Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study

Rapamycin-induced endothelial cell death and tumor vessel thrombosis potentiate cytotoxic therapy against pancreatic cancer

PURPOSE

Despite current chemotherapies, pancreatic cancer remains an uncontrollable, rapidly progressive disease. Here, we tested an approach combining a recently described antiangiogenic drug, rapamycin, with standard gemcitabine cytotoxic therapy on human pancreatic tumor growth.

EXPERIMENTAL DESIGN

Tumor growth was assessed in rapamycin and gemcitabine-treated nude mice orthotopically injected with metastatic L3.6pl human pancreatic cancer cells. H&E staining was performed on tumors, along with Ki67 staining for cell proliferation and immunohistochemical terminal deoxynucleotidyl transferase-mediated nick end labeling and CD31 analysis. Rapamycin-treated tumor vessels were also directly examined in dorsal skin-fold chambers for blood flow after thrombosis induction. Cell death in human umbilical vein endothelial cells was assessed by flow cytometry after annexin-V staining.

RESULTS

Rapamycin therapy alone inhibited tumor growth and metastasis more than gemcitabine, with remarkable long-term tumor control when the drugs were combined. Mechanistically, H&E analysis revealed tumor vessel endothelium damage and thrombosis with rapamycin treatment. Indeed, dorsal skin-fold chamber analysis of rapamycin-treated tumors showed an increased susceptibility of tumor-specific vessels to thrombosis. Furthermore, terminal deoxynucleotidyl transferase-mediated nick end labeling/CD31 double staining of orthotopic tumors demonstrated apoptotic endothelial cells with rapamycin treatment, which also occurred with human umbilical vein endothelial cells in vitro. In contrast, gemcitabine was not antiangiogenic and, despite its known cytotoxicity, did not reduce proliferation in orthotopic tumors; nevertheless, rapamycin did reduce tumor proliferation.

CONCLUSIONS

Our data suggest a novel mechanism whereby rapamycin targets pancreatic tumor endothelium for destruction and thrombosis. We propose that rapamycin-based vascular targeting not only reduces tumor vascularization, it decreases the number of proliferating tumor cells to be destroyed by gemcitabine, thus introducing a new, clinically feasible strategy against pancreatic cancer.

Comprehensive analysis of matrix metalloproteinase and tissue inhibitor expression in pancreatic cancer: increased expression of matrix metalloproteinase-7 predicts poor survival

PURPOSE

To enable the design of improved inhibitors of matrix metalloproteinases (MMPs) for the treatment of pancreatic cancer, the expression profiles of a range of MMPs and tissue inhibitors of MMPs (TIMPs) were determined.

EXPERIMENTAL DESIGN

Nine MMPs (MMPs 1-3, 7-9, 11, 12, and 14) and three TIMPs (TIMPs 1-3) were examined in up to 75 pancreatic ductal adenocarcinomas and 10 normal pancreata by immunohistochemistry. Eighteen additional pancreatic ductal adenocarcinomas and an additional eight normal pancreata were also analyzed by real-time reverse transcription-PCR and additionally for MMP-15.

RESULTS

There was increased expression by immunohistochemistry for MMPs 7, 8, 9, and 11 and TIMP-3 in pancreatic cancer compared with normal pancreas (P < 0.0001, 0.04, 0.0009, 0.005, and 0.0001, respectively). Real-time reverse transcription-PCR showed a significant increase in mRNA levels for MMP-11 in tumor tissue compared with normal pancreatic tissue (P = 0.0005) and also significantly reduced levels of MMP-15 (P = 0.0026). Univariate analysis revealed that survival was reduced by lymph node involvement (P = 0.0007) and increased expression of MMP-7 (P = 0.005) and (for the first time) MMP-11 (P = 0.02) but not reduced by tumor grade, tumor diameter, positive resection margins, adjuvant treatment, or expression of the remaining MMPs and TIMPs. On multivariate analysis, only MMP-7 predicted shortened survival (P < 0.05); however, increased MMP-11 expression was strongly associated with lymph node involvement (P = 0.0073).

CONCLUSIONS

We propose that the principle specificity for effective inhibitors of MMPs in pancreatic cancer should be for MMP-7 with secondary specificity against MMP-11. Moreover, these studies indicate that MMP-7 expression is a powerful independent prognostic indicator and potentially of considerable clinical value.

All-trans retinoic acid inhibits the cell proliferation but enhances the cell invasion through up-regulation of c-met in pancreatic cancer cells

All-trans retinoic acid (ATRA) inhibits proliferation of cancer. However, the effects of ATRA on scattering and invasion of pancreatic cancer cells remain unknown. Also, the effects of ATRA on c-Met expression in pancreatic cancer have never been addressed so far. The effects of ATRA on a pancreatic cancer cell line, Capan-1, were determined by proliferation assay, scattering assay and invasion assay. In addition, the expression of c-Met in pancreatic cancer cell lines treated with ATRA was investigated by real-time PCR and western blotting. The growth-inhibitory effect of ATRA was found when the cells were cultured with 5 microM ATRA for 3 days. In cell scattering assay, ATRA-treated pancreatic cancer cells were found to spread out from their colonies. In invasion assay, cells treated with ATRA invaded the matrigel more than vehicle-treated cells. The expression of c-Met was up-regulated both in the mRNA and protein levels after the treatment of ATRA. The highest expression was found at 48 h after the treatment. ATRA induced scattering and invasion of pancreatic cancer cells, although it inhibited proliferation of those cells. In addition, ATRA also increased the protein level of c-Met. These findings may indicate that the use of retinoic acid as an anti-cancer therapeutic drug needs some additional treatments to control cell invasion or scattering.

Laparoscopic assisted duodenopancreatectomy

BACKGROUND

In the past few years, minimally invasive therapy for pancreatic diseases has made significant strides but the role of laparoscopic pancreaticoduodenectomy is still controversial.

METHODS

Four patients with a mean age of 44 +/- 11 years were chosen for a laparoscopic pancreaticoduodenectomy. Pathological diagnoses were ductal adenocarcinoma in one, neuroendocrine tumor in two, and metastatic malignant melanoma in one.

RESULTS

The procedure was laparoscopically completed in all with a mean operating time, blood loss, and hospital stay of 416 +/- 77 min, 325 +/- 50 ml, and 12 +/- 2 days, respectively. There were no complications attributable to this surgery and there were no deaths. The average number of dissected lymph nodes was 26 +/- 17 (range 16-47). All the patients remained well at a median follow-up of 4.5 months (range 1-10).

CONCLUSIONS

It can be inferred from this small but successful experience that laparoscopic pancreaticoduodenectomy can be considered for the treatment of tumors of the pancreas or periampullary region.

Modern management of pancreatic carcinoma

Pancreatic cancer remains a fearsome disease. New insights into the molecular pathogenesis may influence choice of treatment modalities and provide avenues for novel therapeutic strategies for testing in the clinic. The survival rate of patients with all stages of disease is poor and clinical trials are appropriate alternatives for treatment and should be considered. Surgical resection, when possible, remains the primary treatment modality and can result in long-term cure. Less invasive techniques such as laparoscopy may reduce the rate of unnecessary laparotomies. The role of adjuvant therapy is re-emerging. Patients with unresectable and metastatic disease are incurable and optimal palliation is the goal. These patients may benefit from palliative bypass of biliary or duodenal obstruction if symptomatic. Pain associated with local tumour infiltration may be palliated with radiation, with or without chemotherapy, or with coeliac nerve blocks or local neurosurgical procedures. Chemotherapy with gemcitabine has modest objective response rates but has been shown to improve symptoms.

