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Fujimoto T, Teraishi F, Kanehira N, Tajima T, Sakurai Y, Kondo N, Yamagami M, Kuwada A, Morihara A, Kitamatsu M, Fujimura A, Suzuki M, Takaguchi Y, Shigeyasu K, Fujiwara T, Michiue H. BNCT pancreatic cancer treatment strategy with glucose-conjugated boron drug. Biomaterials 2024; 309:122605. [PMID: 38754291 DOI: 10.1016/j.biomaterials.2024.122605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/01/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Multidisciplinary therapy centered on radical surgery for resectable pancreatic cancer is expected to prolong prognosis, but relies on CA19-9 biomarker levels to determine treatment strategy. Boron neutron capture therapy (BNCT) is a chemoradiotherapy using tumor hyperaccumulator boron drugs and neutron irradiation. The purpose of this study is to investigate novel boron drug agents for BNCT for pancreatic cancer. Bioinformatics was used to evaluate the uptake of current boron amino acid (BPA) drugs for BNCT into pancreatic cancer. The expression of the amino acid transporter LAT1, a BPA uptake transporter, was low in pancreatic cancer and even lower in high CA19-9 pancreatic cancer. In contrast, the glucose transporter was high in high CA19-9 pancreatic cancers and inversely correlated with LAT1 expression. Considering the low EPR effect in pancreatic cancer, we synthesized a small molecule Glucose-BSH, which is boron BSH bound to glucose, and confirmed its specific uptake in pancreatic cancer. uptake of Glucose-BSH was confirmed in an environment compatible with the tumor microenvironment. The therapeutic efficacy and safety of Glucose-BSH by therapeutic neutron irradiation were confirmed with BNCT. We report Glucose-BSH boron drug discovery study of a Precision Medicine BNCT with application to high CA19-9 pancreatic cancer.
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Affiliation(s)
- Takuya Fujimoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan; Neutron Therapy Research Center, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Fuminori Teraishi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Noriyuki Kanehira
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan; Neutron Therapy Research Center, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Tomoyuki Tajima
- Graduate School of Environmental, Life, Natural Science, Okayama University, 3-1-1 Tsushima-Naka, Kita-ku, Okayama, 700-8530, Japan
| | - Yoshinori Sakurai
- Institute for Integrated Radiation and Nuclear Science, Kyoto University, 2, Asashiro-Nishi, Kumatori-cho, Sennan-gun, Osaka, 590-0494, Japan
| | - Natsuko Kondo
- Institute for Integrated Radiation and Nuclear Science, Kyoto University, 2, Asashiro-Nishi, Kumatori-cho, Sennan-gun, Osaka, 590-0494, Japan
| | - Masahiro Yamagami
- Graduate School of Environmental, Life, Natural Science, Okayama University, 3-1-1 Tsushima-Naka, Kita-ku, Okayama, 700-8530, Japan
| | - Atsushi Kuwada
- Graduate School of Environmental, Life, Natural Science, Okayama University, 3-1-1 Tsushima-Naka, Kita-ku, Okayama, 700-8530, Japan
| | - Akira Morihara
- Graduate School of Environmental, Life, Natural Science, Okayama University, 3-1-1 Tsushima-Naka, Kita-ku, Okayama, 700-8530, Japan
| | - Mizuki Kitamatsu
- Department of Applied Chemistry, Kindai University, 3-4-1 Kowakae, Higashi-Osaka, Osaka, 577-8502, Japan
| | - Atsushi Fujimura
- Neutron Therapy Research Center, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan; Department of Cellular Physiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, 700-8558, Japan
| | - Minoru Suzuki
- Institute for Integrated Radiation and Nuclear Science, Kyoto University, 2, Asashiro-Nishi, Kumatori-cho, Sennan-gun, Osaka, 590-0494, Japan
| | - Yutaka Takaguchi
- Graduate School of Environmental, Life, Natural Science, Okayama University, 3-1-1 Tsushima-Naka, Kita-ku, Okayama, 700-8530, Japan; Department of Material Design and Engineering, Faculty of Sustainable Design, University of Toyama, Toyama, 930-8555, Japan
| | - Kunitoshi Shigeyasu
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Hiroyuki Michiue
- Neutron Therapy Research Center, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan.
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Su D, Ding C, Wang R, Qiu J, Liu Y, Tao J, Luo W, Weng G, Yang G, Zhang T. E3 ubiquitin ligase RBCK1 confers ferroptosis resistance in pancreatic cancer by facilitating MFN2 degradation. Free Radic Biol Med 2024; 221:136-154. [PMID: 38763208 DOI: 10.1016/j.freeradbiomed.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/21/2024]
Abstract
Ferroptosis, a novel form of iron-dependent non-apoptotic cell death, plays an active role in the pathogenesis of diverse diseases, including cancer. However, the mechanism through which ferroptosis is regulated in pancreatic ductal adenocarcinoma (PDAC) remains unclear. Here, our study, via combining bioinformatic analysis with experimental validation, showed that ferroptosis is inhibited in PDAC. Genome-wide sequencing further revealed that the ferroptosis activator imidazole ketone erastin (IKE) induced upregulation of the E3 ubiquitin ligase RBCK1 in PDAC cells at the transcriptional or translational level. RBCK1 depletion or knockdown rendered PDAC cells more vulnerable to IKE-induced ferroptotic death in vitro. In a mouse xenograft model, genetic depletion of RBCK1 increased the killing effects of ferroptosis inducer on PDAC cells. Mechanistically, RBCK1 interacts with and polyubiquitylates mitofusin 2 (MFN2), a key regulator of mitochondrial dynamics, to facilitate its proteasomal degradation under ferroptotic stress, leading to decreased mitochondrial reactive oxygen species (ROS) production and lipid peroxidation. These findings not only provide new insights into the defense mechanisms of PDAC cells against ferroptotic death but also indicate that targeting the RBCK1-MFN2 axis may be a promising option for treating patients with PDAC.
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Affiliation(s)
- Dan Su
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Chen Ding
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China
| | - Ruobing Wang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Jiangdong Qiu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Yueze Liu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Jinxin Tao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Wenhao Luo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China; National Science and Technology Key Infrastructure on Translational Medicine in Peking Union Medical College Hospital, Beijing, 100023, PR China
| | - Guihu Weng
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China
| | - Gang Yang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China
| | - Taiping Zhang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China; Key Laboratory of Research in Pancreatic Tumor, Chinese Academy of Medical Science, Beijing, 100730, PR China.
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Franklin O, Sugawara T, Ross RB, Rodriguez Franco S, Colborn K, Karam S, Schulick RD, Del Chiaro M. Adjuvant Chemotherapy With or Without Radiotherapy for Resected Pancreatic Cancer After Multiagent Neoadjuvant Chemotherapy. Ann Surg Oncol 2024; 31:4966-4975. [PMID: 38789615 DOI: 10.1245/s10434-024-15157-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/14/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Adjuvant therapy is associated with improved pancreatic cancer survival after neoadjuvant chemotherapy and surgery. However, whether adjuvant treatment should include radiotherapy is unclear in this setting. METHODS This study queried the National Cancer Database for pancreatic adenocarcinoma patients who underwent curative resection after multiagent neoadjuvant chemotherapy between 2010 and 2019 and received adjuvant treatment. Adjuvant chemotherapy plus radiotherapy (external beam, 45-50.4 gray) was compared with adjuvant chemotherapy alone. Uni- and multivariable Cox regression was used to assess survival associations. Analyses were repeated in a propensity score-matched subgroup. RESULTS Of 1983 patients who received adjuvant treatment after multiagent neoadjuvant chemotherapy and resection, 1502 (75.7%) received adjuvant chemotherapy alone and 481 (24.3%) received concomitant adjuvant radiotherapy (chemoradiotherapy). The patients treated with adjuvant chemoradiotherapy were younger, were treated at non-academic facilities more often, and had higher rates of lymph node metastasis (ypN1-2), positive resection margins (R1), and lymphovascular invasion (LVI+). The median survival was shorter for the chemoradiotherapy-treated patients according to the unadjusted analysis (26.8 vs 33.2 months; p = 0.0017). After adjustment for confounders, chemoradiotherapy was associated with better outcomes in the multivariable model (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.61-0.93; p = 0.008). The association between chemoradiotherapy and improved outcomes was stronger for the patients with grade III tumors (HR, 0.53; 95% CI, 0.37-0.74) or LVI+ tumors (HR, 0.58; 95% CI, 0.44-0.75). In a subgroup of 396 propensity-matched patients, chemoradiotherapy was associated with a survival benefit only for the patients with LVI+ or grade III tumors. CONCLUSION After multiagent neoadjuvant chemotherapy and resection for pancreatic cancer, additional adjuvant chemoradiotherapy versus adjuvant chemotherapy alone is associated with improved survival for patients with LVI+ or grade III tumors.
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Affiliation(s)
- Oskar Franklin
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Richard Blake Ross
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn Colborn
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sana Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- University of Colorado Cancer Center, Aurora, CO, USA.
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Testing new anticancer drugs before curative locoregional therapies: MDICT 2024 recommendations. ESMO Open 2024; 9:103649. [PMID: 39059061 DOI: 10.1016/j.esmoop.2024.103649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Advances in the treatment of cancer have resulted in improved outcomes for patients, but improving the cure rate is a major unmet need. While testing new anticancer drugs in the earliest settings may be attractive as the chance of benefit may be greatest, it is also a setting where researchers must ensure patients are not harmed, by either over or undertreatment, or denial of timely standard curative treatments. The Methodology for the Development of Innovative Cancer Therapies Taskforce (MDICT) meets immediately before the ESMO-Targeted Anticancer Therapies (ESMO-TAT) meeting, usually held annually in Paris, France, to address questions that are considered important for early academic clinical trials. The focus of the MDICT 2024 was on early, signal-seeking phase clinical trials of new drugs conducted in the neoadjuvant (NEO) setting (NEO-ECTs) rather than pivotal confirmatory NEO trials (NEO-CONFs), which are typically phase III in design. Recommendations encompass four key concepts: patient engagement, reviewing risk-benefit ratio and clinical/ethical equipoise, the requirement for a randomization to reduce bias and allow robust conclusions to be drawn, and the selection of appropriate endpoints. The careful design of NEO-ECTs will allow the testing of new anticancer treatments in earlier disease settings where activity is hoped to result in higher cure rates, while also ensuring that patients are not harmed by delays to curative/definitive treatments nor by long-term or late-onset toxicity and morbidity. Additional research and investigation are required to further define and refine robust endpoints for use in this setting, including imaging, tissue and blood based endpoints.
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Crippa S, Malleo G, Mazzaferro V, Langella S, Ricci C, Casciani F, Belfiori G, Galati S, D’Ambra V, Lionetto G, Ferrero A, Casadei R, Ercolani G, Salvia R, Falconi M, Cucchetti A. Futility of Up-Front Resection for Anatomically Resectable Pancreatic Cancer. JAMA Surg 2024:2821587. [PMID: 39046713 PMCID: PMC11270270 DOI: 10.1001/jamasurg.2024.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 07/25/2024]
Abstract
Importance There are currently no clinically relevant criteria to predict a futile up-front pancreatectomy in patients with anatomically resectable pancreatic ductal adenocarcinoma. Objectives To develop a futility risk model using a multi-institutional database and provide unified criteria associated with a futility likelihood below a safety threshold of 20%. Design, Setting, and Participants This retrospective study took place from January 2010 through December 2021 at 5 high- or very high-volume centers in Italy. Data were analyzed during April 2024. Participants included consecutive patients undergoing up-front pancreatectomy at the participating institutions. Exposure Standard management, per existing guidelines. Main Outcomes and Measures The main outcome measure was the rate of futile pancreatectomy, defined as an operation resulting in patient death or disease recurrence within 6 months. Dichotomous criteria were constructed to maintain the futility likelihood below 20%, corresponding to the chance of not receiving postneoadjuvant resection from existing pooled data. Results This study included 1426 patients. The median age was 69 (interquartile range, 62-75) years, 759 patients were male (53.2%), and 1076 had head cancer (75.4%). The rate of adjuvant treatment receipt was 73.7%. For the model construction, the study sample was split into a derivation (n = 885) and a validation cohort (n = 541). The rate of futile pancreatectomy was 18.9% (19.2% in the development and 18.6% in the validation cohort). Preoperative variables associated with futile resection were American Society of Anesthesiologists class (95% CI for coefficients, 0.68-0.87), cancer antigen (CA) 19.9 serum levels (95% CI, for coefficients 0.05-0.75), and tumor size (95% CI for coefficients, 0.28-0.46). Three risk groups associated with an escalating likelihood of futile resection, worse pathological features, and worse outcomes were identified. Four discrete conditions (defined as CA 19.9 levels-adjusted-to-size criteria: tumor size less than 2 cm with CA 19.9 levels less than 1000 U/mL; tumor size less than 3 cm with CA 19.9 levels less than 500 U/mL; tumor size less than 4 cm with CA 19.9 levels less than 150 U/mL; and tumor size less than 5 cm with CA 19.9 levels less than 50 U/mL) were associated with a futility likelihood below 20%. Both disease-free survival and overall survival were significantly longer in patients fulfilling the criteria. Conclusions and relevance In this study, a preoperative model (MetroPancreas) and dichotomous criteria to determine the risk of futile pancreatectomy were developed. This might help in selecting patients for up-front resection or neoadjuvant therapy.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Malleo
- Unit of Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milano, Italy and HPB Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Serena Langella
- Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Fabio Casciani
- Unit of Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Galati
- Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
| | - Vincenzo D’Ambra
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Gabriella Lionetto
- Unit of Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Roberto Salvia
- Unit of Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Department of Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
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Botta GP, Abdelrahim M, Drengler RL, Aushev VN, Esmail A, Laliotis G, Brewer CM, George GV, Abbate SM, Chandana SR, Tejani MA, Malla M, Bansal D, Rivero-Hinojosa S, Spickard E, McCormick N, Cecchini M, Lacy J, Fei N, Kasi PM, Kasi A, Dayyani F, Hanna DL, Sharma S, Malhotra M, Aleshin A, Liu MC, Jurdi A. Association of personalized and tumor-informed ctDNA with patient survival outcomes in pancreatic adenocarcinoma. Oncologist 2024:oyae155. [PMID: 39022993 DOI: 10.1093/oncolo/oyae155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/30/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION Personalized and tumor-informed circulating tumor DNA (ctDNA) testing is feasible and allows for molecular residual disease (MRD) identification in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS In this retrospective analysis of commercial cases from multiple US institutions, personalized, tumor-informed, whole-exome sequenced, and germline-controlled ctDNA levels were quantified and analyzed in patients with PDAC. Plasma samples (n = 1329) from 299 clinically validated patients were collected at diagnosis, perioperatively (MRD-window; within 2-12 weeks after surgery, before therapy), and during surveillance (>12 weeks post-surgery if no ACT or starting 4 weeks post-ACT) from November 2019 to March 2023. RESULTS Of the initially diagnosed patients with stages I-III PDAC who went for resection, the median follow-up time from surgery was 13 months (range 0.1-214). Positive ctDNA detection rates were 29% (29/100) and 29.6% (45/152) during the MRD and surveillance windows, respectively. Positive ctDNA detection was significantly associated with shorter DFS within the MRD window (median DFS of 6.37 months for ctDNA-positive vs 33.31 months for ctDNA-negative patients; HR: 5.45, P < .0001) as well as during the surveillance period (median DFS: 11.40 months for ctDNA-positive vs NR for ctDNA-negative; HR: 12.38, P < .0001). Additionally, DFS was significantly better with KRAS wildtype status followed by KRASG12R (HR: 0.99, P = .97), KRASG12D (HR: 1.42, P = .194), and worse with KRASG12V (HR: 2.19, P = .002) status. In multivariate analysis, ctDNA detection at surveillance was found to be the most significant prognostic factor for recurrence (HR: 24.28, P < .001). CONCLUSIONS Perioperative tumor-informed ctDNA detection in PDAC is feasible across all stages and is associated with patient survival outcomes.
