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Pacilio CA, Cucchetti A, Ercolani G. Local recurrence rate as quality indicator in surgery for pancreatic cancer? Hepatobiliary Pancreat Dis Int 2024; 23:548-550. [PMID: 38538432 DOI: 10.1016/j.hbpd.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/11/2024] [Indexed: 07/02/2024]
Affiliation(s)
- Carlo Alberto Pacilio
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via Carlo Forlanini 34, 47121, Forlì, Italy.
| | - Alessandro Cucchetti
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via Carlo Forlanini 34, 47121, Forlì, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via Carlo Forlanini 34, 47121, Forlì, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
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2
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Hagerty BL, Fekrmandi F, Schneider T, Fountzilas C, Stiles Z, Kukar M, Calvo B, Cherkassky L. Chemotherapy switch for nonresponse or progression on neoadjuvant chemotherapy for pancreatic adenocarcinoma. J Surg Oncol 2024. [PMID: 39155683 DOI: 10.1002/jso.27803] [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: 07/08/2024] [Accepted: 07/21/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND OBJECTIVES Patients with localized pancreatic adenocarcinoma who do not respond to neoadjuvant therapy present a challenge. We sought to define the characteristics and outcomes of those patients to guide clinical practice. METHODS Patients included were those without evidence of biochemical or radiographic response and no evidence of distant progression at the first reassessment after initiation of therapy. RESULTS Of the 45 patients in the cohort, 23 (51.1%) proceeded to surgical exploration with all but one of those undergoing resection. The median overall survival of the study cohort was 28.6 and 48.6 months in those who underwent resection. A total of 13 patients (28.9%) underwent chemotherapy switch (CS) during their course of neoadjuvant therapy. The CS cohort demonstrated higher rates of radiologic progression (25% vs. 10%, p = 0.329), new or worse vascular involvement (58.3% vs. 30%, p = 0.082), and CA 19-9 increase (30.8% vs. 12.9%, p = 0.209) at initial re-staging. Despite this, overall survival was similar between the two groups (20.7 vs. 28.7 months, p = 0.674). CONCLUSION Non-responders to first-line neoadjuvant therapy have poor rates of curative-intent resection. However, resection should be undertaken when feasible. CS may be considered in patients who do not respond to first-line chemotherapy.
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Affiliation(s)
- Brendan L Hagerty
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Fatemeh Fekrmandi
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Tyce Schneider
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Christos Fountzilas
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Zachary Stiles
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Benjamin Calvo
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Leonid Cherkassky
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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Brunner M, Flessa M, Jacobsen A, Merkel S, Krautz C, Weber GF, Grützmann R. Recurrence pattern and its risk factors in patients with resected pancreatic ductal adenocarcinoma - A retrospective analysis of 272 patients. Pancreatology 2024:S1424-3903(24)00697-5. [PMID: 39103253 DOI: 10.1016/j.pan.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 07/17/2024] [Accepted: 07/31/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND The aim of this study was to investigate the patterns of recurrence and their associated risk factors in patients who underwent resection for pancreatic carcinoma. METHODS This retrospective study included 272 patients, who underwent Ro/R1-resection of PDAC from 2005 to 2020 at the University Hospital Erlangen. Risk factors for different recurrence patterns and the prognostic value of recurrence pattern on the overall survival after recurrence were evaluated. RESULTS 61 % of the patients experienced recurrence, mostly within the first 12 postoperative months (62 %) and in the form of metastases (87 %). The median overall survival from recurrence was 9.2 months. The preoperative absence of diabetes and the presence of lymph node metastasis were independent risk factors for recurrence and a preoperative CA19-9 exceeding 97 U/ml for early recurrence. Additionally, lymph node metastases were associated with a higher risk of metastatic recurrence. Early recurrence, but not the site of recurrence, was identified as an independent prognostic factor for worse overall survival from recurrence. CONCLUSION The occurrence of recurrence and especially of early and metastatic recurrence are associated with a worse overall survival. Patients lacking preoperative diabetes, having high preoperative CA19-9 values and lymph node metastases are particularly at risk for (early) recurrence.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany.