Cancer in the elderly: pancreatic cancer

Pancreatic cancer remains a devastating and difficult disease to diagnose and successfully treat. Its incidence increases with age, with 60% of patients being over the age of 65 at presentation. Due to the insidious nature and asymptomatic onset of pancreatic cancer approximately 85% of patients present with disseminated or locally advanced disease resulting in a very poor prognosis. In the past the elderly patient, who may be felt to be too frail for operative procedures or further therapy, may have missed out on optimal treatment. In this article we review the investigation and treatment of pancreatic cancer and examine current evidence with regard to pancreatic cancer in the elderly. The evidence suggests that surgical resection can be performed safely in patients who are fit for surgery in specialist centres but may require more intensive post-operative rehabilitation.

Conclusions from the European Study Group for Pancreatic Cancer adjuvant trial of chemoradiotherapy and chemotherapy for pancreatic cancer

Pancreatic ductal adenocarcinoma remains one of the most difficult cancers to treat. It is a tumor that tends to present late, and surgical resection is only possible in a minority of patients. After successful surgery, the prognosis is still relatively poor. Attempts at more radical pancreatic resections and extended lymphadenectomy, although feasible without excessive morbidity and mortality, have failed to produce any convincing improvement in survival. During the last few years, therefore, efforts have been directed toward the development of adjuvant therapies in an attempt to improve outcome. This article describes the main trials of adjuvant chemotherapy, chemoradiotherapy, and chemoradiotherapy with follow-on chemotherapy and presents the results of the European Study Group for Pancreatic Cancer (ESPAC) 1 trial and the status of the ESPAC 2 and 3 trials.

The HaP-T1 Syrian golden hamster pancreatic cancer model: cell implantation is better than tissue implantation

OBJECTIVES

Pancreatic cancer is characterized by a poor prognosis and an unsatisfactory response to conventional therapy. Appropriate experimental animal models that mimic the disease are essential to establish new therapies. The aim of this study was to compare homologous orthotopic cell implantation (OCI) and orthotopic tissue implantation (OTI) methods in the nitrosamine-derived HaP-T1 Syrian golden hamster pancreatic cancer model.

METHODS

Pancreatic tumors were induced in 32 Syrian hamsters by the OCI (n = 16) and OTI (n = 16) techniques. OTI and OCI subgroups (n = 4) were killed at 1, 2, 5, and 8 weeks post-implantation. Tumor uptake and growth and the rates of local invasion and metastases were compared at autopsy.

RESULTS

Tumor uptake was 100% by OCI and 88% by OTI. Induced pancreatic tumors were significantly larger in the OCI group (mean weight, 1.7 g vs. 0.26 g, P < 0.01.) The incidence of local invasion and rates of lymph node, liver, and peritoneal metastases were all significantly higher in the OCI group.

CONCLUSION

The OCI method is more effective than OTI in terms of tumor uptake. Tumor growth and the rates of local invasion and spontaneous metastases are higher with OCI than OTI. The OCI method is better than OTI and can contribute to the development of therapeutic strategies in pancreatic cancer research.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

Dual-phase 18F-fluoro-2-deoxy-D-glucose positron emission tomography as a prognostic parameter in patients with pancreatic cancer

PURPOSE

Recently, dual-phase 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) was shown to be useful in the differentiation between malignant and benign pancreatic lesions. The aim of this prospective study was to evaluate the value of dual-phase FDG-PET as a prognostic parameter in patients with pancreatic cancer.

METHODS

Sixty-five consecutive patients with pancreatic cancer underwent dual-phase FDG-PET. Standardised uptake values at 1 h (SUV1) and 2 h (SUV2) following the injection of FDG were determined, and the retention index (RI) was calculated by dividing the difference between SUV2 and SUV1 by SUV1. The prognostic value of SUV1, SUV2 and RI was analysed, along with the various clinical and biochemical parameters.

RESULTS

Multivariate analysis showed that only three factors had an independent association with longer patient survival: female gender (p<0.01), TNM stage I-III (p<0.05) and RI>10% (p<0.01). Neither SUV1 nor SUV2 showed any prognostic significance. Combination of tumour stage and RI allowed more accurate prognostic evaluation. Patients at stage I-III with RI>10% survived longer than did patients at the same stage with RI<10% (15.3 vs 11.5 months, p<0.01). Patients at stage IV with RI>10% had an intermediate prognosis, with a median survival of 9.5 months; patients at stage IV with RI<10% showed the worst prognosis, with a median survival of 4.9 months (p<0.05).

CONCLUSION

RI calculated with dual-phase FDG-PET can be used not only as a tool for initial diagnosis and staging of pancreatic cancer but also as a strong independent prognostic parameter that can allow accurate identification of those patients who will benefit from intensive anticancer treatment at different stages of the disease.

Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study

Pancreatic cancer is associated with a very poor prognosis; however, in selected patients, resection may improve survival. Several recent reports have demonstrated that concentration of treatment activity for patients with pancreatic cancer has resulted in improved outcomes. The aim of this study was to ascertain if there was any evidence of benefit for specialised care of patients with pancreatic cancer in Scotland. Records of patients diagnosed with pancreatic cancer during the period 1993–1997 were identified. Three indicators of co-morbidity were calculated for each patient. Operative procedures were classified as resection, other surgery or biliary stent. Prior to analysis, consultants were assigned as specialist pancreatic surgeons, clinicians with an interest in pancreatic disease or nonspecialists. Data were analysed with regard to 30-day mortality and survival outcome. The final study population included 2794 patients. The 30-day mortality following resection was 8%, and hospital or consultant volume did not affect postoperative mortality. The 30-day mortality rate following palliative surgical operations was 20%, and consultants with higher case loads or with a specialist pancreatic practice had significantly fewer postoperative deaths (P=0.014 and 0.002, respectively). For patients undergoing potentially curative or palliative surgery, the adjusted hazard of death was higher in patients with advanced years, increased co-morbidity, metastatic disease, and was lower for those managed by a specialist (RHR 0.63, 95% CI 0.50–0.78) or by a clinician with an interest in pancreatic disease (RHR 0.63, 0.48–0.82). The risk of death 3 years after diagnosis of pancreatic cancer is higher among patients undergoing surgical intervention by nonspecialists. Specialisation and concentration of cancer care has major implications for the delivery of health services.

Radiation to stromal fibroblasts increases invasiveness of pancreatic cancer cells through tumor-stromal interactions

Radiotherapy represents a major treatment option for patients with pancreatic cancer, but recent evidence suggests that radiation can promote invasion and metastasis of cancer cells. Interactions between cancer cells and surrounding stromal cells may play an important role in aggressive tumor progression. In the present study, we investigated the invasive phenotype of pancreatic cancer cells in response to coculture with irradiated fibroblasts. Using in vitro invasion assay, we demonstrated that coculture with nonirradiated fibroblasts significantly increased the invasive ability of pancreatic cancer cells and, surprisingly, the increased invasiveness was further accelerated when they were cocultured with irradiated fibroblasts. The hepatocyte growth factor (HGF) secretion from fibroblasts remained unchanged after irradiation, whereas exposure of pancreatic cancer cells to supernatant from irradiated fibroblasts resulted in increased phosphorylation of c-Met (HGF receptor) and mitogen-activated protein kinase activity, possibly or partially via increased expression of c-Met. We also demonstrated that scattering of pancreatic cancer cells was accelerated by the supernatant from irradiated fibroblasts. The enhanced invasiveness of pancreatic cancer cells induced by coculture with irradiated fibroblasts was completely blocked by NK4, a specific antagonist of HGF. These data suggest that invasive potential of certain pancreatic cancer cells is enhanced by soluble mediator(s) released from irradiated fibroblasts possibly through up-regulation of c-Met expression/phosphorylation and mitogen-activated protein kinase activity in pancreatic cancer cells. Our present findings further support the potential use of NK4 during radiotherapy for patients with pancreatic cancer.