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Affiliation(s)
- Gregory P Botta
- Division of Hematology and Oncology, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA 92037, United States
| | - Maen Abdelrahim
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, United States
| | - Ronald L Drengler
- Medical Oncology, The START Center for Cancer Care, San Antonio, TX 78229, United States
| | | | - Abdullah Esmail
- Section of GI Oncology, Department of Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77030, United States
| | | | | | - Giby V George
- Oncology, Natera, Inc., Austin, TX 78753, United States
| | - Steven M Abbate
- Medical Oncology, The START Center for Cancer Care, San Antonio, TX 78229, United States
| | - Sreenivasa R Chandana
- Department of Gastrointestinal Medical Oncology, Cancer & Hematology Centers of Western Michigan, Grand Rapids, MI 49546, United States
| | - Mohamedtaki A Tejani
- Hematology and Oncology, Advent Health Cancer Institute, Orlando, FL 32804, United States
| | - Midhun Malla
- Section of Hematology and Oncology, University of Alabama at Birmingham, AL 35233, United States
| | - Dhruv Bansal
- Department of Hematology-Oncology, Saint Luke's Cancer Institute, Kansas City, MO 64111, United States
| | | | - Erik Spickard
- Oncology, Natera, Inc., Austin, TX 78753, United States
| | | | - Michael Cecchini
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT 06520, United States
| | - Jill Lacy
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT 06520, United States
| | - Naomi Fei
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
| | - Pashtoon Murtaza Kasi
- Division of Internal Medicine, Department of Oncology/Hematology, Weill Cornell Medicine, New York, NY 10021, United States
| | - Anup Kasi
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS 66160, United States
| | - Farshid Dayyani
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA 92868, United States
| | - Diana L Hanna
- Division of Medical Oncology, Norris Cancer Center, Keck Medicine of USC, Los Angeles, CA 90033, United States
| | - Shruti Sharma
- Oncology, Natera, Inc., Austin, TX 78753, United States
| | | | | | - Minetta C Liu
- Oncology, Natera, Inc., Austin, TX 78753, United States
| | - Adham Jurdi
- Oncology, Natera, Inc., Austin, TX 78753, United States
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Snyder RA, Zemla TJ, Shi Q, Segovia D, Ahmad SA, O'Reilly EM, Herman JM, Katz MHG. Postoperative Adverse Events Following Neoadjuvant Therapy and Surgery for Borderline Resectable Pancreatic Cancer in a Phase 2 Clinical Trial (Alliance A021501). Ann Surg Oncol 2024:10.1245/s10434-024-15670-6. [PMID: 39008208 DOI: 10.1245/s10434-024-15670-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/10/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Postoperative adverse events (AEs) in patients with borderline resectable pancreatic ductal adenocarcinoma (BR-PC) treated with neoadjuvant therapy and pancreatectomy in the national cooperative group setting have not been previously characterized. We conducted a preplanned secondary analysis of patients enrolled on the Alliance A021501 clinical trial to quantify perioperative AE rates. METHODS The A021501 phase 2 trial randomized patients with BR-PC to receive 8 doses of mFOLFIRINOX (Arm 1) or 7 doses of mFOLFIRINOX and hypofractionated radiotherapy (Arm 2), followed by pancreatectomy (December 31, 2016 to May 31, 2019). Adverse events were assessed 90 days after pancreatectomy. RESULTS Of 126 enrolled patients, 51 (40%) underwent pancreatectomy (n = 32, Arm 1; n = 19, Arm 2) at 28 institutions. Five (10%) patients required reoperation within 90 days; 56% of patients (n = 27/48) experienced at least one grade 3 or higher AE (50% vs. 67%, p = 0.37). Ninety-day mortality was 2.0%. Readmission was less frequent in Arm 1 (16% vs. 42%, p = 0.05), but there were no differences between study arms in rates of reoperation (13% vs. 5%), pancreatic fistula or intra-abdominal abscess requiring drainage (9% vs. 16%), or wound infection (6% vs. 16%). Pancreatic fistula or intra-abdominal abscess requiring drainage was associated with receipt of adjuvant therapy (p = 0.012). No difference in overall survival was observed based on occurrence of postoperative AEs (hazard ratio = 1.1; 95% confidence interval 0.5-2.6). CONCLUSIONS In this multicenter study, rates of postoperative AEs were consistent with those previously reported. Multimodality trials of preoperative therapy for BR-PC may be performed in the cooperative group setting with careful quality assurance and safety monitoring. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02839343.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tyler J Zemla
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Qian Shi
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Diana Segovia
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eileen M O'Reilly
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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8
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Labiano I, Huerta AE, Alsina M, Arasanz H, Castro N, Mendaza S, Lecumberri A, Gonzalez-Borja I, Guerrero-Setas D, Patiño-Garcia A, Alkorta-Aranburu G, Hernández-Garcia I, Arrazubi V, Mata E, Gomez D, Viudez A, Vera R. Building on the clinical applicability of ctDNA analysis in non-metastatic pancreatic ductal adenocarcinoma. Sci Rep 2024; 14:16203. [PMID: 39003322 PMCID: PMC11246447 DOI: 10.1038/s41598-024-67235-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024] Open
Abstract
Pancreatic ductal adenocarcinoma represents one of the solid tumors showing the worst prognosis worldwide, with a high recurrence rate after adjuvant or neoadjuvant therapy. Circulating tumor DNA analysis raised as a promising non-invasive tool to characterize tumor genomics and to assess treatment response. In this study, surgical tumor tissue and sequential blood samples were analyzed by next-generation sequencing and were correlated with clinical and pathological characteristics. Thirty resectable/borderline pancreatic ductal adenocarcinoma patients treated at the Hospital Universitario de Navarra were included. Circulating tumoral DNA sequencing identified pathogenic variants in KRAS and TP53, and in other cancer-associated genes. Pathogenic variants at diagnosis were detected in patients with a poorer outcome, and were correlated with response to neoadjuvant therapy in borderline pancreatic ductal adneocarcinoma patients. Higher variant allele frequency at diagnosis was associated with worse prognosis, and thesum of variant allele frequency was greater in samples at progression. Our results build on the potential value of circulating tumor DNA for non-metastatic pancreatic ductal adenocarcinoma patients, by complementing tissue genetic information and as a non-invasive tool for treatment decision. Confirmatory studies are needed to corroborate these findings.
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Affiliation(s)
- Ibone Labiano
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Ana E Huerta
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Maria Alsina
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain.
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Hugo Arasanz
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - Natalia Castro
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Saioa Mendaza
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Arturo Lecumberri
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - Iranzu Gonzalez-Borja
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - David Guerrero-Setas
- Molecular Pathology of Cancer Group, Navarrabiomed, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Ana Patiño-Garcia
- Department of Pediatrics and Clinical Genetics, Clínica Universidad de Navarra (CUN), Cancer Center Clínica Universidad de Navarra (CCUN), Program in Solid Tumors, Center for Applied Medical Research (CIMA) and Navarra Institute for Health Research (IdiSNA), University of Navarra, Pamplona, Spain
| | | | - Irene Hernández-Garcia
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - Virginia Arrazubi
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - Elena Mata
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - David Gomez
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
| | - Antonio Viudez
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
| | - Ruth Vera
- Oncobiona Group, Navarrabiomed-Instituto de Investigación Sanitaria de Navarra (IdiSNA), Irunlarrea 3, 31008, Pamplona, Spain
- Medical Oncology Department, Hospital Universitario de Navarra (HUN), Irunlarrea 3, 31008, Pamplona, Spain
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Franklin O, Karam S, Schulick RD, Del Chiaro M. ASO Author Reflections: Is There a Role for Selective Adjuvant Radiotherapy in the Modern Era of Pancreatic Cancer Treatment? Ann Surg Oncol 2024; 31:4695-4696. [PMID: 38647913 DOI: 10.1245/s10434-024-15297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Oskar Franklin
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden.
| | - Sana Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
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10
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Yamada D, Kobayashi S, Takahashi H, Iwagami Y, Akita H, Asukai K, Shimizu J, Yamada T, Tanemura M, Yokoyama S, Tsujie M, Asaoka T, Takeda Y, Morimoto O, Tomokuni A, Doki Y, Eguchi H. Results of a Randomized Clinical Study of Gemcitabine Plus Nab-Paclitaxel Versus Gemcitabine Plus S-1 as Neoadjuvant Chemotherapy for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma (RCT, CSGO-HBP-015). Ann Surg Oncol 2024; 31:4621-4633. [PMID: 38546797 PMCID: PMC11164807 DOI: 10.1245/s10434-024-15199-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/05/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The optimal neoadjuvant chemotherapy (NAC) regimen for patients with localized pancreatic ductal adenocarcinoma (PDAC) remains uncertain. This trial aimed to evaluate the efficacy and safety of two neoadjuvant chemotherapy (NAC) regimens, gemcitabine plus nab-paclitaxel (GA) and gemcitabine plus S-1 (GS), in patients with resectable/borderline-resectable (R/BR) PDAC. PATIENTS AND METHODS Treatment-naïve patients with R/BR-PDAC were enrolled and randomly allocated. They received two cycles (2 months) of each standard protocol, followed by radical surgery for those without tumor progression in general hospitals belonging to our intergroup. The primary endpoint was to determine the superior regimen on the basis of achieving a 10% increase in the rate of patients with progression-free survival (PFS) at 2 years from allocation. RESULTS A total of 100 patients were enrolled, with 94 patients randomly assigned to the GS arm (N = 46) or GA arm (N = 48). The 2-year PFS rates did not show the stipulated difference [GA, 31% (24-38%)/GS, 26% (18-33%)], but the Kaplan-Myer analysis showed significance (median PFS, GA/GS 14 months/9 months, P = 0.048; HR 0.71). Secondary endpoint comparisons yielded the following results (GA/GS arm, P-value): rates of severe adverse events during NAC, 73%/78%, P = 0.55; completion rates of the stipulated NAC, 92%/83%, P = 0.71; resection rates, 85%/72%, P = 0.10; average tumor marker (CA19-9) reduction rates, -50%/-21%, P = 0.01; average numbers of lymph node metastasis, 1.7/3.2, P = 0.04; and median overall survival times, 42/22 months, P = 0.26. CONCLUSIONS This study found that GA and GS are viable neoadjuvant treatment regimens in R/BR-PDAC. Although the GA group exhibited a favorable PFS outcome, the primary endpoint was not achieved.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junzo Shimizu
- Department of Gastroenterological Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Terumasa Yamada
- Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Higashiosaka, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Rinku General Medical Center, Izumisano, Japan
| | - Shigekazu Yokoyama
- Department of Gastroenterological Surgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | - Masanori Tsujie
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Sakai, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osakuni Morimoto
- Department of Surgery, Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | - Akira Tomokuni
- Department of Gastroenterological Surgery, Osaka General Medical Center, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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11
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Saúde-Conde R, El Ghali B, Navez J, Bouchart C, Van Laethem JL. Total Neoadjuvant Therapy in Localized Pancreatic Cancer: Is More Better? Cancers (Basel) 2024; 16:2423. [PMID: 39001485 PMCID: PMC11240662 DOI: 10.3390/cancers16132423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge in oncology due to its advanced stage upon diagnosis and limited treatment options. Surgical resection, the primary curative approach, often results in poor long-term survival rates, leading to the exploration of alternative strategies like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to enhance resectability and overall survival, there appears to be potential for improvement, prompting consideration of alternative neoadjuvant strategies integrating full-dose chemotherapy (CT) and radiotherapy (RT) in TNT approaches. TNT integrates chemotherapy and radiotherapy prior to surgery, potentially improving margin-negative resection rates and enabling curative resection for locally advanced cases. The lingering question: is more always better? This article categorizes TNT strategies into six main groups based on radiotherapy (RT) techniques: (1) conventional chemoradiotherapy (CRT), (2) the Dutch PREOPANC approach, (3) hypofractionated ablative intensity-modulated radiotherapy (HFA-IMRT), and stereotactic body radiotherapy (SBRT) techniques, which further divide into (4) non-ablative SBRT, (5) nearly ablative SBRT, and (6) adaptive ablative SBRT. A comprehensive analysis of the literature on TNT is provided for both borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), with detailed sections for each.
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Affiliation(s)
- Rita Saúde-Conde
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Benjelloun El Ghali
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Julie Navez
- Department of Abdominal Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles (HUB), Hopital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Christelle Bouchart
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Jean-Luc Van Laethem
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
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12
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Dallavalle S, Campagnoli G, Pastena P, Martinino A, Schiliró D, Giovinazzo F. New Frontiers in Pancreatic Cancer Management: Current Treatment Options and the Emerging Role of Neoadjuvant Therapy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1070. [PMID: 39064499 PMCID: PMC11278520 DOI: 10.3390/medicina60071070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) ranks among the 15 most prevalent cancers globally, characterized by aggressive growth and late-stage diagnosis. Advances in imaging and surgical techniques have redefined the classification of pancreatic PDAC into resectable, borderline resectable, and locally advanced pancreatic cancer. While surgery remains the most effective treatment, only 20% of patients are eligible at diagnosis, necessitating innovative strategies to improve outcomes. Therefore, traditional treatment paradigms, primarily surgical resection for eligible patients, are increasingly supplemented by neoadjuvant therapies (NAT), which include chemotherapy, radiotherapy, or a combination of both. By administering systemic therapy prior to surgery, NAT aims to reduce tumor size and increase the feasibility of complete surgical resection, thus enhancing overall survival rates and potentially allowing more patients to undergo curative surgeries. Recent advances in treatment protocols, such as FOLFIRINOX and gemcitabine-nab-paclitaxel, now integral to NAT strategies, have shown promising results in increasing the proportion of patients eligible for surgery by effectively reducing tumor size and addressing micrometastatic disease. Additionally, they offer improved response rates and survival benefits compared to traditional regimes. Despite these advancements, the role of NAT continues to evolve, necessitating ongoing research to optimize treatment regimens, minimize adverse effects, and identify patient populations that would benefit most from these approaches. Through a detailed analysis of current literature and recent clinical trials, this review highlights the transformative potential of NAT in managing PDAC, especially in patients with borderline resectable or locally advanced stages, promising a shift towards more personalized and effective management strategies for PDAC.
