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | | | - Cristina Granetto
- Medical Oncology, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | - Bartomeu Massuti
- Ensayos Clínicos Oncología, Hospital General Universitario de Alicante, Alicante, Spain
| | - Karen McAdam
- Oncology Department, Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK
| | - Raymond McDermott
- Medical Oncology, St Vincent's University Hospital and The Adelaide and Meath Hospital, Dublin, Republic of Ireland
| | - Andrés J Muñoz Martín
- Gastrointestinal Cancer Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Roberto Pazo-Cid
- Servicio de Oncología Médica, Hospital Miguel Servet, Zaragoza, Spain
| | - Jose M Vieitez
- Area and Neuroendocrine Tumors Gastrointestinal Medical Oncology, Hospital Central de Asturias, Asturias, Spain
| | | | | | | | - Andrew Gaya
- Clinical Oncology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| | - Satvinder S Mudan
- St George's University of London, Imperial College, London and The Royal Marsden Hospital, London, UK
| |
Collapse
|
164
|
Lahoud MJ, Kourie HR, Antoun J, El Osta L, Ghosn M. Road map for pain management in pancreatic cancer: A review. World J Gastrointest Oncol 2016; 8:599-606. [PMID: 27574552 PMCID: PMC4980650 DOI: 10.4251/wjgo.v8.i8.599] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/25/2016] [Accepted: 05/13/2016] [Indexed: 02/05/2023] Open
Abstract
Beside its poor prognosis and its late diagnosis, pancreatic cancer remains one of the most painful malignancies. Optimal management of pain in this cancer represents a real challenge for the oncologist whose objective is to ensure a better quality of life to his patients. We aimed in this paper to review all the treatment modalities incriminated in the management of pain in pancreatic cancer going from painkillers, chemotherapy, radiation therapy and interventional techniques to agents under investigation and alternative medicine. Although specific guidelines and recommendations for pain management in pancreatic cancer are still absent, we present all the possible pain treatments, with a progression from medical multimodal treatment to radiotherapy and chemotherapy then interventional techniques in case of resistance. In addition, alternative methods such as acupuncture and hypnosis can be added at any stage and seems to contribute to pain relief.
Collapse
|
165
|
Axtner J, Steele M, Kröz M, Spahn G, Matthes H, Schad F. Health services research of integrative oncology in palliative care of patients with advanced pancreatic cancer. BMC Cancer 2016; 16:579. [PMID: 27485618 PMCID: PMC4971628 DOI: 10.1186/s12885-016-2594-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 07/21/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pancreatic cancer has a dire prognosis and is associated with a high mortality. Palliative patients have special needs and often seek help in integrative oncological concepts (IO) that combine conventional and complementary therapies. Nevertheless there are few recommendations regarding IO in current cancer guidelines. The aims of this study were to report on implementation of IO in everyday palliative care and to analyze patient survival in advanced pancreatic cancer. METHODS This multicenter observational study investigates the implementation of IO and length of survival of patients suffering from advanced pancreatic cancer (stage IV). We analyzed patient's survival by employing multivariable proportional hazard models using different parametric distribution functions and compared patients receiving chemotherapy only, a combination of chemotherapy and Viscum album (VA) treatment, and VA treatment only. RESULTS Records of 240 patients were analyzed. Complementary therapy showed high acceptance (93 %). Most frequent therapy was VA treatment (74 %) that was often administered concomitantly to chemotherapy (64 %). Both therapies had positive effects on patient survival as they had significant negative effects on the hazard in our log-normal model. A second analysis showed that patients with combined chemotherapy and VA therapy performed significantly better than patients receiving only chemotherapy (12.1 to 7.3 month). Patients receiving only VA therapy showed longer survival than those receiving neither chemotherapy nor VA therapy (5.4 to 2.5 months). Our data demonstrates that IO can be implemented in the everyday care of patients without disregarding conventional treatment. Patients combining VA with chemotherapy showed longest survival. CONCLUSIONS Our data demonstrate the importance and potential of health services research showing that IO treatment can be successfully implemented in the every-day care of patients suffering from advanced pancreatic cancer. Patients combining VA with chemotherapy showed longest survival. To address patients' needs adequately, future cancer guidelines might increasingly include comments on complementary treatment options in addition to conventional therapies. Further studies should investigate the effect of complementary treatments on survival and quality of life in more detail.
Collapse
Affiliation(s)
- Jan Axtner
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany
| | - Megan Steele
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,ihop Research Group, Queensland University of Technology, School of Public Health and Social Work, Victoria Park Road, 4059, Brisbane, Australia
| | - Matthias Kröz
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Günther Spahn
- Institut für Integrative Krebstherapie, Hans-Böckler-Str. 7, 55128, Mainz, Germany
| | - Harald Matthes
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Friedemann Schad
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany. .,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
| |
Collapse
|
166
|
Overexpression of C16orf74 is involved in aggressive pancreatic cancers. Oncotarget 2016; 8:50460-50475. [PMID: 28881575 PMCID: PMC5584151 DOI: 10.18632/oncotarget.10912] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/13/2016] [Indexed: 01/05/2023] Open
Abstract
Clinical outcome of pancreatic ductal adenocarcinoma (PDAC) has not been improved in the last three decades due to the lack of effective molecular-targeted drugs. To identify a novel therapeutic target for PDAC, we have performed genome-wide anamysis and found that Homo sapienschromosome 16 open reading frame 74 (C16orf74) was up-regulated in the vast majority of PDAC. Overexpression of C16orf74protein detected by immunohistochemical analysis was an independent prognostic factor for patients with PDAC. The knockdown of endogenous C16orf74 expression in the PDAC cell lines KLM-1 and PK-59 by vector-based small hairpin-RNA (shRNA) drastically attenuated the growth of those cells, whereas ectopic C16orf74 overexpression in HEK293T and NIH3T3 cells promoted cell growth and invasion, respectively. More importantly, the endogenous threonine 44 (T44)-phosphorylated form of C16orf74 interacted with the protein phosphatase 3 catalytic subunit alpha (PPP3CA) via the PDIIIT sequence in the PPP3CA-binding motif within the middle portion of C16orf74 in PDAC cells. The overexpression of mutants of C16orf74 lacking the PDIIIT sequence or T44 phosphorylation resulted in the suppression of invasive activity compared with wild-type C16orf74, indicating that their interaction should be indispensable for PDAC cell invasion. These results suggest that C16orf74 plays an important role for PDAC invasion and proliferation, and is a promising target for a specific treatment for patients with PDAC.
Collapse
|
167
|
Lamarca A, Rigby C, McNamara MG, Hubner RA, Valle JW. Impact of biliary stent-related events in patients diagnosed with advanced pancreatobiliary tumours receiving palliative chemotherapy. World J Gastroenterol 2016; 22:6065-6075. [PMID: 27468198 PMCID: PMC4948275 DOI: 10.3748/wjg.v22.i26.6065] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/02/2016] [Accepted: 03/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the impact (morbidity/mortality) of biliary stent-related events (SRE) (cholangitis or stent obstruction) in chemotherapy-treated pancreatico-biliary patients.
METHODS: All consecutive patients with advanced pancreatobiliary cancer and a biliary stent in-situ prior to starting palliative chemotherapy were identified retrospectively from local electronic case-note records (Jan 13 to Jan 15). The primary end-point was SRE rate and the time-to-SRE (defined as time from first stenting before chemotherapy to date of SRE). Progression-free survival and overall survival were measured from the time of starting chemotherapy. Kaplan-Meier, Cox and Fine-Gray regression (univariate and multivariable) analyses were employed, as appropriate. For the analysis of time-to-SRE, death was considered as a competing event.
RESULTS: Ninety-six out of 693 screened patients were eligible; 89% had a metal stent (the remainder were plastic). The median time of follow-up was 9.6 mo (range 2.2 to 26.4). Forty-one patients (43%) developed a SRE during follow-up [cholangitis (39%), stent obstruction (29%), both (32%)]. There were no significant differences in baseline characteristics between the SRE group and no-SRE groups. Recorded SRE-consequences were: none (37%), chemotherapy delay (24%), discontinuation (17%) and death (22%). The median time-to-SRE was 4.4 mo (95%CI: 3.6-5.5). Patients with severe comorbidities (P < 0.001) and patients with ≥ 2 baseline stents/biliary procedures [HR = 2.3 (95%CI: 1.2-4.44), P = 0.010] had a shorter time-to-SRE on multivariable analysis. Stage was an independent prognostic factor for overall survival (P = 0.029) in the multivariable analysis adjusted for primary tumour site, performance status and development of SRE (SRE group vs no-SRE group).
CONCLUSION: SREs are common and impact on patient’s morbidity. Our results highlight the need for prospective studies exploring the role of prophylactic strategies to prevent/delay SREs.