Pancreaticoduodenectomy with En Bloc Portal Vein Resection for Pancreatic Carcinoma with Suspected Portal Vein Involvement

Pancreaticoduodenectomy combined with portal vein resection is increasingly accepted as a viable treatment option for pancreatic carcinoma with suspected involvement of the portal vein.However, its clinical benefit remains controversial. This study evaluated the outcomes of pancreaticoduodenectomy with portal vein resection for pancreatic carcinoma in a group of Chinese patients operated on by a specialized team in a center with a low case volume of pancreatic cancer. The perioperative and long-term outcomes of 12 patients with portal vein resection for suspected involvement of the portal vein and 38 patients who underwent pancreaticoduodenectomy without portal vein resection during the same period were compared. In the former group, eight patients underwent segmental resection, and four patients underwent wedge resection of the portal vein. There were no significant differences in operative blood loss (median 0.8 vs. 0.8 liter, p = 0.313), hospital mortality (0% vs. 2.6%, p = 1.000), or operative morbidity (41.7% vs. 42.1%, p = 0.979) between the two groups. Patients who required portal vein resection had higher frequencies of microscopic lymphatic permeation (58.3% vs. 18.4%, p = 0.023) and vascular invasion (50.0% vs. 15.8%, p = 0.025). Long-term survival was comparable between patients with portal vein resection and those without it (median 19.5 vs. 20.7 months,p = 0.769). These findings suggest that pancreaticoduodenectomy combined with portal vein resection can be performed safely by a specialized team in a center with a low case volume of pancreatic carcinoma and that it may offer survival benefit in patients with suspected portal vein involvement.

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma

Background

Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma.

Methods

Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models.

Results

Fifty-eight patients (15·8 per cent) underwent surgical exploration only, 97 patients (26·5 per cent) underwent palliative bypass surgery and 211 patients (57·7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9·0 per cent, stage II in 18·0 per cent, stage III in 68·7 per cent and stage IV in 4·3 per cent of patients who underwent resection. Resection was curative (R0) in 75·8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41·2 per cent), classical Whipple resection (37·0 per cent), left pancreatic resection (13·7 per cent) and total pancreatectomy (8·1 per cent). The in-hospital mortality and cumulative morbidity rates were 2·8 and 44·1 per cent respectively. The overall actuarial 5-year survival rate was 19·8 per cent after resection. Survival was better after curative resection (R0) (24·2 per cent) and in lymph-node negative patients (31·6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival.

Conclusion

Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained.

A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer

BACKGROUND

The effect of adjuvant treatment on survival in pancreatic cancer is unclear. We report the final results of the European Study Group for Pancreatic Cancer 1 Trial and update the interim results.

METHODS

In a multicenter trial using a two-by-two factorial design, we randomly assigned 73 patients with resected pancreatic ductal adenocarcinoma to treatment with chemoradiotherapy alone (20 Gy over a two-week period plus fluorouracil), 75 patients to chemotherapy alone (fluorouracil), 72 patients to both chemoradiotherapy and chemotherapy, and 69 patients to observation.

RESULTS

The analysis was based on 237 deaths among the 289 patients (82 percent) and a median follow-up of 47 months (interquartile range, 33 to 62). The estimated five-year survival rate was 10 percent among patients assigned to receive chemoradiotherapy and 20 percent among patients who did not receive chemoradiotherapy (P=0.05). The five-year survival rate was 21 percent among patients who received chemotherapy and 8 percent among patients who did not receive chemotherapy (P=0.009). The benefit of chemotherapy persisted after adjustment for major prognostic factors.

CONCLUSIONS

Adjuvant chemotherapy has a significant survival benefit in patients with resected pancreatic cancer, whereas adjuvant chemoradiotherapy has a deleterious effect on survival.

Role of unlabelled somatostatin analogues in the prevention of complications after elective pancreatic and peripancreatic surgery: a critical review

Although studies on the use of the somatostatin analogues in the elective pancreatic surgery are mostly prospective, double blind and randomised, the results are contradictory and not univocally interpretable. Through the examination of all randomised perspective works published on this subject, a critical interpretation is attempted which may give relevant suggestions for further studies. A new clinical, randomised, double blind and multicentric prospective trial should take into proper consideration even the changes which have occurred in the care of the patients. Over the years a significant decrease of postoperative hospital stay and a deeper awareness of the medical expenses have been observed. Moreover, since the drug has a potential advantage on specific pancreatic complications, only these must be considered among the end points of the study and the population studied will be limited exclusively to patients who underwent resection of the pancreatic head or of the periampullar region because of neoplastic disease. Finally, the selection of the centres that enrol the patients must be considered, since the expertise of each operator or of the team, affects, as an independent variable, both morbidity and mortality.

A phase II irinotecan-cisplatin combination in advanced pancreatic cancer

We report a cisplatin and irinotecan combination in patients with biopsy-proven advanced pancreatic adenocarcinoma. Patients were selected from a specialist centre and required good performance status (KPS>70%), measurable disease on CT scan, and biochemical and haematological parameters within normal limits. Based on a two-stage phase II design, we aimed to treat 22 patients initially. The study was stopped because of the death of the 19th patient during the first treatment cycle, with neutropenic sepsis and multiorgan failure. A total of 89 treatments were administered to 17 patients. Serious grade 3/4 toxicities were haematological (neutropenia) 6%, diarrhoea 6%, nausea 7% and vomiting 6%. Using the clinical benefit response (CBR) criteria, no patients had an overall CBR. For responses confirmed by CT examination, there was one partial response (5%), three stable diseases lasting greater than 6 weeks (16%), with an overall 22% with disease control (PR+SD). The median progression-free and overall survival was 3.1 months (95% CI: 1.3–3.7) and 5.0 (95% CI: 3.9–10.1) months, respectively. Although this synergistic combination has improved the response rates and survival of other solid tumours, we recommend caution when using this combination in the palliation of advanced pancreatic cancer, because of unexpected toxicity.

Registro hospitalario de tumoraciones pancreáticas. Experiencia del Hospital Clínic de Barcelona

OBJECTIVE

To describe the characteristics of patients included in the pancreatic tumor registry of the Hospital Clínic of Barcelona.

PATIENTS AND METHOD

All patients with pancreatic tumors attended between July 1990 and March 2003 were registered. Data collection included: age, gender, date of diagnosis, diagnosis, histology, size, location and tumor stage, and treatment. The correlation between tumor stage and age, date of diagnosis, and tumor location was also evaluated.

RESULTS

Six hundred thirty patients with pancreatic tumors were included, representing an incidence of 60 patients/year. The mean age was 66 years and the male-to-female ratio was 1,18:1. The most frequent lesion was malignant tumor of the pancreas (92%), and the most frequent histological type was pancreatic ductal adenocarcinoma (73%). The most frequent location was the head of the pancreas (64%). In 28% of the patients, pancreatic cancer was diagnosed in stage I and II. Resection was performed in 31% of patients, whereas 48% of the patients received no treatment. The ratio between local (stage I)/disseminated (stage IV) disease was 0,34. The ratio between stage I/IV increased with age, diagnosis prior to 1994, and tumor location in the head of the pancreas.

CONCLUSION

Hospital tumor registries can be used to define the profile of the attended population, which can help to delineate the best diagnostic-therapeutic strategy and can be useful in clinical research.