| | - Marteen Flessa
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Anne Jacobsen
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, Erlangen, Germany
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4
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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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Miyahara S, Takahashi H, Tomimaru Y, Kobayashi S, Sasaki K, Iwagami Y, Yamada D, Akita H, Noda T, Doki Y, Eguchi H. Organ-specific variations in tumor marker dynamics in postoperative pancreatic cancer recurrence: Trends in lung and liver recurrence highlighting biological heterogeneity. Surg Oncol 2024; 55:102103. [PMID: 38986312 DOI: 10.1016/j.suronc.2024.102103] [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: 04/26/2024] [Revised: 06/12/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND/OBJECTIVES Although tumor recurrence after surgical resection in pancreatic cancer (PC) is generally considered incurable, it is well-accepted that clinical presentations and outcomes vary according to the recurrent sites (e.g., liver vs. lung recurrence), suggesting a possible biological inhomogeneity of PC recurrence. Understanding the behavior of biological factors, specifically tumor markers (TMs), at different recurrence sites may contribute to individualized treatment strategies. Therefore, this study aimed to compare the dynamics of pre-recurrence TMs at liver and lung recurrence sites. METHODS Patients with isolated postoperative liver or lung recurrence as their first recurrence were enrolled. Starting from the recurrence date confirmed by imaging examinations, the values of TMs (carbohydrate antigen 19-9: CA19-9; carcinoembryonic antigen: CEA) were retrospectively evaluated 6 and 3 months before recurrence and at the time of recurrence. RESULTS Patients with liver recurrence displayed a significant increase in CA19-9 and CEA levels from as early as 6 months before recurrence. Contrastingly, patients with lung recurrence demonstrated a significant elevation of CA19-9 levels starting from 3 months before recurrence, with no increase in CEA levels, even at the time of recurrence. The relative change in CA19-9 and CEA levels during each period were significantly lower in patients with lung recurrence. CONCLUSIONS Both TMs exhibited organ-specific variations in patients with postoperative PC recurrence. This disparity may reflect the biological heterogeneity of PC between recurrence patterns, thereby highlighting the importance of conducting postoperative follow-up with consideration of this fact.
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Affiliation(s)
- Satoru Miyahara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuki Sasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Park EJ, Jang JK, Byun JH, Kim JH, Lee SS, Kim HJ, Yoo C, Kim KP, Hong SM, Seo DW, Hwang DW, Kim SC. Comparison of the different versions of NCCN guidelines for predicting margin-negative resection of pancreatic cancer in patients undergoing upfront surgery. Abdom Radiol (NY) 2024; 49:2737-2745. [PMID: 38802630 DOI: 10.1007/s00261-024-04299-4] [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: 12/06/2023] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES The purpose of this study was to compare the different versions of the National Comprehensive Cancer Network (NCCN) guidelines for defining resectability of pancreatic ductal adenocarcinoma (PDAC) in predicting margin-negative (R0) resection, and to assess inter-reader agreement. METHODS This retrospective study included 283 patients (mean age, 65.1 years ± 9.4 [SD]; 155 men) who underwent upfront pancreatectomy for PDAC between 2017 and 2019. Two radiologists independently determined the resectability on preoperative CT according to the 2017, 2019, and 2020 NCCN guidelines. The sensitivity and specificity for R0 resection were analyzed using a multivariable logistic regression analysis with generalized estimating equations. Inter-reader agreement was assessed using kappa statistics. RESULTS R0 resection was accomplished in 239 patients (84.5%). The sensitivity and specificity averaged across two readers were, respectively, 76.6% and 29.5% for the 2020 guidelines, 74.1% and 32.9% for the 2019 guidelines, and 72.6% and 34.1% for the 2017 guidelines. Compared with the 2020 guidelines, both 2019 and 2017 guidelines showed significantly lower sensitivity for R0 resection (p ≤ .009). Specificity was significantly higher with the 2017 guidelines (p = .043) than with the 2020 guidelines. Inter-reader agreements for determining the resectability of PDCA were strong (k ≥ 0.83) with all guidelines, being highest with the 2020 guidelines (k = 0.91). CONCLUSION The 2020 NCCN guidelines showed significantly higher sensitivity for prediction of R0 resection than the 2017 and 2019 guidelines.
