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Conroy T, Bachet JB, Ayav A, Huguet F, Lambert A, Caramella C, Maréchal R, Van Laethem JL, Ducreux M. Current standards and new innovative approaches for treatment of pancreatic cancer. Eur J Cancer 2016; 57:10-22. [PMID: 26851397 DOI: 10.1016/j.ejca.2015.12.026] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/20/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022]
Abstract
Pancreatic adenocarcinoma remains a devastating disease with a 5-year survival rate not exceeding 6%. Treatment of this disease remains a major challenge. This article reviews the state-of-the-art in the management of this disease and the new innovative approaches that may help to accelerate progress in treating its victims. After careful pre-therapeutic evaluation, only 15-20% of patients diagnosed with a pancreatic cancer (PC) are eligible for upfront radical surgery. After R0 or R1 resection in such patients, evidence suggests a significantly positive impact on survival of adjuvant chemotherapy comprising 6 months of gemcitabine or fluorouracil/folinic acid. Delayed adjuvant chemoradiation is considered as an option in cases of positive margins. Borderline resectable pancreatic cancer (BRPC) is defined as a tumour involving the mesenteric vasculature to a limited extend. Resection of these tumours is technically feasible, yet runs the high risk of a R1 resection. Neoadjuvant treatment probably offers the best chance of achieving successful R0 resection and long-term survival, but the best treatment options should be determined in prospective randomised studies. Gemcitabine has for 15 years been the only validated therapy for advanced PC. Following decades of negative phase III studies, increasing evidence now suggests that further significant improvements to overall survival can be achieved via either Folfirinox or gemcitabine + nab-paclitaxel regimens. Progress in systemic therapy may improve the chances of resection in borderline resectable pancreatic cancer (BRPC) or locally advanced PC. This requires first enhancing knowledge of the genetic events driving carcinogenesis, which may then be translated into clinical studies.
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Affiliation(s)
- Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Lorraine University, 6 avenue de Bourgogne, CS 30519, 54519, Vandoeuvre-lès-Nancy, France.
| | - Jean-Baptiste Bachet
- Department of Hepato-Gastroenterology, Pitié-Salpétrière University Hospital, 47-83 boulevard de l'hôpital, 75651, Paris Cedex 13, France
| | - Ahmet Ayav
- Department of Surgery, Nancy University Hospital Lorraine and Lorraine University, rue du Morvan, 54511, Vandoeuvre-lès Nancy, France
| | - Florence Huguet
- Department of Radiation Therapy, Tenon Hospital, Paris Est University Hospitals, 4 rue de la Chine, 75020, Paris, France
| | - Aurélien Lambert
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Lorraine University, 6 avenue de Bourgogne, CS 30519, 54519, Vandoeuvre-lès-Nancy, France
| | - Caroline Caramella
- Gustave Roussy Cancer Campus Grand Paris, 114 rue Edouard-Vaillant, 94805, Villejuif Cedex, France
| | - Raphaël Maréchal
- Department of Gastroenterology, Erasme University Hospital-ULB-Brussels, Lennikstreet 808, 1070, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Erasme University Hospital-ULB-Brussels, Lennikstreet 808, 1070, Brussels, Belgium
| | - Michel Ducreux
- Gustave Roussy Cancer Campus Grand Paris, 114 rue Edouard-Vaillant, 94805, Villejuif Cedex, France
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252
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Pancreatic neck cancer has specific and oncologic characteristics regarding portal vein invasion and lymph node metastasis. Surgery 2016; 159:426-40. [DOI: 10.1016/j.surg.2015.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/23/2015] [Accepted: 07/01/2015] [Indexed: 01/08/2023]
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253
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Oliver JB, Son JY, Bongu A, Anandalwar SP, Chokshi RJ. Colorectal Cancer Disparities at an Urban Tertiary Care Center. Am Surg 2016. [DOI: 10.1177/000313481608200225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph B. Oliver
- Department of Surgery New Jersey Medical School Rutgers University Newark, New Jersey
| | - Julie Y. Son
- Department of Surgery New Jersey Medical School Rutgers University Newark, New Jersey
| | - Advaith Bongu
- Department of Surgery New Jersey Medical School Rutgers University Newark, New Jersey
| | - Seema P. Anandalwar
- Department of Surgery New Jersey Medical School Rutgers University Newark, New Jersey
| | - Ravi J. Chokshi
- Division of Surgical Oncology New Jersey Medical School Rutgers University Newark, New Jersey
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254
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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.
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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
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Zhang M, Fang R, Mou Y, Chen R, Xu X, Zhang R, Yan J, Jin W, Ajoodhea H. LDP vs ODP for pancreatic adenocarcinoma: a case matched study from a single-institution. BMC Gastroenterol 2015; 15:182. [PMID: 26695506 PMCID: PMC4687064 DOI: 10.1186/s12876-015-0411-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 12/10/2015] [Indexed: 12/31/2022] Open
Abstract
Background Laparoscopic distal pancreatectomy (LDP) showed advantage of perioperation outcomes for benign and low-grade tumor of the pancreas. The application of LDP for pancreatic ductal adenocarcinoma (PDAC) didn’t gain popular acceptance and the number of LDP for PDAC remains low. We designed a case-matched study to analysis the short- and long-term outcomes of the patients undergoing either Laparoscopic distal pancreatectomy or open distal pancreatectomy for PDAC. Method From 2003 to 2013, 17 patients were underwent LDP and 34 patients were underwent ODP for PDAC were matched by tumor size, age and body mass index (BMI). The two groups’ demographic information, perioperative outcomes and survival data were compared. Results Baseline characteristics were comparable between the LDP and ODP groups. The intraoperative blood loss, first flatus, first oral intake and postoperative hospital stay were significantly less in LDP group than ODP group (50 ml vs400ml, P = 0.000; 3d vs 4d, P = 0.001; 3d vs 4d, P = 0.003; 13d vs 15.5d, P = 0.022). The mean operation time, overall postoperative morbidity and postoperative pancreatic fistula rates were similar in the two groups. 5 patients (29.4 %) in LDP group and 7 patients (20.6 %) in ODP group underwent extended resections. There were no significant differences in tumor sizes (3.5 cm vs 3.9 cm, P = 0.664) and number of harvested lymph nodes (9 vs8 P = 0.534). The median overall survival for both groups was 14.0 months. Cox proportional hazards analysis showed extended resections, R1 resection, perineural invasion and tumor differentiation were associated with worse survival. Conclusion LDP is technically feasible and safe for PDAC in selected patients and the short-term oncologic outcomes were not inferior to ODP in this small sample study. However the long-term oncologic safety of LDP for PDAC has to be further evaluated by multicenter or randomized controlled trials.
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Affiliation(s)
- Miaozun Zhang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Ren Fang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Yiping Mou
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China.
| | - Ronggao Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Xiaowu Xu
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China.
| | - Renchao Zhang
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China.
| | - Jiafei Yan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Weiwei Jin
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
| | - Harsha Ajoodhea
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
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256
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Mendoza AS, Han HS, Yoon YS, Cho JY, Choi Y. Laparoscopy-assisted pancreaticoduodenectomy as minimally invasive surgery for periampullary tumors: a comparison of short-term clinical outcomes of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:819-24. [PMID: 26455716 DOI: 10.1002/jhbp.289] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/07/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few reports have described laparoscopy-assisted pancreaticoduodenectomy (LAPD) as an alternative to the conventional open approach for periampullary tumors. The safety and feasibility of this procedure remain to be determined. In this study, we compared the short-term clinical outcomes of LAPD with those of open pancreaticoduodenectomy (OPD). METHODS A retrospective review of patients who had undergone pancreaticoduodenectomy for periampullary tumors between June and December 2014 was conducted. Patient demographic data and their pathological and short-term clinical parameters were compared between the LAPD and OPD groups. RESULTS Fifty-two patients were included in the study: 18 had undergone LAPD and 34 had undergone OPD. The mean operation time was longer for LAPD than for OPD (531.1 vs. 383.2 min, P < 0.001). The estimated blood loss, rate of blood transfusion, surgical resection margin status, and number of lymph nodes retrieved were similar in both groups. Overall morbidity and the incidence of pancreatic fistula did not differ significantly between the two groups. However, the mean length of hospital stay was significantly shorter in the LAPD group (12.6 vs. 18.6 days, P = 0.001). CONCLUSION LAPD is a technically safe and feasible alternative treatment for periampullary tumors, with short-term clinical outcomes equivalent to those of OPD, with a shorter hospital stay.