Loss of DPC4 expression and its correlation with clinicopathological parameters in pancreatic carcinoma

AIM: DPC4 is a tumor suppressor gene on chromosome 18q21.1 that has high mutant frequencies in pancreatic carcinogenesis. The purpose of this study was to investigate the role of DPC4 alterations in tumorigenesis and progression of pancreatic carcinomas.

METHODS: We studied the immunohistochemical markers of DPC4 in 34 adenocarcinomas and 16 nonmalignant specimens from the pancreas. The 16 nonmalignant specimens from the pancreas included 8 non-neoplastic cysts and 8 normal pancreatic tissues. The relationship between DPC4 alterations and various clinicopathological parameters was evaluated by chi-square test or Fisher’s exact test. Survivals were calculated using Kaplan-Meier method (by a log-rank test).

RESULTS: All the 16 nonmalignant cases of the pancreas showed expression of DPC4 gene. Loss of DPC4 expression was seen in 8 of 34(23.5%) pancreatic adenocarcinomas. The frequency of loss of DPC4 expression was higher in poorly differentiated adenocarcinoma (G3) than in well and moderately differentiated adenocarcinoma (G1 and G2) histologically (P = 0.037). Loss of DPC4 expression of the patients at TNM stage IV was also higher than that of the patients at TNM stages I, II and III (60.0% at stage IV, versus 14.3% at stage I, 18.2% at stage II, and 18.2% at stage III) (P = 0.223). The mean and median survival in patients with DPC4 expression was longer than those in patients with loss of DPC4 expression. Kaplan-Meier survival analysis demonstrated patients with DPC4 expression had a higher survival rate than patients with loss of DPC4 expression, but the difference did not reach statistical significance (P = 0.879).

CONCLUSION: This study suggests that DPC4 is involved in the development of pancreatic carcinoma and is a late event in pancreatic carcinogenesis, DPC4 expression may be a molecular prognostic marker for pancreatic carcinoma.

Review article: chemotherapy for pancreatic cancer

Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.

Establishment of gemcitabine-resistant human pancreatic cancer cells and effect of brefeldin-a on the resistant cell line

To date, no therapy has been found to which pancreatic cancer responds with the exception of surgical resection in early stages. Recently, gemcitabine has become the standard of care for chemotherapy in those patients with advanced disease. Most pancreatic tumors however, develop resistance to gemcitabine. The aim of this study is to clarify the mechanism of resistance to gemcitabine in human pancreatic cells. Using a cell selection method, a human pancreatic cancer cell line resistant to gemcitabine was established. Cellular proliferation and viability were determined by MTT assay. The cell line with acquired resistance was also found to have cross resistance to fluorouracil. Brefeldin-A (BFA) has been used as a tool for studies of intracellular protein traffic, rather than as an anticancer drug. BFA displays the same effects on wild type cells and those with acquired resistance. Gemcitabine combined with BFA in low doses is significantly more effective than gemcitabine alone against MIA PaCa-2 cell line. Our data suggest that the gemcitabine-resistant and 5-FU-resistant pathways may partially overlap each other. In short, BFA may be used as a modulator of gemcitabine.

Treatment of pancreatic cancer: challenge of the facts

Adenocarcinoma of the pancreas is associated with the worst survival of any form of gastrointestinal malignancy. In spite of the progress in surgical treatment, resulting in increasing resection rates and a decrease in treatment-related morbidity and mortality, the true figures of cure are even today below 3%. The dissemination of pancreatic cancer behind the local tissue compartments restricts the short-term (< 3 years) and long-term outcome for patients who have undergone resection. By histological evaluation, less than 15% of the patients undergoing R(0) resection have a pN(0) status, more than 60% suffer from lymph angiosis carcinomatosa, and more than 50% suffer extrapancreatic nerve plexus infiltration. Hematoxylin and eosin-negative lymph nodes were found to be cancer positive when reverse transcriptase polymerase chain reaction (RT- PCR) or immunostaining was applied to the HE-negative lymph nodes. Cancer of the uncinate process has a very poor prognosis because there are no early symptoms; vessel wall involvement occurs early and frequently; a high association of liver metastasis exists as well. Surgery offers a low success rate, but it provides the only chance of cure. Ductal pancreatic cancer is diagnosed in more than 95% of the cases in an advanced stage; potentially curative resection can be performed only in about 10%-15% of these patients. Major contributions of surgery to improved treatment results are the reduction of surgical morbidity--e.g., early postoperative local and systemic complications--and a decrease of hospital mortality below 3%-5%. In most recently published prospective trials, R(0) resection has been reported to result in an increase in short-term survival beyond that recorded for patients with residual tumor. However, R(0) resection fails to improve long-term survival. In many published R(0) series, standard tissue resection of pancreatic head cancer with the Kausch-Whipple procedure failed to include remote cancer cell-positive tissues in the operative specimen; e.g., N(2)-lymph nodes, nerve plexus, and perivascular extrapancreatic and retropancreatic tissues were not excised. Cancer recurrence after so-called R(0) resection with curative intent is frequently the consequence of cancer left behind. Thus, long-term survival (> 5 years) is observed in a very small group of patients, contradicting the published 5-year actuarial survival rates of 20%-45% for resected patients. The assessment of clinical benefit from surgical or medical cancer treatment should therefore be based on several end points, not only on actuarial survival. Publication of actuarial survival figures must include the number of observed (actual) survivals, the definition of the subset of patients followed after resection, and the total number of patients in the study group; anything less is misleading. In reporting pancreatic cancer treatment trial results after oncological resections, more convincing primary end points to evaluate treatment efficacy are median survival (in months), actual survival at 1-5 years, and progression-free survival (in months). In series with multimodality treatment, clinical benefit response as well as quality of life measurements using the EORTC Quality of Life index C30 (QLQ-C30) are of importance in evaluating survival data. Adjuvant treatment improves survival after oncological resection; however, the short-term and long-term benefit after adjuvant chemotherapy in R(0) as well as in R(1)-(2) resected patients has not yet been underscored by data from controlled clinical trials. The survival benefit (median survival time) of adjuvant chemotherapy or radiochemotherapy has been demonstrated to be 6-10 months. Therefore, after oncological resection of pancreatic cancer each patient should be offered adjuvant treatment. A neoadjuvant treatment protocol for pancreatic cancer, however, has not been established.

The 'two-week' target for the diagnosis of pancreatic carcinoma: an achievable aim?

AIM

The aim of this study was to evaluate the current diagnostic process for patients with pancreatic cancer in a University teaching hospital and to determine whether the 'two-week' target for rapid assessment was being met.

METHODS

The notes of all patients with pancreatic cancer from June 1998 to June 2000 were reviewed to determine the time to diagnosis, investigations and procedures performed, number of admissions, length of hospital stay and survival

RESULTS

There were 146 patients in total with a median (range) age of 71 (38-92) years. 18 (12%) had resectable lesions, while the remaining 128 patients had 134 palliative interventions (33 surgical; 101 radiological or endoscopic). The median number of hospital admissions for each patient was 2 (range 1-6) with a median length of hospital stay of 9 days (range 1-35 days). The median (IQR) time to diagnosis was significantly less in the jaundiced patients [7 (6-10) days vs. 32 (18-46) days, P<0.0001]. There was no significant correlation between age and time to diagnosis (r=0.08, P=0.36). There were 105 (72%) deaths in the study population, 82 in the jaundiced group and 23 in the non-jaundiced group. There was no significant difference in median (IQR) duration from referral to death in the jaundiced and non-jaundiced groups [59.5 (18-175) days vs. 35 (16-137) days, P=0.45].