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Affiliation(s)
- Eun Joo Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
- Department of Radiology, Inje University Haeundae Paik Hospital, Busan, 48108, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea.
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Changhoon Yoo
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Kyu-Pyo Kim
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Dae Wook Hwang
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
| | - Song Cheol Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa- gu, Seoul, 05505, Republic of Korea
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Rompen IF, Levine J, Habib JR, Sereni E, Mughal N, Hewitt DB, Sacks GD, Welling TH, Simeone DM, Kaplan B, Berman RS, Cohen SM, Wolfgang CL, Javed AA. Progression of Site-specific Recurrence of Pancreatic Cancer and Implications for Treatment. Ann Surg 2024; 280:317-324. [PMID: 37870253 PMCID: PMC11259998 DOI: 10.1097/sla.0000000000006142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To analyze postrecurrence progression in the context of recurrence sites and assess implications for postrecurrence treatment. BACKGROUND Most patients with resected pancreatic ductal adenocarcinoma (PDAC) recur within 2 years. Different survival outcomes for location-specific patterns of recurrence are reported, highlighting their prognostic value. However, a lack of understanding of postrecurrence progression and survival remains. METHODS This retrospective analysis included surgically treated patients with PDAC at NYU Langone Health (2010-2021). Sites of recurrence were identified at the time of diagnosis and further follow-up. Kaplan-Meier curves, log-rank test, and Cox regression analyses were applied to assess survival outcomes. RESULTS Recurrence occurred in 57.3% (196/342) patients with a median time to recurrence of 11.3 months (95% CI: 12.6-16.5). The first site of recurrence was local in 43.9% of patients, liver in 23.5%, peritoneal in 8.7%, lung in 3.6%, whereas 20.4% had multiple sites of recurrence. Progression to secondary sites was observed in 11.7%. Only lung involvement was associated with significantly longer survival after recurrence compared with other sites (16.9 vs 8.49 months, P = 0.003). In local recurrence, 21 (33.3%) patients were alive after 1 year without progression to secondary sites. This was associated with a CA19-9 of <100 U/mL at the time of primary diagnosis ( P = 0.039), nodal negative disease ( P = 0.023), and well-moderate differentiation ( P = 0.042) compared with patients with progression. CONCLUSION Except for lung recurrence, postrecurrence survival after PDAC resection is associated with poor survival. A subset of patients with local-only recurrence do not quickly succumb to systemic spread. This is associated with markers for favorable tumor biology, making them candidates for potential curative re-resections when feasible.