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Affiliation(s)
- Sofia Dallavalle
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Gabriele Campagnoli
- Faculty of Medicine and Surgery, University of Milan, 20122 Milan, Italy; (S.D.); (G.C.)
| | - Paola Pastena
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY 11794, USA;
| | | | - Davide Schiliró
- Department of Surgery, Duke University, Durham, NC 27710, USA
| | - Francesco Giovinazzo
- Department of Surgery, Saint Camillus Hospital, 31100 Treviso, Italy
- Department of Surgery, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Department of Surgery, Agostino Gemelli University Hospital, 00168 Rome, Italy
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13
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Cecchini M, Salem RR, Robert M, Czerniak S, Blaha O, Zelterman D, Rajaei M, Townsend JP, Cai G, Chowdhury S, Yugawa D, Tseng R, Mejia Arbelaez C, Jiao J, Shroyer K, Thumar J, Kortmansky J, Zaheer W, Fischbach N, Persico J, Stein S, Khan SA, Cha C, Billingsley KG, Kunstman JW, Johung KL, Wiess C, Muzumdar MD, Spickard E, Aushev VN, Laliotis G, Jurdi A, Liu MC, Escobar-Hoyos L, Lacy J. Perioperative Modified FOLFIRINOX for Resectable Pancreatic Cancer: A Nonrandomized Controlled Trial. JAMA Oncol 2024:2820217. [PMID: 38900452 PMCID: PMC11190830 DOI: 10.1001/jamaoncol.2024.1575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/09/2024] [Indexed: 06/21/2024]
Abstract
Importance Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignant tumor, and durable disease control is rare with the current standard of care, even for patients who undergo surgical resection. Objective To assess whether neoadjuvant modified 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (mFOLFIRINOX) leads to early control of micrometastasis and improves survival. Design, Setting, and Participants This open-label, single-arm, phase 2 nonrandomized controlled trial for resectable PDAC was conducted at the Yale Smilow Cancer Hospital from April 3, 2014, to August 16, 2021. Pancreatic protocol computed tomography was performed at diagnosis to assess surgical candidacy. Data were analyzed from January to July 2023. Interventions Patients received 6 cycles of neoadjuvant mFOLFIRINOX before surgery and 6 cycles of adjuvant mFOLFIRINOX. Whole blood was collected and processed to stored plasma for analysis of circulating tumor DNA (ctDNA) levels. Tumors were evaluated for treatment response and keratin 17 (K17) expression. Main Outcomes and Measures The primary end point was 12-month progression-free survival (PFS) rate. Additional end points included overall survival (OS), ctDNA level, tumor molecular features, and K17 tumor levels. Survival curves were summarized using Kaplan-Meier estimator. Results Of 46 patients who received mFOLFIRINOX, 31 (67%) were male, and the median (range) age was 65 (46-80) years. A total of 37 (80%) completed 6 preoperative cycles and 33 (72%) underwent surgery. A total of 27 patients (59%) underwent resection per protocol (25 with R0 disease and 2 with R1 disease); metastatic or unresectable disease was identified in 6 patients during exploration. Ten patients underwent surgery off protocol. The 12-month PFS was 67% (90% CI, 56.9-100); the median PFS and OS were 16.6 months (95% CI, 13.3-40.6) and 37.2 months (95% CI, 17.5-not reached), respectively. Baseline ctDNA levels were detected in 16 of 22 patients (73%) and in 3 of 17 (18%) after 6 cycles of mFOLFIRINOX. Those with detectable ctDNA levels 4 weeks postresection had worse PFS (hazard ratio [HR], 34.0; 95% CI, 2.6-4758.6; P = .006) and OS (HR, 11.7; 95% CI, 1.5-129.9; P = .02) compared with those with undetectable levels. Patients with high K17 expression had nonsignificantly worse PFS (HR, 2.7; 95% CI, 0.7-10.9; P = .09) and OS (HR, 3.2; 95% CI, 0.8-13.6; P = .07). Conclusions and Relevance This nonrandomized controlled trial met its primary end point, and perioperative mFOLFIRINOX warrants further evaluation in randomized clinical trials. Postoperative ctDNA positivity was strongly associated with recurrence. K17 and ctDNA are promising biomarkers that require additional validation in future prospective studies. Trial Registration ClinicalTrials.gov Identifier: NCT02047474.
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Affiliation(s)
- Michael Cecchini
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Ronald R. Salem
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Marie Robert
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Suzanne Czerniak
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Ondrej Blaha
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Daniel Zelterman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Moein Rajaei
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Jeffrey P. Townsend
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Guoping Cai
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Sumedha Chowdhury
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
| | - Deanne Yugawa
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
| | - Robert Tseng
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
| | - Carlos Mejia Arbelaez
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
| | - Jingjing Jiao
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Kenneth Shroyer
- Department of Pathology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Jaykumar Thumar
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Jeremy Kortmansky
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Wajih Zaheer
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Neal Fischbach
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Justin Persico
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Stacey Stein
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | - Sajid A. Khan
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Cha
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin G. Billingsley
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - John W. Kunstman
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kimberly L. Johung
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
| | - Christina Wiess
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Mandar D. Muzumdar
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | - Luisa Escobar-Hoyos
- Department of Therapeutic Radiology, Yale School of Public Health, New Haven, Connecticut
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - Jill Lacy
- Department of Internal Medicine (Medical Oncology), Yale University School of Medicine, New Haven, Connecticut
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14
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Safyan RA, Kim E, Dekker E, Homs M, Aguirre AJ, Koerkamp BG, Chiorean EG. Multidisciplinary Standards and Evolving Therapies for Patients With Pancreatic Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e438598. [PMID: 38781541 DOI: 10.1200/edbk_438598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease that presents at an advanced stage and results in many symptoms that negatively influence patients' quality of life and reduce their ability to receive effective treatment. Early implementation of expert multidisciplinary care with nutritional support, exercise, and palliative care for both early-stage and advanced disease promises to maintain or improve the patients' physical, social, and psychological well-being, decrease aggressive interventions at the end of life, and ultimately improve survival. Moreover, advances in treatment strategies in the neoadjuvant and metastatic setting combined with novel therapeutic agents targeting the key drivers of the disease are leading to improvements in the care of patients with pancreatic cancer. Here, we emphasize the multidisciplinary supportive and therapeutic care of patients with PDA, review current guidelines and new developments of neoadjuvant and perioperative treatments for localized disease, as well as the treatment standards and the evolving field of precision oncology and immunotherapies for advanced PDA.
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Affiliation(s)
- Rachael A Safyan
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
| | - Eejung Kim
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emmelie Dekker
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Marjolein Homs
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, the Netherlands
| | - Andrew J Aguirre
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
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15
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Goetze TO, Reichart A, Bankstahl US, Pauligk C, Loose M, Kraus TW, Elshafei M, Bechstein WO, Trojan J, Behrend M, Homann N, Venerito M, Bohle W, Varvenne M, Bolling C, Behringer DM, Kratz-Albers K, Siegler GM, Hozaeel W, Al-Batran SE. Adjuvant Gemcitabine Versus Neoadjuvant/Adjuvant FOLFIRINOX in Resectable Pancreatic Cancer: The Randomized Multicenter Phase II NEPAFOX Trial. Ann Surg Oncol 2024; 31:4073-4083. [PMID: 38459418 PMCID: PMC11076394 DOI: 10.1245/s10434-024-15011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Although addition of adjuvant chemotherapy is the current standard, the prognosis of pancreatic cancers still remains poor. The NEPAFOX trial evaluated perioperative treatment with FOLFIRINOX in resectable pancreatic cancer. PATIENTS AND METHODS This multicenter phase II trial randomized patients with resectable or borderline resectable pancreatic cancer without metastases into arm (A,) upfront surgery plus adjuvant gemcitabine, or arm (B,) perioperative FOLFIRINOX. The primary endpoint was overall survival (OS). RESULTS Owing to poor accrual, recruitment was prematurely stopped after randomization of 40 of the planned 126 patients (A: 21, B: 19). Overall, approximately three-quarters were classified as primarily resectable (A: 16, B: 15), and the remaining patients were classified as borderline resectable (A: 5, B: 4). Of the 12 evaluable patients, 3 achieved partial response under neoadjuvant FOLFIRINOX. Of the 21 patients in arm A and 19 patients in arm B, 17 and 7 underwent curative surgery, and R0-resection was achieved in 77% and 71%, respectively. Perioperative morbidity occurred in 72% in arm A and 46% in arm B, whereas non-surgical toxicity was comparable in both arms. Median RFS/PFS was almost doubled in arm B (14.1 months) compared with arm A (8.4 months) in the population with surgical resection, whereas median OS was comparable between both arms. CONCLUSIONS Although the analysis was only descriptive owing to small patient numbers, no safety issues regarding surgical complications were observed in the perioperative FOLFIRINOX arm. Thus, considering the small number of patients, perioperative treatment approach appears feasible and potentially effective in well-selected cohorts of patients. In pancreatic cancer, patient selection before initiation of neoadjuvant therapy appears to be critical.
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Affiliation(s)
- Thorsten O Goetze
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany.
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany.
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany.
| | - Alexander Reichart
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Ulli S Bankstahl
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Claudia Pauligk
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Maria Loose
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Thomas W Kraus
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Moustafa Elshafei
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Wolf O Bechstein
- Klinik für Allgemein-, Viszeral-, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jörg Trojan
- Gastrointestinale Onkologie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Matthias Behrend
- Viszeral-, Thorax- und Gefäßchirurgie, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Nils Homann
- Medizinische Klinik II, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Wolfram Bohle
- Klinik für Gastroenterologie, Gastroenterologische Onkologie, Klinikum Stuttgart, Stuttgart, Germany
- Hepatologie, Infektiologie und Pneumologie, Stuttgart, Germany
| | | | - Claus Bolling
- Hämatologie/Onkologie, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Dirk M Behringer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | | | - Gabriele M Siegler
- Klinikum Nürnberg Nord/Paracelsus Medizinische Privatuniversität, Medizinische Klinik, Hämatologie/Onkologie, Nürnberg, Germany
| | - Wael Hozaeel
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Salah-Eddin Al-Batran
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
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16
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Wattenberg MM, Colby S, Garrido-Laguna I, Xue Y, Chang R, Delman D, Lee J, Affolter K, Mulvihill SJ, Beg MS, Wang-Gillam A, Wade JL, Guthrie KA, Chiorean EG, Ahmad SA, Lowy AM, Philip PA, Sohal DPS, Beatty GL. Intratumoral Cell Neighborhoods Coordinate Outcomes in Pancreatic Ductal Adenocarcinoma. Gastroenterology 2024; 166:1114-1129. [PMID: 38244727 PMCID: PMC11102852 DOI: 10.1053/j.gastro.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDA) is a highly lethal disease characterized by a spatially heterogeneous tumor microenvironment. Within the PDA microenvironment, cells organize into communities where cell fate is influenced by neighboring cells of diverse ontogeny and function. However, it remains unclear how cell neighborhoods in the tumor microenvironment evolve with treatment and impact clinical outcomes. METHODS Here, using automated chromogenic multiplex immunohistochemistry and unsupervised computational image analysis of human PDA tumors, we investigated cell neighborhoods in surgically resected tumors from patients with chemotherapy-naïve PDA (n = 59) and neoadjuvant chemotherapy-treated PDA (n = 57). Single cells were defined by lineage markers (CD3, CD8, Foxp3, CD68, CK19), proliferation (Ki67), and neighboring cells. RESULTS Distinct intratumoral immune and tumor cell subsets were defined by neighboring cells. Higher content of stromal-associated macrophages was seen in chemotherapy-naïve tumors from long-term survivors (overall survival >3 years) compared with short-term survivors (overall survival <1 year), whereas immune-excluded tumor cells were higher in short-term survivors. Chemotherapy-treated vs -naïve tumors showed lower content of tumor-associated T cells and macrophages but similar densities of stromal-associated immune cells. However, proliferating tumor cell subsets with immune-rich neighborhoods were higher in chemotherapy-treated tumors. In a blinded analysis of tumors from patients treated with neoadjuvant chemotherapy, a composite index comprising lower quantities of immune-excluded tumor cells and higher spatially distinct immune cell subsets was associated with prolonged survival. CONCLUSIONS Together, these data provide new insights into discrete cell communities in PDA and show their clinical relevance.
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Affiliation(s)
- Max M Wattenberg
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Colby
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ignacio Garrido-Laguna
- Division of Oncology, Department of Internal Medicine, University of Utah School of Medicine, University of Utah, Salt Lake City, Utah
| | - Yuqing Xue
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee Chang
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Devora Delman
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Lee
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kajsa Affolter
- Department of Pathology, University of Utah School of Medicine, University of Utah, Salt Lake City, Utah
| | - Sean J Mulvihill
- Department of Surgery, University of Utah School of Medicine, University of Utah, Salt Lake City, Utah
| | | | | | | | - Katherine A Guthrie
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - E Gabriela Chiorean
- University of Washington, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Andrew M Lowy
- Division of Surgical Oncology, Department of Surgery, UC San Diego, La Jolla, California
| | - Philip Agop Philip
- Henry Ford Health, Wayne State University, Oncology and Pharmacology, Detroit, Michigan
| | | | - Gregory L Beatty
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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17
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Liu M, Wei AC. Advances in Surgery and (Neo) Adjuvant Therapy in the Management of Pancreatic Cancer. Hematol Oncol Clin North Am 2024; 38:629-642. [PMID: 38429197 DOI: 10.1016/j.hoc.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
A multimodality approach, which usually includes chemotherapy, surgery, and/or radiotherapy, is optimal for patients with localized pancreatic cancer. The timing and sequence of these interventions depend on anatomic resectability and the biological suitability of the tumor and the patient. Tumors with vascular involvement (ie, borderline resectable/locally advanced) require surgical reassessments after therapy and participation of surgeons familiar with advanced techniques. When indicated, venous reconstruction should be offered as standard of care because it has acceptable morbidity. Morbidity and mortality of pancreas surgery may be mitigated when surgery is performed at high-volume centers.
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Affiliation(s)
- Mengyuan Liu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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18
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Ji Y, Xu Q, Wang W. Single-cell transcriptome reveals the heterogeneity of malignant ductal cells and the prognostic value of REG4 and SPINK1 in primary pancreatic ductal adenocarcinoma. PeerJ 2024; 12:e17350. [PMID: 38827297 PMCID: PMC11141562 DOI: 10.7717/peerj.17350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/17/2024] [Indexed: 06/04/2024] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related deaths, with very limited therapeutic options available. This study aims to comprehensively depict the heterogeneity and identify prognostic targets for PDAC with single-cell RNA sequencing (scRNA-seq) analysis. Methods ScRNA-seq analysis was performed on 16 primary PDAC and three adjacent lesions. A series of analytical methods were applied for analysis in cell clustering, gene profiling, lineage trajectory analysis and cell-to-cell interactions. In vitro experiments including colony formation, wound healing and sphere formation assay were performed to assess the role of makers. Results A total of 32,480 cells were clustered into six major populations, among which the ductal cell cluster expressing high copy number variants (CNVs) was defined as malignant cells. Malignant cells were further subtyped into five subgroups which exhibited specific features in immunologic and metabolic activities. Pseudotime trajectory analysis indicated that components of various oncogenic pathways were differentially expressed along tumor progression. Furthermore, intensive substantial crosstalk between ductal cells and stromal cells was identified. Finally, genes (REG4 and SPINK1) screened out of differentially expressed genes (DEGs) were upregulated in PDAC cell lines. Silencing either of them significantly impaired proliferation, invasion, migration and stemness of PDAC cells. Conclusions Our findings offer a valuable resource for deciphering the heterogeneity of malignant ductal cells in PDAC. REG4 and SPINK1 are expected to be promising targets for PDAC therapy.