CONCLUSIONS

A diagnosis within 14 days was achieved in 77% of patients. Patients with jaundice were more likely to have an earlier diagnosis than those without jaundice but this had no impact on survival.

A novel biweekly pancreatic cancer treatment schedule with gemcitabine, 5-fluorouracil and folinic acid

Pancreatic adenocarcinoma is a common disease considered to be poorly responsive to antiblastic treatment. Recent clinical and preclinical results suggest that a combined treatment of gemcitabine (GEM), 5-flurouracil (5-FU) and folinic acid (FA) offers a clinical benefit in patients with advanced pancreas adenocarcinoma. The aim of this phase II clinical trial was to evaluate the antitumour activity and toxicity of a novel biweekly schedule of this combination in patients with pancreatic adenocarcinoma. A total of 42 patients received a 30 min infusion of FA (100 mg m(-2)) and 5-FU (400 mg m(-2)) (FUFA) on days 1-3, and GEM 1000 mg m(-2) on day 1 every 15 days. We observed 13 objective responses (two complete, 11 partial) and 23 stable diseases. The median time to progression was 9.75 months (95% Confidence Interval (CI), 6.88-12.62) and the median overall survival was 13.10 months (95% CI 9.64-16.56). There were seven cases of each grade III gastroenteric and haematological toxicity. The GEM plus FUFA combination appears to be well tolerated and very active in patients with pancreatic carcinoma.

Prognostic factors in the palliation of pancreatic cancer

AIM

Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy. The aim is to evaluate the prognostic significance of clinical and laboratory variables in patients with unresectable pancreatic cancer.

METHODS

Information was gathered retrospectively for 325 patients with unresectable pancreatic cancer who underwent palliative interventions, including surgical bypass, endoscopic or percutaneous stenting or who received supportive care only.

RESULTS

Histological proof was obtained in 182 patients (56%). Median survival was 5.7 months. Absence of therapeutic intervention, leukocytosis (WCC> or =11 x 10(9)/l), gamma glutamyl transferase (gamma GT)>165U/L, prothrombin time ratio > or =1.1, and C-reactive protein (CRP) > or = 5mg/dL were associated with shorter survival on univariate analysis. Only absence of therapeutic intervention, leukocytosis, and gamma GT>165 U/L reached significance on multivariate analysis. In the 51 patients in whom serum CRP was available, CRP was the only significant predictor of survival on multivariate analysis.

CONCLUSIONS

Leukocytosis, elevated gamma GT and raised CRP predict shorter survival and may help to guide the choice of palliative intervention for patients with unresectable pancreatic cancer.

Radiation stimulates HGF receptor/c-Met expression that leads to amplifying cellular response to HGF stimulation via upregulated receptor tyrosine phosphorylation and MAP kinase activity in pancreatic cancer cells

Hepatocyte growth factor (HGF) is a stromal-derived cytokine that plays a crucial role in invasion and metastasis of tumor cells through the interaction with HGF receptor, c-Met, which is frequently overexpressed in pancreatic cancer. The present study was designed to investigate the change in HGF receptor and HGF-mediated signaling after irradiation in pancreatic cancer cells. Six cell lines from human pancreatic cancer were included in the study. Gamma-radiation was used for irradiation treatment. The changes in expression levels of c-Met were evaluated by immunoblot and confirmed morphologically by indirect immunofluorescence staining. Whether the resultant alteration in c-Met would cascade as biologically usable signals upon HGF ligation was traced by receptor tyrosine phosphorylation analysis and mitogen activated protein kinase (MAP kinase or MAPK) activity assay. The various biological responses to HGF (including cell proliferation, cell scattering, migration and invasion) were evaluated as well. We also used a 4-kringle antagonist of HGF, NK4, to block the HGF/c-Met signaling pathway. Both immunoblot and immunofluorescent analysis showed moderate increased expression of c-Met in 3 of 6 pancreatic cancer cell lines after irradiation. The actions seemed to be dose-responsible, which began at 3 hr and reached its peak value at 24 hr following irradiation. The radiation-increased expression of c-Met could transform into magnifying receptor tyrosine phosphorylation reaction and MAP kinase activity once the ligand was added, fairly corresponding with alteration in the receptor. Sequentially, the cellular responses to HGF, including scattering and invasion but not proliferation, were enhanced. Also, in the presence of HGF, the elevated receptor could help to recover the radiation-compromised cell migration. A recombinant HGF antagonist, NK4 could effectively block these aberrant effects activated by irradiation both in molecular and cellular levels, thus suggesting the deep involvement of the c-Met/HGF pathway in the enhanced malignant potential after irradiation. These results suggest that radiation may promote HGF-induced malignant biological behaviors of certain pancreatic cancer cells through the up-regulated HGF/c-Met signal pathway. Selectively targeted blockade of the HGF/c-Met pathway could help to abolish the enforced malignant behavior of tumor cells by irradiation and therefore may improve the efficacy of radiotherapy for pancreatic cancer.

Adjuvant therapy in pancreatic cancer: historical and current perspectives

The results from pancreatic ductal adenocarcinoma appear to be improving with increased resection rates and reduced postoperative mortality reported by specialist pancreatic cancer teams. Developments with medical oncological treatments have been difficult, however, due to the fundamentally aggressive biological nature of pancreatic cancer and its resistance to chemotherapy coupled with a relative dearth of randomised controlled trials. The European Study Group for Pancreatic Cancer (ESPAC)-1 trial recruited nearly 600 patients and is the largest trial in pancreatic cancer. The results demonstrated that the current best adjuvant treatment is chemotherapy using bolus 5-fluorouracil with folinic acid. The median survival of patients randomly assigned to chemoradiotherapy was 15.5 months and is comparable with many other studies, but the median survival in the chemotherapy arm was 19.7 months and is as good or superior to multimodality treatments including intra-operative radiotherapy, adjuvant chemoradiotherapy and neo-adjuvant therapies. The use of adjuvant 5-fluorouracil with folinic acid may be supplanted by gemcitabine but requires confirmation by ongoing clinical trials, notably ESPAC-3, which plans to recruit 990 patients from Europe, Canada and Australasia. Major trials such as ESPAC-1 and ESPAC-3 have set new standards for the development of adjuvant treatment and it is now clear that such treatment in this field has the potential to significantly improve both patient survival and quality of life after curative resection.

Usage of the NF-kappaB inhibitor sulfasalazine as sensitizing agent in combined chemotherapy of pancreatic cancer

Sulfasalazine is commonly used as an anti inflammatory agent and is known as a potent inhibitor of NF-kappaB. Some pancreatic carcinomas are characterized by a constitutively elevated NF-kappaB activity accounting for chemoresistance. To elucidate whether blockade of NF-kappaB activity with sulfasalazine is suitable for overcoming this chemoresistance in vivo, we employed a mouse model with subcutaneously xenotransplanted human Capan-1 pancreatic carcinoma cells. Fourteen days upon tumor inoculation, animals were randomized in 6 groups, receiving no treatment, treatment with gemcitabine or with etoposide, either alone or in combination with sulfasalazine, or with sulfasalazine alone. Two therapy regimens were given with a 7-day interval in between. Upon treatment with etoposide or gemcitabine alone, tumor sizes were moderately reduced to 65-68% and 50-65%, respectively, as compared to untreated tumors. Sulfasalazine alone only decreased temporarily the tumor sizes. Sulfasalazine in combination with gemcitabine showed only partially higher reduction in tumor sizes than gemcitabine alone, whereas the combination with etoposide reduced significantly the tumor sizes in all experiments (down to 20%). TUNEL-staining showed higher numbers of apoptotic cells in tumors from the combination groups, in particular with etoposide, and proliferation as indicated by Ki67 staining was strongly reduced. Furthermore, combined treatment of sulfasalazine with the cytostatic drugs led to a decreased blood vessel density. Immunohistochemical staining of the activated p65 subunit showed that sulfasalazine treatment abolished the basal NF-kappaB activity in tumor xenografts. These data imply that the well established anti-inflammatory drug sulfasalazine sensitizes pancreatic carcinoma cells to anti cancer drugs, in particular to etoposide in vivo by inhibition of NF-kappaB. This combined chemotherapy offers great potential for improved anti-tumor responses in pancreatic carcinomas.