Collapse
|
168
|
Skoda J, Hermanova M, Loja T, Nemec P, Neradil J, Karasek P, Veselska R. Co-Expression of Cancer Stem Cell Markers Corresponds to a Pro-Tumorigenic Expression Profile in Pancreatic Adenocarcinoma. PLoS One 2016; 11:e0159255. [PMID: 27414409 PMCID: PMC4945008 DOI: 10.1371/journal.pone.0159255] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 06/29/2016] [Indexed: 01/12/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies. Its dismal prognosis is often attributed to the presence of cancer stem cells (CSCs) that have been identified in PDAC using various markers. However, the co-expression of all of these markers has not yet been evaluated. Furthermore, studies that compare the expression levels of CSC markers in PDAC tumor samples and in cell lines derived directly from those tumors are lacking. Here, we analyzed the expression of putative CSC markers—CD24, CD44, epithelial cell adhesion molecule (EpCAM), CD133, and nestin—by immunofluorescence, flow cytometry and quantitative PCR in 3 PDAC-derived cell lines and by immunohistochemistry in 3 corresponding tumor samples. We showed high expression of the examined CSC markers among all of the cell lines and tumor samples, with the exception of CD24 and CD44, which were enriched under in vitro conditions compared with tumor tissues. The proportions of cells positive for the remaining markers were comparable to those detected in the corresponding tumors. Co-expression analysis using flow cytometry revealed that CD24+/CD44+/EpCAM+/CD133+ cells represented a significant population of the cells (range, 43 to 72%) among the cell lines. The highest proportion of CD24+/CD44+/EpCAM+/CD133+ cells was detected in the cell line derived from the tumor of a patient with the shortest survival. Using gene expression profiling, we further identified the specific pro-tumorigenic expression profile of this cell line compared with the profiles of the other two cell lines. Together, CD24+/CD44+/EpCAM+/CD133+ cells are present in PDAC cell lines derived from primary tumors, and their increased proportion corresponds with a pro-tumorigenic gene expression profile.
Collapse
Affiliation(s)
- Jan Skoda
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marketa Hermanova
- 1st Department of Pathological Anatomy, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Loja
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Pavel Nemec
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Jakub Neradil
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Karasek
- Department of Complex Oncology Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Renata Veselska
- Laboratory of Tumor Biology, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- * E-mail:
| |
Collapse
|
169
|
Diouf M, Filleron T, Pointet AL, Dupont-Gossard AC, Malka D, Artru P, Gauthier M, Lecomte T, Aparicio T, Thirot-Bidault A, Lobry C, Fein F, Dubreuil O, Landi B, Zaanan A, Taieb J, Bonnetain F. Prognostic value of health-related quality of life in patients with metastatic pancreatic adenocarcinoma: a random forest methodology. Qual Life Res 2016; 25:1713-23. [PMID: 26615615 DOI: 10.1007/s11136-015-1198-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE Eastern Cooperative Oncology Group Performance Status (ECOG-PS) is currently an important parameter in the choice of treatment strategy for metastatic pancreatic adenocarcinoma (mPA) patients. However, previous research has shown that patients' self-reported health-related quality of life (HRQOL) scales provided additional prognostic information in homogeneous groups of patients with respect to ECOG-PS. The aim of this study was to identify HRQOL scales with independent prognostic value in mPA and to propose prognostic groups for these patients. METHODS We analysed data from 98 chemotherapy-naive patients with histologically proven mPA recruited from 2007 to 2011 in the FIRGEM phase II study which aimed to compare the effectiveness of two chemotherapy regimen. HRQOL data were assessed with the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. A random survival forest methodology was used to impute missing data and to identify major prognostic factors for overall survival. RESULTS Baseline HRQOL assessment was completed by 60 % of patients (59/98). Twelve prognostic variables were identified. The three most important prognostic variables were fatigue, appetite loss, and role functioning, followed by three laboratory variables. The model's discriminative power assessed by Harrell's C statistic was 0.65. Fatigue score explained almost all the survival variability. CONCLUSION HRQOL scores have prognostic value for mPA patients with good ECOG-PS. Moreover, the patient's fatigue, appetite loss, and self-perception of daily activities were more reliable prognostic indicators than clinical and laboratory variables. These HRQOL scores, especially the fatigue symptom, should be urgently included for prognostic assessment of mPA patients (with good ECOG-PS).
Collapse
Affiliation(s)
- Momar Diouf
- Clinical Research and Innovation Directorate, Amiens University Hospital, Amiens, France.
- Methodology and Quality of Life in Oncology Unit, EA 3181 CHU Besançon and the Qualité de Vie et Cancer Clinical Research Platform, Besançon, France.
| | - Thomas Filleron
- Biostatistics Unit, Claudius Régaud Institute, Toulouse, France
| | - Anne-Laure Pointet
- Hepatogastroenterology and Digestive Oncology Department, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | | | | | | | | | | | - Thomas Aparicio
- CHU Avicenne, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | | | | | | | - Olivier Dubreuil
- Hepatogastroenterology and Digestive Oncology Department, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | - Bruno Landi
- Hepatogastroenterology and Digestive Oncology Department, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | - Aziz Zaanan
- Hepatogastroenterology and Digestive Oncology Department, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | - Julien Taieb
- Hepatogastroenterology and Digestive Oncology Department, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France.
| | - Franck Bonnetain
- Methodology and Quality of Life in Oncology Unit, EA 3181 CHU Besançon and the Qualité de Vie et Cancer Clinical Research Platform, Besançon, France
| |
Collapse
|
170
|
Abstract
OBJECTIVES Structured follow-up after surgery for pancreatic ductal adenocarcinoma (PDAC) remains controversial and is currently not recommended due to a supposed lack of therapeutic consequences. Furthermore, it is not clear whether noncancer patients after pancreas resection need to be seen in the clinic on a regular basis. The present study analyzed how follow-up after pancreatic surgery affected postoperative treatment and long-term outcomes. METHODS Data of all postoperative visits in a specialized outpatient clinic for pancreatic diseases were analyzed for a 1-year period with regard to symptoms, diagnostic procedures, and therapeutic consequences. RESULTS Six hundred eighteen patients underwent 940 postoperative follow-ups. Nearly half of them needed a change of medication due to altered pancreatic function. In 74 (40%) of 184 resected PDAC patients, recurrence (local or systemic) was detected during follow-up, although only 19 of these had shown associated symptoms (26%). In all patients with recurrence, a cancer-directed treatment was induced. Eleven (69%) of 16 patients with isolated local recurrence were referred for reresection. CONCLUSIONS Follow-up examinations are a substantial part of the clinical management after pancreas resections. Follow-up is particularly important for PDAC because recurrence is often asymptomatic, but its detection allows for therapeutic interventions and potentially improved prognosis. This should be implemented in future guidelines.
Collapse
|
171
|
Burmeister EA, Waterhouse M, Jordan SJ, O'Connell DL, Merrett ND, Goldstein D, Wyld D, Beesley V, Gooden H, Janda M, Neale RE. Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study. Pancreatology 2016; 16:873-81. [PMID: 27374480 DOI: 10.1016/j.pan.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery. METHODS Data were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable. RESULTS Data were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery. CONCLUSIONS This study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.
Collapse
Affiliation(s)
- E A Burmeister
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia; The University of Queensland, Brisbane, Queensland, Australia.
| | - M Waterhouse
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - S J Jordan
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - D L O'Connell
- Cancer Council NSW, Sydney, Australia; University of Newcastle, NSW, Australia; University of Sydney, NSW, Australia
| | - N D Merrett
- Western Sydney University, NSW, Australia; Bankstown Hospital, NSW, Australia
| | - D Goldstein
- University of New South Wales, NSW, Australia; Prince of Wales Hospital, NSW, Australia
| | - D Wyld
- The University of Queensland, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - V Beesley
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - H Gooden
- University of Sydney, NSW, Australia
| | - M Janda
- Queensland University of Technology, Brisbane, Australia
| | - R E Neale
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| |
Collapse
|
172
|
Westphalen CB, Kruger S, Haas M, Heinemann V, Boeck S. Safety of palliative chemotherapy in advanced pancreatic cancer. Expert Opin Drug Saf 2016; 15:947-54. [PMID: 27070177 DOI: 10.1080/14740338.2016.1177510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Pancreatic cancer is a major health burden. Currently, the majority of patients is diagnosed at advanced stages and thus qualifies for palliative chemotherapy. Gemcitabine monotherapy has been the gold standard for many years. Recently, more effective chemotherapeutic regimens have shown meaningful clinical activity in patients with metastatic pancreatic cancer. AREAS COVERED In this review we have aimed to give an overview on the treatment options for patients diagnosed with metastatic pancreatic cancer with an emphasis on the safety and toxicity of the applied regimens. We have conducted a pubmed search using the terms 'metastatic pancreatic cancer', 'palliative chemotherapy', 'safety' and 'toxicity'. Our special focus rested on randomized phase III trials to provide readers with the highest level of available evidence. EXPERT OPINION The emergence of new and more effective chemotherapy regimens gives clinicians more freedom in the treatment of metastatic pancreatic cancer. While being more effective, these regiments have a considerable degree of toxicity. Choosing the right treatment for any individual will be the next major challenge treating patients with pancreatic cancer.