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Affiliation(s)
- Ingmar F. Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonah Levine
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Joseph R. Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisabetta Sereni
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Nabiha Mughal
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - D. Brock Hewitt
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Greg D. Sacks
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Theodore H. Welling
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Diane M. Simeone
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Brian Kaplan
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Russell S. Berman
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Steven M. Cohen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Christopher L. Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Ammar A. Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
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8
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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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9
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Fuller RN, Morcos A, Bustillos JG, Molina DC, Wall NR. Small non-coding RNAs and pancreatic ductal adenocarcinoma: Linking diagnosis, pathogenesis, drug resistance, and therapeutic potential. Biochim Biophys Acta Rev Cancer 2024; 1879:189153. [PMID: 38986720 DOI: 10.1016/j.bbcan.2024.189153] [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: 01/22/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
This review comprehensively investigates the intricate interplay between small non-coding RNAs (sncRNAs) and pancreatic ductal adenocarcinoma (PDAC), a devastating malignancy with limited therapeutic options. Our analysis reveals the pivotal roles of sncRNAs in various facets of PDAC biology, spanning diagnosis, pathogenesis, drug resistance, and therapeutic strategies. sncRNAs have emerged as promising biomarkers for PDAC, demonstrating distinct expression profiles in diseased tissues. sncRNA differential expression patterns, often detectable in bodily fluids, hold potential for early and minimally invasive diagnostic approaches. Furthermore, sncRNAs exhibit intricate involvement in PDAC pathogenesis, regulating critical cellular processes such as proliferation, apoptosis, and metastasis. Additionally, mechanistic insights into sncRNA-mediated pathogenic pathways illuminate novel therapeutic targets and interventions. A significant focus of this review is dedicated to unraveling sncRNA mechanisms underlying drug resistance in PDAC. Understanding these mechanisms at the molecular level is imperative for devising strategies to overcome drug resistance. Exploring the therapeutic landscape, we discuss the potential of sncRNAs as therapeutic agents themselves as their ability to modulate gene expression with high specificity renders them attractive candidates for targeted therapy. In summary, this review integrates current knowledge on sncRNAs in PDAC, offering a holistic perspective on their diagnostic, pathogenic, and therapeutic relevance. By elucidating the roles of sncRNAs in PDAC biology, this review provides valuable insights for the development of novel diagnostic tools and targeted therapeutic approaches, crucial for improving the prognosis of PDAC patients.
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Affiliation(s)
- Ryan N Fuller
- Department of Basic Science, Division of Biochemistry, Center for Health Disparity and Mol. Med., Loma Linda University, Loma Linda, CA 92350, USA; Department of Radiation Medicine, James M. Slater, MD Proton Treatment and Research Center, Loma Linda University, Loma Linda, CA 92350, USA
| | - Ann Morcos
- Department of Basic Science, Division of Biochemistry, Center for Health Disparity and Mol. Med., Loma Linda University, Loma Linda, CA 92350, USA; Department of Radiation Medicine, James M. Slater, MD Proton Treatment and Research Center, Loma Linda University, Loma Linda, CA 92350, USA
| | - Joab Galvan Bustillos
- Department of Basic Science, Division of Biochemistry, Center for Health Disparity and Mol. Med., Loma Linda University, Loma Linda, CA 92350, USA; Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA 92350, USA
| | - David Caba Molina
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA 92350, USA
| | - Nathan R Wall
- Department of Basic Science, Division of Biochemistry, Center for Health Disparity and Mol. Med., Loma Linda University, Loma Linda, CA 92350, USA; Department of Radiation Medicine, James M. Slater, MD Proton Treatment and Research Center, Loma Linda University, Loma Linda, CA 92350, USA.
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10
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Kinny-Köster B, Ahmad Y, Pflüger MJ, Habib JR, Fujikura K, Hutchings D, Cameron JL, Shubert CR, Lafaro KJ, Burkhart RA, Burns WR, Javed AA, Yu J, Hruban RH, Wood LD, Thompson ED, He J. Clinical Relevance of Cancerization of Ducts in Resected Pancreatic Ductal Adenocarcinoma. Pancreas 2024; 53:e528-e536. [PMID: 38888841 DOI: 10.1097/mpa.0000000000002326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVES Although prevalent in 50%-90% of pancreatic ductal adenocarcinomas, the clinical relevance of "cancerization of ducts" (COD) remains unknown. METHODS Pathologists retrospectively reviewed slides classifying prevalence of COD. Histopathological parameters, location of first recurrence, recurrence-free survival (RFS), and overall survival (OS) were collected from the institutional pancreatectomy registry. RESULTS Among 311 pancreatic ductal adenocarcinomas, COD was present in 216 (69.5%) and more prevalent in the cohort that underwent upfront surgery (75.3% vs 63.1%, P = 0.019). Furthermore, COD was associated with female gender (P = 0.040), advanced T stage (P = 0.007), perineural invasion (P = 0.014), lymphovascular invasion (P = 0.025), and R1 margin (P = 0.009), but not N stage (P = 0.401) or tumor differentiation (P = 0.717). In multivariable regression, COD was associated with less liver recurrence (odds ratio, 0.44; P < 0.005). This association was driven by the cohort of patients who had received preoperative treatment (odds ratio, 0.18; P < 0.001). COD was not predictive for RFS or OS. CONCLUSIONS Cancerization of ducts was not associated with RFS or OS. Currently underrecognized, standardized implementation into histopathological reports may have merit, and further mechanistic scientific experiments need to illuminate its clinical and biologic impact.