Resection for pancreatic cancer in the new millennium

BACKGROUND AND AIM OF THE STUDY

Complications of pancreatic resections are dangerous and costly. A literature review was therefore done to investigate the evidence for improving the results by regionalizing this demanding surgery.

RESULTS

Studies from four countries (USA, UK, the Netherlands and Finland) with advanced health care systems have shown a significant inverse correlation between case volume for pancreatic cancer resection and post-operative mortality. Further analysis reveals lower complications, reduced hospital stay, reduced hospital costs and improved survival of patients treated in high-volume hospitals. The relationship volume and outcome is with institutional volume rather than single surgeon caseload. The evidence therefore strongly supports the regionalization of pancreatic cancer surgery into large specialized multi-disciplinary units. In the UK, the National Health Service Executive has instructed Regional Health Authorities to concentrate pancreatic cancer surgery into designated Regional Centres ideally with catchment populations of 2-4 million. There is now considerable pressure to adopt a similar policy in all countries with advanced health care systems.

CONCLUSION

There is today enough evidence to advocate the regionalization of pancreatic cancer resections.

Gemcitabine monotherapy in patients with locally advanced or metastatic pancreatic cancer: a prospective observational study

Pancreatic cancer has one of the worst prognosis of any malignant disease. Systemic therapy is often administered because the disease is usually detected at advanced stages. Gemcitabine (Gemzar trade mark, Eli Lilly & Co.) has proven activity in the treatment of pancreatic cancer. Gemcitabine 1000 mg/m(2) was given on days 1, 8 and 15, every 4 weeks. A total of 100 chemonaive patients with locally advanced or metastatic pancreatic cancer were enrolled; 32 and 68% had stage III and IV disease, respectively. The average number of administered cycles was 3.5 (range: 1 - 12). The overall response rate was 13%, with 13 partial responders. The median time to progression was 13.5 weeks (range: 3 - 56; 95% CI = 12 - 14). The median survival was 32 weeks (range: 4 - 104; 95% CI = 27 - 36). Clinical benefit response was acheived for 26 patients (26%). Grade 3/4 haematological toxicities occurred infrequently (anaemia: 5%; neutropenia: 8% and thrombocytopenia: 3% of patients). Grade 3/4 non-haematological toxicities were not observed. There were no treatment-related deaths. Gemcitabine treatment of patients with locally advanced or metastatic pancreatic cancer is effective and well-tolerated.

Physical activity, body weight, and pancreatic cancer mortality

In a study of 32 687 subjects with data on physical activity and body mass index (BMI) collected serially over time, we examined associations with pancreatic cancer mortality (n=212). Despite plausible biologic mechanisms, neither physical activity (multivariate relative risks for increasing levels: 1.00, 0.98, 0.92, and 1.31, respectively) nor BMI (corresponding findings: 1.00, 0.84, 1.08, and 0.99, respectively) significantly predicted pancreatic cancer mortality.

Inhibition of constitutive NF-kappa B activity by I kappa B alpha M suppresses tumorigenesis

We have demonstrated that nuclear factor-kappa B (NF-kappa B) is constitutively activated in human pancreatic adenocarcinoma and human pancreatic cancer cell lines but not in normal pancreatic tissues or in immortalized, nontumorigenic pancreatic epithelial cells, suggesting that NF-kappa B plays a critical role in the development of pancreatic adenocarcinoma. To elucidate the role of constitutive NF-kappa B activity in human pancreatic cancer cells, we generated pancreatic tumor cell lines that express a phosphorylation defective I kappa B alpha (S32, 36A) (I kappa B alpha M) that blocks NF-kappa B activity. In this study, we showed that inhibiting constitutive NF-kappa B activity by expressing I kappa B alpha M suppressed the tumorigenicity of a nonmetastatic human pancreatic cancer cell line, PANC-1, in an orthotopic nude mouse model. Immunohistochemical analysis showed that PANC-1-derived tumors expressed vascular endothelial growth factor (VEGF) and induced angiogenesis. Inhibiting NF-kappa B signaling by expressing I kappa B alpha M significantly reduced expression of Bcl-x(L) and Bcl-2. The cytokine-induced expression of VEGF and Interleukin-8 in PANC-1 cells is also decreased. Taken together, these results suggest that the inhibition of NF-kappa B signaling can suppress tumorigenesis of pancreatic cancer cells and that the NF-kappa B signaling pathway is a potential target for anticancer agents.

CT and pathologic assessment of prospective nodal staging in patients with ductal adenocarcinoma of the head of the pancreas

OBJECTIVE

The aim of our study was to compare the assessment of peripancreatic lymph nodes using CT with the gold standard of detailed histopathologic assessment of resected specimens in patients with pancreatic ductal adenocarcinoma.

SUBJECTS AND METHODS

Sixty-two patients with presumed pancreatic carcinoma were prospectively studied with dual-phase contrast-enhanced helical CT, and images were interpreted in consensus by three radiologists. Complete surgical resection was performed in 28 patients. A detailed nodal classification system was used for radiologic, surgical, and pathologic staging in the nine patients whose final diagnosis at histology was pancreatic ductal adenocarcinoma.

RESULTS

Forty lymph nodes were prospectively identified on CT in these nine patients. Two of 23 nodes (9%) measuring less than 5 mm in the short-axis diameter were malignant, four of 11 nodes (36%) measuring 5-10 mm were malignant, and one of six nodes (17%) larger than 10 mm was malignant. Using a short-axis diameter of greater than 10 mm as the criterion for nodal involvement, we found a sensitivity of 14% (1/7) and a specificity of 85% (28/33), with a positive predictive value of 17% (1/6), a negative predictive value of 82% (28/34), and an overall accuracy of 73% (29/40). Ovoid nodal shape, clustering of nodes, and the absence of a fatty hilum were not useful predictors of malignancy on CT.

CONCLUSION

In resectable pancreatic ductal adenocarcinoma, CT is not accurate overall for the prediction of nodal involvement. In a patient with presumed pancreatic carcinoma that is considered to be resectable, the depiction on CT of peripancreatic nodes should not prevent attempted curative resection.

Locoregional chemotherapy for patients with pancreatic cancer intra-arterial adjuvant chemotherapy after pancreatectomy with portal vein resection

INTRODUCTION AND AIMS

The survival of pancreatic cancer patients with portal vein resection is extremely poor due to the high incidence of liver metastasis. The occurrence of liver metastasis is decreased by locoregional arterial infusion after pancreatic surgery. Chemosensitivity tests can provide the basis for individualized chemotherapy in each patient and predict the clinical response. Therefore, the current study was designed to clarify whether locoregional chemotherapy based on the results of chemosensitivity tests has the clinical effects of preventing liver metastasis and improving survival for patients with portal vein resection.

METHODOLOGY

The resected specimens from 40 of 47 patients with resection of pancreatic cancer were assessed for chemosensitivity to various anticancer drugs. Fourteen patients underwent portal vein resection due to direct invasion, and nine of these patients received intra-arterial adjuvant chemotherapy on the basis of the results of MTT assay to prevent liver metastasis. The remaining five patients received no chemotherapy.