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MESH Headings
- Humans
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/metabolism
- Carcinoma, Pancreatic Ductal/mortality
- Trypsin Inhibitor, Kazal Pancreatic/genetics
- Trypsin Inhibitor, Kazal Pancreatic/metabolism
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/metabolism
- Prognosis
- Single-Cell Analysis
- Transcriptome
- Lectins, C-Type/genetics
- Lectins, C-Type/metabolism
- Cell Line, Tumor
- Gene Expression Regulation, Neoplastic
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Female
- Male
- Pancreatitis-Associated Proteins
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Affiliation(s)
- Yutian Ji
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
| | | | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, China
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19
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Manojlovic N, Savic G, Manojlovic S. Neoadjuvant treatment of pancreatic ductal adenocarcinoma: Whom, when and how. World J Gastrointest Surg 2024; 16:1223-1230. [PMID: 38817288 PMCID: PMC11135299 DOI: 10.4240/wjgs.v16.i5.1223] [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] [Received: 12/28/2023] [Revised: 03/13/2024] [Accepted: 04/22/2024] [Indexed: 05/23/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC), which is notorious for its aggressiveness and poor prognosis, remains an area of great unmet medical need, with a 5-year survival rate of 10% - the lowest of all solid tumours. At diagnosis, only 20% of patients have resectable pancreatic cancer (RPC) or borderline RPC (BRPC) disease, while 80% of patients have unresectable tumours that are locally advanced pancreatic cancer (LAPC) or have distant metastases. Nearly 60% of patients who undergo upfront surgery for RPC are unable to receive adequate adjuvant chemotherapy (CHT) because of postoperative complications and early cancer recurrence. An important paradigm shift to achieve better outcomes has been the sequence of therapy, with neoadjuvant CHT preceding surgery. Three surgical stages have emerged for the preoperative assessment of nonmetastatic pancreatic cancers: RPC, BRPC, and LAPC. The main goal of neoadjuvant treatment (NAT) is to improve postoperative outcomes through enhanced selection of candidates for curative-intent surgery by identifying patients with aggressive or metastatic disease during initial CHT, reducing tumour volume before surgery to improve the rate of margin-negative resection (R0 resection, a microscopic margin-negative resection), reducing the rate of positive lymph node occurrence at surgery, providing early treatment of occult micrometastatic disease, and assessing tumour chemosensitivity and tolerance to treatment as potential surgical criteria. In this editorial, we summarize evidence concerning NAT of PDAC, providing insights into future practice and study design. Future research is needed to establish predictive biomarkers, measures of therapeutic response, and multidisciplinary strategies to improve patient-centered outcomes.
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Affiliation(s)
- Nebojsa Manojlovic
- Clinic for Gastroenterology and Hepatology, Military Medical Academy, Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade 11000, Serbia
| | - Goran Savic
- Military Medical Academy, Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade 11000, Serbia
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20
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K GB, Koyyala VPB. The Role of Neoadjuvant and Adjuvant Chemotherapy in Pancreatic Cancer. Indian J Surg Oncol 2024; 15:315-321. [PMID: 38818012 PMCID: PMC11133239 DOI: 10.1007/s13193-024-01938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/30/2024] [Indexed: 06/01/2024] Open
Abstract
Pancreatic cancer is an aggressive malignancy. Recurrences are very high despite high-quality surgery necessitating adjuvant therapy. The evolution of adjuvant therapy took several decades and gradually evolved from single-agent chemotherapy to multi-agent chemotherapy. The two important agents that are active in pancreatic cancer are 5-fluorouracil and gemcitabine, and with several combinations showing better results in the subsequent trials, the most recent trial PRODIGE 24 shows a median survival of 54.4 months. The role of neoadjuvant therapy is still evolving in resectable cancers. The role of adjuvant radiotherapy is not well defined due to controversial results from historical trials.
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Affiliation(s)
- Govind Babu K
- HCG Hospitals St. Johns Medical College and Hospital, Bangalore, Karnataka India
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21
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Endo Y, Kitago M, Kitagawa Y. Evidence and Future Perspectives for Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Scoping Review. Cancers (Basel) 2024; 16:1632. [PMID: 38730584 PMCID: PMC11083108 DOI: 10.3390/cancers16091632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Pancreatic cancer (PC) is a lethal disease that requires innovative therapeutic approaches to enhance the survival outcomes. Neoadjuvant treatment (NAT) has gained attention for resectable and borderline resectable PC, offering improved resection rates and enabling early intervention and patient selection. Several retrospective studies have validated its efficacy. However, previous studies have lacked intention-to-treat analyses and appropriate resectability classifications. Randomized comparative trials may help to enhance the clinical applicability of evidence. Therefore, after searching the MEDLINE database, this scoping review presents a comprehensive summary of the evidence from published (n = 14) and ongoing (n = 12) randomized Phase II and III trials. Diverse regimens and their outcomes were explored for both resectable and borderline resectable PC. While some trials have supported the efficacy of NAT, others have demonstrated no clear survival benefits for patients with resectable PC. The utility of NAT has been confirmed in patients with borderline resectable PC, but the optimal regimens remain debatable. Ongoing trials are investigating novel regimens, including immunotherapy, thereby highlighting the dynamic landscape of PC treatment. Studies should focus on biomarker identification, which may enable precision in oncology. Future endeavors aim to refine treatment strategies, guided by precision oncology.
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Affiliation(s)
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo 160-8582, Japan; (Y.E.); (Y.K.)
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22
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Error in Visual Abstract. JAMA Oncol 2024; 10:541. [PMID: 34554201 PMCID: PMC8461550 DOI: 10.1001/jamaoncol.2021.5278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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23
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Jethwa KR, Kim E, Berlin J, Anker CJ, Tchelebi L, Abood G, Hallemeier CL, Jabbour S, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Williams V, Russo S. Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma: Systematic Review and Guidelines. Am J Clin Oncol 2024; 47:185-199. [PMID: 38131628 DOI: 10.1097/coc.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and "Preferred Reporting Items for Systematic Reviews and Meta-analyses" 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jordan Berlin
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Christopher J Anker
- Department of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, VT
| | - Leila Tchelebi
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
| | | | | | | | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, NJ
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Sibley Memorial Hospital, Washington DC
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, PA
| | - William Small
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, IL
| | - Vonetta Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, NY
| | - Suzanne Russo
- Department of Radiation Oncology, University Hospitals Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH
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24
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Dias E Silva D, Chung V. Neoadjuvant treatment for pancreatic cancer: Controversies and advances. Cancer Treat Res Commun 2024; 39:100804. [PMID: 38508132 DOI: 10.1016/j.ctarc.2024.100804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 03/22/2024]
Abstract
Despite the advancements in the treatment of localized pancreatic cancer, several unresolved issues persist in clinical practice, especially in the neoadjuvant setting. These include determining the criteria for selecting patients for treatment, identifying the most effective chemotherapy regimens, understanding the role of radiotherapy, and accurately assessing how patients respond to treatment. Current strategies for assessing patients before surgery involve thoroughly evaluating their overall health status, analyzing tumor markers, and using advanced imaging techniques. However, existing methods for staging the disease still have limitations when it comes to accurately detecting metastatic cancer. The ongoing debate between performing surgery upfront or administering neoadjuvant therapy highlights the need for robust clinical evidence to guide treatment decisions effectively. This review analyzes the evidence regarding controversial topics in neoadjuvant pancreatic cancer treatment and discusses further research efforts to enhance patient outcomes. To improve the outcomes found with surgery alone, multimodal treatment with chemotherapy.
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Affiliation(s)
| | - Vincent Chung
- City of Hope, 1500 E. Duarte Road, Duarte, CA 91010, United States.
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25
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Huan L, Yu F, Cao D, Zhou H, Qin M, Cao Y. Comparison of neoadjuvant treatment and surgery first for resectable or borderline resectable pancreatic carcinoma: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2024; 19:e0295983. [PMID: 38451955 PMCID: PMC10919605 DOI: 10.1371/journal.pone.0295983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/03/2023] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Current treatment recommendations for resectable or borderline pancreatic carcinoma support upfront surgery and adjuvant therapy. However, neoadjuvant therapy (NT) seems to increase prognosis of pancreatic carcinoma and come to everyone's attention gradually. Randomized controlled trials offering comparison with the NT are lacking and optimal neoadjuvant treatment regimen still remains uncertain. This study aims to compare both treatment strategies for resectable or borderline resectable pancreatic cancer. METHODS The PRISMA checklist was used as a guide to systematically review relevant peer-reviewed literature reporting primary data analysis. We searched PubMed, Medline, EMBASE, Cochrane Datebase and related reviews for randomized controlled trials comparing neoadjuvant therapy with surgery first for resectable or borderline resectable pancreatic carcinoma. We estimated relative hazard ratios (HRs) for median overall survival and ratios risks (RRs) for microscopically complete (R0) resection among different neoadjuvant regimens and major complications. We assessed the effects of neoadjuvant therapy on R0 resection rate and median overall survival with Bayesian analysis. RESULTS Thirteen eligible articles were included. Eight studies performed comparison neoadjuvant therapy with surgery first, and R0 resection rate was recorded in seven studies. Compared with surgery first, neoadjuvant therapy did increase the R0 resection rate (RR = 1.53, I2 = 0%, P< 0.00001), there was a certain possibility that gemcitabine + cisplatin (Gem+Cis) + Radiotherapy was the most favorable in terms of the fact that there was no significant difference concerning the results from the individual studies. In direct comparison, four studies were included and estimated that Neoadjuvant therapy improved mOS compared with upfront surgery (HR 0.68, 95% CI 0.58-0.92; P = 0.012; I2 = 15%), after Bayesian analysis it seemed that regimen with Cisplatin/ Epirubicin then Gemcitabine/ Capecitabine (PEXG) was most likely the best with a relatively small sample size. The rate of major surgical complications was available for six studies and ranged from 11% to 56% with neoadjuvant therapy and 11% to 45% with surgery first. There was no significant difference between neoadjuvant therapy and surgery first, also with a high heterogeneity (RR = 0.96, 95%CI = 0.65-1.43; P = 0.85; I2 = 46%). CONCLUSION In conclusion neoadjuvant therapy might offer benefit over up-front surgery. Neoadjuvant therapy increased the R0 resection rate with gemcitabine + cisplatin + Radiotherapy that was the most favorable and improved mOS with Cisplatin/ Epirubicin then Gemcitabine/ Capecitabine (PEXG) that was most likely the best.
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Affiliation(s)
- Lu Huan
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Fucai Yu
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Ding Cao
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Hantao Zhou
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Maoling Qin
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, China
| | - Yang Cao
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
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Sohal DPS, Boutin RD, Lenchik L, Kim J, Beg MS, Wang-Gillam A, Wade JL, Guthrie KA, Chiorean EG, Ahmad SA, Lowy AM, Philip PA, Chang VTS. Body composition measurements and clinical outcomes in patients with resectable pancreatic adenocarcinoma - analysis from SWOG S1505. J Gastrointest Surg 2024; 28:232-235. [PMID: 38445914 DOI: 10.1016/j.gassur.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/08/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Sarcopenic obesity and muscle attenuation have been associated with survival in patients with borderline resectable and advanced pancreatic ductal adenocarcinoma (PDA); however, these relationships are unknown for patients with resectable PDA. This study examined the associations between skeletal muscle and adipose tissue as measured on baseline computed tomography (CT) and the overall survival (OS) of participants with resectable PDA in a secondary analysis of the Southwest Oncology Group S1505 clinical trial (identifier: NCT02562716). METHODS The S1505 phase II clinical trial enrolled patients with resectable PDA who were randomized to receive modified FOLFIRINOX or gemcitabine and nab-paclitaxel as perioperative chemotherapy, followed by surgical resection. Baseline axial CT images at the L3 level were analyzed with externally validated software, and measurements were recorded for skeletal muscle area and skeletal muscle density, visceral adipose tissue area (VATA) and density, and subcutaneous adipose tissue area and density. The relationships between CT metrics and OS were analyzed using Cox regression models, with adjustment for baseline participant characteristics. RESULTS Of 98 eligible participants with available baseline abdominal CT, 8 were excluded because of imaging quality (eg, orthopedic hardware), resulting in 90 evaluable cases: 51 men (57.0%; mean age, 63.2 years [SD, 8.5]; mean body mass index [BMI], 29.3 kg/m2 [SD, 6.4]), 80 White (89.0%), 6 Black (7.0%), and 4 unknown race (4.0%). Sarcopenia was present in 32 participants (35.9%), and sarcopenic obesity was present in 10 participants (11.2%). Univariable analyses for the 6 variables of interest indicated that the standardized mean difference (hazard ratio [HR], 0.75; 95% CI, 0.57-0.98; P = .04) was statistically significantly associated with OS. In models adjusted for sex, race, age, BMI, performance score, contrast use, sarcopenia, and sarcopenic obesity, VATA was statistically significantly associated with OS (HR, 1.58; 95% CI, 1.00-2.51; P = .05). No difference was observed in OS between participants according to sarcopenic obesity or sarcopenia categories. The median OS estimates were 25.1 months for participants without sarcopenic obesity, 18.6 months for participants with sarcopenic obesity, 23.6 months for participants without sarcopenia, and 27.9 months for participants with sarcopenia. CONCLUSION This was the first study to systematically evaluate body composition parameters in a prospective multicenter trial of patients with resectable PDA who received perioperative chemotherapy. Visceral adipose tissue was associated with survival; however, there was no association between OS and sarcopenia or sarcopenic obesity. Further studies should evaluate these findings in more detail.