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Affiliation(s)
- Arturo S Mendoza
- Department of Surgery, University of Santo Tomas Hospital, Manila, Philippines
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea
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257
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Nussbaum DP, Adam MA, Youngwirth LM, Ganapathi AM, Roman SA, Tyler DS, Sosa JA, Blazer DG. Minimally Invasive Pancreaticoduodenectomy Does Not Improve Use or Time to Initiation of Adjuvant Chemotherapy for Patients With Pancreatic Adenocarcinoma. Ann Surg Oncol 2015; 23:1026-33. [PMID: 26542590 DOI: 10.1245/s10434-015-4937-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND The modifiable variable best proven to improve survival after resection of pancreatic adenocarcinoma is the addition of adjuvant chemotherapy. A theoretical advantage of minimally invasive pancreaticoduodenectomy (MI-PD) is the potential for greater use and earlier initiation of adjuvant therapy, but this benefit remains unproven. METHODS The 2010-2012 National Cancer Data Base (NCDB) was queried for patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Subjects were classified as MI-PD versus open pancreaticoduodenectomy (O-PD). Baseline variables were compared between groups. The independent effect of surgical approach on the use and timing of adjuvant chemotherapy was estimated using multivariable regression analyses. RESULTS For this study, 7967 subjects were identified: 1191 MI-PD (14.9%) and 6776 O-PD (85.1%) patients. Patients who underwent MI-PD were more likely to have been treated at academic hospitals. Otherwise, the groups had no baseline differences. In both the MI-PD and O-PD groups, approximately 50% of the patients received adjuvant chemotherapy, initiated at a median of 54 versus 55 days postoperatively (p = 0.08). After multivariable adjustment, surgical approach was not independently associated with use (odds ratio 1.00; p = 0.99) or time to initiation of adjuvant chemotherapy (-2.3 days; p = 0.07). Younger age, insured status, lower comorbidity score, higher tumor stage, and the presence of lymph node metastases were independently associated with the use of adjuvant chemotherapy. CONCLUSIONS At a national level, MI-PD does not result in greater use or earlier initiation of adjuvant chemotherapy. As surgeons and institutions continue to gain experience with this complex procedure, it will be important to revisit this benchmark as a justification for its increasing use for patients with pancreatic cancer.
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Affiliation(s)
| | | | | | | | | | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Julie A Sosa
- Department of Surgery, Duke University, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University, Durham, NC, USA
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258
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Quel traitement adjuvant de l’adénocarcinome du pancréas aujourd’hui : quelles perspectives ? ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2558-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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259
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Adénocarcinomes pancréatiques « localisés »: limites de la « résécabilité »; principes et résultats des résections. ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2557-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Yu M, Ma YM, Chen HL, Liu J, Fang XL. Application of inhibitors of differentiation 2 and 3 for evaluation of chemotherapy efficacy in liver cancer. Shijie Huaren Xiaohua Zazhi 2015; 23:4499-4506. [DOI: 10.11569/wcjd.v23.i28.4499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the influence of surgery alone and in combination with postoperative adjuvant chemotherapy on tumor markers, inhibitor of differentiation 2 (ID2), ID3 and survival time in patients with liver cancer, analyze the influence of ID2 and ID3 on the invasion and metastasis of liver cancer, and explore the feasibility of detection of ID2 and ID3 expression in evaluating efficacy of postoperative adjuvant chemotherapy.
METHODS: This was a 1:1 matched case-control study. ELISA was used to detect the levels of tumor markers, ID2 and ID3 in the serum of patients. Western blot was used to detect the protein expression levels of ID2 and ID3 in tumor tissues and adjacent tissues. Transwell assay was used to detect the invasion and metastasis of liver cancer cells. The correlation between the content of AFP and the expression levels of ID2 and ID3 was statistically analyzed.
RESULTS: The tumor markers CEA, CA50, AFP, and CA242 as well as ID2 and ID3 in the serum decreased significantly and the survival time was longer in patients receiving surgery with postoperative adjuvant chemotherapy when compared with patients receiving surgery alone (P < 0.05). The protein expression levels of ID2 and ID3 were decreased in the adjacent normal tissues compared with the liver cancer tissues (P < 0.05). Transwell analysis indicated that ID2 and ID3 knockdown inhibited the invasion and metastasis ability of HepG2 cells while overexpression of ID2 and ID3 promoted the invasion and metastasis of HepG2 cells (P < 0.05). There was a positive correlation between the content of AFP and the expression levels of ID2 and ID3 (rID2 = 0.881, rID3 = 0.928, P < 0.05).
CONCLUSION: ID2 and ID3 have similar effects to liver tumor markers, and the increased expression of ID2 and ID3 indicates greater invasion and metastasis ability of HepG2 cells and shorter survival time in patients with liver cancer. ID2 and ID3 expression might be used for clinical evaluation of efficacy of postoperative adjuvant chemotherapy.
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261
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Shrikhande SV, Sivasanker M. Laparoscopic pancreatoduodenectomy: How far have we come and where are we headed? World J Gastrointest Surg 2015; 7:128-132. [PMID: 26328031 PMCID: PMC4550838 DOI: 10.4240/wjgs.v7.i8.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/29/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023] Open
Abstract
Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure has been described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon’s experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.
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262
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Neuzillet C, Tijeras-Raballand A, Bourget P, Cros J, Couvelard A, Sauvanet A, Vullierme MP, Tournigand C, Hammel P. State of the art and future directions of pancreatic ductal adenocarcinoma therapy. Pharmacol Ther 2015; 155:80-104. [PMID: 26299994 DOI: 10.1016/j.pharmthera.2015.08.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/17/2015] [Indexed: 12/12/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second cause of cancer-related death in 2030. PDAC is the poorest prognostic tumor of the digestive tract, with 80% of patients having advanced disease at diagnosis and 5-year survival rate not exceeding 7%. Until 2010, gemcitabine was the only validated therapy for advanced PDAC with a modest improvement in median overall survival as compared to best supportive care (5-6 vs 3 months). Multiple phase II-III studies have used various combinations of gemcitabine with other cytotoxics or targeted agents, most in vain, in attempt to improve this outcome. Over the past few years, the landscape of PDAC management has undergone major and rapid changes with the approval of the FOLFIRINOX and gemcitabine plus nab-paclitaxel regimens in patients with metastatic disease. These two active combination chemotherapy options yield an improved median overall survival (11.1 vs 8.5 months, respectively) thus making longer survival a reasonably achievable goal. This breakthrough raises some new clinical questions about the management of PDAC. Moreover, better knowledge of the environmental and genetic events that underpin multistep carcinogenesis and of the microenvironment surrounding cancer cells in PDAC has open new perspectives and therapeutic opportunities. In this new dynamic context of deep transformation in basic research and clinical management aspects of the disease, we gathered updated preclinical and clinical data in a multifaceted review encompassing the lessons learned from the past, the yet unanswered questions, and the most promising research priorities to be addressed for the next 5 years.
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Affiliation(s)
- Cindy Neuzillet
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Digestive Oncology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Medical Oncology, Henri Mondor University Hospital, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - Annemilaï Tijeras-Raballand
- Department of Translational Research, AAREC Filia Research, 1 place Paul Verlaine, 92100 Boulogne-Billancourt, France
| | - Philippe Bourget
- Department of Clinical Pharmacy, Necker-Enfants Malades University Hospital, 149 Rue de Sèvres, 75015 Paris, France
| | - Jérôme Cros
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Pathology, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Anne Couvelard
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Pathology, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Alain Sauvanet
- Department of Biliary and Pancreatic Surgery, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Marie-Pierre Vullierme
- Department of Radiology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Christophe Tournigand
- Department of Medical Oncology, Henri Mondor University Hospital, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Pascal Hammel
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Digestive Oncology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
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Labori KJ, Katz MH, Tzeng CW, Bjørnbeth BA, Cvancarova M, Edwin B, Kure EH, Eide TJ, Dueland S, Buanes T, Gladhaug IP. Impact of early disease progression and surgical complications on adjuvant chemotherapy completion rates and survival in patients undergoing the surgery first approach for resectable pancreatic ductal adenocarcinoma - A population-based cohort study. Acta Oncol 2015; 55:265-77. [PMID: 26213211 DOI: 10.3109/0284186x.2015.1068445] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/24/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Multimodality treatment (MMT) improves survival for patients with pancreatic ductal adenocarcinoma (PDAC). The surgery-first (SF) strategy is the most universally accepted approach. MATERIAL AND METHODS Population-based retrospective cohort study of all cases of resectable PDAC from 2006 to 2012. Patients were planned for adjuvant chemotherapy (AC) with the Nordic 5-fluorouracil/leucovorin regimen. Reasons for and rates of failure to complete AC, postoperative major complications (PMC), and overall survival (OS) were analysed. RESULTS Of 203 patients, 85 (41.9%) completed AC, 41 (20.2%) failed to complete AC, and 77 (37.9%) never initiated AC. Primary reasons for not initiating or completing AC were early disease progression (34.7%), postoperative complications/poor performance status (32.2%), and age > 75 years (24.6%). Median OS in the whole cohort was 17.0 months, and 20.0 months in patients who initiated AC. Median OS in patients who completed AC was higher than in patients who did not (25.0 months vs. 12.0 months, p < 0.001). PMC (n = 41) were associated with decreased initiation rate (p < 0.001) and completion rate (p = 0.007) of AC, and decreased median OS (11.0 months vs. 19.0 months, p = 0.028). Among patients with R1 resection, PMC again were associated with worse median OS (8.0 months vs. 16.0 months, p = 0.028). Multivariate analysis demonstrated that completion of MMT and tumour grade (G1/G2) were related to mortality rate (p < 0.001). Mortality risk for patients who completed AC was reduced also when adjusting for competing risk (SHR 0.426, p < 0.001). CONCLUSIONS MMT completion is strongly associated with reduced mortality risk in patients with resectable PDAC undergoing the SF approach. Early disease progression and PMC/poor performance status preclude MMT completion in more than one third of the patients. These reasons for failure to complete MMT underscore the need for strategies to improve patient selection and reduce surgical morbidity in patients with resectable PDAC.