RESULTS

None of the patients who received intra-arterial chemotherapy had liver metastasis, and this group of patients had improved survival. The mean survival of patients with intra-arterial chemotherapy was significantly longer than that of patients without chemotherapy (25.6 months with chemotherapy versus 9.4 months without chemotherapy).

CONCLUSION

A pilot study of postoperative intra-arterial chemotherapy showed the reduction of liver metastasis and improvement of survival among pancreatic cancer patients with portal vein resection.

Low sensitivity of the ki-ras polymerase chain reaction for diagnosing pancreatic cancer from pancreatic juice and bile: a multicenter prospective trial

PURPOSE

Early detection of pancreatic cancer using molecular markers may improve outcome. Mutations of the ki-ras oncogene are detected in 70% to 90% of pancreatic adenocarcinomas. A prospective, partially blinded, multicenter diagnostic trial was performed to test the sensitivity and specificity of the ki-ras polymerase chain reaction (PCR) analysis of pancreatic juice and bile specimens.

PATIENTS AND METHODS

Specimens of pancreatic juice and bile were collected from 532 consecutive patients. Mutations in codon 12 of the ki-ras gene were identified by two independent enrichment PCRs and confirmed by direct sequencing.

RESULTS

One hundred seventy-four of 532 patients were excluded from the final analysis (reasons: no amplifiable DNA, no specimen or only duodenal juice sent, lost to follow-up). Sixty-three of 358 patients had ductal pancreatic cancer. In 24 (38.1%) of 63 patients, a mutated ki-ras gene was identified in pancreatic juice and/or bile. Ki-ras mutations were found in four (8%) of 50 cases of chronic pancreatitis, in 10 (18.7%) of 53 cases of other malignancies of the pancreaticobiliary tree, and in 14 (7.3%) of 192 cases of benign diseases or normal findings. Sensitivity and specificity of the ki-ras PCR analysis for the detection of pancreatic cancer was 38.1% and 90.5%, respectively.

CONCLUSION

In this prospective trial performed in nonselected patients, mutations of the ki-ras gene were detected in 38.1% of cases with pancreatic cancer. This test in its present form is not appropriate to confirm or screen for pancreatic cancer. More sensitive and/or quantitative PCR tests may improve the molecular diagnosis of pancreatic cancer.

Phase II study of anti-gastrin-17 antibodies, raised to G17DT, in advanced pancreatic cancer

PURPOSE

The prognosis for advanced pancreatic cancer remains poor. Gastrin acts as a growth factor for pancreatic cancer. We describe the first study of the antigastrin immunogen G17DT in pancreatic cancer. Our aims were to determine the antibody response, safety, tolerability, and preliminary evidence of efficacy of G17DT in advanced pancreatic cancer.

PATIENTS AND METHODS

Thirty patients with advanced pancreatic cancer were immunized with three doses of either 100 micro g or 250 micro g of G17DT.

RESULTS

In the whole group, 20 (67%) of 30 patients produced an antibody response. The 250- micro g dose resulted in a significantly greater response rate of 82% compared with 46% for the 100- micro g group (P =.018). The most significant side effects, seen in three patients, were local abscess and/or fever. The median survival for the whole group from the date of the first immunization was 187 days; median survival was 217 days for the antibody responders and 121 days for the antibody nonresponders. The difference in survival between the antibody responders and nonresponders was significant (P =.0023).

CONCLUSION

Patients with advanced pancreatic cancer are able to mount an adequate antibody response to G17DT. The 250- micro g dose is superior to the 100- micro g dose, and it appears to be generally well tolerated. Antibody responders demonstrate significantly greater survival than antibody nonresponders. Phase III studies are currently underway in order to determine efficacy.

How to pass on expertise: pancreatoduodenectomy at a teaching hospital

Pancreatoduodenectomy (PD) has become a routine procedure. Recent series report perioperative mortality rates of 5% or less, moderate morbidity, and even improved long-term survival. Nevertheless, being one of the most complex abdominal operations, a certain number of surgical procedures (i.e., personal caseload) seems essential for acceptable results. The objectives of this retrospective study were to evaluate whether PD can be safely performed as a teaching operation, and if the personal caseload of the senior surgeon affects morbidity and mortality. A series of 128 consecutive PDs carried out at a large academic teaching hospital were analyzed. The 49 operations performed by 11 residents of the surgical department as teaching operations under supervision of an experienced (senior) surgeon (ES) were compared with operations performed by an ES (group 2, n = 79). Three patients died from non-procedure-related causes (two in group 1). Eleven patients of group 2 had to be reoperated, in contrast to three in group 1 (NS). The total number of complications and number of pancreatic fistulas were comparable in the two groups. Surgeons performing less than one PD per year had significantly more complications. Under direct supervision of an experienced surgeon PD can be performed safely as a teaching operation. A caseload of at least one resection per year seems necessary for consistently good results.

Gene transduction of NK4, HGF antagonist, inhibits in vitro invasion and in vivo growth of human pancreatic cancer

In this study, we investigated the therapeutic effects of adenovirally-mediated transfer of the sequence of NK4, an antagonist for hepatocyte growth factor (HGF), against human pancreatic carcinoma. HGF has been implicated to play an important role in invasion and metastasis of various human cancers through tumor-stromal interactions. Although NK4 has been shown to block the metastatic behavior of cancer cells, problems with cellular delivery of NK4 must be addressed before it can be used for clinical trials. The effects of NK4 gene transduction mediated by recombinant adenovirus (Ad-NK4) were evaluated in a human pancreatic cancer cell line (SUIT-2) by in vitro scattering assays, invasion assays, and subcutaneous transplantation in nude mice. NK4 transduction markedly inhibited scattering and invasion of SUIT-2 cells stimulated by HGF without affecting cell proliferation in vitro. Furthermore, Ad-NK4 significantly inhibited the growth of tumors transplanted to nude mice. The tumor reduction induced by Ad-NK4 was associated with a decreased number of blood vessels surrounding the tumors. These findings suggest that Ad-NK4 gene therapy may be a unique and promising strategy for the treatment of pancreatic cancer.

Molecular diagnosis of early pancreatic ductal adenocarcinoma in high-risk patients

The prevalence of pancreatic cancer in the general population is too low--even in high-prevalence areas such as Northern Europe and North America (8-12 per 10(5) population)--relative to the diagnostic accuracy of present detection methods to permit primary screening in the asymptomatic adult population. The recognition that the lifetime risk of developing pancreatic cancer for patients with hereditary pancreatitis (HP) is extremely high (20% by the age of 60 years and 40% by the age of 70 years) poses considerable challenges and opportunities for secondary screening in those patients without any clinical features of pancreatic cancer. Even for secondary screening, the detection of cancer at a biological stage that would be amenable to cure by surgery (total pancreatectomy) still requires diagnostic modalities with a very high sensitivity and specificity. Conventional radiological imaging methods such as endoluminal ultrasound and endoscopic retrograde pancreatography, which have proved to be valuable in the early detection of early neoplastic lesions in patients with familial pancreatic cancer, may well be applicable to patients with HP but only in those without gross morphological features of chronic pancreatitis (other than parenchymal atrophy). Unfortunately, most cases of HP also have associated gross features of chronic pancreatitis that are likely to seriously undermine the diagnostic value of these conventional imaging modalities. Pre-malignant molecular changes can be detected in the pancreatic juice of patients. Thus, the application of molecular screening in patients with HP is potentially the most powerful method of detection of early pancreatic cancer. Although mutant (mt) K-ras can be detected in the pancreatic juice of most patients with pancreatic cancer, it is also present in patients with non-inherited chronic pancreatitis who do not progress to pancreatic cancer (at least in the short to medium term), as well as increasingly in the older population without pancreatic disease. Nevertheless, the presence of mt-K-ras may identify a genuinely higher-risk group, enabling additional diagnostic imaging and molecular resources to be focussed on such a group. What is clear is that prospective multi-centre studies, such as that being pursued by the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC), are essential for the development of an effective secondary screening programme for these patients.