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Affiliation(s)
| | - Robert D Boutin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington State, United States
| | - Leon Lenchik
- Stanford University, Stanford, California, United States
| | - Jiyoon Kim
- Wake Forest University, Winston-Salem, North Carolina, United States
| | - M Shaalan Beg
- University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Andrea Wang-Gillam
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States
| | - James Lloyd Wade
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, Illinois, United States
| | - Katherine A Guthrie
- Southwest Oncology Group Statistics and Data Management Center, Seattle, Washington State, United States
| | - E Gabriela Chiorean
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington State, United States
| | - Syed A Ahmad
- University of Cincinnati, Cincinnati, Ohio, United States
| | - Andrew M Lowy
- University of California San Diego Moores Cancer Center, La Jolla, California, United States
| | | | - Victor Tsu-Shih Chang
- Section of Hematology/Oncology, Veterans Administration New Jersey Health Care System, East Orange, New Jersey, United States
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Labori KJ, Bratlie SO, Andersson B, Angelsen JH, Biörserud C, Björnsson B, Bringeland EA, Elander N, Garresori H, Grønbech JE, Haux J, Hemmingsson O, Liljefors MG, Myklebust TÅ, Nymo LS, Peltola K, Pfeiffer P, Sallinen V, Sandström P, Sparrelid E, Stenvold H, Søreide K, Tingstedt B, Verbeke C, Öhlund D, Klint L, Dueland S, Lassen K. Neoadjuvant FOLFIRINOX versus upfront surgery for resectable pancreatic head cancer (NORPACT-1): a multicentre, randomised, phase 2 trial. Lancet Gastroenterol Hepatol 2024; 9:205-217. [PMID: 38237621 DOI: 10.1016/s2468-1253(23)00405-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND In patients undergoing resection for pancreatic cancer, adjuvant modified fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) improves overall survival compared with alternative chemotherapy regimens. We aimed to compare the efficacy and safety of neoadjuvant FOLFIRINOX with the standard strategy of upfront surgery in patients with resectable pancreatic ductal adenocarcinoma. METHODS NORPACT-1 was a multicentre, randomised, phase 2 trial done in 12 hospitals in Denmark, Finland, Norway, and Sweden. Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, and had a resectable tumour of the pancreatic head radiologically strongly suspected to be pancreatic adenocarcinoma. Participants were randomly assigned (3:2 before October, 2018, and 1:1 after) to the neoadjuvant FOLFIRINOX group or upfront surgery group. Patients in the neoadjuvant FOLFIRINOX group received four neoadjuvant cycles of FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2, and fluorouracil 400 mg/m2 bolus then 2400 mg/m2 over 46 h on day 1 of each 14-day cycle), followed by surgery and adjuvant chemotherapy. Patients in the upfront surgery group underwent surgery and then received adjuvant chemotherapy. Initially, adjuvant chemotherapy was gemcitabine plus capecitabine (gemcitabine 1000 mg/m2 over 30 min on days 1, 8, and 15 of each 28-day cycle and capecitabine 830 mg/m2 twice daily for 3 weeks with 1 week of rest in each 28-day cycle; four cycles in the neoadjuvant FOLFIRINOX group, six cycles in the upfront surgery group). A protocol amendment was subsequently made to permit use of adjuvant modified FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 150 mg/m2, leucovorin 400 mg/m2, and fluorouracil 2400 mg/m2 over 46 h on day 1 of each 14-day cycle; eight cycles in the neoadjuvant FOLFIRINOX group, 12 cycles in the upfront surgery group). Randomisation was performed with a computerised algorithm that stratified for each participating centre and used a concealed block size of two to six. Patients, investigators, and study team members were not masked to treatment allocation. The primary endpoint was overall survival at 18 months. Analyses were done in the intention-to-treat (ITT) and per-protocol populations. Safety was assessed in all patients who were randomly assigned and received at least one cycle of neoadjuvant or adjuvant therapy. This trial is registered with ClinicalTrials.gov, NCT02919787, and EudraCT, 2015-001635-21, and is ongoing. FINDINGS Between Feb 8, 2017, and April 21, 2021, 77 patients were randomly assigned to receive neoadjuvant FOLFIRINOX and 63 to undergo upfront surgery. All patients were included in the ITT analysis. For the per-protocol analysis, 17 (22%) patients were excluded from the neoadjuvant FOLFIRINOX group (ten did not receive neoadjuvant therapy, four did not have pancreatic ductal adenocarcinoma, and three received another neoadjuvant regimen), and eight (13%) were excluded from the upfront surgery group (seven did not have pancreatic ductal adenocarcinoma and one did not undergo surgical exploration). 61 (79%) of 77 patients in the neoadjuvant FOLFIRINOX group received neoadjuvant therapy. The proportion of patients alive at 18 months by ITT was 60% (95% CI 49-71) in the neoadjuvant FOLFIRINOX group versus 73% (62-84) in the upfront surgery group (p=0·032), and median overall survival by ITT was 25·1 months (95% CI 17·2-34·9) versus 38·5 months (27·6-not reached; hazard ratio [HR] 1·52 [95% CI 1·00-2·33], log-rank p=0·050). The proportion of patients alive at 18 months in per-protocol analysis was 57% (95% CI 46-67) in the neoadjuvant FOLFIRINOX group versus 70% (55-83) in the upfront surgery group (p=0·14), and median overall survival in per-protocol population was 23·0 months (95% CI 16·2-34·9) versus 34·4 months (19·4-not reached; HR 1·46 [95% CI 0·99-2·17], log-rank p=0·058). In the safety population, 42 (58%) of 73 patients in the neoadjuvant FOLFIRINOX group and 19 (40%) of 47 patients in the upfront surgery group had at least one grade 3 or worse adverse event. 63 (82%) of 77 patients in the neoadjuvant group and 56 (89%) of 63 patients in the upfront surgery group had resection (p=0·24). One sudden death of unknown cause and one COVID-19-related death occurred after the first cycle of neoadjuvant FOLFIRINOX. Adjuvant chemotherapy was initiated in 51 (86%) of 59 patients with resected pancreatic ductal adenocarcinoma in the neoadjuvant FOLFIRINOX group and 44 (90%) of 49 patients with resected pancreatic ductal adenocarcinoma in the upfront surgery group (p=0·56). Adjuvant modified FOLFIRINOX was given to 13 (25%) patients in the neoadjuvant FOLFIRINOX group and 19 (43%) patients in the upfront surgery group. During adjuvant chemotherapy, neutropenia (11 [22%] patients in the neoadjuvant FOLFIRINOX group and five [11%] in the upfront surgery group) was the most common grade 3 or worse adverse event. INTERPRETATION This phase 2 trial did not show a survival benefit from neoadjuvant FOLFIRINOX in resectable pancreatic ductal adenocarcinoma compared with upfront surgery. Implementation of neoadjuvant FOLFIRINOX was challenging. Future trials on treatment sequencing in resectable pancreatic ductal adenocarcinoma should be biomarker driven. FUNDING Norwegian Cancer Society, South Eastern Norwegian Health Authority, The Sjöberg Foundation, and Helsinki University Hospital Research Grants.
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Affiliation(s)
- Knut Jørgen Labori
- Department of Hepato Pancreato Biliary Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Jon-Helge Angelsen
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christina Biörserud
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bergthor Björnsson
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erling Audun Bringeland
- Department of Gastrointestinal Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nils Elander
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Herish Garresori
- Department of Hematology and Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Jon Erik Grønbech
- Department of Gastrointestinal Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Haux
- Department of Oncology, Skaraborg Hospital Skövde, Skövde, Sweden; School of Health Sciences, University of Skövde, Skövde, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Maria Gustafsson Liljefors
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tor Åge Myklebust
- Department of Registration, Cancer Registry of Norway, Oslo, Norway; Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Linn Såve Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Katriina Peltola
- Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Per Pfeiffer
- Department of Medical Oncology, Odense University Hospital, Odense, Denmark
| | - Ville Sallinen
- Gastroenterological Surgery/ Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Per Sandström
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ernesto Sparrelid
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Helge Stenvold
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
| | - Kjetil Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Bobby Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Caroline Verbeke
- Department of Pathology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Daniel Öhlund
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden; Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Leif Klint
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Oncology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Svein Dueland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Kristoffer Lassen
- Department of Hepato Pancreato Biliary Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
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Turner KM, Wilson GC, Patel SH, Ahmad SA. ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer. Ann Surg Oncol 2024; 31:1884-1897. [PMID: 37980709 DOI: 10.1245/s10434-023-14585-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/29/2023] [Indexed: 11/21/2023]
Abstract
Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well-selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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29
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Narita M, Hatano E, Kitamura K, Fukumitsu K, Kitagawa H, Hamaguchi Y, Yazawa T, Terajima H, Kitaguchi K, Hata T. Identification of patients at high risk for recurrence in carcinoma of the ampulla of Vater: Analysis in 460 patients. Ann Gastroenterol Surg 2024; 8:190-201. [PMID: 38455488 PMCID: PMC10914706 DOI: 10.1002/ags3.12764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/09/2023] [Accepted: 11/21/2023] [Indexed: 03/09/2024] Open
Abstract
Aim Carcinoma of the ampulla of Vater (CAV) shows a favorable prognosis compared to that with the other periampullary tumors, while some cases have a poor prognosis. The aims of the present study are to clarify the clinicopathological factors associated with poor recurrence-free survival (RFS) in patients with CAV after curative resection and to validate the usefulness of adjuvant chemotherapy (AC). Patients The study design is a multicenter retrospective cohort study. Patients with CAV who underwent pancreaticoduodenectomy between January 2008 and December 2020 at 26 hospitals were analyzed. The 30 clinicopathological factors were evaluated. A propensity score matching (PSM) was used to compare between patients with and without AC. Results Finally, 460 patients were analyzed. Median duration of follow-up was 47.2 months. Twenty-one prognostic factors associated with poor RFS were identified by univariate analysis. In multivariate analysis, aged ≥71, tumor diameter ≥12 mm, pT2 or higher stage (pT≥2), portal vein invasion (PV+), venous invasion(V+), and node positive disease (pN+) were independent prognostic factors for poor RFS. Out of 80 patients who received AC, 63 patients were assigned to analysis for PSM. The results showed no beneficial effect of AC on RFS. The preoperative factors potentially predicting pT≥2, V+, and/or N+ were at least one of following; (1) CA19-9 > 37 IU/mL, (2) ulcerative or mixed type appearance, (3) except for well-differentiated tumor, or (4) except for intestinal subtype of histology. Conclusions Aged ≥71, tumor diameter ≥12 mm, pT≥2, PV+, V+, and pN+ were independent prognostic factors for poor RFS in patients with CAV. An additional therapeutic strategy may be desirable in CAV patients at high risk for recurrence.
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Affiliation(s)
- Masato Narita
- Department of SurgeryNational Hospital Organization Kyoto Medical CenterKyotoJapan
- Department of SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Koji Kitamura
- Department of SurgeryHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Ken Fukumitsu
- Department of SurgeryKyoto Katsura HospitalKyotoJapan
| | | | - Yuhei Hamaguchi
- Department of SurgeryJapanese Red Cross Osaka HospitalOsakaJapan
| | | | | | | | - Toshihiko Hata
- Department of SurgeryKobe City Medical Center West HospitalKobeJapan
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Aoki T, Mori S, Kubota K. Neoadjuvant and Adjuvant Chemotherapy for Pancreatic Adenocarcinoma: Literature Review and Our Experience of NAC-GS. Cancers (Basel) 2024; 16:910. [PMID: 38473272 DOI: 10.3390/cancers16050910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
In addition to established evidence of the efficacy of adjuvant chemotherapy (AC) for pancreatic ductal adenocarcinoma (PDAC), evidence of the effects of neoadjuvant treatments (NATs), including chemotherapy and chemoradiotherapy, has also been accumulating. Recent results from prospective studies and meta-analyses suggest that NATs may be beneficial not only for borderline resectable PDAC, but also for resectable PDAC, by increasing the likelihood of successful R0 resection, decreasing the likelihood of the development of lymph node metastasis, and improving recurrence-free and overall survival. In addition, response to NAT may be informative for predicting the clinical course after preoperative NAT followed by surgery; in this way, the postoperative treatment strategy can be revised based on the effect of NAT and the post-neoadjuvant therapy/surgery histopathological findings. On the other hand, the response to NAT and AC is also influenced by the tumor biology and the patient's immune/nutritional status; therefore, planning of the treatment strategy and meticulous management of NAT, surgery, and AC is required on a patient-by-patient basis. Our experience of using gemcitabine plus S-1 showed that this NAT regimen achieved tumor shrinkage and decreased the levels of tumor markers but failed to provide a survival benefit. Our results also suggested that response/adverse events to NAT may be predictive of the efficacy of AC, as well as survival outcomes.
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Affiliation(s)
- Taku Aoki
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Mibu 321-0293, Tochigi, Japan
| | - Shozo Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Mibu 321-0293, Tochigi, Japan
| | - Keiichi Kubota
- Department of Hepato-Biliary-Pancreatic Surgery, Dokkyo Medical University, Mibu 321-0293, Tochigi, Japan
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31
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Ali LR, Lenehan PJ, Cardot-Ruffino V, Dias Costa A, Katz MH, Bauer TW, Nowak JA, Wolpin BM, Abrams TA, Patel A, Clancy TE, Wang J, Mancias JD, Reilley MJ, Stucky CCH, Bekaii-Saab TS, Elias R, Merchant N, Slingluff CL, Rahma OE, Dougan SK. PD-1 Blockade Induces Reactivation of Nonproductive T-Cell Responses Characterized by NF-κB Signaling in Patients with Pancreatic Cancer. Clin Cancer Res 2024; 30:542-553. [PMID: 37733830 PMCID: PMC10831338 DOI: 10.1158/1078-0432.ccr-23-1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/28/2023] [Accepted: 09/19/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) trials have evaluated CTLA-4 and/or PD-(L)1 blockade in patients with advanced disease in which bulky tumor burden and limited time to develop antitumor T cells may have contributed to poor clinical efficacy. Here, we evaluated peripheral blood and tumor T cells from patients with PDAC receiving neoadjuvant chemoradiation plus anti-PD-1 (pembrolizumab) versus chemoradiation alone. We analyzed whether PD-1 blockade successfully reactivated T cells in the blood and/or tumor to determine whether lack of clinical benefit could be explained by lack of reactivated T cells versus other factors. EXPERIMENTAL DESIGN We used single-cell transcriptional profiling and TCR clonotype tracking to identify TCR clonotypes from blood that match clonotypes in the tumor. RESULTS PD-1 blockade increases the flux of TCR clonotypes entering cell cycle and induces an IFNγ signature like that seen in patients with other GI malignancies who respond to PD-1 blockade. However, these reactivated T cells have a robust signature of NF-κB signaling not seen in cases of PD-1 antibody response. Among paired samples between blood and tumor, several of the newly cycling clonotypes matched activated T-cell clonotypes observed in the tumor. CONCLUSIONS Cytotoxic T cells in the blood of patients with PDAC remain sensitive to reinvigoration by PD-1 blockade, and some have tumor-recognizing potential. Although these T cells proliferate and have a signature of IFN exposure, they also upregulate NF-κB signaling, which potentially counteracts the beneficial effects of anti-PD-1 reinvigoration and marks these T cells as non-productive contributors to antitumor immunity. See related commentary by Lander and DeNardo, p. 474.