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Affiliation(s)
- Knut J Labori
- a Department of Hepato-Pancreato-Biliary Surgery , Oslo University Hospital , Oslo , Norway
| | - Matthew H Katz
- b Department of Surgical Oncology , The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Ching W Tzeng
- c Department of Surgery , University of Kentucky , Lexington, Kentucky , USA
| | - Bjørn A Bjørnbeth
- a Department of Hepato-Pancreato-Biliary Surgery , Oslo University Hospital , Oslo , Norway
| | - Milada Cvancarova
- d Department of Oncology , National Resource Center for Late Effects, Oslo University Hospital , Oslo , Norway
| | - Bjørn Edwin
- e Intervention Centre, Rikshospitalet, Oslo University Hospital , Oslo , Norway
- f Institute of Clinical Medicine, University of Oslo , Oslo , Norway
| | - Elin H Kure
- g Department of Genetics , Institute for Cancer Research, Oslo University Hospital , Oslo , Norway
| | - Tor J Eide
- f Institute of Clinical Medicine, University of Oslo , Oslo , Norway
- h Department of Pathology , Oslo University Hospital , Oslo , Norway
| | - Svein Dueland
- i Department of Oncology , Oslo University Hospital , Oslo , Norway
| | - Trond Buanes
- a Department of Hepato-Pancreato-Biliary Surgery , Oslo University Hospital , Oslo , Norway
- f Institute of Clinical Medicine, University of Oslo , Oslo , Norway
| | - Ivar P Gladhaug
- a Department of Hepato-Pancreato-Biliary Surgery , Oslo University Hospital , Oslo , Norway
- f Institute of Clinical Medicine, University of Oslo , Oslo , Norway
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Trueba-Arguiñarena FJ, de Prado-Otero DS, Poves-Alvarez R. Pancreatic Adenocarcinoma Treated With Irreversible Electroporation Case Report: First Experience and Outcome. Medicine (Baltimore) 2015; 94:e946. [PMID: 26131840 PMCID: PMC4504632 DOI: 10.1097/md.0000000000000946] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Irreversible electroporation (IRE) is a new nonthermal tumor ablation modality that induces apoptosis in the treated tissue without affecting collagen. Its use is particularly indicated for tumors involving major structures, such as encompassed or infiltrated vessels and/or ducts, which need to be preserved and hinder or preclude surgical resection. We report a 66-year-old male patient with locally advanced pancreatic adenocarcinoma, treated with IRE.Two cycles of neoadjuvant chemotherapy with nab-paclitaxel and gemcitabine were administered. After these 2 cycles, IRE ablation was performed with a percutaneous transgastric access under general anesthesia. Later, 4 additional chemotherapy cycles were administrated. At 48 hours of electroporation, blood tests were normal. On day 5, a computed tomography (CT) scan showed portal vein and celiac artery were normal in appearance. Three months later, a positron emission tomography (PET) scan showed disappearance of abnormal uptake in the pancreas and other sites. A 12-month follow-up the patient is disease free.IRE opens a new way to treat tumors with involvement or proximity of neighboring structures. This procedure is more costly than other techniques and is not free of complications. The percutaneous transgastric access is feasible and without serious complications. In our case, complications were resolved and the patient presented a good short/medium-term outcome.
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Affiliation(s)
- Francisco Javier Trueba-Arguiñarena
- From the Department of Radiodiagnosis (FJT-A); Department of Oncology (DSDP-O); and Department of Anesthesia and Postoperative Care, University Clinical Hospital, Valladolid, Spain (RP-A)
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265
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Barreto SG, Singh MK, Sharma S, Chaudhary A. Determinants of Surgical Site Infections Following Pancreatoduodenectomy. World J Surg 2015; 39:2557-63. [DOI: 10.1007/s00268-015-3115-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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266
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Uemura K, Murakami Y, Satoi S, Sho M, Motoi F, Kawai M, Matsumoto I, Honda G, Kurata M, Yanagimoto H, Nishiwada S, Fukumoto T, Unno M, Yamaue H. Impact of Preoperative Biliary Drainage on Long-Term Survival in Resected Pancreatic Ductal Adenocarcinoma: A Multicenter Observational Study. Ann Surg Oncol 2015; 22 Suppl 3:S1238-46. [PMID: 26014151 DOI: 10.1245/s10434-015-4618-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to evaluate the impact of preoperative biliary drainage (PBD) on the long-term survival of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy (PD). METHODS A multicenter observational study was performed using a common database of patients with resected PDAC from seven high-volume surgical institutions in Japan. RESULTS Of 932 patients who underwent PD for PDAC, 573 (62 %) underwent PBD, including 407 (44 %) who underwent endoscopic biliary drainage (EBD) and 166 (18 %) who underwent percutaneous transhepatic biliary drainage (PTBD). The patients who did not undergo PBD and those who underwent EBD had a significantly better overall survival than those who underwent PTBD, with median survival times of 25.7 months (P < 0.001), 22.3 months (P = 0.001), and 16.7 months, respectively. Multivariate analysis showed that seven clinicopathologic factors, including the use of PTBD but not EBD, were independently associated with poorer overall survival. Furthermore, patients who underwent PTBD more frequently experienced peritoneal recurrence (23 %) than those who underwent EBD (10 %; P < 0.001) and those who did not undergo PBD (11 %; P = 0.001). Multivariate analysis demonstrated that the independent risk factors for peritoneal recurrence included surgical margin status (P < 0.001) and use of PTBD (P = 0.004). CONCLUSIONS Use of PTBD, but not EBD, was associated with a poorer prognosis, with an increased rate of peritoneal recurrence among patients who underwent PD for PDAC.
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Affiliation(s)
- Kenichiro Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Fuyuhiko Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Ippei Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masanao Kurata
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | | | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Michiakil Unno
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
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267
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Optimal indication of neoadjuvant chemoradiotherapy for pancreatic cancer. Langenbecks Arch Surg 2015; 400:477-85. [PMID: 25929828 DOI: 10.1007/s00423-015-1304-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/20/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Much attention has been paid to preoperative treatment as a new strategy especially for borderline resectable pancreatic cancer (BRPC). The purpose of this study was to define the optimal indication of neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer. METHODS We analyzed consecutive 184 patients who had undergone pancreatic resection in Nara Medical University Hospital. Resectability status was classified by NCCN guidelines. Full-dose gemcitabine with concurrent radiation was used as NACRT. We evaluated 85 patients treated with NACRT in comparison with 99 patients without NACRT as control. RESULTS The regimen of NACRT was well tolerated and feasible. The perioperative outcomes were almost comparable. The postoperative complications were significantly less frequent in NACRT group than non-NACRT group. The pathological effects on both resectable and borderline tumors were favorable in NACRT group compared to non-NACRT group. The overall survival of resectable pancreatic cancer was significantly better than that of BRPC regardless of whether the patients were treated with or without NACRT. The prognosis of the patients with NACRT in resectable tumors was significantly better than without, while there was no significant difference in BRPC. Furthermore, multivariate analysis of various factors in the patients with NACRT identified resectability status and completion of adjuvant chemotherapy as independent prognostic factors. CONCLUSIONS NACRT did not improve the prognosis of the patients with BRPC, although it induced substantial pathological antitumor effect. In contrast, the prognosis of resectable pancreatic cancer treated with NACRT was favorable. Therefore, resectable pancreatic cancer may be good indication for multimodal treatment including NACRT.