Detection and prognostic impact of disseminated tumor cells in pancreatic carcinoma

BACKGROUND/AIMS

Metastatic disease determines the prognosis of patients with pancreatic cancer. Current routine staging methods often underestimate the tumor stage because they do not include the search for disseminated tumor cells that spread early in different compartments of the body. Immunohistochemical and molecular methods developed recently are able to detect these cells in multiple compartments of the body.

METHODS

The current status of the detection and the prognostic impact of disseminated tumor cells detected in lymph nodes, bone marrow, blood and peritoneal lavage of patients with pancreatic carcinoma are reviewed.

RESULTS

Disseminated tumor cells can be detected in different compartments of the body even in early tumor stages and when a resection of the primary tumor in curative intention was performed. Furthermore, the detection of these cells has importance for the prognosis and therefore will have therapeutic implications. Standardization of the methods is a prerequisite for further studies.

CONCLUSION

The detection of disseminated tumor cells should be included into studies to reveal that this increased staging has an prognostic impact and can be useful for therapeutic decisions in patients with pancreatic carcinoma.

Survival statistics gone awry: pancreatic cancer, a case in point

Resections for pancreatic cancer have been performed for 65 years, with approximately 20,000 reported. A number of authors claim a 5-year survival rate of 30% to 58%. Review of the literature reveals only about 1,200 5-year survivors; however, 10 times as many individual resected survivors have been reported (in various countries), and nonresected survivors are overlooked. This high survival percentage is obtained by reducing the subset on which calculations are based and by using methods such as the Kaplan-Meier method, which produces higher figures as increasing numbers of patients are lost to follow-up. After adjustments, hardly more than 350 resected survivors could be found. Revision of statistical methods is urgently needed.

A phase II single institutional experience with preoperative radiochemotherapy in pancreatic adenocarcinoma

BACKGROUND

Resection of pancreatic adenocarcinoma has a limited impact on survival. We hypothesized that delivering preoperative radiochemotherapy (RTCT) might enhance local control of the cancer and improve survival.

METHODS

Nineteen patients with localized pancreatic cancer (14 head and 5 body) were treated during the past 4 years with an intramural protocol consisting of continuous infusion of fluorouracile (5-FU: 650 mg/m(2)/D1-D5 and D21-D25 and Cisplatin 80 mg/m(2)/bolus D2 and D22 with preoperative external beam radiotherapy (RT) (30Gy split course RT or 45 Gy standard fractionation RT).

RESULTS

Four patients did not have surgical resection: Three patients were noted to have liver metastases and 1 patient developed peritoneal carcinomatosis. The remaining 15 patients had potentially curative resection (12 Whipple procedure and 3 distal subtotal pancreatectomy). There was no postoperative death. Pathologic findings showed five major responses including 2 patients with complete pathologic response. The overall median survival for the 19 study patients was 20 months. The median disease free and 2-year overall survival for the group with resection were 30 months and 52.3%.

CONCLUSIONS

Preoperative RTCT followed by resection is well-tolerated and safe for patients with localized pancreatic cancer. Major histological response occurred for 25% of patients. This approach could offer improvement in patient survival.

A randomised trial comparing 5-FU with 5-FU plus cisplatin in advanced pancreatic carcinoma

BACKGROUND

Chemotherapy is moderately efficient as a treatment for pancreatic adenocarcinoma, but patient survival and quality of life has improved with this modality in some trials. In a previous phase II trial, 5-fluorouracil (5-FU) plus cisplatin (FUP) yielded a 26.5% response rate and a 29% survival rate at 1 year. The present study aimed to compare FUP with 5-FU alone, which was the control arm in former Mayo Clinic trials.

PATIENTS AND METHODS

Patients with untreated cytologically or histologically proven metastatic or locally advanced adenocarcinoma of the pancreas were deemed measurable or evaluable. Chemotherapy regimens consisted of a control FU arm (5-FU 500 mg/m(2)/day for 5 days) and the investigational FUP arm (continuous 5-FU 1000 mg/m(2)/day for 5 days plus cisplatin 100 mg/m(2) on day 1 or day 2). In both arms, chemotherapy was repeated at day 29.

RESULTS

Two-hundred and seven patients from 18 centres were randomised: 103 in the FU arm and 104 in FUP arm. Treatment arms were balanced with respect to performance status grade 0-1 (83% versus 86%, respectively) and the presence of metastases (92% versus 89%, respectively). The median number of cycles administered was two in both arms (range 0-14). Five patients did not receive any chemotherapy and 45 received only one cycle. Toxicity (WHO grade 3-4) was lower with FU than with FUP (20% versus 48%, P <0.001), as was neutropenia (6% versus 23%), vomiting (4% versus 17%) and toxicity-related deaths (one versus four early in the trial). The response rate was low in both arms, but superior in the FUP arm: 12% versus 0% (intention-to-treat analysis, P <0.01). The survival rates at 6 months were 28% and 38% for the FU and FUP arms, respectively, and 1-year survival rates were 9% and 17% (log-rank test, P = 0.10). One-year progression-free survival was 0% with FU versus 10% with FUP (log-rank test, P = 0.0001).

CONCLUSIONS

In advanced pancreatic carcinomas with a poor prognosis, FUP was superior to FU in terms of response and progression-free survival, but not in terms of overall survival. The low response rate is partly related to the number of patients who received only one cycle of chemotherapy. A more effective, better tolerated version of this FUP combination is needed.

A double-blind placebo-controlled, randomised study comparing gemcitabine and marimastat with gemcitabine and placebo as first line therapy in patients with advanced pancreatic cancer

Pancreatic cancer is the fifth most common cause of cancer death in the western world and the prognosis for unresectable disease remains poor. Recent advances in conventional chemotherapy and the development of novel 'molecular' treatment strategies with different toxicity profiles warrant investigation as combination treatment strategies. This randomised study in pancreatic cancer compares marimastat (orally administered matrix metalloproteinase inhibitor) in combination with gemcitabine to gemcitabine alone. Two hundred and thirty-nine patients with unresectable pancreatic cancer were randomised to receive gemcitabine (1000 mg m(-2)) in combination with either marimastat or placebo. The primary end-point was survival. Objective tumour response and duration of response, time to treatment failure and disease progression, quality of life and safety were also assessed. There was no significant difference in survival between gemcitabine and marimastat and gemcitabine and placebo (P=0.95 log-rank test). Median survival times were 165.5 and 164 days and 1-year survival was 18% and 17% respectively. There were no significant differences in overall response rates (11 and 16% respectively), progression-free survival (P=0.68 log-rank test) or time to treatment failure (P=0.70 log-rank test) between the treatment arms. The gemcitabine and marimastat combination was well tolerated with only 2.5% of patients withdrawn due to presumed marimastat toxicity. Grade 3 or 4 musculoskeletal toxicities were reported in only 4% of the marimastat treated patients, although 59% of marimastat treated patients reported some musculoskeletal events. The results of this study provide no evidence to support a combination of marimastat with gemcitabine in patients with advanced pancreatic cancer. The combination of marimastat with gemcitabine was well tolerated. Further studies of marimastat as a maintenance treatment following a response or stable disease on gemcitabine may be justified.