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Affiliation(s)
- Lestat R. Ali
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Immunology, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Patrick J. Lenehan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Immunology, Harvard Medical School, Boston, Massachusetts
| | - Victoire Cardot-Ruffino
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Immunology, Harvard Medical School, Boston, Massachusetts
| | - Andressa Dias Costa
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Matthew H.G. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Todd W. Bauer
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jonathan A. Nowak
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Brian M. Wolpin
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Thomas A. Abrams
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Anuj Patel
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Thomas E. Clancy
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jiping Wang
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph D. Mancias
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew J. Reilley
- Division of Hematology and Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Rawad Elias
- Hartford Healthcare Cancer Institute, Hartford, Connecticut
| | - Nipun Merchant
- Department of Surgery, University of Miami, Miami, Florida
| | - Craig L. Slingluff
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Osama E. Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Stephanie K. Dougan
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Immunology, Harvard Medical School, Boston, Massachusetts
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Sugawara T, Rodriguez Franco S, Sherman S, Torphy RJ, Colborn K, Franklin O, Ishida J, Grandi S, Al-Musawi MH, Gleisner A, Schulick RD, Del Chiaro M. Neoadjuvant Chemotherapy Versus Upfront Surgery for Resectable Pancreatic Adenocarcinoma: An Updated Nationwide Study. Ann Surg 2024; 279:331-339. [PMID: 37226812 DOI: 10.1097/sla.0000000000005925] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The objective of this study was to assess the association of survival with neoadjuvant chemotherapy (NAC) in resectable pancreatic adenocarcinoma (PDAC). BACKGROUND The early control of potential micrometastases and patient selection using NAC has been advocated for patients with PDAC. However, the role of NAC for resectable PDAC remains unclear. METHODS Patients with clinical T1 and T2 PDAC were identified in the National Cancer Database from 2010 to 2017. Kaplan-Meier estimates, and Cox regression models were used to compare survival. To address immortal time bias, landmark analysis was performed. Interactions between preoperative factors and NAC were investigated in subgroup analyses. A propensity score analysis was performed to compare survival between multiagent NAC and upfront surgery. RESULTS In total, 4041 patients were treated with upfront surgery and 1,175 patients were treated with NAC (79.4% multiagent NAC, 20.6% single-agent NAC). Using a landmark time of 6 months after diagnosis, patients treated with multiagent NAC had longer median overall survival compared with upfront surgery and single-agent NAC. (35.8 vs 27.1 vs 27.4 mo). Multiagent NAC was associated with lower mortality rates compared with upfront surgery (adjusted hazard ratio, 0.77; 95% CI, 0.70-0.85), whereas single-agent NAC was not. The association of survival with multiagent NAC were consistent in analyses using the matched data sets. Interaction analysis revealed that the association between multiagent NAC and a lower mortality rate did not significantly differ across age, facility type, tumor location, CA 19-9 levels, and clinical T/N stages. CONCLUSIONS The findings suggest that multiagent NAC followed by resection is associated with improved survival compared with upfront surgery.
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Affiliation(s)
- Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Samantha Sherman
- Department of Surgery, Parkview Hospital Randallia, Fort Wayne, IN
| | - Robert J Torphy
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn Colborn
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Oskar Franklin
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jun Ishida
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Samuele Grandi
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | | | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO
| | - Richard D Schulick
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO
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Okui N, Tsunematsu M, Furukawa K, Shirai Y, Haruki K, Sakamoto T, Uwagawa T, Onda S, Gocho T, Ikegami T. The prognosis-based classification model in resectable pancreatic cancer. Surg Oncol 2024; 52:102035. [PMID: 38198986 DOI: 10.1016/j.suronc.2024.102035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/07/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
AIM Pancreatic ductal adenocarcinoma treatment is mainly based on the anatomical resectability classification. However, prognosis-based classification may be more reasonable. In this study, we stratified resectable pancreatic ductal adenocarcinoma according to preoperative factors and reconsidered treatment strategies. METHODS We retrospectively evaluated 131 patients who underwent upfront surgery for resectable pancreatic ductal adenocarcinoma between 2007 and 2019. Recurrence within 1 year after surgery was defined as early recurrence, and the risk factors for early recurrence were identified using preoperative factors. Subsequently, we calculated the scores and stratified the participant groups. RESULTS Fifty-five (42 %) patients who relapsed within 1 year showed significantly poorer survival than those without recurrence (median overall survival, 14.0 vs. 80.6 months; p < 0.01). Multivariate analysis revealed that a tumor diameter of ≥24 mm (p < 0.01) and preoperative serum carbohydrate antigen 19-9 level of ≥380 U/mL (p = 0.04) were the independent risk factors for early recurrence. Early recurrence score was created using these factors, stratifying the participant group into three groups of 0-2 points, and the prognosis was significantly different (median overall survival, 49.3 vs. 31.2 vs. 16.0 months; p < 0.01). CONCLUSION We stratified the upfront surgical cases of resectable pancreatic ductal adenocarcinoma. The group with a score of 0 had a good prognosis, and upfront surgery was possibly not futile on patients in poor general condition. The group with a score of 2 had a poor prognosis and may require stronger preoperative treatment.
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Affiliation(s)
- Norimitsu Okui
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Taro Sakamoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Uwagawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Yan X, Fu X, Gui Y, Chen X, Cheng Y, Dai M, Wang W, Xiao M, Tan L, Zhang J, Shao Y, Wang H, Chang X, Lv K. Development and validation of a nomogram model based on pretreatment ultrasound and contrast-enhanced ultrasound to predict the efficacy of neoadjuvant chemotherapy in patients with borderline resectable or locally advanced pancreatic cancer. Cancer Imaging 2024; 24:13. [PMID: 38245789 PMCID: PMC10800053 DOI: 10.1186/s40644-024-00662-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES To develop a nomogram using pretreatment ultrasound (US) and contrast-enhanced ultrasound (CEUS) to predict the clinical response of neoadjuvant chemotherapy (NAC) in patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC). METHODS A total of 111 patients with pancreatic ductal adenocarcinoma (PDAC) treated with NAC between October 2017 and February 2022 were retrospectively enrolled. The patients were randomly divided (7:3) into training and validation cohorts. The pretreatment US and CEUS features were reviewed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of clinical response in the training cohort. Then a prediction nomogram model based on the independent predictors was constructed. The area under the curve (AUC), calibration plot, C-index and decision curve analysis (DCA) were used to assess the nomogram's performance, calibration, discrimination and clinical benefit. RESULTS The multivariate logistic regression analysis showed that the taller-than-wide shape in the longitudinal plane (odds ratio [OR]:0.20, p = 0.01), time from injection of contrast agent to peak enhancement (OR:3.64; p = 0.05) and Peaktumor/ Peaknormal (OR:1.51; p = 0.03) were independent predictors of clinical response to NAC. The predictive nomogram developed based on the above imaging features showed AUCs were 0.852 and 0.854 in the primary and validation cohorts, respectively. Good calibration was achieved in the training datasets, with C-index of 0.852. DCA verified the clinical usefulness of the nomogram. CONCLUSIONS The nomogram based on pretreatment US and CEUS can effectively predict the clinical response of NAC in patients with BRPC and LAPC; it may help guide personalized treatment.
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Affiliation(s)
- Xiaoyi Yan
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xianshui Fu
- Department of Ultrasound, No.304 Hospital of Chinese PLA, Beijing, 100037, China
| | - Yang Gui
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xueqi Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yuejuan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Weibin Wang
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Mengsu Xiao
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Tan
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jing Zhang
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yuming Shao
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huanyu Wang
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiaoyan Chang
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ke Lv
- Department of Ultrasound, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Erdem S, Narayanan JS, Worni M, Bolli M, White RR. Local ablative therapies and the effect on antitumor immune responses in pancreatic cancer - A review. Heliyon 2024; 10:e23551. [PMID: 38187292 PMCID: PMC10767140 DOI: 10.1016/j.heliyon.2023.e23551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, projected to rank as the second most prevalent cause of cancer-related mortality by 2030. Despite significant progress in advances in surgical techniques and chemotherapy protocols, the overall survival (OS) remains to be less than 10 % for all stages combined. In recent years, local ablative techniques have been introduced and utilized as additional therapeutic approaches for locally advanced pancreatic cancer (LAPC), with promising results with respect to local tumor control and OS. In addition to successful cytoreduction, there is emerging evidence that local ablation induces antitumor immune activity that could prevent or even treat distant metastatic tumors. The enhancement of antitumor immune responses could potentially make ablative therapy a therapeutic option for the treatment of metastatic PDAC. In this review, we summarize current ablative techniques used in the management of LAPC and their impact on systemic immune responses.
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Affiliation(s)
- Suna Erdem
- Moores Cancer Center, University of California San Diego, CA, USA
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | | | - Mathias Worni
- Department of Surgery, Hirslanden Clinic Beau Site, Bern, Switzerland
- Department of Surgery, Duke University Switzerland
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
- Medical Center, Duke University, Durham, NC, USA
- Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland
| | - Martin Bolli
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Rebekah R. White
- Moores Cancer Center, University of California San Diego, CA, USA
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Allan Z, Liu DS, Lee MM, Tie J, Clemons NJ. A Practical Approach to Interpreting Circulating Tumor DNA in the Management of Gastrointestinal Cancers. Clin Chem 2024; 70:49-59. [PMID: 38175583 DOI: 10.1093/clinchem/hvad188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/19/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND There is accumulating evidence supporting the clinical use of circulating tumor DNA (ctDNA) in solid tumors, especially in different types of gastrointestinal cancer. As such, appraisal of the current and potential clinical utility of ctDNA is needed to guide clinicians in decision-making to facilitate its general applicability. CONTENT In this review, we firstly discuss considerations surrounding specimen collection, processing, storage, and analysis, which affect reporting and interpretation of results. Secondly, we evaluate a selection of studies on colorectal, esophago-gastric, and pancreatic cancer to determine the level of evidence for the use of ctDNA in disease screening, detection of molecular residual disease (MRD) and disease recurrence during surveillance, assessment of therapy response, and guiding targeted therapy. Lastly, we highlight current limitations in the clinical utility of ctDNA and future directions. SUMMARY Current evidence of ctDNA in gastrointestinal cancer is promising but varies depending on its specific clinical role and cancer type. Larger prospective trials are needed to validate different aspects of ctDNA clinical utility, and standardization of collection protocols, analytical assays, and reporting guidelines should be considered to facilitate its wider applicability.
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Affiliation(s)
- Zexi Allan
- Division of Cancer Research, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - David S Liu
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Upper Gastrointestinal Surgery Unit, Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Margaret M Lee
- Division of Personalised Oncology, the Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Jeanne Tie
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Division of Personalised Oncology, the Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Nicholas J Clemons
- Division of Cancer Research, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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Melisi D, Zecchetto C, Merz V, Malleo G, Landoni L, Quinzii A, Casalino S, Fazzini F, Gaule M, Pesoni C, Casetti L, Esposito A, Marchegiani G, Piazzola C, D'Onofrio M, de Robertis R, Gabbrielli A, Bernardoni L, Crino SF, Pietrobono S, Luchini C, Aliberti C, Martignoni G, Milleri S, Butturini G, Scarpa A, Salvia R, Bassi C. Perioperative NALIRIFOX in patients with resectable pancreatic ductal adenocarcinoma: The open-label, multicenter, phase II nITRO trial. Eur J Cancer 2024; 196:113430. [PMID: 37995598 DOI: 10.1016/j.ejca.2023.113430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Upfront surgery followed by postoperative treatment is a commonly adopted treatment for resectable pancreatic ductal adenocarcinoma (rPDAC). However, the risk of positive surgical margins, the poor recovery that often impairs postoperative treatments, and the risk of recurrence might limit the outcome of this strategy. This study evaluated the safety and the activity of liposomal irinotecan 50 mg/m2 + 5-fluorouracil 2400 mg/m2 + leucovorin 400 mg/m2 + oxaliplatin 60 mg/m2 (NALIRIFOX) in the perioperative treatment of patients with rPDAC. METHODS Eligible patients had a rPDAC with < 180° interface with major veins' wall. Patients received 3 cycles before and 3 cycles after resection with NALIRIFOX, days 1 and 15 of a 28-day cycle. The primary endpoint was the proportion of patients undergoing an R0 resection. RESULTS 107 patients began preoperative treatment. Nine patients discontinued the treatment because of related or unrelated adverse events. Disease-control rate was 92.9%. 87 patients underwent surgical exploration, 11 had intraoperative evidence of metastatic disease, and 1 died for surgical complications. R0 resection rate was 65.3%. 49 patients completed the three postoperative cycles. The most common grade ≥ 3 adverse events were diarrhea and neutropenia. Median overall survival (OS) of ITT patients was 32.3 months (95% CI 27.8-44.3). Median disease-free and OS from surgery of resected patients were 19.3 (95% CI 12.6-34.1) and 40.3 months (95% CI 29-NA), respectively. CONCLUSION Perioperative NALIRIFOX was manageable and active, and deserves further investigation in randomized trials comparing it with standard upfront surgery followed by adjuvant therapy.
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Affiliation(s)
- Davide Melisi
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Integrata, Verona, Italy; Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy.
| | - Camilla Zecchetto
- Medical Oncology Unit, Azienda Ospedaliera Integrata, Verona, Italy; Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy
| | - Valeria Merz
- Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy
| | - Giuseppe Malleo
- Pancreatic Surgery Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Luca Landoni
- Pancreatic Surgery Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Alberto Quinzii
- Medical Oncology Unit, Azienda Ospedaliera Integrata, Verona, Italy; Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy
| | - Simona Casalino
- Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy
| | - Federica Fazzini
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Marina Gaule
- Medical Oncology Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Camilla Pesoni
- Medical Oncology Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Luca Casetti
- Pancreatic Surgery Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | | | - Giovanni Marchegiani
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Integrata, Verona, Italy; Hepatopancreatobiliary and Liver Transplant Surgery Unit, University of Padua, Padua, Italy
| | | | - Mirko D'Onofrio
- Radiology Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | | | | | - Laura Bernardoni
- Digestive Endoscopy Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Stefano F Crino
- Digestive Endoscopy Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Silvia Pietrobono
- Digestive Molecular Clinical Oncology Research Unit, University of Verona, Verona, Italy
| | - Claudio Luchini
- Pathology Unit, Azienda Ospedaliera Universitaria Integrata, Azienda Ospedaliera Integrata, Verona, Italy
| | | | | | - Stefano Milleri
- Centro Ricerche Cliniche, Azienda Ospedaliera Integrata, Verona, Italy
| | | | - Aldo Scarpa
- Pathology Unit, Azienda Ospedaliera Universitaria Integrata, Azienda Ospedaliera Integrata, Verona, Italy
| | - Roberto Salvia
- Pancreatic Surgery Unit, Azienda Ospedaliera Integrata, Verona, Italy
| | - Claudio Bassi
- Pancreatic Surgery Unit, Azienda Ospedaliera Integrata, Verona, Italy
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de Ortiz de Choudens S, Visotcky A, Banerjee A, Aldakkak M, Tsai S, Evans DB, Christians KK, Clarke CN, George B, Shreenivas A, Kamgar M, Chakrabarti S, Dua KS, Khan AH, Madhavan S, Erickson BA, Hall WA. Characterization of an oligometastatic state in patients with metastatic pancreatic adenocarcinoma undergoing systemic chemotherapy. Cancer Med 2023; 13:e6582. [PMID: 38140796 PMCID: PMC10807686 DOI: 10.1002/cam4.6582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/28/2023] [Accepted: 09/13/2023] [Indexed: 12/24/2023] Open
Abstract
PURPOSE/OBJECTIVES Most patients with pancreatic adenocarcinoma (PDAC) will present with distant metastatic disease at diagnosis. We sought to identify clinical characteristics associated with prolonged overall survival (OS) in patients presenting with metastatic PDAC. MATERIALS/METHODS Patients presenting with metastatic PDAC that received treatment at our institution with FOLFIRINOX or gemcitabine-based chemotherapies between August 1, 2011 and September 1, 2017 were included in the study. Metastatic disease burden was comprehensively characterized radiologically via individual diagnostic imaging segmentation. Landmark analysis was performed at 18 months, and survival curves were estimated using the Kaplan-Meier method and compared between groups via the log-rank test. ECOG and Charlson Comorbidity Index (CCI) were calculated for all patients. RESULTS 121 patients were included with a median age of 62 years (37-86), 40% were female, 25% had ECOG 0 at presentation. Of the 121 patients included, 33% (n = 41) were alive at 12 months and 25% (n = 31) were alive at 18 months. Landmark analysis demonstrated a significant difference between patients surviving <18 months and ≥18 months regarding the presence of lung only metastases (36% vs. 16%, p = 0.04), number of organs with metastases (≥2 vs. 1, p = 0.04), and disease volume (mean of 19.1 cc vs. 1.4 cc, p = 0.04). At Year 1, predictors for improved OS included ECOG status at diagnosis (ECOG 0 vs. ECOG 1, p = 0.04), metastatic disease volume at diagnosis (≤0.1 cc vs. >60 cc, p = 0.004), metastasis only in the liver (p = 0.04), and normalization of CA 19-9 (p < 0.001). At Year 2, the only predictor of improved OS was normalization of the CA 19-9 (p = 0.03). In those patients that normalized their CA 19-9, median overall survival was 16 months. CONCLUSIONS In this exploratory analysis normalization of CA-19-9 or volumetric metastatic disease burden less than 0.2 cc demonstrated a remarkable OS, similar to that of patients with non-metastatic disease. These metrics are useful for counseling patients and identifying cohorts that may be optimal for trials exploring metastatic and/or local tumor-directed interventions.