Collapse
Affiliation(s)
- C Benedikt Westphalen
- a Department of Internal Medicine III and Comprehensive Cancer Center , Klinikum Grosshadern, Ludwig-Maximilians-University of Munich , Munich , Germany
| | - Stephan Kruger
- a Department of Internal Medicine III and Comprehensive Cancer Center , Klinikum Grosshadern, Ludwig-Maximilians-University of Munich , Munich , Germany
| | - Michael Haas
- a Department of Internal Medicine III and Comprehensive Cancer Center , Klinikum Grosshadern, Ludwig-Maximilians-University of Munich , Munich , Germany
| | - Volker Heinemann
- a Department of Internal Medicine III and Comprehensive Cancer Center , Klinikum Grosshadern, Ludwig-Maximilians-University of Munich , Munich , Germany
| | - Stefan Boeck
- a Department of Internal Medicine III and Comprehensive Cancer Center , Klinikum Grosshadern, Ludwig-Maximilians-University of Munich , Munich , Germany
| |
Collapse
|
173
|
Balzano G, Capretti G, Callea G, Cantù E, Carle F, Pezzilli R. Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy. HPB (Oxford) 2016; 18:470-8. [PMID: 27154812 PMCID: PMC4857063 DOI: 10.1016/j.hpb.2015.11.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND According to current guidelines, pancreatic cancer patients should be strictly selected for surgery, either palliative or resective. METHODS Population-based study, including all patients undergoing surgery for pancreatic cancer in Italy between 2010 and 2012. Hospitals were divided into five volume groups (quintiles), to search for differences among volume categories. RESULTS There were 544 hospitals performing 10 936 pancreatic cancer operations. The probability of undergoing palliative/explorative surgery was inversely related to volume, being 24.4% in very high-volume hospitals and 62.5% in very low-volume centres (adjusted OR 5.175). Contrarily, the resection rate in patients without metastases decreased from 86.9% to 46.1% (adjusted OR 7.429). As for resections, the mortality of non-resective surgery was inversely related to volume (p < 0.001). Surprisingly, mortality of non-resective surgery was higher than that for resections (8.2% vs. 6.7%; p < 0.01). Approximately 9% of all resections were performed on patients with distant metastases, irrespective of hospital volume group. The excess cost for the National Health System from surgery overuse was estimated at 12.5 million euro. DISCUSSION Discrepancies between guidelines on pancreatic cancer treatment and surgical practice were observed. An overuse of surgery was detected, with serious clinical and economic consequences.
Collapse
Affiliation(s)
- Gianpaolo Balzano
- Unit of Pancreatic Surgery, San Raffaele Scientific Institute, Milan, Italy,Italian Association for the Study of Pancreas (AISP), Italy,Correspondence: Gianpaolo Balzano, Unit of Pancreatic Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy. Tel: +39 0 226432664. Fax: +39 0 226437807.
| | - Giovanni Capretti
- Unit of Pancreatic Surgery, San Raffaele Scientific Institute, Milan, Italy,Italian Association for the Study of Pancreas (AISP), Italy
| | - Giuditta Callea
- Centre for Research on Health and Social Care Management (CERGAS), Università Commerciale Luigi Bocconi, Milan, Italy
| | - Elena Cantù
- Centre for Research on Health and Social Care Management (CERGAS), Università Commerciale Luigi Bocconi, Milan, Italy
| | - Flavia Carle
- Directorate of Health Care Planning, Ministry of Health, Roma, Italy,Centre of Epidemiology, Biostatistics and Information Technology, Università Politecnica delle Marche, Ancona, Italy
| | - Raffaele Pezzilli
- Italian Association for the Study of Pancreas (AISP), Italy,Pancreas Unit, Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
174
|
Abstract
OBJECTIVES With increasing numbers of therapeutic options in inoperable pancreatic cancer (PAC), patients tend to receive more than just a first line (FL) therapy. METHODS All patients who started FL for PAC at our institution (1997-2012) were retrospectively studied to identify patient's and treatment characteristics. Significant parameters in regard to second-line (SL) related survival were looked for as the basis for a prognostic model. This score was validated in a patient cohort from the CONKO-003 study. RESULTS Two hundred eighty of 521 (53.7%) patients received SL therapy, median overall survival (OS) from the beginning of SL (OS2) was 5.1 months. Significant more SL patients had undergone surgery, a higher Karnofsky performance state (KPS) and a duration of FL longer than 4 months.Prognostic factors impacting OS2 were KPS, carbohydrate antigen 19-9 levels at start of SL and the duration of FL. These 3 factors establish a prognostic score--validated in CONKO-003--for SL patients with 3 subgroups: "good" (median OS2, 9.3 months), "intermediate" (median OS2, 7.1 months), "poor" prognosis (median OS2, 3.8 months; P < 0.001). CONCLUSIONS Among patients with PAC, more than 50% receive SL therapy. Our prognostic model identifies 3 subgroups and can identify patients with a maximum benefit of SL therapy.
Collapse
|
175
|
Engebretson A, Matrisian L, Thompson C. Patient and caregiver awareness of pancreatic cancer treatments and clinical trials. J Gastrointest Oncol 2016; 7:228-33. [PMID: 27034790 DOI: 10.3978/j.issn.2078-6891.2015.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The poor prognosis of pancreatic cancer has been well established. For many patients, active treatments can improve patient outcomes, such as overall survival and symptom control. Nevertheless, there is evidence that pancreatic cancer is undertreated, even in patients with resectable disease. In addition, although participation in a clinical trial is recommended by current pancreatic cancer treatment guidelines, recent data suggest that patient participation in ongoing trials is below overall target accrual. METHODS A survey was prepared and distributed to patients with pancreatic cancer and caregivers of patients with pancreatic cancer by the Pancreatic Cancer Action Network (funding for the survey was provided by Celgene Corporation). The 70-question survey was completed between July 30, 2013, and September 18, 2013, by respondents in the United States. The goal of this analysis was to evaluate patient and caregiver interactions with physicians about pancreatic cancer treatments and participation in clinical trials. RESULTS The survey was completed by 184 patients and 213 caregivers (not necessarily paired). Quality of life, extension of survival, and symptom management were identified as the most important concerns among both patients and caregivers. A large majority of respondents (94.9%) reported that the patient followed the physician's treatment recommendation. Approximately 30% of respondents indicated that the diagnosing physician offered treatment options at the time of diagnosis. Among the respondents who indicated that the physician did not offer treatment options at diagnosis, 20.4% stated that no doctor had ever spoken to them about treatment options. Most respondents (83.1%) reported that the patient received chemotherapy for pancreatic cancer. Approximately half of respondents (49.1%) indicated that they had never discussed clinical trials with a physician. Twelve percent of respondents reported that the patient participated in a clinical trial. In those cases, physicians were listed as the primary source of trial information 80.4% of the time. Familiarity with Patient Central (known as "Patient and Liaison Services" at the time of the study), a support service offered by the Pancreatic Cancer Action Network, was associated with higher rates of receiving treatment (P<0.05), searching the Internet for information on clinical trials (P<0.05), and participating in clinical trials (not statistically significant). CONCLUSIONS The results of this study suggest that large numbers of patients and caregivers had never had discussions with physicians about pancreatic cancer treatments or clinical trials. The point about trials takes on even greater importance, considering that patients who participate in clinical trials report better outcomes than those receiving the same treatment outside of clinical trials. Increased discussions with patients could potentially increase treatment and trial participation, possibly improving patient- and caregiver-stated priorities of quality of life, extension of survival, and symptom management.