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268
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Sho M, Akahori T, Tanaka T, Kinoshita S, Nagai M, Tamamoto T, Ohbayashi C, Hasegawa M, Kichikawa K, Nakajima Y. Importance of resectability status in neoadjuvant treatment for pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:563-70. [PMID: 25921623 DOI: 10.1002/jhbp.258] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Much attention has been paid to neoadjuvant treatment (NAT) as a new strategy especially for borderline resectable pancreatic cancer (BRPC). However, the optimal indication of NAT remains undetermined. METHODS We analyzed 248 patients with pancreatic cancer (PC). One hundred resectable tumors were classified as R group. Sixty-nine tumors with venous involvement were classified as BR-P group, while 31 tumors with arterial involvement were classified as BR-A group. Ninety-nine patients received NAT. Furthermore, 48 unresectable locally advanced PC served as controls (LAPC group). Among them, 11 patients received adjuvant surgery afterwards (Ad-surg group). RESULTS The overall median survival time in the R, BR-P and BR-A groups was 45.3, 24.8 and 16.8 months. In the R and BR-P groups, patients treated with NAT had a better prognosis than those without. In contrast, NAT had no impact on prognosis in the BR-A group. Patients treated with NAT in the BR-P, but not BR-A group, had a better prognosis than patients in the LAPC group. Furthermore, patients in the Ad-surg group had a significantly better prognosis than patients in the BR-A group. CONCLUSIONS Borderline resectable pancreatic cancer with venous involvement, but without arterial involvement, may be a good indication for NAT. Our data highlight the importance of preoperative resectability assessment to evaluate the indication and efficacy of NAT.
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Affiliation(s)
- Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoichi Kinoshita
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Chiho Ohbayashi
- Department of Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
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269
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Szmola R, Farkas G, Hegyi P, Czakó L, Dubravcsik Z, Hritz I, Kelemen D, Lásztity N, Morvay Z, Oláh A, Párniczky A, Rubovszky G, Sahin-Tóth M, Szentkereszti Z, Szücs Á, Takács T, Tiszlavicz L, Pap Á. [Pancreatic cancer. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. Orv Hetil 2015; 156:326-39. [PMID: 25662149 DOI: 10.1556/oh.2015.30063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.
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Affiliation(s)
- Richárd Szmola
- Országos Onkológiai Intézet Intervenciós Gasztroenterológiai Részleg Budapest Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
| | - Gyula Farkas
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Sebészeti Klinika Szeged
| | - Péter Hegyi
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged MTA-SZTE Lendület Gasztroenterológiai Multidiszciplináris Kutatócsoport Szeged
| | - László Czakó
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged
| | | | - István Hritz
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged Bács-Kiskun Megyei Kórház Gasztroenterológia Kecskemét
| | - Dezső Kelemen
- Pécsi Tudományegyetem, Általános Orvostudományi Kar Klinikai Központ, Sebészeti Klinika Pécs
| | | | - Zita Morvay
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Radiológiai Klinika Szeged
| | - Attila Oláh
- Petz Aladár Megyei Oktató Kórház Sebészeti Osztály Győr
| | | | - Gábor Rubovszky
- Országos Onkológiai Intézet B Belgyógyászati-Onkológiai és Klinikai Farmakológiai Osztály Budapest
| | - Miklós Sahin-Tóth
- Boston University Henry M. Goldman School of Dental Medicine Department of Molecular and Cell Biology Boston Massachusetts USA
| | - Zsolt Szentkereszti
- Debreceni Egyetem, Általános Orvostudományi Kar, Orvos- és Egészségtudományi Centrum Sebészeti Klinika Debrecen
| | - Ákos Szücs
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest
| | - Tamás Takács
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ I. Belgyógyászati Klinika Szeged
| | - László Tiszlavicz
- Szegedi Tudományegyetem, Általános Orvostudományi Kar, Szent-Györgyi Albert Klinikai Központ Pathologiai Intézet Szeged
| | - Ákos Pap
- Péterfy Sándor utcai Kórház-Rendelőintézet Budapest
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Seufferlein T, Porzner M, Heinemann V, Tannapfel A, Stuschke M, Uhl W. Ductal pancreatic adenocarcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:396-402. [PMID: 24980565 DOI: 10.3238/arztebl.2014.0396] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ductal adenocarcinoma of the pancreas is the fourth most common cause of death from cancer in men and women in Germany: about 15 000 persons die of this disease each year. METHOD The S3 guideline on exocrine pancreatic carcinoma was updated with the aid of systematic literature reviews on the surgical, neoadjuvant, and adjuvant treatment of ductal pancreatic carcinoma, and on treatment in the metastatic stage. These reviews covered the periods 2002 to February 2012 (for radiotherapy) and 2006 to August 2011 (for all other topics). RESULTS The criteria for borderline resectable pancreatic tumors are the same as those of the guidelines of the National Comprehensive Cancer Network. Preoperative biliary drainage with a stent is recommended only if cholangitis is present or if a planned operation cannot be performed soon after the diagnosis is made. When a pancreatic carcinoma is resected, at least 10 regional lymph nodes should be excised, and the ratio of affected to excised nodes should be documented in the pathology report. Gemcitabine and 5-fluorouracil are recommended for adjuvant therapy. Neither of these drugs is preferred over the other; if the one initially given is poorly tolerated, the other one should be given instead. When gemcitabine and erlotinib are given for palliative treatment, erlotinib should be given for no longer than 8 weeks if no skin rash develops. In selected patients, the folfirinox protocol yields markedly better results than gemcitabin. Moreover, the new combination of nab-paclitaxel and gemcitabine can be used as first-line treatment. In the event of disease progression under first-line treatment, second-line treatment should be initiated. CONCLUSION In recent years, new chemotherapeutic protocols have brought about marked improvement in palliative care. Further trials are needed to determine whether the perioperative or adjuvant use of these protocols might also improve the outcome of surgical treatment with curative intent.
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Affiliation(s)
- Thomas Seufferlein
- Ulm University Hospital Medical Center, Department of Internal Medicine I, Medical Clinic III, Department of Hematology & Oncology, Großhadern Hospital, Ludwig-Maximilian-¬Universität, Munich, Institute of Pathology, Ruhr-University Bochum, Radiation and Tumor Clinic, University Hospital of Duisburg-Essen, Surgical Clinic at the St. Josef-Hospital, Ruhr-University Bochum
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271
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Kinoshita S, Sho M, Yanagimoto H, Satoi S, Akahori T, Nagai M, Nishiwada S, Yamamoto T, Hirooka S, Yamaki S, Ikeda N, Kwon AH, Nakajima Y. Potential role of surgical resection for pancreatic cancer in the very elderly. Pancreatology 2015; 15:240-6. [PMID: 25888010 DOI: 10.1016/j.pan.2015.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is increasing need to evaluate the surgical indication of pancreatic cancer in very elderly patients. However, the available clinical data are limited, and the optimal treatment is still controversial. The aim of this study was to evaluate the benefit of pancreatic resection in pancreatic cancer patients over the age of 80. METHODS Between 2005 and 2012, 26 octogenarian patients who received pancreatic resection and 20 who received chemotherapy for pancreatic cancer were retrospectively reviewed. Clinicopathological factors, chemotherapy administration status, and survival were compared. Univariate and multivariate analysis of prognostic factors for survival was performed. RESULTS Postoperative major complication rate was 8%, with no mortality. The one-year survival rate and median survival time of the surgery and chemotherapy groups were 50% and 45%, and 12.4 months and 11.7 months, respectively (P = 0.263). Of the 26 resected cases, 6 completed the planned adjuvant chemotherapy treatment course. The median survival time of those 6 completed cases was significantly longer than that of the 20 not completed cases (23.4 versus 10.0 months, P = 0.034). Furthermore, a multivariate analysis of the 26 resected cases showed that distant metastasis (HR 3.206, 95%CI 1.005-10.22, P = 0.049) and completion of the planned adjuvant therapy (HR 4.078, 95%CI 1.162-14.30, P = 0.028) were independent prognostic factors of surgical resection. CONCLUSIONS Surgical resection was safe, but not superior to chemotherapy for pancreatic cancer in octogenarians. In the very elderly, only selected patients may benefit from pancreatic resection.
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Affiliation(s)
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Japan.
| | | | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Japan
| | | | - Minako Nagai
- Department of Surgery, Nara Medical University, Japan
| | | | | | | | - So Yamaki
- Department of Surgery, Kansai Medical University, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Prefecture Western Medical Center, Japan
| | - A-Hon Kwon
- Department of Surgery, Kansai Medical University, Japan
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272
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Patel AA, Nagarajan S, Scher ED, Schonewolf CA, Balasubramanian S, Poplin E, Moss R, August D, Carpizo D, Melstrom L, Jabbour SK. Early vs. Late Chemoradiation Therapy and the Postoperative Interval to Adjuvant Therapy Do Not Correspond to Local Recurrence in Resected Pancreatic Cancer. ACTA ACUST UNITED AC 2015; 5. [PMID: 26779392 PMCID: PMC4712931 DOI: 10.4172/2165-7092.1000151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective Standard postoperative therapy for pancreatic cancer consists of both chemotherapy alone and chemoradiation. We sought to investigate whether the sequence of chemotherapy and chemoradiation and overall time to initiation of adjuvant therapy would impact local vs. distant recurrence. Methods After Institutional Review Board approval, resected pancreas cancer patient charts were evaluated for medical background, surgical, pathological, chemoradiation (CRT), and follow-up. Local recurrence (LR) was defined as failures occurring in the postoperative bed and regional lymph nodes. Early vs. late CRT was defined by whether CRT was given early (within 1–2 cycles of adjuvant chemotherapy) or late in the course of adjuvant chemotherapy (after the 3rd cycle of chemotherapy). The postoperative interval variance was compared to LR factors such as progression-free survival (PFS) and overall survival (OS). Results Of the 34 eligible patients, 47% (n=16) underwent early CRT and 41% (n=14) underwent late CRT. 12% (n=14) did not undergo any induction chemotherapy. At median follow-up of 22 months, 53% (n=18) had metastases, 24% (n=8) had LR, and 24% (n=8) were disease free. Kaplan-Meier curves revealed that early vs. late CRT did not appear to significantly impact OS (p=0.63), PFS (p=0.085) or LR (p=0.19). Postoperative interval did not affect PFS (p=0.42) or OS (p=0.93). Conclusions Early vs. late CRT and the time to initiation of adjuvant therapy were not significantly associated with LR in patients with resected pancreatic cancer. Future prospective studies are required to determine if sequencing of chemotherapy, CRT, or the postoperative interval impact survival and patterns of recurrence.