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Affiliation(s)
| | - Alexis Visotcky
- Division of BiostatisticsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Anjishnu Banerjee
- Division of BiostatisticsMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mohammed Aldakkak
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Susan Tsai
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Douglas B. Evans
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Kathleen K. Christians
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Callisia N. Clarke
- Department of SurgeryMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - Ben George
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Aditya Shreenivas
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Mandana Kamgar
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Sakti Chakrabarti
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Kulwinder S. Dua
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Abdul Haq Khan
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Srivats Madhavan
- Division of Medical OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- Division of GastroenterologyMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Beth A. Erickson
- Department of Radiation OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
| | - William A. Hall
- Department of Radiation OncologyMedical College of WisconsinMilwaukeeWisconsinUSA
- LaBahn Pancreatic Cancer ProgramMilwaukeeWisconsinUSA
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Wahler IL, Damanakis A, Große Hokamp N, Bruns C, Schmidt T. Therapy of Locally Advanced and Oligometastatic Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:5881. [PMID: 38136425 PMCID: PMC10741431 DOI: 10.3390/cancers15245881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Pancreatic adenocarcinoma is a lethal disease, and surgical resection remains the only curative treatment option. Unfortunately, upon primary diagnosis, only 15-20% of all patients with pancreatic ductal adenocarcinoma (PDAC) have localized disease that is eligible for operation. The remainder of patients either have borderline resectable or locally advanced disease or present with distant metastasis. In this review, we present a comprehensive overview regarding the current strategies and future directions in the multimodal therapy of locally advanced and oligometastasized pancreatic adenocarcinoma and discuss the benefit of surgery following neoadjuvant therapy in these patients.
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Affiliation(s)
- Isabell Luisa Wahler
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (I.L.W.); (A.D.)
| | - Alexander Damanakis
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (I.L.W.); (A.D.)
| | - Nils Große Hokamp
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital of Cologne, 50923 Cologne, Germany
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (I.L.W.); (A.D.)
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; (I.L.W.); (A.D.)
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Del Chiaro M, Sugawara T, Karam SD, Messersmith WA. Advances in the management of pancreatic cancer. BMJ 2023; 383:e073995. [PMID: 38164628 DOI: 10.1136/bmj-2022-073995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Pancreatic cancer remains among the malignancies with the worst outcomes. Survival has been improving, but at a slower rate than other cancers. Multimodal treatment, including chemotherapy, surgical resection, and radiotherapy, has been under investigation for many years. Because of the anatomical characteristics of the pancreas, more emphasis on treatment selection has been placed on local extension into major vessels. Recently, the development of more effective treatment regimens has opened up new treatment strategies, but urgent research questions have also become apparent. This review outlines the current management of pancreatic cancer, and the recent advances in its treatment. The review discusses future treatment pathways aimed at integrating novel findings of translational and clinical research.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sana D Karam
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wells A Messersmith
- University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Al Abbas AI, Meier J, Hester CA, Radi I, Yan J, Zhu H, Mansour JC, Porembka MR, Wang SC, Yopp AC, Zeh HJ, Polanco PM. Impact of Neoadjuvant Treatment and Minimally Invasive Surgery on Perioperative Outcomes of Pancreatoduodenectomy: an ACS NSQIP Analysis. J Gastrointest Surg 2023; 27:2823-2842. [PMID: 37903972 DOI: 10.1007/s11605-023-05859-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/31/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND There is an increasing use of neoadjuvant treatment (NAT) for pancreatic cancer (PC) followed by minimally invasive pancreatoduodenectomy (MIPD). We evaluate the impact of the surgical approach on 30-day outcomes in PC patients who underwent NAT. METHODS Patients with PC who had NAT followed by MIPD or open pancreatoduodenectomy (OPD) were identified from a pancreatectomy-targeted dataset (2014-2020) of the National Surgical Quality Improvement Program. Comparisons were made between MIPD and OPD within NAT groups. RESULTS A total of 5588 patients were analyzed. Of those, 4907 underwent OPD and 476 underwent MIPD. In addition, 3559 patients received neoadjuvant chemotherapy alone and 1830 received neoadjuvant chemoradiation. In the chemotherapy-alone group, the MIPD subgroup had lower rates of any complication (38.2% vs. 45.8%, P = 0.005), but there were no differences in mortality (2.1% for MIPD vs 1.9% for OPD, P=0.8) or serious complication (11.8% for MIPD vs 15% for OPD, P=0.1). On multivariable analysis, MIPD was independently predictive of lower rates of any complication (OR: 0.74, 95% CI 0.6-0.93, P = 0.0009), CR-POPF (OR: 0.58, 95% CI 0.35-0.96, P = 0.04), and shorter LOS (estimate: -1.03, 95% CI -1.73 to -0.32, P = 0.004). In the chemoradiation group, patients undergoing MIPD had higher rates of preoperative diabetes (P < 0.05), but there were no significant differences in any outcomes between the two approaches in this group. CONCLUSION MIPD is safe and feasible after NAT. Patients having neoadjuvant chemotherapy alone followed by MIPD had lower rates of complications, shorter LOS, and fewer CR-POPFs compared to OPD.
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Affiliation(s)
- Amr I Al Abbas
- University of Texas Southwestern, Department of Surgery, Dallas, TX, USA
| | - Jennie Meier
- University of Texas Southwestern, Department of Surgery, Dallas, TX, USA
| | - Caitlin A Hester
- University of Texas Southwestern, Department of Surgery, Dallas, TX, USA
| | - Imad Radi
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Jinsheng Yan
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Hong Zhu
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - John C Mansour
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Matthew R Porembka
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Sam C Wang
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Adam C Yopp
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Herbert J Zeh
- University of Texas Southwestern, Department of Surgery, Dallas, TX, USA
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA
| | - Patricio M Polanco
- University of Texas Southwestern, Department of Surgery, Dallas, TX, USA.
- University of Texas Southwestern, Harold C. Simmons Cancer Center, Dallas, TX, USA.
- Division of Surgical Oncology, University of Texas Southwestern Medical Center, 2201 Inwood Road, 3rd Floor, Dallas, TX, 75390, USA.
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Xing J, Ge Y, Gong X, Liu Y, Cheng Y. Initial chemotherapy option for pancreatic ductal adenocarcinoma in patients with adequate performance status. JOURNAL OF PANCREATOLOGY 2023; 6:196-201. [DOI: 10.1097/jp9.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly progressive lethal malignancy, with chemotherapy being the primary treatment modality. This article provides a review of the initial chemotherapy options for PDAC patients with adequate performance status, comparing FOLFIRINOX (oxaliplatin, irinotecan, 5-fluorouracil, and leucovorin) or modified FOLFIRINOX and gemcitabine plus nab-paclitaxel (GEM-NabP) regimens. The availability of limited evidence from randomized trials restricts a direct comparison between the 2 regimens. Based on our review, (m)FOLFIRINOX yields superior survival outcomes compared to GEM-NabP in metastatic PDAC. For locally advanced PDAC, either (m)FOLFIRINOX or GEM-NabP can be considered initial chemotherapy. In the neoadjuvant setting for borderline resectable PDAC, both regimens have demonstrated promising results in achieving feasible resection rates. However, mFOLFIRINOX remains the preferred choice for adjuvant chemotherapy. The selection of initial chemotherapy for PDAC depends on the disease stage, patients’ performance status, and tumor molecular alterations. Further research and clinical trials are necessary to optimize treatment approaches for PDAC patients.
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Affiliation(s)
- Jiazhang Xing
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuping Ge
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolei Gong
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan Liu
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuejuan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Wattenberg MM, Coho H, Herrera VM, Graham K, Stone ML, Xue Y, Chang RB, Cassella C, Liu M, Choi-Bose S, Thomas SK, Choi H, Li Y, Markowitz K, Melendez L, Gianonne M, Bose N, Beatty GL. Cancer immunotherapy via synergistic coactivation of myeloid receptors CD40 and Dectin-1. Sci Immunol 2023; 8:eadj5097. [PMID: 37976347 PMCID: PMC11034815 DOI: 10.1126/sciimmunol.adj5097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/15/2023] [Indexed: 11/19/2023]
Abstract
Myeloid cells facilitate T cell immune evasion in cancer yet are pliable and have antitumor potential. Here, by cotargeting myeloid activation molecules, we leveraged the myeloid compartment as a therapeutic vulnerability in mouse models of pancreatic cancer. Myeloid cells in solid tumors expressed activation receptors including the pattern recognition receptor Dectin-1 and the TNF receptor superfamily member CD40. In mouse models of checkpoint inhibitor-resistant pancreatic cancer, coactivation of Dectin-1, via systemic β-glucan therapy, and CD40, with agonist antibody treatment, eradicated established tumors and induced immunological memory. Antitumor activity was dependent on cDC1s and T cells but did not require classical T cell-mediated cytotoxicity or blockade of checkpoint molecules. Rather, targeting CD40 drove T cell-mediated IFN-γ signaling, which converged with Dectin-1 activation to program distinct macrophage subsets to facilitate tumor responses. Thus, productive cancer immune surveillance in pancreatic tumors resistant to checkpoint inhibition can be invoked by coactivation of complementary myeloid signaling pathways.
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Affiliation(s)
- Max M. Wattenberg
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Heather Coho
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Veronica M. Herrera
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kathleen Graham
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meredith L. Stone
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yuqing Xue
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Renee B. Chang
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Christopher Cassella
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mingen Liu
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shaanti Choi-Bose
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stacy K. Thomas
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hana Choi
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yan Li
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kelly Markowitz
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lauren Melendez
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Gianonne
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Gregory L. Beatty
- Division of Hematology-Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Sugiura T, Toyama H, Fukutomi A, Asakura H, Takeda Y, Yamamoto K, Hirano S, Satoi S, Matsumoto I, Takahashi S, Morinaga S, Yoshida M, Sakuma Y, Iwamoto H, Shimizu Y, Uesaka K. Randomized phase II trial of chemoradiotherapy with S-1 versus combination chemotherapy with gemcitabine and S-1 as neoadjuvant treatment for resectable pancreatic cancer (JASPAC 04). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1249-1260. [PMID: 37746781 DOI: 10.1002/jhbp.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The aim of the present study was to investigate which treatment, neoadjuvant chemoradiotherapy (NAC-RT) with S-1 or combination neoadjuvant chemotherapy with gemcitabine and S-1 (NAC-GS), is more promising as neoadjuvant treatment (NAT) for resectable pancreatic cancer in terms of effectiveness and safety. METHODS In the NAC-RT with S-1 group, the patients received a total radiation dose of 50.4 Gy in 28 fractions with oral S-1. In the NAC-GS group, the patients received intravenous gemcitabine at a dose of 1000 mg/m2 with oral S-1 for two cycles. The primary endpoint was the 2-year progression-free survival (PFS) rate. The trial was registered with the UMIN Clinical Trial Registry as UMIN000014894. RESULTS From April 2014 to April 2017, a total of 103 patients were enrolled. After exclusion of one patient because of ineligibility, 51 patients were included in the NAC-RT with S-1 group, and 51 patients were included in the NAC-GS group in the intention-to-treat analysis. The 2-year PFS rate was 45.0% (90% confidence interval [CI]: 33.3%-56.0%) in the NAC-RT with S-1 group and 54.9% (42.8%-65.5%) in the NAC-GS group (p = .350). The 2-year overall survival rate was 66.7% in the NAC-RT with S-1 group and 72.4% in the NAC-GS group (p = .300). Although leukopenia and neutropenia rates were significantly higher in the NAC-GS group than in the NAC-RT with S-1 group (p = .023 and p < .001), other adverse events of NAT and postoperative complications were comparable between the two groups. CONCLUSION Both NAC-RT with S-1 and NAC-GS are considered promising treatments for resectable pancreatic cancer.
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Affiliation(s)
- Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akira Fukutomi
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirofumi Asakura
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuriko Takeda
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan
- Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ippei Matsumoto
- Department of Surgery, Kindai University, Osaka-Sayama, Japan
| | | | - Soichiro Morinaga
- Department of Hepato-Biliary-Pancreatic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University, Sapporo, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Jichi Medical University, Tochigi-Shimotsuke, Japan
| | - Hidetaka Iwamoto
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Maloney S, Clarke SJ, Sahni S, Hudson A, Colvin E, Mittal A, Samra J, Pavlakis N. The role of diagnostic, prognostic, and predictive biomarkers in the management of early pancreatic cancer. J Cancer Res Clin Oncol 2023; 149:13437-13450. [PMID: 37460806 PMCID: PMC10587199 DOI: 10.1007/s00432-023-05149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/09/2023] [Indexed: 10/20/2023]
Abstract
Despite modern advances in cancer medicine, pancreatic cancer survival remains unchanged at just 12%. For the small proportion of patients diagnosed with 'early' (upfront or borderline resectable) disease, recurrences are common, and many recur soon after surgery. Whilst chemotherapy has been shown to increase survival in this cohort, the morbidity of surgery renders many candidates unsuitable for adjuvant treatment. Due to this, and the success of upfront chemotherapy in the advanced setting, use of neoadjuvant chemotherapy has been introduced in patients with upfront or borderline resectable disease. Randomized controlled trials have been conducted to compare upfront surgery to neoadjuvant chemotherapy in this patient cohort, opinions on the ideal upfront treatment approach are divided. This lack of consensus has highlighted the need for biomarkers to assist in clinical decision making. This review analyses the potential diagnostic, prognostic and predictive biomarkers that may assist in the diagnosis and management of early (upfront and borderline resectable) pancreatic cancer.