Collapse
Affiliation(s)
- Anitra Engebretson
- 1 Pancreatic Cancer Action Network, Manhattan Beach, CA, USA ; 2 Pancreatic Cancer Action Network, Washington, DC, USA ; 3 Celgene Corporation, Summit, NJ, USA
| | - Lynn Matrisian
- 1 Pancreatic Cancer Action Network, Manhattan Beach, CA, USA ; 2 Pancreatic Cancer Action Network, Washington, DC, USA ; 3 Celgene Corporation, Summit, NJ, USA
| | - Cara Thompson
- 1 Pancreatic Cancer Action Network, Manhattan Beach, CA, USA ; 2 Pancreatic Cancer Action Network, Washington, DC, USA ; 3 Celgene Corporation, Summit, NJ, USA
| |
Collapse
|
176
|
Lee JC, Ahn S, Paik KH, Kim HW, Kang J, Kim J, Hwang JH. Clinical impact of neoadjuvant treatment in resectable pancreatic cancer: a systematic review and meta-analysis protocol. BMJ Open 2016; 6:e010491. [PMID: 27016245 PMCID: PMC4809107 DOI: 10.1136/bmjopen-2015-010491] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/15/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Although the only curative strategy for pancreatic cancer is surgical resection, up to 85% of patients relapse after surgery. The efficacy of neoadjuvant treatment in resectable pancreatic cancer (RPC) remains unclear and there is no systematic review focusing fully on this issue. Recently, two prospective trials of neoadjuvant treatment in RPC were terminated early because of slow recruiting and existing randomised controlled trials (RCTs) have too small sample sizes. Therefore, to overcome probable biases, it would be more reasonable to include both RCTs and non-randomised studies (NRSs) with selected criteria. This review aims to investigate the effect of neoadjuvant chemotherapy (CTx) and chemoradiation therapy (CRT) in RPC using RCTs and specific NRSs. METHOD AND ANALYSIS This systematic review will include conventional RCTs as group I, and quasi-randomised controlled trials, non-randomised controlled trials and prospective cohort studies as group II. Two groups will be assessed and analysed separately. Comprehensive literature search will use Medline, Embase, Cochrane library and Scopus databases. Additionally, we will search references from relevant studies and abstracts from major conferences. Two authors will independently identify, screen, include studies, extract data and assess the risk of bias. Discrepancies will be resolved by consensus with another author. An independent methodologist will categorise and assess NRSs to minimise heterogeneity. In each study group, meta-analysis will be conducted using a random-effect model and statistical heterogeneity will be evaluated using I(2)-statistics. Publication bias will be visualised with contour-enhanced funnel plots and analysed with Egger's test. In group I, cumulative meta-analysis will be considered because the CTx regimen and CRT protocol have changed. The quality of evidence will be summarised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. ETHICS AND DISSEMINATION This review does not use primary data, and formal ethical approval is not required. Findings will be disseminated through peer-reviewed journals and committee conferences. TRIAL REGISTRATION NUMBER CRD42015023820.
Collapse
Affiliation(s)
- Jong-chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soyeon Ahn
- Department of Biostatistics, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyu-hyun Paik
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyoung Woo Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jingu Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
177
|
Sinn M, Bahra M, Denecke T, Travis S, Pelzer U, Riess H. Perioperative treatment options in resectable pancreatic cancer - how to improve long-term survival. World J Gastrointest Oncol 2016; 8:248-57. [PMID: 26989460 PMCID: PMC4789610 DOI: 10.4251/wjgo.v8.i3.248] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Surgery remains the only chance of cure for pancreatic cancer, but only 15%-25% of patients present with resectable disease at the time of primary diagnosis. Important goals in clinical research must therefore be to allow early detection with suitable diagnostic procedures, to further broaden operation techniques and to determine the most effective perioperative treatment of either chemotherapy and/or radiation therapy. More extensive operations involving extended pancreatectomy, portal vein resection and pancreatic resection in resectable pancreatic cancer with limited liver metastasis, performed in specialized centers seem to be the surgical procedures with a possible impact on survival. After many years of stagnation in pharmacological clinical research on advanced pancreatic ductal adenocarcinomas (PDAC) - since the approval of gemcitabine in 1997 - more effective cytotoxic substances (nab-paclitaxel) and combinations (FOLFIRINOX) are now available for perioperative treatment. Additionally, therapies with a broader mechanism of action are emerging (stroma depletion, immunotherapy, anti-inflammation), raising hopes for more effective adjuvant and neoadjuvant treatment concepts, especially in the context of "borderline resectability". Only multidisciplinary approaches including radiology, surgery, medical and radiation oncology as the backbones of the treatment of potentially resectable PDAC may be able to further improve the rate of cure in the future.
Collapse
|
178
|
Hackert T, Ulrich A, Büchler MW. Borderline resectable pancreatic cancer. Cancer Lett 2016; 375:231-237. [PMID: 26970276 DOI: 10.1016/j.canlet.2016.02.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023]
Abstract
Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20-25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications. The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.
Collapse
Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
| |
Collapse
|
179
|
Lamarca A, Asselin MC, Manoharan P, McNamara MG, Trigonis I, Hubner R, Saleem A, Valle JW. 18F-FLT PET imaging of cellular proliferation in pancreatic cancer. Crit Rev Oncol Hematol 2016; 99:158-69. [PMID: 26778585 DOI: 10.1016/j.critrevonc.2015.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/19/2015] [Accepted: 12/22/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is known for its poor prognosis. Since the development of computerized tomography, magnetic resonance and endoscopic ultrasound, novel imaging techniques have struggled to get established in the management of patients diagnosed with pancreatic adenocarcinoma for several reasons. Thus, imaging assessment of pancreatic cancer remains a field with scope for further improvement. In contrast to cross-sectional anatomical imaging methods, molecular imaging modalities such as positron emission tomography (PET) can provide information on tumour function. Particularly, tumour proliferation may be assessed by measurement of intracellular thymidine kinase 1 (TK1) activity level using thymidine analogues radiolabelled with a positron emitter for use with PET. This approach, has been widely explored with [(18)F]-fluoro-3'-deoxy-3'-L-fluorothymidine ((18)F-FLT) PET. This manuscript reviews the rationale and physiology behind (18)F-FLT PET imaging, with special focus on pancreatic cancer and other gastrointestinal malignancies. Potential benefit and challenges of this imaging technique for diagnosis, staging and assessment of treatment response in abdominal malignancies are discussed.
Collapse
Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Marie-Claude Asselin
- University of Manchester Wolfson Molecular Imaging Centre (WMIC), Manchester, United Kingdom
| | - Prakash Manoharan
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; University of Manchester, Institute of Cancer Sciences, Manchester Academic Health Science Centre, Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ioannis Trigonis
- University of Manchester Wolfson Molecular Imaging Centre (WMIC), Manchester, United Kingdom
| | - Richard Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Azeem Saleem
- University of Manchester Wolfson Molecular Imaging Centre (WMIC), Manchester, United Kingdom; Imanova Centre for Imaging Sciences, Imperial College Hammersmith Hospital, Du Cane Road, London W12 0NN, United Kingdom
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; University of Manchester, Institute of Cancer Sciences, Manchester Academic Health Science Centre, Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| |
Collapse
|
180
|
Dyrla P, Lubas A, Gil J, Niemczyk S. Doppler tissue perfusion parameters in recognizing pancreatic malignant tumors. J Gastroenterol Hepatol 2016; 31:691-5. [PMID: 26455432 DOI: 10.1111/jgh.13193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Histopathology, radiological imaging methods with the administration of contrast agents are efficient to differentiate focal lesions of the pancreas. Invasiveness, contrast toxicity, and limited accessibility ameliorate their application. Noninvasive and contrast-agent-free method could improve diagnostics and accelerate treatment. AIMS The aim of the study is to evaluate the diagnostic properties of ultrasound parameters of organ perfusion in the detection of malignant tumors of the pancreas. METHODS Thirty-six patients with a focal lesion of the pancreas underwent endosonography with color flow imaging and biopsy for histological evaluation. Five patients were excluded because of the absence of the Doppler signal in pancreatic lesion. In the dynamic tissue perfusion measurement (DTPM) means of flow velocity (FV), resistive index, pulsatility index, and perfusion relief intensity (PR) were estimated. RESULTS In the group with malignant tumors FV was significantly lower compared with the group with inflammatory changes. In receiver operating characteristic (ROC) analysis FV below the optimal cut-off point of 2.382 cm/s identified patients with malignant lesions with a sensitivity of 92% and specificity of 90%. In the group with malignant tumors significantly lower values of PR in all considered percentiles were observed. Based on the ROC analysis in the group with solid tumors, it was found that PR25 ≤ 0.057 allowed to recognize malignancies with a sensitivity of 100% and specificity of 80%, and in the groups with solid and cystic tumors with a sensitivity of 100% and specificity of 79%. CONCLUSIONS FV and PR intensity derived from DTPM are reliable markers in recognition of pancreatic malignant masses.