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Affiliation(s)
- Ajay A Patel
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
| | - Sairaman Nagarajan
- Center on Genomics, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Eli D Scher
- Rowan University School of Osteopathic Medicine, Stratford NJ, USA
| | - Caitlin Ab Schonewolf
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA; Department of Radiation Oncology, University of Pennsylvania, Philadelphia PA, USA
| | - Sairam Balasubramanian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
| | - Elizabeth Poplin
- Department of Medicine, Division of Medical Oncology, Cancer Institute of New Jersey
| | - Rebecca Moss
- Department of Medicine, Division of Medical Oncology, Cancer Institute of New Jersey
| | - David August
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Darren Carpizo
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Laleh Melstrom
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, State University of New Jersey, USA
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Shimoda M, Kubota K, Shimizu T, Katoh M. Randomized clinical trial of adjuvant chemotherapy with S-1 versus gemcitabine after pancreatic cancer resection. Br J Surg 2015; 102:746-54. [PMID: 25833230 DOI: 10.1002/bjs.9775] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/21/2014] [Accepted: 12/16/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Randomized studies of adjuvant chemotherapy using gemcitabine suggest a survival benefit after resection of pancreatic cancer. S-1 has also been shown to prolong survival in patients with unresectable pancreatic cancer. This study compared the effects of adjuvant chemotherapy with S-1 or gemcitabine after resection of pancreatic cancer in a randomized trial. METHODS Patients who had undergone resection of pancreatic cancer were registered in this randomized clinical trial. The primary endpoint was disease-free survival (DFS). Expression levels of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) mRNAs in cancer tissues were measured as indicators of fluoropyrimidine sensitivity. RESULTS Of 57 patients registered, 29 were allocated to the S-1 group and 28 to gemcitabine. DFS tended to be better with S-1 (median 14·6 (90 per cent c.i. 8·8 to 28·4) months versus 10·5 (7·0 to 28·4) months in the gemcitabine group; P = 0·188), with a similar pattern for overall survival: 21·5 (95 per cent c.i. 14·4 to 42·3) and 18·0 (13·3 to 42·8) months respectively (P = 0·293). When patients were divided into subgroups based on high or low DPD and TS expression, those with a DPD level below the median of 0·88 or a TS level of at least 2·00 had a significant prolongation of DFS after S-1 treatment compared with gemcitabine (P = 0·008 and P = 0·035 respectively). CONCLUSION Overall, S-1 did not improve DFS compared with gemcitabine after pancreatic cancer resection, but there seemed to be a DFS advantage in patients with low expression of DPD or high expression of TS. Reference number: UMIN000009118 (http://www.umin.ac.jp/ctr/).
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Affiliation(s)
- M Shimoda
- Second Department of Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi 321-0293, Japan
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274
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Ricci C, Casadei R, Taffurelli G, Toscano F, Pacilio CA, Bogoni S, D'Ambra M, Pagano N, Di Marco MC, Minni F. Laparoscopic versus open distal pancreatectomy for ductal adenocarcinoma: a systematic review and meta-analysis. J Gastrointest Surg 2015; 19:770-81. [PMID: 25560180 DOI: 10.1007/s11605-014-2721-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy was proposed as an oncologically safe approach for pancreatic ductal adenocarcinoma. METHODS A systematic review of the studies comparing laparoscopic and open distal pancreatectomy was conducted. The primary endpoint was an R0 resection rate. The secondary endpoints were intra- and postoperative results, tumour size, mean harvested lymph node, number of patients eligible for adjuvant therapy and overall survival. RESULTS Five comparative case control studies involving 261 patients (30.7% laparoscopic and 69.3% open) who underwent a distal pancreatectomy were included. The R0 resection rate was similar between the two groups (P = 0.53). The laparoscopic group had longer operative times (P = 0.04), lesser blood loss (P = 0.01), a shorter hospital stay (P < 0.001) and smaller tumour size (P = 0.04) as compared with the laparotomic group. Overall morbidity, postoperative pancreatic fistula, reoperation, mortality and number of patients eligible for adjuvant therapy were similar. The mean harvested lymph nodes were comparable in the two groups (P = 0.33). The laparoscopic approach did not affect the overall survival rate (P = 0.32). CONCLUSION Even if the number of patients compared is underpowered, the laparoscopic approach in the treatment of PDAC seems to be safe and efficacious. However, additional prospective, randomised, multicentric trials are needed to correctly evaluate the laparoscopic approach in PDAC.
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Affiliation(s)
- Claudio Ricci
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum-Università di Bologna, Policlinico S.Orsola-Malpighi Via Massarenti n, 9 40138, Bologna, Italy,
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275
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Sirohi B, Singh A, Dawood S, Shrikhande SV. Advances in chemotherapy for pancreatic cancer. Indian J Surg Oncol 2015; 6:47-56. [PMID: 25937764 PMCID: PMC4412866 DOI: 10.1007/s13193-014-0371-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 12/17/2014] [Indexed: 12/26/2022] Open
Abstract
Pancreatic cancer remains challenging to treat. Over the past decade, there have been some major improvements in systemic therapy. Gemcitabine remains the key drug for both early and advanced cancer but combination chemotherapy is emerging as a new paradigm for patients with good performance status. This review focuses on current chemotherapy status for patients with pancreatic cancer.
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Affiliation(s)
- Bhawna Sirohi
- />Department of Medical Oncology, Mazumdar Shaw Cancer Centre, Narayana Health, Bangalore, India
| | - Ashish Singh
- />Department of Medical Oncology, CMC, Vellore, India
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276
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Delpero JR, Boher JM, Sauvanet A, Le Treut YP, Sa-Cunha A, Mabrut JY, Chiche L, Turrini O, Bachellier P, Paye F. Pancreatic adenocarcinoma with venous involvement: is up-front synchronous portal-superior mesenteric vein resection still justified? A survey of the Association Française de Chirurgie. Ann Surg Oncol 2015; 22:1874-83. [PMID: 25665947 DOI: 10.1245/s10434-014-4304-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venous resection (VR) during pancreatectomy has been reported to neither increase mortality nor morbidity and to provide similar survival outcomes in same stage tumors. However, controversy remains regarding the indications for up-front surgery according to the degree of venous involvement. METHODS From 2004 to 2009, 1,399 patients included in a French multicenter survey underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic adenocarcinoma, either without VR (997 standard resections [SR]) or with VR (402 patients; 29 %). Postoperative and long-term outcomes were compared in both groups. RESULTS VR was associated with the following factors: larger tumors (p < 0.001), poorly differentiated tumors (p = 0.004), higher numbers of positive lymph nodes (p = 0.042), and positive resection margins (R1; p < 0.001). Overall, VR increased neither postoperative morbidity nor postoperative mortality (5 vs. 3 % in SR patients; p = 0.16). The median and 3-year survival rates in VR patients versus SR patients were 21 months and 31 % vs. 29 months and 44 %, respectively (p = 0.0002). In the entire cohort, multivariate analysis identified VR as a significant poor prognostic factor for long-term survival (hazard ratio [HR] 1.75, 95 % confidence interval [CI] 1.28-2.40; p = 0.0005). In the VR patients, lymph node ratio, whatever the cutoff (<0.3: p = 0.093; ≥ 0.3: p = 0.0098), R1 resection (p = 0.010), and segmental resection (p = 0.016) were independent risk factors; neoadjuvant treatment (HR 0.52, 95 % CI 0.29-0.94; p = 0.031) and adjuvant treatment (HR 0.55, 95 % CI 0.35-0.85; p = 0.006) were significantly associated with improved long-term survival. CONCLUSIONS Long-term survival after pancreatectomy was significantly altered when up-front VR was performed. Neoadjuvant treatment may be a better strategy than up-front resection in patients with preoperative suspicion of venous involvement.