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Affiliation(s)
- Sarah Maloney
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia.
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia.
- Department of Medical Oncology, Royal North Shore Hospital, St. Leonards, Sydney, NSW, 2065, Australia.
| | - Stephen J Clarke
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St. Leonards, Sydney, NSW, 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
| | - Amanda Hudson
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
| | - Emily Colvin
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, Sydney, NSW, 2065, Australia
| | - Jaswinder Samra
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, Sydney, NSW, 2065, Australia
| | - Nick Pavlakis
- Faculty of Medicine and Health Sciences, Northern Clinical School, The University of Sydney, Sydney, 2065, Australia
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, 2065, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St. Leonards, Sydney, NSW, 2065, Australia
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Molnár A, Halimi A, Svensson J, Bayadsi H, Innala M, Hansén M, Hemmingsson O, Franklin O. Portomesenteric venous contact ≤180° and overall survival in resectable head and body pancreatic adenocarcinoma treated with upfront surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107097. [PMID: 37804583 DOI: 10.1016/j.ejso.2023.107097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/21/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Upfront surgery is the standard of care for resectable pancreatic cancer, defined as the absence of or ≤180° tumour contact with the portal/superior mesenteric vein. We hypothesized that portomesenteric venous tumour contact is prognostically unfavourable and aimed to assess whether it is associated with poorer survival compared with no venous contact in resectable head and body pancreatic cancer. METHODS This single-centre retrospective study included patients undergoing upfront surgery for resectable head and body pancreatic cancer in 2010-2020 at Umeå University Hospital, Sweden. No venous contact was compared with portomesenteric venous contact of ≤180° based on preoperative imaging. Overall survival on an intention-to-treat basis was compared with Kaplan-Meier curves, a log-rank test and Cox proportional hazards models. RESULTS The final study cohort included 39 patients with portomesenteric venous tumour contact and 144 patients without venous tumour contact. Patients with venous tumour contact had a median overall survival of 15.3 months compared to 23.0 months (log rank P = 0.059). Portomesenteric venous tumour contact was an independent negative prognostic factor for survival in the multivariable Cox model (HR 1.68; 95% CI 1.11-2.55, P = 0.014) and was associated with higher rates of microscopically non-radical resections (R1) (50% vs 26.1%, P = 0.012) and pathological lymph node metastasis (76.7% vs 56.8%, P = 0.012). There was no difference in adjuvant chemotherapy receipt or postoperative complications between the groups. CONCLUSIONS Portomesenteric venous tumour contact is associated with poorer overall survival and higher rates of R1 resections and lymph node metastasis in patients with resectable head and body pancreatic cancer treated with upfront surgery.
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Affiliation(s)
- Adrienne Molnár
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Asif Halimi
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Johan Svensson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Haytham Bayadsi
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Marcus Innala
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Maria Hansén
- Oncology Clinic, Sundsvall Regional Hospital, Sundsvall, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Oskar Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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Lacalle-Gonzalez C, Florez-Cespedes M, Sanz-Criado L, Ochieng’ Otieno M, Ramos-Muñoz E, Fernandez-Aceñero MJ, Ortega-Medina L, Garcia-Foncillas J, Martinez-Useros J. DLL3 Is a Prognostic and Potentially Predictive Biomarker for Immunotherapy Linked to PD/PD-L Axis and NOTCH1 in Pancreatic Cancer. Biomedicines 2023; 11:2812. [PMID: 37893184 PMCID: PMC10604228 DOI: 10.3390/biomedicines11102812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/05/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive neoplasm with very poor patient survival outcomes despite available treatments. There is an urgent need for new potential treatment options and novel biomarkers for these patients. Delta-like canonical Notch ligand 3 (DLL3) interacts with the Notch receptor and causes inhibition of Notch signaling, which confers a survival advantage to PDAC cells. Thus, DLL3 expression could affect cell survival, and its inhibition could increase a patient's survival. To test this hypothesis, a survival analysis was conducted using the progression-free and overall survival from two independent datasets of PDAC patients, with one using mRNA z-score levels and the other using the Hscore protein expression level; both were carried out using a log-rank test and plotted using Kaplan-Meier curves. DLL3 at the mRNA expression level showed an association between high mRNA expression and both a longer progression-free survival (PFS) and overall survival (OS) of patients. Then, we designed a retrospective study with resected PDAC samples. Our primary objective with this dataset was to assess the relationship between PFS and OS and DLL3 protein expression. The secondary assessment was to provide a rationale for the use of anti-DLL3-based treatments in combination with immunotherapy that is supported by the link between DLL3 and other factors that are involved in immune checkpoints. The survival analyses revealed a protective effect of high DLL3 protein expression levels in both PFS and OS. Interestingly, high DLL3 protein expression levels were significantly correlated with PD-L1/2 and negatively correlated with NOTCH1. Therefore, DLL3 could be considered a biomarker for better prognosis in resectable PDAC patients as well as a therapeutic biomarker for immunotherapy response. These facts set a rationale for testing anti-DLL3-based treatments either alone or combined with immunotherapy or other NOTCH1 inhibitors.
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Affiliation(s)
- Carlos Lacalle-Gonzalez
- Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain;
| | | | - Lara Sanz-Criado
- Translational Oncology Division, Oncohealth Institute, Fundacion Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.S.-C.); (M.O.O.)
| | - Michael Ochieng’ Otieno
- Translational Oncology Division, Oncohealth Institute, Fundacion Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.S.-C.); (M.O.O.)
| | - Edurne Ramos-Muñoz
- Biomarkers and Therapeutic Targets Group and Core Facility, RICORS2040, EATRIS, Ramón y Cajal Health Research Institute, (IRYCIS), C/Carretera Colmenar Km 9,100, 28034 Madrid, Spain;
| | - Maria Jesus Fernandez-Aceñero
- Pathology Department, Clinico San Carlos University Hospital, C/Profesor Martin Lagos, 28040 Madrid, Spain; (M.J.F.-A.); (L.O.-M.)
| | - Luis Ortega-Medina
- Pathology Department, Clinico San Carlos University Hospital, C/Profesor Martin Lagos, 28040 Madrid, Spain; (M.J.F.-A.); (L.O.-M.)
| | - Jesus Garcia-Foncillas
- Department of Medical Oncology, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain;
- Translational Oncology Division, Oncohealth Institute, Fundacion Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.S.-C.); (M.O.O.)
| | - Javier Martinez-Useros
- Translational Oncology Division, Oncohealth Institute, Fundacion Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.S.-C.); (M.O.O.)
- Area of Physiology, Department of Basic Health Sciences, Faculty of Health Sciences, Rey Juan Carlos University, 28922 Madrid, Spain
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Tincu (Iurciuc) CE, Andrițoiu CV, Popa M, Ochiuz L. Recent Advancements and Strategies for Overcoming the Blood-Brain Barrier Using Albumin-Based Drug Delivery Systems to Treat Brain Cancer, with a Focus on Glioblastoma. Polymers (Basel) 2023; 15:3969. [PMID: 37836018 PMCID: PMC10575401 DOI: 10.3390/polym15193969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Glioblastoma multiforme (GBM) is a highly aggressive malignant tumor, and the most prevalent primary malignant tumor affecting the brain and central nervous system. Recent research indicates that the genetic profile of GBM makes it resistant to drugs and radiation. However, the main obstacle in treating GBM is transporting drugs through the blood-brain barrier (BBB). Albumin is a versatile biomaterial for the synthesis of nanoparticles. The efficiency of albumin-based delivery systems is determined by their ability to improve tumor targeting and accumulation. In this review, we will discuss the prevalence of human glioblastoma and the currently adopted treatment, as well as the structure and some essential functions of the BBB, to transport drugs through this barrier. We will also mention some aspects related to the blood-tumor brain barrier (BTBB) that lead to poor treatment efficacy. The properties and structure of serum albumin were highlighted, such as its role in targeting brain tumors, as well as the progress made until now regarding the techniques for obtaining albumin nanoparticles and their functionalization, in order to overcome the BBB and treat cancer, especially human glioblastoma. The albumin drug delivery nanosystems mentioned in this paper have improved properties and can overcome the BBB to target brain tumors.
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Affiliation(s)
- Camelia-Elena Tincu (Iurciuc)
- Department of Natural and Synthetic Polymers, “Cristofor Simionescu” Faculty of Chemical Engineering and Protection of the Environment, “Gheorghe Asachi” Technical University, 73, Prof. Dimitrie Mangeron Street, 700050 Iasi, Romania;
- Department of Pharmaceutical Technology, Faculty of Pharmacy, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania;
| | - Călin Vasile Andrițoiu
- Apitherapy Medical Center, Balanesti, Nr. 336-337, 217036 Gorj, Romania;
- Specialization of Nutrition and Dietetics, Faculty of Pharmacy, Vasile Goldis Western University of Arad, Liviu Rebreanu Street, 86, 310045 Arad, Romania
| | - Marcel Popa
- Department of Natural and Synthetic Polymers, “Cristofor Simionescu” Faculty of Chemical Engineering and Protection of the Environment, “Gheorghe Asachi” Technical University, 73, Prof. Dimitrie Mangeron Street, 700050 Iasi, Romania;
- Faculty of Dental Medicine, “Apollonia” University of Iasi, 11, Pacurari Street, 700511 Iasi, Romania
- Academy of Romanian Scientists, 3 Ilfov Street, 050045 Bucharest, Romania
| | - Lăcrămioara Ochiuz
- Department of Pharmaceutical Technology, Faculty of Pharmacy, “Grigore T. Popa” University of Medicine and Pharmacy, 16, University Street, 700115 Iasi, Romania;
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49
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Snyder RA, Dueck AC, Fruth B, Shi Q, Hubbard JM, Herman JM, O'Reilly EM, Katz MHG. Patient-reported Adverse Events During Neoadjuvant Therapy in a Phase 2 Borderline Resectable Pancreatic Cancer Clinical Trial (Alliance A021501). Ann Surg 2023; 278:598-608. [PMID: 37334719 PMCID: PMC10527167 DOI: 10.1097/sla.0000000000005958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE We sought to evaluate symptomatic adverse event (AE) rates among patients with pancreatic cancer receiving neoadjuvant therapy on clinical trial (A021501) using the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE). BACKGROUND To date, pancreatic cancer clinical trials have measured AEs using standard physician reporting [Common Terminology Criteria for Adverse Events (CTCAE)]. Patient-reported symptomatic AEs have been incompletely characterized. METHODS A021501 (December 31, 2016-January 1, 2019) randomized patients with borderline resectable pancreatic ductal adenocarcinoma to 8 doses of mFOLFIRINOX (Arm 1) or 7 doses of mFOLFIRINOX+hypofractionated radiotherapy (Arm 2), followed by pancreatectomy and adjuvant FOLFOX6. Patients completed PRO-CTCAE assessments at baseline, on day 1 of each chemotherapy cycle, and daily during radiotherapy. RESULTS Of 126 patients, 96 (76%) initiated treatment and completed a baseline plus at least 1 postbaseline PRO-CTCAE assessment. Diarrhea and fatigue were the only symptomatic grade 3 or higher AEs identified in at least 10% of patients using CTCAE. At least 10% of all patients reported an adjusted PRO-CTCAE composite grade 3 AE during neoadjuvant treatment for 10 of 15 items: anxiety (10%), bloating of abdomen (16%), decreased appetite (18%), diarrhea (13%), dry mouth (21%), fatigue (36%), nausea (18%), generalized pain (16%), abdominal pain (21%), and problems tasting (32%). Decreased appetite was higher in Arm 2 than in Arm 1 ( P =0.0497); no other differences between study arms were observed. CONCLUSION Symptomatic AEs during neoadjuvant therapy were common and were reported more frequently by patients using PRO-CTCAE than were recorded by clinicians using standard CTCAE.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amylou C Dueck
- Alliance Statistics and Data Center, Mayo Clinic, Scottsdale, AZ
| | - Briant Fruth
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Qian Shi
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | | | | | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, TX
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50
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Wu VS, Elshami M, Stitzel HJ, Lee JJ, Hue JJ, Kyasaram RK, Hardacre JM, Ammori JB, Winter JM, Selfridge JE, Mohamed A, Chakrabarti S, Bajor D, Mahipal A, Ocuin LM. Why the Treatment Sequence Matters: Interplay Between Chemotherapy Cycles Received, Cumulative Dose Intensity, and Survival in Resected Early-stage Pancreas Cancer. Ann Surg 2023; 278:e677-e684. [PMID: 37071769 DOI: 10.1097/sla.0000000000005830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE To define the optimal threshold of perioperative chemotherapy completion and relative dose intensity (RDI) for patients with resected pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Many patients who undergo pancreatectomy for PDAC fail to initiate or complete recommended perioperative chemotherapy. The association between the amount of perioperative chemotherapy received and overall survival (OS) is not well-defined. METHODS Single-institution analysis of 225 patients who underwent pancreatectomy for stage I/II PDAC (2010-2021). Associations between OS, chemotherapy cycles completed, and RDI were analyzed. RESULTS Regardless of treatment sequence, completion of ≥67% of recommended cycles was associated with improved OS compared with no chemotherapy [median OS: 34.5 vs 18.1 months; hazard ratio (HR): 0.43; 95% CI: 0.25-0.74] and <67% of cycles (median OS: 17.9 months; HR: 0.39; 95% CI: 0.24-0.64). A near-linear relationship existed between cycles completed and the RDI received (β = 0.82). A median RDI of 56% corresponded to the completion of 67% of cycles. Receipt of ≥56% RDI was associated with improved OS compared with no chemotherapy (median OS: 35.5 vs 18.1 months; HR: 0.44; 95% CI: 0.23-0.84) and <56% RDI (median OS: 27.2 months; HR: 0.44; 95% CI: 0.20-0.96). Neoadjuvant chemotherapy is associated with increased odds of receiving ≥67% of recommended cycles (odds ratio: 2.94; 95% CI: 1.45-6.26) and ≥56% RDI (odds ratio: 4.47; 95% CI: 1.72-12.50). CONCLUSIONS Patients with PDAC who received ≥67% of recommended chemotherapy cycles or ≥56% cumulative RDI had improved OS. Neoadjuvant therapy was associated with increased odds of receiving ≥67% of cycles and ≥56% cumulative RDI and should be considered in all patients with resectable PDAC.
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Affiliation(s)
- Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan J Lee
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Ravi K Kyasaram
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jennifer Eva Selfridge
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Amr Mohamed
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Sakti Chakrabarti
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - David Bajor
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Amit Mahipal
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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