Collapse
Affiliation(s)
- Przemysław Dyrla
- Department of Gastroenterology, Military Institute of Medicine, Warsaw, Poland
| | - Arkadiusz Lubas
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| | - Jerzy Gil
- Department of Gastroenterology, Military Institute of Medicine, Warsaw, Poland
| | - Stanisław Niemczyk
- Department of Internal Medicine, Nephrology and Dialysis, Military Institute of Medicine, Warsaw, Poland
| |
Collapse
|
181
|
Creutzfeldt A, Suling A, Oechsle K, Mehnert A, Atanackovic D, Kripp M, Arnold D, Stein A, Quidde J. Integrating patient reported measures as predictive parameters into decisionmaking about palliative chemotherapy: a pilot study. BMC Palliat Care 2016; 15:25. [PMID: 26928745 PMCID: PMC4772352 DOI: 10.1186/s12904-016-0101-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 02/25/2016] [Indexed: 12/19/2022] Open
Abstract
Background Systemic treatment has proven to improve physical symptoms in patients with advanced cancer. Relationship between quality of life (QoL) or symptom burden (SYB) and treatment efficacy (tumour response and survival) is poorly described. Therefore, we evaluated the predictive value of pretreatment QoL and SYB on treatment outcomes. Methods Eligible patients had metastatic gastrointestinal cancers and were about to receive 1st/2nd line palliative chemotherapy. 47 patients were consecutively enrolled. QoL and SYB were assessed by EORTC QLQ-C30 and MSKCC MSAS questionnaires before treatment and after first response evaluation after 8–12 weeks. Logistic regression analysis of QoL and SYB for prediction of objective treatment efficacy was performed. Patients were categorized according to response rate (RR) based on RECIST1.1 and progression free survival (PFS). PFS was categorized by a ratio (individual PFS/expected PFS) in above median (ratio ≥ 1) or below median PFS (ratio < 1). QoL and SYB were analysed for RR groups (partial response, stable or progressive disease) and PFS ratio (PFSR). Results Objective response to chemotherapy and increase in PFS were associated with better pretreatment QoL and less SYB. Patients with future objective treatment efficacy (PFSR ≥ 1) evidenced clinically relevant better role/emotional/cognitive/social functioning and less fatigue and appetite loss at baseline in comparison to PFSR < 1 (>10 points difference). Lowest scores in all functioning scales at treatment start were seen in patients with future PFSR < 1. Global health status (EORTC), PSYCH subscale and global distress index (MSAS) predicted PFSR, even if adjusted for gender, age, cancer type, ECOG and line of treatment (p < 0.05). Interestingly, improved QoL and SYB (subjective benefit) were noted even in patients with worse pretreatment status and no objective tumour response. Conclusion Future non-responders seem to show distinct QoL patterns before chemotherapy. This may facilitate early detection of patients deriving less or even no benefit from treatment regarding prolongation of survival. Even in patients with primarily progressive disease QoL and SYB may improve during treatment. Integration of QoL and SYB assessment into decision-making about palliative chemotherapy seem to be an important approach to improve patient outcome and should be further evaluated.
Collapse
Affiliation(s)
- Anna Creutzfeldt
- Department of Oncology, Hematology, BMT with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumour Center - University Cancer Center Hamburg, Martinistr. 52, 20246, Hamburg, Germany.
| | - Anna Suling
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karin Oechsle
- Department of Oncology, Hematology, BMT with Section Pneumology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anja Mehnert
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - Djordje Atanackovic
- Department of Oncology, Hematology, BMT with Section Pneumology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Melanie Kripp
- Department of Oncology/Hematology, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Dirk Arnold
- Tumour Biology Center Freiburg, Breisacher Straße 117, 79106, Freiburg, Germany
| | - Alexander Stein
- Department of Oncology, Hematology, BMT with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumour Center - University Cancer Center Hamburg, Martinistr. 52, 20246, Hamburg, Germany
| | - Julia Quidde
- Department of Oncology, Hematology, BMT with Section Pneumology, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumour Center - University Cancer Center Hamburg, Martinistr. 52, 20246, Hamburg, Germany
| |
Collapse
|
182
|
Ambrosetti MC, Zamboni GA, Mucelli RP. Distribution of liver metastases based on the site of primary pancreatic carcinoma. Eur Radiol 2016; 26:306-10. [PMID: 26017740 DOI: 10.1007/s00330-015-3843-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 05/04/2015] [Accepted: 05/11/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate whether the different location of pancreatic adenocarcinoma affects the lobar distribution of metastases to the liver. METHODS From all patients who underwent multidetector computed tomography (MDCT) examinations for staging of pancreatic adenocarcinoma in the last 4 years we selected 80 patients (42 men, 38 women; mean age, 60.56 years) with liver metastases and a pancreatic adenocarcinoma of the head (group A, 40 patients; diameter, 32.41 ± 2.28 mm) or body-tail (group B, 40 patients; diameter, 52.21 ± 2.8 mm). We analysed tumour site, diameter, vascular invasion and number of metastases in each lobe of the liver. The total number of metastases was compared between the two groups with an unpaired t-test, while Fisher's test was used to compare the number of metastases within the two lobes. RESULTS As expected, the number of liver metastases was higher in group B than in group A. The ratio of metastases in the right-to-left hemi-liver was 7.4:1 for group A compared with 3.3:1 for group B (p < 0.0001). CONCLUSIONS Although the number of liver metastases is higher in the right lobe than in the left lobe in both groups, there is a significant difference in the ratio of metastases between the right and the left hemi-liver. This supports the existence of a streamline phenomenon and a selective lobar distribution of metastases within the liver. KEY POINTS • Pancreatic adenocarcinoma presents with liver metastases in 40% of cases • The presence of liver metastases disqualifies the patient from curative surgery • The distribution of metastases within the liver depends on the site of pancreatic adenocarcinoma • The distribution of liver metastases is due to the streamline phenomenon.
Collapse
Affiliation(s)
- Maria Chiara Ambrosetti
- Istituto di Radiologia, Policlinico GB Rossi, Azienda Ospedaliera Universitaria Integrata di Verona, P. le LA Scuro 10, 37134, Verona, Italy.
| | - Giulia A Zamboni
- Istituto di Radiologia, Policlinico GB Rossi, Azienda Ospedaliera Universitaria Integrata di Verona, P. le LA Scuro 10, 37134, Verona, Italy
| | - Roberto Pozzi Mucelli
- Istituto di Radiologia, Policlinico GB Rossi, Azienda Ospedaliera Universitaria Integrata di Verona, P. le LA Scuro 10, 37134, Verona, Italy
| |
Collapse
|
183
|
Burmeister EA, Jordan SJ, O'Connell DL, Beesley VL, Goldstein D, Gooden HM, Janda M, Merrett ND, Wyld D, Neale RE. Using a Delphi process to determine optimal care for patients with pancreatic cancer. Asia Pac J Clin Oncol 2016; 12:105-14. [PMID: 26800012 DOI: 10.1111/ajco.12450] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/07/2015] [Accepted: 11/23/2015] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Dianne L O'Connell
- Cancer Council NSW
- University of Newcastle
- University of New South Wales
- University of Sydney
| | | | | | | | | | - Neil D Merrett
- University of Western Sydney
- Bankstown Hospital; NSW Australia
| | - David Wyld
- Royal Brisbane and Women's Hospital; Brisbane
- School of Medicine; University of Queensland; Queensland
| | | | | |
Collapse
|
184
|
Singh T, Chaudhary A. Improving Survival of Pancreatic Cancer. What Have We Learnt? Indian J Surg 2016; 77:436-45. [PMID: 26722209 DOI: 10.1007/s12262-015-1368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022] Open
Abstract
Pancreatic adenocarcinoma still ranks high among cancer-related deaths worldwide. In spite of substantial strides in preoperative staging, surgery, perioperative care, and adjuvant treatment, the survival still remains dismal. A number of patient-, disease-, and surgeon-related factors play a role in deciding the eventual outcome of the patient. The aim of this commentary is to review the current knowledge of various factors and the recent advances that impact the survival of patients with pancreatic adenocarcinoma. A search of scientific literature using Embase and MEDLINE, for the years 1985-2015, was carried out for search terms "pancreatic cancer" and "survival." Further search was based on the various specific prognostic factors that contribute towards survival of patients with pancreatic cancer found in the literature. Most of the studies used for this review include those that deal with pancreatic head cancers, some include patients with pancreatic cancers in all locations while very few included patients with tumors of body and tail only. In spite of significant developments in pre- and perioperative management, increased rates of margin-negative resections, and use of adjuvant treatment, the survival rates of pancreatic cancer patients remains poor. A paradigm shift with more effective adjuvant regimen and genetic interventions may help change the outcomes of patients with pancreatic cancer.
Collapse
Affiliation(s)
- Tanveer Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Medanta, The Medicity Hospital, Gurgaon, 122001 India
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Medanta, The Medicity Hospital, Gurgaon, 122001 India
| |
Collapse
|
185
|
Management of Advanced Pancreatic Cancer in Daily Clinical Practice. TUMORI JOURNAL 2016; 102:51-8. [DOI: 10.5301/tj.5000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 11/20/2022]
Abstract
Purpose The aim of this outcome study was to evaluate the management of advanced pancreatic cancer in a real-world clinical practice; few such experiences have been reported in the literature. Methods A retrospective analysis was performed of all consecutive patients with advanced pancreatic ductal adenocarcinoma followed at our medical oncology unit between January 2003 and December 2013. Results We evaluated 78 patients, mostly with metastatic disease (64.1%). Median follow-up was 10.77 months, by which time 74 patients (94.9%) had died. Median overall survival was 8.29 months. Median age was 67 years. In univariate analysis, pain at onset (p = 0.020), ECOG performance status (p<0.001), stage (p = 0.047), first-line chemotherapy (p<0.001), second-line chemotherapy (p<0.001) and weight loss at diagnosis (p = 0.029) were factors that had an impact on overall survival. In multivariate analysis, the presence of pain at onset (p = 0.043), stage (p = 0.003) and second-line chemotherapy (p = 0.004) were confirmed as independent prognostic factors. Conclusions Our data, derived from daily clinical practice, confirmed advanced pancreatic cancer as an aggressive malignant disease with a very short expected survival. Second-line treatment seems to provide an advantage in terms of overall survival in patients who showed a partial response as their best response to first-line treatment.