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Affiliation(s)
- Jean Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Université de la Méditerranée, Marseille, France,
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277
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Combining clinicopathological predictors and molecular biomarkers in the oncogenic K-RAS/Ki67/HIF-1α pathway to predict survival in resectable pancreatic cancer. Br J Cancer 2015; 112:514-22. [PMID: 25584484 PMCID: PMC4453663 DOI: 10.1038/bjc.2014.659] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/25/2014] [Accepted: 12/10/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The dismal prognosis of patients diagnosed with pancreatic cancer points to our limited arsenal of effective anticancer therapies. Oncogenic K-RAS hyperactivation is virtually universal in pancreatic cancer, that confers drug resistance, drives aggressive tumorigenesis and rapid metastasis. Pancreatic tumours are often marked by hypovascularity, increased hypoxia and ineffective drug delivery. Thus, biomarker discovery and developing innovative means of countervailing oncogenic K-RAS activation are urgently needed. METHODS Tumour specimens from 147 pancreatic cancer patients were analysed by immunohistochemical (IHC) staining and tissue microarray (TMA). Statistical correlations between selected biomarkers and clinicopathological predictors were examined to predict survival. RESULTS We find that heightened hypoxia response predicts poor clinical outcome in resectable pancreatic cancer. SIAH is a tumour-specific biomarker. The combination of five biomarkers (EGFR, phospho-ERK, SIAH, Ki67 and HIF-1α) and four clinicopathological predictors (tumour size, pathological grade, margin and lymph node status) predict patient survival post surgery in pancreatic cancer. CONCLUSIONS Combining five biomarkers in the K-RAS/Ki67/HIF-1α pathways with four clinicopathological predictors may assist to better predict survival in resectable pancreatic cancer.
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278
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Hidalgo M, Cascinu S, Kleeff J, Labianca R, Löhr JM, Neoptolemos J, Real FX, Van Laethem JL, Heinemann V. Addressing the challenges of pancreatic cancer: future directions for improving outcomes. Pancreatology 2015; 15:8-18. [PMID: 25547205 DOI: 10.1016/j.pan.2014.10.001] [Citation(s) in RCA: 356] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 10/01/2014] [Accepted: 10/03/2014] [Indexed: 12/11/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC), which accounts for more than 90% of all pancreatic tumours, is a devastating malignancy with an extremely poor prognosis, as shown by a 1-year survival rate of around 18% for all stages of the disease. The low survival rates associated with PDAC primarily reflect the fact that tumours progress rapidly with few specific symptoms and are thus at an advanced stage at diagnosis in most patients. As a result, there is an urgent need to develop accurate markers of pre-invasive pancreatic neoplasms in order to facilitate prediction of cancer risk and to help diagnose the disease at an earlier stage. However, screening for early diagnosis of prostate cancer remains challenging and identifying a highly accurate, low-cost screening test for early PDAC for use in clinical practice remains an important unmet need. More effective therapies are also crucial in PDAC, since progress in identifying novel therapies has been hampered by the genetic complexity of the disease and treatment remains a major challenge. Presently, the greatest step towards improved treatment efficacy has been made in the field of palliative chemotherapy by introducing FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan and oxaliplatin) and gemcitabine/nab-paclitaxel. Strategies designed to raise the profile of PDAC in research and clinical practice are a further requirement in order to ensure the best treatment for patients. This article proposes a number of approaches that may help to accelerate progress in treating patients with PDAC, which, in turn, may be expected to improve the quality of life and survival for those suffering from this devastating disease.
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Affiliation(s)
- Manuel Hidalgo
- Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid, Spain.
| | - Stefano Cascinu
- Department of Medical Oncology, University of Ancona, Ancona, Italy
| | - Jörg Kleeff
- Department of General Surgery, Technische Universität München, Munich, Germany
| | | | - J-Matthias Löhr
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - John Neoptolemos
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Cancer Research UK Liverpool Clinical Trials Unit Director, University of Liverpool and Royal Liverpool University Hospital, Liverpool, UK
| | - Francisco X Real
- Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid and Universitat Pompeu Fabra, Barcelona, Spain
| | - Jean-Luc Van Laethem
- Department of Gastroenterology-GI Cancer Unit, Erasme University Hospital, Brussels, Belgium
| | - Volker Heinemann
- Comprehensive Cancer Centre Munich, Klinikum der Universität München, Munich, Germany
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279
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Joglekar S, Asghar A, Mott SL, Johnson BE, Button AM, Clark E, Mezhir JJ. Sarcopenia is an independent predictor of complications following pancreatectomy for adenocarcinoma. J Surg Oncol 2014; 111:771-5. [PMID: 25556324 DOI: 10.1002/jso.23862] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Sarcopenia, which is subclinical loss of skeletal muscle mass, is commonly observed in patients with malignancy. The objective of this study is to determine the correlation between sarcopenia and operative complications following pancreatectomy for cancer. METHODS A retrospective review of a pancreatectomy database was performed. The Hounsfield Unit Average Calculation (HUAC) of the psoas muscle, a marker of muscle density and fatty infiltration, was measured from preoperative CT scans. Complications were graded and multivariate logistic regression analysis was performed. RESULTS One hundred eighteen patients met criteria for analysis; the overall morbidity rate was 78.8% (n = 93). There were 31 (26.3%) patients who met criteria for sarcopenia using the HUAC. When analyzed as a continuous variable, sarcopenia was an independent predictor of major grade III complications, length of stay, intensive care unit admission, delayed gastric emptying, and infectious, gastrointestinal, pulmonary, and cardiac complications. CONCLUSIONS These data suggest that sarcopenia as measured with the HUAC, a value that can be obtained from a preoperative CT scan, is a significant independent predictor of surgical outcome and can be used to improve patient selection and informed consent prior to pancreatectomy in patients with cancer.
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Affiliation(s)
- Savita Joglekar
- Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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280
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Abstract
Pancreatic resection is a complex procedure that involves exposure of the retroperitoneal gland, dissection around major vascular structures, and management of an intricate organ, all of which results in a procedure associated with a high morbidity. The application of minimally invasive techniques to pancreatic resection have been studied only relatively recently. This analysis of the current concepts in minimally invasive pancreatic surgery focuses on a select look at currently published series or reviews from centers and groups that have the most experience with this procedure. We aim to present a comprehensive review gained from the experiences of those who are on the leading edge of the learning curve, with an emphasis on describing the similarities and differences between the minimally invasive and open pancreatic procedure. Minimally invasive distal pancreatectomy appears to be on the verge of widespread acceptance and shows clear benefits over its open counterpart. Minimally invasive proximal (right-sided) pancreatectomy, on the other hand, appears to be limited to select centers that have been able to demonstrate promising results despite its challenges. Additionally, minimally invasive central pancreatectomy and enucleation appear feasible as experience is gained in laparoscopic and robotic pancreatic resection.
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Affiliation(s)
- John A Stauffer
- Mayo College of Medicine, Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Mayo College of Medicine, Department of General Surgery, Mayo Clinic, Jacksonville, FL.
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281
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Abstract
The last two decades of research in the adjuvant setting of pancreas adenocarcinoma have established the value of adjuvant systemic therapy as being able to delay recurrence and increase overall survival. International standards of care in the adjuvant setting include either 6 months of gemcitabine or 5-fluorouracil and leucovorin. The added value of additional agents in the adjuvant setting is being evaluated in several large adjuvant studies. The role of a targeted agent in the adjuvant setting remains investigational. Other major areas of exploration include the integration of adjuvant immunotherapeutic approaches, which provide promise in a setting of micrometastatic disease volumes where such approaches may have greatest value.
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Affiliation(s)
- Daneng Li
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, NY.
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282
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Peixoto RD, Kumar A, Speers C, Renouf D, Kennecke HF, Lim HJ, Cheung WY, Melosky B, Gill S. Effect of delay in adjuvant oxaliplatin-based chemotherapy for stage III colon cancer. Clin Colorectal Cancer 2014; 14:25-30. [PMID: 25465343 DOI: 10.1016/j.clcc.2014.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/16/2014] [Accepted: 10/27/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Less than 8 weeks has been recommended as the optimal time to initiate AC based on 2 meta-analyses that suggested worse survival with delayed AC. However, neither study included patients treated with an oxaliplatin-based chemotherapy. We aimed to investigate the effect of delay in initiating oxaliplatin-based chemotherapy on RFS and CSS for stage III colon cancer. PATIENTS AND METHODS Records of patients who initiated oxaliplatin-based AC for stage III colon cancer between 2006 and 2011 at the British Columbia Cancer Agency were retrospectively reviewed. Cox proportional models were used to analyze the effect of time to AC (TTAC) on RFS and CSS. TTAC was categorized into ≤ 8 weeks (G1) and > 8 weeks (G2). RESULTS Six hundred thirty-five patients were included (G1, n = 291; G2, n = 344). Median time from surgery to initiation of AC was 8.3 weeks. At a median follow-up of 57.9 months, 176 patients (27.7%) had disease recurrence and 118 (18.6%) had died. Five-year RFS was 70.9% (95% confidence interval [CI], 65.2-76.5) for G1 and 72.1% (95% CI, 67.2-77) for G2. Five-year CSS was 82% for G1 (95% CI, 87.09-76.91) and 82.8% for G2 (95% CI, 78.30-87.30). On multivariate analysis, delayed TTAC did not have prognostic significance on either RFS (hazard ratio [HR], 1.08; P = .609) or CSS (HR, 1.02; P = .893). CONCLUSION In our population-based study, TTAC after stage III colon cancer resection did not have an effect on RFS or CSS. Contrary to most of the existing data, which are primarily based on 5-fluorouracil-based AC, delay of oxaliplatin-based AC beyond 8 weeks did not appear to be associated with inferior outcomes.