Collapse
|
186
|
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
|
187
|
Brunet LR, Hagemann T, Andrew G, Mudan S, Marabelle A. Have lessons from past failures brought us closer to the success of immunotherapy in metastatic pancreatic cancer? Oncoimmunology 2015; 5:e1112942. [PMID: 27141395 PMCID: PMC4839322 DOI: 10.1080/2162402x.2015.1112942] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is extremely resistant to chemo- and radiation-therapies due to its inherent genetic instability, the local immunosuppressive microenvironment and the remarkable desmoplastic stromal changes which characterize this cancer. Therefore, there is an urgent need for improvement on standard current therapeutic options. Immunotherapies aimed at harnessing endogenous antitumor immunity have shown promise in multiple tumor types. In this review, we give an overview of new immune-related therapeutic strategies currently being tested in clinical trials in pancreatic cancer. We propose that immunotherapeutic strategies in combination with current therapies may offer new hopes in this most deadly disease.
Collapse
Affiliation(s)
| | | | - Gayab Andrew
- Deparment of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust , London, UK
| | | | - Aurelien Marabelle
- INSERM, U1015, Villejuif, France; Center of Clinical Investigations in Biotherapies of Cancer (CICBT) 507, Villejuif, France; Drug Development Department, Gustave Roussy Cancer Campus, Villejuif, France
| |
Collapse
|
188
|
Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2015; 103:179-91. [PMID: 26663252 DOI: 10.1002/bjs.9969] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 08/27/2015] [Accepted: 09/15/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection. METHODS A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes. RESULTS Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results. CONCLUSION This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.
Collapse
Affiliation(s)
- F Giovinazzo
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - G Turri
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - M H Katz
- MD Anderson Cancer Center, Houston, Texas, USA
| | - N Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - I Ahmed
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| |
Collapse
|
189
|
Nagrial AM, Chin VT, Sjoquist KM, Pajic M, Horvath LG, Biankin AV, Yip D. Second-line treatment in inoperable pancreatic adenocarcinoma: A systematic review and synthesis of all clinical trials. Crit Rev Oncol Hematol 2015; 96:483-97. [PMID: 26481952 DOI: 10.1016/j.critrevonc.2015.07.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 05/23/2015] [Accepted: 07/16/2015] [Indexed: 12/14/2022] Open
Abstract
There remains uncertainty regarding the optimal second-line chemotherapy in advanced pancreatic ductal adenocarcinoma (PDAC). The current recommendation of 5-fluorouracil and oxaliplatin may not be relevant in current practice, as FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan and oxaliplatin) has become a more popular first line therapy in fit patients. The majority of studies in this setting are single-arm Phase II trials with significant heterogeneity of patient populations, treatments and outcomes. In this review, we sought to systematically review and synthesise all prospective data available for the second-line treatment of advanced PDAC.
Collapse
Affiliation(s)
- Adnan M Nagrial
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia.
| | - Venessa T Chin
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia
| | - Katrin M Sjoquist
- NHMRC Clinical Trials Centre, University of Sydney, NSW, Australia; Cancer Care Centre, St. George Hospital, Kogarah, NSW, Australia
| | - Marina Pajic
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; St. Vincents's Clinical School, Faculty of Medicine, University of NSW, Australia
| | - Lisa G Horvath
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW 2050, Australia
| | - Andrew V Biankin
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; The Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; Department of Surgery, Bankstown Hospital, Eldridge Road, Bankstown, Sydney, NSW 2200, Australia; South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Liverpool, NSW 2170, Australia; Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Glasgow G61 1BD, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, Scotland G4 0SF, UK
| | - Desmond Yip
- Department of Medical Oncology, The Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Acton, ACT, Australia
| |
Collapse
|
190
|
CA-125, but not galectin-3, complements CA 19-9 for discriminating ductal adenocarcinoma versus non-malignant pancreatic diseases. Pancreatology 2015; 16:115-20. [PMID: 26613889 DOI: 10.1016/j.pan.2015.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/27/2015] [Accepted: 10/29/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES CA 19-9 is the gold standard biomarker of pancreatic adenocarcinoma despite several weaknesses in particular a high rate of false positives or negatives. CA-125 corresponding to MUC16 and galectin-3, a lectin able to interact with mucin-associated carbohydrates, are tumor-associated proteins. We investigated whether combined measurement of CA 19-9, galectin-3 and CA-125 may help to better discriminate pancreatic adenocarcinoma versus non-malignant pancreatic diseases. METHODS We evaluated by immunohistochemistry the expression of MUC4, MUC16 (CA-125) and galectin-3 in 31 pancreatic adenocarcinomas. We measured CA 19-9, CA-125 and Gal-3 in the serum from patients with pancreatic benign diseases (n = 58) or adenocarcinoma (n = 44). Clinical performance of the 3 biomarkers for cancer diagnosis and prognosis was analyzed. RESULTS By immunohistochemistry, MUC16 and Gal-3 were expressed in 74% and 84% of adenocarcinomas versus 0% and 3.2% in peri-tumoral regions, respectively. At the serum level, CA 19-9 and CA125 were significantly higher in patients with pancreatic adenocarcinoma whereas Gal-3 levels did not differ. The performance of CA 19-9 for cancer detection was higher than those of CA-125 or Gal-3 by ROC analysis. However, CA-125 offers the highest specificity for malignancy (81%) because of an absence of false positives among type 2 diabetic patients. Cancer deaths assessed 6 or 12 months after diagnosis varied according to the initial CA-125 level (p < 0.006). CONCLUSION Gal-3 is not an interesting biomarker for pancreatic adenocarcinoma detection. CA 19-9 alone exhibits the best performance but measuring CA-125 provides complementary information in terms of diagnosis and prognosis.
Collapse
|
191
|
Zijlstra M, Bernards N, de Hingh IHJT, van de Wouw AJ, Goey SH, Jacobs EMG, Lemmens VEPP, Creemers GJ. Does long-term survival exist in pancreatic adenocarcinoma? Acta Oncol 2015; 55:259-64. [PMID: 26559995 DOI: 10.3109/0284186x.2015.1096020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND We conducted a population-based study to investigate long-term survival in patients diagnosed with a (suspected) pancreatic adenocarcinoma. METHODS All patients diagnosed with a pancreatic adenocarcinoma or with a pathologically unverified tumour of the pancreas between 1993 and 2008 in the South of the Netherlands were selected from the Netherlands Cancer Registry (NCR). Medical charts of patients who were alive five years or longer since diagnosis were reviewed. RESULTS A total of 2 564 patients were included, of whom 1 365 had a pancreatic adenocarcinoma and 1 199 had a pathologically unverified pancreatic tumour. Five-year survival of patients with pathologically verified adenocarcinomas was 1.7% (24 of 1 365 patients). Twenty-one-one of these 24 long-term survivors were among the 207 cases that underwent surgical resection as initial treatment; five-year survival after resection thus being 10.1%. Half of the long-term survivors who underwent surgical resection still eventually died of recurrent disease. Five-year survival among patients with clinically suspected but microscopically unverified pancreatic tumours was 1.3% (16 of 1 199 patients). In 15 of these 16 long-term survivors the initial clinical diagnosis was revised: 14 had benign disease and one a premalignant tumour. CONCLUSIONS Long-term survival among patients with pancreatic adenocarcinoma is extremely rare. As long-term survival in clinically suspected but pathologically unverified cancer is very unlikely, repeated fine needle aspiration or, preferably, histological biopsy is recommended in order to establish an alternative diagnosis in patients who survive longer than expected (more than 6-12 months).
Collapse
Affiliation(s)
- Myrte Zijlstra
- Department of Internal Medicine, Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nienke Bernards
- Department of Internal Medicine, Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
- The Netherlands Cancer Registry, Comprehensive Cancer Organization the Netherlands, Utrecht, The Netherlands
| | | | - Agnes J. van de Wouw
- Department of Internal Medicine, Medical Oncology, VieCuri Medical Center, Venlo, The Netherlands
| | - Swan Hoo Goey
- Department of Internal Medicine, Medical Oncology, TweeSteden Hospital, Tilburg, The Netherlands
| | - Esther M. G. Jacobs
- Department of Internal Medicine, Medical Oncology, Elkerliek Hospital, Helmond, The Netherlands
| | - Valery E. P. P. Lemmens
- The Netherlands Cancer Registry, Comprehensive Cancer Organization the Netherlands, Utrecht, The Netherlands
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Geert-Jan Creemers
- Department of Internal Medicine, Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| |
Collapse
|
192
|
Current State of Vascular Resections in Pancreatic Cancer Surgery. Gastroenterol Res Pract 2015; 2015:120207. [PMID: 26609306 PMCID: PMC4644845 DOI: 10.1155/2015/120207] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/05/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer (PDAC) is the fourth leading cause of cancer-related mortality in the Western world and, even in 2014, a therapeutic challenge. The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis. As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies. In contrast to adjuvant treatment which has to be regarded as a cornerstone to achieve long-term survival after resection, neoadjuvant treatment strategies for locally advanced findings are currently under debate. This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.
Collapse
|
193
|
Mayerle J, Beyer G, Simon P, Dickson EJ, Carter RC, Duthie F, Lerch MM, McKay CJ. Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions. Pancreatology 2015; 16:110-4. [PMID: 26602088 DOI: 10.1016/j.pan.2015.10.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA. PATIENTS AND METHODS This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome. RESULTS 91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison. CONCLUSION Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.
Collapse
Affiliation(s)
- J Mayerle
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany.
| | - G Beyer
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - P Simon
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - E J Dickson
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - R C Carter
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - F Duthie
- Department of Pathology, Southern General Hospital, Glasgow, United Kingdom
| | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Ernst-Moritz-Arndt-University Greifswald, Germany
| | - C J McKay
- Lister Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom
| |
Collapse
|
194
|
Martinez-Useros J, Georgiev-Hristov T, Borrero-Palacios A, Fernandez-Aceñero MJ, Rodríguez-Remírez M, Del Puerto-Nevado L, Cebrian A, Gomez Del Pulgar MT, Cazorla A, Vega-Bravo R, Perez N, Celdran A, Garcia-Foncillas J. Identification of Poor-outcome Biliopancreatic Carcinoma Patients With Two-marker Signature Based on ATF6α and p-p38 "STARD Compliant". Medicine (Baltimore) 2015; 94:e1972. [PMID: 26559273 PMCID: PMC4912267 DOI: 10.1097/md.0000000000001972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Biliopancreatic cancer is one of the most aggressive solid neoplasms, and incidence is rising worldwide. It is known that ATF6α is one of the transmembrane proteins that acts crucially in endoplasmic reticulum stress response, and knockdown induces apoptosis of pancreatic cells. Apart from this, p-p38 has been previously correlated with better outcome in pancreatic cancer. Interestingly, ATF6α knockdown pancreatic cells showed increased p-p38. The aim of this study was to evaluate the expression of these 2 proteins, p-p38 and ATF6α, and their correlation with the outcome of biliopancreatic adenocarcinoma patients. Samples from patients with biliopancreatic adenocarcinoma that underwent pancreaticoduodenectomy from 2007 to 2013 were used to construct a tissue microarray to evaluate p-p38 and ATF6α proteins by immunohistochemistry. We observed that both markers showed a tendency to impact in the time to recurrence; then a combination of these 2 proteins was analyzed. Combination of ATF6α(high) and p-p38(low) was strongly associated with a higher risk of recurrence (hazard ratio 2.918, P = 0.013). This 2-protein model remained significant after multivariate adjustment.We proposed a 2-protein signature based on ATF6α(high) and p-p38(low) as a potential biomarker of risk of recurrence in resected biliopancreatic adenocarcinoma patients.
Collapse
Affiliation(s)
- J Martinez-Useros
- From the Translational Oncology Division, OncoHealth Institute, University Hospital Fundacion Jimenez Diaz (JM-U, AB-P, MR-R, L.P-N, AC, MTGP, JG-F); Hepatobiliary and Pancreatic Surgery Unit, General and Digestive Tract Surgery Department, University Hospital Fundacion Jimenez Diaz (TG-H, AC); Department of Pathology, University Hospital Clinico San Carlos (MJF-A); and Department of Pathology, University Hospital Fundacion Jimenez Diaz, Madrid, Spain (AC, RV-B, NP)
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
195
|
Vogel A, Kullmann F, Kunzmann V, Al-Batran SE, Oettle H, Plentz R, Siveke J, Springfeld C, Riess H. Patients with Advanced Pancreatic Cancer and Hyperbilirubinaemia: Review and German Expert Opinion on Treatment with nab-Paclitaxel plus Gemcitabine. Oncol Res Treat 2015; 38:596-603. [PMID: 26599274 DOI: 10.1159/000441310] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/28/2015] [Indexed: 11/19/2022]
Abstract
In patients with advanced unresectable pancreatic cancer, the prognosis is generally poor. Within recent years, new treatment options such as the FOLFIRINOX regimen (5-fluorouracil, leucovorin, irinotecan and oxaliplatin) or the combination of nanoparticle albumin-bound (nab)-paclitaxel plus gemcitabine have shown a clinically relevant survival benefit over the standard gemcitabine in patients with good performance status. Unfortunately, patients with hyperbilirubinaemia, who constitute a substantial proportion of the pancreatic cancer patients, have been excluded from most clinical studies. Consequently, our knowledge on the appropriate medical treatment of this patient group is limited. In a meeting of German medical oncology experts, the available clinical evidence and own clinical experience regarding the management of patients with advanced pancreatic cancer and hyperbilirubinaemia was discussed. The present publication summarises the discussion outcomes with regard to appropriate management of these patients, including consensus-based recommendations for nab-paclitaxel/gemcitabine treatment, according to the best available evidence. In summary, knowledge of the underlying aetiology of hyperbilirubinaemia and the metabolisation routes of the cytotoxic drugs is crucial before initiating chemotherapy. As effective treatment options should also be made available to patients with comorbid conditions, including hyperbilirubinaemia, the experts provide advice for an initial dose reduction of chemotherapy with nab-paclitaxel/gemcitabine based on the total bilirubin level in patients with biliary obstruction or extensive liver metastasis.
Collapse
Affiliation(s)
- Arndt Vogel
- Klinik fx00FC;r Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
196
|
Korkeila EA. Advanced pancreatic cancer - how to choose an adequate treatment option. World J Gastroenterol 2015; 21:10709-10713. [PMID: 26478662 PMCID: PMC4600572 DOI: 10.3748/wjg.v21.i38.10709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 05/26/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
The prognosis of pancreatic adenocarcinoma is poor, making it one of the leading causes of cancer-related death. The 5-year overall survival rate remains below 5% and little progress is made during the past decade. Only about 10%-20% of patients are eligible for curative-intent surgery and the majority end up having recurring disease even after radical surgery and postoperative adjuvant chemotherapy. Chemotherapy in metastatic disease is palliative at best, aiming at disease and symptom control and prolongation of life. Treatment always causes side effects, the degree of which varies from patient to patient, depending on the patient’s general condition, concomitant morbidities as well as on the chosen treatment modality. Why is pancreatic cancer so resistant to treatment? How to best help the patient to reach the set treatment goals?
Collapse
|
197
|
Brieau B, Barret M, Rouquette A, Dréanic J, Brezault C, Regnard JF, Coriat R. Resection of Late Pulmonary Metastases from Pancreatic Adenocarcinoma: Is Surgery an Option? Cancer Invest 2015; 33:522-5. [PMID: 26461032 DOI: 10.3109/07357907.2015.1080831] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with recurrences from pancreas adenocarcinoma have a poor survival rate despite new chemotherapy treatment options. Recurrences are mainly hepatic metastases or peritoneal dissemination and surgical treatment is not recommended. Late and single metachronous pulmonary recurrences are uncommon and may mimic primary lung carcinoma. We report two patients with late and unique pulmonary metastasis from pancreatic cancer. These two patients underwent surgical resection; three and five years later, they did not experience recurrences. Cases called for a surgical approach in late and unique pulmonary metastases from pancreatic cancer, and paved the way for a prolonged chemotherapy free period.
Collapse
Affiliation(s)
- Bertrand Brieau
- a Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Maximilien Barret
- a Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Alexandre Rouquette
- b Pathology Department, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Johann Dréanic
- a Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Catherine Brezault
- a Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Jean François Regnard
- c Department of Thoracic Surgery, Cochin Teaching Hospital , Paris Descartes University , Paris , France
| | - Romain Coriat
- a Department of Gastroenterology and Digestive Oncology, Cochin Teaching Hospital , Paris Descartes University , Paris , France
- d U-1016 INSERM, Paris Descartes University , Paris , France
| |
Collapse
|
198
|
Abstract
OBJECTIVE Smoking may affect pharmacokinetics of chemotherapeutic agents and hemodynamics of the smokers, thereby influencing adverse events and efficacy of chemotherapy in patients with pancreatic cancer (PC). The aim of this study was to clarify how smoking totally affected patients with PC receiving current chemotherapy. METHODS We evaluated the impact of smoking status on the performance of chemotherapy and survival in 262 patients with PC including 158 resectable and 104 unresectable PC. RESULTS There were more male and younger patients in current smokers than in nonsmokers. In unresectable PC, current smokers had more metastatic tumors than locally advanced tumors compared with nonsmokers. In current smokers receiving chemotherapy, the baseline white blood cell count, neutrophil count, and hemoglobin concentration were significantly higher in current smokers than in nonsmokers. Furthermore, grades 3 to 4 neutropenia was observed more often in nonsmokers than smokers. On the other hand, the performance and efficacy of the planned adjuvant chemotherapy were similar between smokers and nonsmokers. More importantly, there was no significant difference in overall prognosis between smokers and nonsmokers receiving chemotherapy. CONCLUSIONS Smoking status has no significant impact on the efficacy of current chemotherapy for both resectable and unresectable PC.