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Affiliation(s)
- Renata D'Alpino Peixoto
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
| | - Aalok Kumar
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Daniel Renouf
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Howard J Lim
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Barbara Melosky
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Sharlene Gill
- Division of Medical Oncology, University of British Columbia, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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283
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Serrano PE, Cleary SP, Dhani N, Kim PTW, Greig PD, Leung K, Moulton CA, Gallinger S, Wei AC. Improved long-term outcomes after resection of pancreatic adenocarcinoma: a comparison between two time periods. Ann Surg Oncol 2014; 22:1160-7. [PMID: 25348784 DOI: 10.1245/s10434-014-4196-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite reduced perioperative mortality and routine use of adjuvant therapy following pancreatectomy for pancreatic ductal adenocarcinoma (PDAC), improvement in long-term outcome has been difficult to ascertain. This study compares outcomes in patients undergoing resection for PDAC within a single, high-volume academic institution over two sequential time periods. METHODS Retrospective review of patients with resected PDAC, in two cohorts: period 1 (P1), 1991-2000; and period 2 (P2), 2001-2010. Univariate and multivariate analyses using the Cox proportional hazards model were performed to determine prognostic factors associated with long-term survival. Survival was evaluated using Kaplan-Meier analyses. RESULTS A total of 179 pancreatectomies were performed during P1 and 310 during P2. Perioperative mortality was 6.7 % (12/179) in P1 and 1.6 % (5/310) in P2 (p = 0.003). P2 had a greater number of lymph nodes resected (17 [0-50] vs. 7 [0-31]; p < 0.001), and a higher lymph node positivity rate (69 % [215/310] vs. 58 % [104/179]; p = 0.021) compared with P1. The adjuvant therapy rate was 30 % (53/179) in P1 and 63 % (195/310) in P2 (p < 0.001). By multivariate analysis, node and margin status, tumor grade, adjuvant therapy, and time period of resection were independently associated with overall survival (OS) for both time periods. Median OS was 16 months (95 % confidence interval [CI] 14-20) in P1 and 27 months (95 % CI 24-30) in P2 (p < 0.001). CONCLUSIONS Factors associated with improved long-term survival remain comparable over time. Short- and long-term survival for patients with resected PDAC has improved over time due to decreased perioperative mortality and increased use of adjuvant therapy, although the proportion of 5-year survivors remains small.
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Affiliation(s)
- Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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284
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Lee GC, Fong ZV, Ferrone CR, Thayer SP, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. High performing whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy. J Gastrointest Surg 2014; 18:1760-9. [PMID: 25091843 DOI: 10.1007/s11605-014-2604-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/21/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite the decreasing mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged length of postoperative hospital stay (LOS). This study aimed to determine factors that could predict short LOS after PD. Additionally, as preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume center to set a standard to which minimally invasive PD can be compared. METHODS A total of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at the Massachusetts General Hospital comprised the study cohort. "High performers" were defined as patients with postoperative LOS ≤5 days. RESULTS Median LOS was 7 days. A total of 61 patients (9.6%) had LOS ≤5 days and were deemed "high performing." In multivariate logistic regression analysis, male gender (p = 0.032), neoadjuvant chemoradiation (p = 0.001), epidural success (p = 0.019), epidural duration ≤3 days (p = 0.001), lack of complications (p < 0.001), surgery on Thursday or Friday (p = 0.001), and discharge on Monday through Wednesday (p < 0.001) were independently associated with LOS ≤5 days. Readmission rate, time to readmission, and mortality were not different between the two groups. The proportion of patients with pancreatic ductal adenocarcinoma who went on to receive adjuvant therapy was no different if LOS was ≤5 or >5 days, but high performance was predictive of beginning therapy <8 weeks after surgery (p = 0.010). CONCLUSION In our experience, median LOS was 7 days, and early discharge (≤5 days) after open PD is safe and feasible in about 10 % of patients. These high performers are more likely to be male, have received neoadjuvant therapy, and had successful epidural analgesia. High performers with cancer are more likely to start chemotherapy <8 weeks after surgery. Minimally invasive PD should be compared to this high standard for median LOS, among other quality metrics, to justify its increased cost, operative duration, and learning curve.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
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285
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Total Laparoscopic Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma. Ann Surg 2014; 260:633-8; discussion 638-40. [DOI: 10.1097/sla.0000000000000937] [Citation(s) in RCA: 351] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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286
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Wu W, He J, Cameron JL, Makary M, Soares K, Ahuja N, Rezaee N, Herman J, Zheng L, Laheru D, Choti MA, Hruban RH, Pawlik TM, Wolfgang CL, Weiss MJ. The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma. Ann Surg Oncol 2014; 21:2873-81. [PMID: 24770680 PMCID: PMC4454347 DOI: 10.1245/s10434-014-3722-6] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy (PD) for adenocarcinoma is still unclear. METHODS A retrospective review of all patients undergoing PD at our institution between 1995 and 2011 was performed. Clinicopathological data, including Clavien-Dindo complication grade, time to adjuvant therapy (TTA), and survival, were analyzed. RESULTS A total of 1,144 patients underwent PD for adenocarcinoma between 1995 and 2011. The overall complication rate was 49.1 % and clinically severe complications (≥IIIb) occurred in 4.2 %. Overall, 621 patients (54.3 %) were known to have received adjuvant therapy. The median TTA was 60 days. Although the presence of a complication was associated with a delay in TTA (p = 0.002), the grade of complication was not (p = 0.112). On multivariate analysis, only age > 68 years (p < 0.001) and length of stay >9 days (p = 0.002) correlated with no adjuvant therapy. Patients with postoperative complications were more likely to receive single adjuvant chemotherapy or radiation therapy (31.4 %) than were patients without complications (17.1 %; p < 0.001). Patients without a complication had a longer median survival compared with patients who experienced complications (19.5 vs. 16.1 months; p = 0.001). Patients without complications who received adjuvant therapy had longer median survival than patients with complications who received no adjuvant therapy (22.5 vs. 10.7 months; p < 0.001). Multivariate analysis demonstrated that complications [hazard ratio (HR) 1.16; p = 0.023] and adjuvant therapy (HR 0.67; p < 0.001) were related to survival. CONCLUSION Complications and no adjuvant therapy are common following PD for adenocarcinoma. Postoperative complications delay TTA and reduce the likelihood of multimodality adjuvant therapy. Identifying patients at increased risk for complications and those unlikely to receive adjuvant therapy warrants further investigation as they may benefit from a neoadjuvant approach.
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Affiliation(s)
- Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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287
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Maftouh M, Belo AI, Avan A, Funel N, Peters GJ, Giovannetti E, van Die I. Galectin-4 expression is associated with reduced lymph node metastasis and modulation of Wnt/β-catenin signalling in pancreatic adenocarcinoma. Oncotarget 2014; 5:5335-49. [PMID: 24977327 PMCID: PMC4170638 DOI: 10.18632/oncotarget.2104] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/12/2014] [Indexed: 12/19/2022] Open
Abstract
Galectin-4 (Gal-4) has been recently identified as a pivotal factor in the migratory capabilities of a set of defined pancreatic ductal adenocarcinoma (PDAC) cell lines using zebrafish as a model system. Here we evaluated the expression of Gal-4 in PDAC tissues selected according to their lymph node metastatic status (N0 vs. N1), and investigated the therapeutic potential of targeting the cross-link with the Wnt signaling pathway in primary PDAC cells. Analysis of Gal-4 expression in PDACs showed high expression of Gal-4 in 80% of patients without lymph node metastasis, whereas 70% of patients with lymph node metastases had low Gal-4 expression. Accordingly, in primary PDAC cells high Gal-4 expression was negatively associated with migratory and invasive ability in vitro and in vivo. Knockdown of Gal-4 in primary PDAC cells with high Gal-4 expression resulted in significant increase of invasion (40%) and migration (50%, P<0.05), whereas enforced expression of Gal-4 in primary cells with low Gal-4 expression reduced the migratory and invasive behavior compared to the control cells. Gal-4 markedly reduces β-catenin levels in the cell, counteracting the function of Wnt signaling, as was assessed by down-regulation of survivin and cyclin D1. Furthermore, Gal-4 sensitizes PDAC cells to the Wnt inhibitor ICG-001, which interferes with the interaction between CREB binding protein (CBP) and β-catenin. Collectively, our data suggest that Gal-4 lowers the levels of cytoplasmic β-catenin, which may lead to lowered availability of nuclear β-catenin, and consequently diminished levels of nuclear CBP-β-catenin complex and reduced activation of the Wnt target genes. Our findings provide novel insights into the role of Gal-4 in PDAC migration and invasion, and support the analysis of Gal-4 for rational targeting of Wnt/β-catenin signaling in the treatment of PDAC.
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Affiliation(s)
- Mina Maftouh
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Ana I. Belo
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Amir Avan
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
- Biochemistry of Nutrition Research Center, and Department of New Sciences and Technology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Godefridus J. Peters
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Elisa Giovannetti
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
- Start-Up Unit, University of Pisa, Pisa, Italy
| | - Irma van Die
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
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289
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Middleton G, Silcocks P, Cox T, Valle J, Wadsley J, Propper D, Coxon F, Ross P, Madhusudan S, Roques T, Cunningham D, Falk S, Wadd N, Harrison M, Corrie P, Iveson T, Robinson A, McAdam K, Eatock M, Evans J, Archer C, Hickish T, Garcia-Alonso A, Nicolson M, Steward W, Anthoney A, Greenhalf W, Shaw V, Costello E, Naisbitt D, Rawcliffe C, Nanson G, Neoptolemos J. Gemcitabine and capecitabine with or without telomerase peptide vaccine GV1001 in patients with locally advanced or metastatic pancreatic cancer (TeloVac): an open-label, randomised, phase 3 trial. Lancet Oncol 2014; 15:829-40. [PMID: 24954781 DOI: 10.1016/s1470-2045(14)70236-0] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to assess the efficacy and safety of sequential or simultaneous telomerase vaccination (GV1001) in combination with chemotherapy in patients with locally advanced or metastatic pancreatic cancer. METHODS TeloVac was a three-group, open-label, randomised phase 3 trial. We recruited patients from 51 UK hospitals. Eligible patients were treatment naive, aged older than 18 years, with locally advanced or metastatic pancreatic ductal adenocarcinoma, and Eastern Cooperative Oncology Group performance status of 0-2. Patients were randomly assigned (1:1:1) to receive either chemotherapy alone, chemotherapy with sequential GV1001 (sequential chemoimmunotherapy), or chemotherapy with concurrent GV1001 (concurrent chemoimmunotherapy). Treatments were allocated with equal probability by means of computer-generated random permuted blocks of sizes 3 and 6 in equal proportion. Chemotherapy included six cycles of gemcitabine (1000 mg/m(2), 30 min intravenous infusion, at days 1, 8, and 15) and capecitabine (830 mg/m(2) orally twice daily for 21 days, repeated every 28 days). Sequential chemoimmunotherapy included two cycles of combination chemotherapy, then an intradermal lower abdominal injection of granulocyte-macrophage colony-stimulating factor (GM-CSF; 75 μg) and GV1001 (0·56 mg; days 1, 3, and 5, once on weeks 2-4, and six monthly thereafter). Concurrent chemoimmunotherapy included giving GV1001 from the start of chemotherapy with GM-CSF as an adjuvant. The primary endpoint was overall survival; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN4382138. FINDINGS The first patient was randomly assigned to treatment on March 29, 2007, and the trial was terminated on March 27, 2011. Of 1572 patients screened, 1062 were randomly assigned to treatment (358 patients were allocated to the chemotherapy group, 350 to the sequential chemoimmunotherapy group, and 354 to the concurrent chemoimmunotherapy group). We recorded 772 deaths; the 290 patients still alive were followed up for a median of 6·0 months (IQR 2·4-12·2). Median overall survival was not significantly different in the chemotherapy group than in the sequential chemoimmunotherapy group (7·9 months [95% CI 7·1-8·8] vs 6·9 months [6·4-7·6]; hazard ratio [HR] 1·19, 98·25% CI 0·97-1·48, p=0·05), or in the concurrent chemoimmunotherapy group (8·4 months [95% CI 7·3-9·7], HR 1·05, 98·25% CI 0·85-1·29, p=0·64; overall log-rank of χ(2)2df=4·3; p=0·11). The commonest grade 3-4 toxic effects were neutropenia (68 [19%] patients in the chemotherapy group, 58 [17%] patients in the sequential chemoimmunotherapy group, and 79 [22%] patients in the concurrent chemoimmunotherapy group; fatigue (27 [8%] in the chemotherapy group, 35 [10%] in the sequential chemoimmunotherapy group, and 44 [12%] in the concurrent chemoimmunotherapy group); and pain (34 [9%] patients in the chemotherapy group, 39 [11%] in the sequential chemoimmunotherapy group, and 41 [12%] in the concurrent chemoimmunotherapy group). INTERPRETATION Adding GV1001 vaccination to chemotherapy did not improve overall survival. New strategies to enhance the immune response effect of telomerase vaccination during chemotherapy are required for clinical efficacy. FUNDING Cancer Research UK and KAEL-GemVax.
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Affiliation(s)
| | - Paul Silcocks
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Trevor Cox
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Juan Valle
- Manchester Academic Health Sciences Centre, Christie Hospital NHS Foundation Trust and University of Manchester, Manchester UK
| | - Jonathan Wadsley
- Weston Park Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - David Propper
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Fareeda Coxon
- Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Paul Ross
- Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Tom Roques
- Norfolk and Norwich University Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - David Cunningham
- The Royal Marsden, The Royal Marsden NHS Foundation Trust, London, UK
| | - Stephen Falk
- Bristol Haematology And Oncology Centre, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - Nick Wadd
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middleborough, UK
| | - Mark Harrison
- Mount Vernon Hospital, The Hillingdon Hospitals NHS Foundation Trust, Northwood, UK
| | - Pippa Corrie
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim Iveson
- Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Angus Robinson
- Conquest Hospital, East Sussex Healthcare NHS Trust, The Ridge, St Leonards-on-Sea, East Sussex, UK
| | - Karen McAdam
- Peterborough City Hospital, Peterborough and Stamford Hospitals NHS Foundation Trust, Edith, Cavell Campus, Peterborough, UK
| | - Martin Eatock
- Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Jeff Evans
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Caroline Archer
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, UK
| | - Tamas Hickish
- Royal Bournemouth Hospital, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | | | | | - William Steward
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alan Anthoney
- St James University Hospital, The Leeds Teaching Hospital Trust, Beckett Street, Leeds, UK
| | - William Greenhalf
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Victoria Shaw
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Eithne Costello
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Dean Naisbitt
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Charlotte Rawcliffe
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - Gemma Nanson
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK
| | - John Neoptolemos
- Liverpool Cancer Research UK Cancer Trials Unit and GCLP Facility, University of Liverpool, Liverpool, UK.
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Multimodal treatment strategies for advanced hilar cholangiocarcinoma. Langenbecks Arch Surg 2014; 399:679-92. [PMID: 24962146 DOI: 10.1007/s00423-014-1219-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 12/17/2022]
Abstract
Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50-70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.
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291
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Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths in the Western world. Due to lack of specific symptoms and no accessible precursor lesions, primary diagnosis is commonly delayed, resulting in the identification of only 15-20% of patients with potentially curable disease. The major limiting factor is an already locally advanced or metastatic disease at the time of diagnosis. Consequently, systemic therapy forms the backbone of treatment strategy for the majority of patients. SUMMARY A deeper understanding of the molecular characteristics of pancreatic cancer has led to the identification of several potential therapeutic targets. A variety of targeted therapies are currently under clinical evaluation as single agents or in combination with chemotherapy for PDAC. This review highlights the current state of chemotherapy in pancreatic cancer and provides an outlook on its future perspectives. KEY MESSAGE This review focuses on the current chemotherapy regimens for the systemic treatment of PDAC. PRACTICAL IMPLICATIONS Various neoadjuvant approaches have been explored, including chemoradiation, chemotherapy followed by chemoradiation or intensified chemotherapy without defining a standard of care so far. The standard of care is gemcitabine or 5-fluorouracil. The oral fluoropyrimidine S-1 may be a promising new agent in this setting. For first-line treatment of metastatic pancreatic cancer, no targeted therapy has yet demonstrated clinical benefit apart from the combination of the tyrosine kinase inhibitor erlotinib plus gemcitabine. Recently, novel chemotherapeutic regimens such as FOLFIRINOX and gemcitabine plus nanoparticle albumin-bound paclitaxel have been introduced. Both combinations have proved to be superior to the standard gemcitabine regimen. For second-line treatment the combination of 5-fluorouracil/leucovorin and oxaliplatin yields improved results compared to best supportive care.
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Affiliation(s)
| | | | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
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292
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Chan E, Berlin J. Timing versus duration of adjuvant therapy for pancreatic cancer: all the lessons we need in life are taught to us as children. J Clin Oncol 2014; 32:487-8. [PMID: 24419124 DOI: 10.1200/jco.2013.53.5617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Emily Chan
- Vanderbilt University Medical Center, Nashville, TN
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