Collapse
|
199
|
Lepage C, Capocaccia R, Hackl M, Lemmens V, Molina E, Pierannunzio D, Sant M, Trama A, Faivre J, Zielonke N, Oberaigner W, Van Eycken E, Henau K, Valerianova Z, Dimitrova N, Sekerija M, Zvolský M, Dušek L, Storm H, Engholm G, Mägi M, Aareleid T, Malila N, Seppä K, Velten M, Troussard X, Bouvier V, Launoy G, Guizard A, Faivre J, Bouvier A, Arveux P, Maynadié M, Woronoff A, Robaszkiewicz M, Baldi I, Monnereau A, Tretarre B, Bossard N, Belot A, Colonna M, Molinié F, Bara S, Schvartz C, Lapôtre-Ledoux B, Grosclaude P, Meyer M, Stabenow R, Luttmann S, Eberle A, Brenner H, Nennecke A, Engel J, Schubert-Fritschle G, Kieschke J, Heidrich J, Holleczek B, Katalinic A, Jónasson J, Tryggvadóttir L, Comber H, Mazzoleni G, Bulatko A, Buzzoni C, Giacomin A, Sutera Sardo A, Mancuso P, Ferretti S, Crocetti E, Caldarella A, Gatta G, Sant M, Amash H, Amati C, Baili P, Berrino F, Bonfarnuzzo S, Botta L, Di Salvo F, Foschi R, Margutti C, Meneghini E, Minicozzi P, Trama A, Serraino D, Dal Maso L, De Angelis R, Caldora M, Capocaccia R, Carrani E, Francisci S, Mallone S, Pierannunzio D, Roazzi P, Rossi S, Santaquilani M, Tavilla A, Pannozzo F, Busco S, Bonelli L, Vercelli M, Gennaro V, Ricci P, Autelitano M, Randi G, Ponz De Leon M, Marchesi C, Cirilli C, Fusco M, Vitale M, Usala M, Traina A, Staiti R, Vitale F, Ravazzolo B, Michiara M, Tumino R, Giorgi Rossi P, Di Felice E, Falcini F, Iannelli A, Sechi O, Cesaraccio R, Piffer S, Madeddu A, Tisano F, Maspero S, Fanetti A, Zanetti R, Rosso S, Candela P, Scuderi T, Stracci F, Bianconi F, Tagliabue G, Contiero P, Dei Tos A, Guzzinati S, Pildava S, Smailyte G, Calleja N, Agius D, Johannesen T, Rachtan J, Gózdz S, Mezyk R, Blaszczyk J, Bebenek M, Bielska-Lasota M, Forjaz de Lacerda G, Bento M, Castro C, Miranda A, Mayer-da-Silva A, Nicula F, Coza D, Safaei Diba C, Primic-Zakelj M, Almar E, Ramírez C, Errezola M, Bidaurrazaga J, Torrella-Ramos A, Díaz García J, Jimenez-Chillaron R, Marcos-Gragera R, Izquierdo Font A, Sanchez M, Chang D, Navarro C, Chirlaque M, Moreno-Iribas C, Ardanaz E, Galceran J, Carulla M, Lambe M, Khan S, Mousavi M, Bouchardy C, Usel M, Ess S, Frick H, Lorez M, Ess S, Herrmann C, Bordoni A, Spitale A, Konzelmann I, Visser O, van der Geest L, Otter R, Coleman M, Allemani C, Rachet B, Verne J, Easey N, Lawrence G, Moran T, Rashbass J, Roche M, Wilkinson J, Gavin A, Donnelly C, Brewster D, Huws D, White C. Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5. Eur J Cancer 2015; 51:2169-2178. [PMID: 26421820 DOI: 10.1016/j.ejca.2015.07.034] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 07/10/2015] [Accepted: 07/20/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival. METHODS This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach. RESULTS The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers. CONCLUSIONS The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.
Collapse
Affiliation(s)
- Côme Lepage
- Burgundy Cancer Registry, INSERM U866, Dijon, France; Department of Gastroenterology, University Hospital, Dijon, France; Burgundy University, Dijon, France.
| | | | - Monika Hackl
- Bundesanstalt statistical Osterreich, Vienna, Austria
| | - Valerie Lemmens
- Departement of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Esther Molina
- Escuela Andaluza de Salud Peblica, Insituto de Investigation biosanitaria, Hospitales Universitarios Universidad Granada, Spain
| | | | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Annalisa Trama
- Evaluative Epidemiology Unit, Department of Preventive and Predictive medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy
| | - Jean Faivre
- Burgundy Cancer Registry, INSERM U866, Dijon, France; Department of Gastroenterology, University Hospital, Dijon, France; Burgundy University, Dijon, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
200
|
Hurwitz HI, Uppal N, Wagner SA, Bendell JC, Beck JT, Wade SM, Nemunaitis JJ, Stella PJ, Pipas JM, Wainberg ZA, Manges R, Garrett WM, Hunter DS, Clark J, Leopold L, Sandor V, Levy RS. Randomized, Double-Blind, Phase II Study of Ruxolitinib or Placebo in Combination With Capecitabine in Patients With Metastatic Pancreatic Cancer for Whom Therapy With Gemcitabine Has Failed. J Clin Oncol 2015; 33:4039-47. [PMID: 26351344 DOI: 10.1200/jco.2015.61.4578] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Patients with advanced pancreatic adenocarcinoma have a poor prognosis and limited second-line treatment options. Evidence suggests a role for the Janus kinase (JAK)/signal transducer and activator of transcription pathway in the pathogenesis and clinical course of pancreatic cancer. PATIENTS AND METHODS In this double-blind, phase II study, patients with metastatic pancreatic cancer who had experienced treatment failure with gemcitabine were randomly assigned 1:1 to the JAK1/JAK2 inhibitor ruxolitinib (15 mg twice daily) plus capecitabine (1,000 mg/m(2) twice daily) or placebo plus capecitabine. The primary end point was overall survival (OS); secondary end points included progression-free survival, clinical benefit response, objective response rate, and safety. Prespecified subgroup analyses evaluated treatment heterogeneity and efficacy in patients with evidence of inflammation. RESULTS In the intent-to-treat population (ruxolitinib, n = 64; placebo, n = 63), the hazard ratio was 0.79 (95% CI, 0.53 to 1.18; P = .25) for OS and was 0.75 (95% CI, 0.52 to 1.10; P = .14) for progression-free survival. In a prespecified subgroup analysis of patients with inflammation, defined by serum C-reactive protein levels greater than the study population median (ie, 13 mg/L), OS was significantly greater with ruxolitinib than with placebo (hazard ratio, 0.47; 95% CI, 0.26 to 0.85; P = .011). Prolonged survival in this subgroup was supported by post hoc analyses of OS that categorized patients by the modified Glasgow Prognostic Score, a systemic inflammation-based prognostic system. Grade 3 or greater adverse events were observed with similar frequency in the ruxolitinib (74.6%) and placebo (81.7%) groups. Grade 3 or greater anemia was more frequent with ruxolitinib (15.3%; placebo, 1.7%). CONCLUSION Ruxolitinib plus capecitabine was generally well tolerated and may improve survival in patients with metastatic pancreatic cancer and evidence of systemic inflammation.
Collapse
Affiliation(s)
- Herbert I Hurwitz
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE.
| | - Nikhil Uppal
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Stephanie A Wagner
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Johanna C Bendell
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - J Thaddeus Beck
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Seaborn M Wade
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - John J Nemunaitis
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Philip J Stella
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - J Marc Pipas
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Zev A Wainberg
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Robert Manges
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - William M Garrett
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Deborah S Hunter
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Jason Clark
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Lance Leopold
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Victor Sandor
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| | - Richard S Levy
- Herbert I. Hurwitz, Duke University Medical Center, Durham, NC; Nikhil Uppal, New York University Langone Arena Oncology, Lake Success, NY; Stephanie A. Wagner, Indiana University Melvin and Bren Simon Cancer Center; Robert Manges, Investigative Clinical Research of Indiana, Indianapolis, IN; Johanna C. Bendell, Sarah Cannon Research Institute, Nashville, TN; J. Thaddeus Beck, Highlands Oncology Group, Fayetteville, AR; Seaborn M. Wade III, Virginia Cancer Institute, Richmond, VA; John J. Nemunaitis, Mary Crowley Medical Research Center, Dallas, TX; Philip J. Stella, St Joseph Mercy Health System, Alexander Cancer Care Center, Ann Arbor, MI; J. Marc Pipas, Dartmouth Hitchcock Medical Center/Norris Cotton Cancer Center, Lebanon, NH; Zev A. Wainberg, University of California, Los Angeles, Los Angeles, CA; and William M. Garrett, Deborah S. Hunter, Jason Clark, Lance Leopold, Victor Sandor, and Richard S. Levy, Incyte Corporation, Wilmington, DE
| |
Collapse
|