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Affiliation(s)
- Benedict Kinny-Köster
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yembur Ahmad
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J Pflüger
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph R Habib
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kohei Fujikura
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Danielle Hutchings
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher R Shubert
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A Burkhart
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jun Yu
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura D Wood
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth D Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- From the Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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van Goor IWJM, Andel PCM, Buijs FS, Besselink MG, Bonsing BA, Bosscha K, Busch OR, Cirkel GA, van Dam RM, Festen S, Koerkamp BG, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, Meijer G, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Verdonk RC, van Santvoort HC, Molenaar IQ, Intven MPW, Daamen LA. Prediction of Isolated Local Recurrence After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Study. Ann Surg Oncol 2024:10.1245/s10434-024-15664-4. [PMID: 38937412 DOI: 10.1245/s10434-024-15664-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Distinguishing postoperative fibrosis from isolated local recurrence (ILR) after resection of pancreatic ductal adenocarcinoma (PDAC) is challenging. A prognostic model that helps to identify patients at risk of ILR can assist clinicians when evaluating patients' postoperative imaging. This nationwide study aimed to develop a clinically applicable prognostic model for ILR after PDAC resection. PATIENTS AND METHODS An observational cohort study was performed, including all patients who underwent PDAC resection in the Netherlands (2014-2019; NCT04605237). On the basis of recurrence location (ILR, systemic, or both), multivariable cause-specific Cox-proportional hazard analysis was conducted to identify predictors for ILR and presented as hazard ratios (HRs) with 95% confidence intervals (CIs). A predictive model was developed using Akaike's Information Criterion, and bootstrapped discrimination and calibration indices were assessed. RESULTS Among 1194/1693 patients (71%) with recurrence, 252 patients (21%) developed ILR. Independent predictors for ILR were resectability status (borderline versus resectable, HR 1.42; 95% CI 1.03-1.96; P = 0.03, and locally advanced versus resectable, HR 1.11; 95% CI 0.68-1.82; P = 0.66), tumor location (head versus body/tail, HR 1.50; 95% CI 1.00-2.25; P = 0.05), vascular resection (HR 1.86; 95% CI 1.41-2.45; P < 0.001), perineural invasion (HR 1.47; 95% CI 1.01-2.13; P = 0.02), number of positive lymph nodes (HR 1.04; 95% CI 1.01-1.08; P = 0.02), and resection margin status (R1 < 1 mm versus R0 ≥ 1 mm, HR 1.64; 95% CI 1.25-2.14; P < 0.001). Moderate performance (concordance index 0.66) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS This nationwide study identified factors predictive of ILR after PDAC resection. Our prognostic model, available through www.pancreascalculator.com , can be utilized to identify patients with a higher a priori risk of developing ILR, providing important information in patient evaluation and prognostication.
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Affiliation(s)
- I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands.
| | - P C M Andel
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - F S Buijs
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - G A Cirkel
- Department of Medical Oncology, University Medical Center Utrecht Cancer Center & Meander Medical Center Amersfoort, Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Festen
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - G Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - G Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - D Roos
- Department of Surgery, Renier de Graaf Gasthuis, Delft, The Netherlands
| | | | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - R C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Imaging Division, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
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12
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Daamen LA, van Goor IWJM, Groot VP, Andel PCM, Brosens LAA, Busch OR, Cirkel GA, Mohammad NH, Heerkens HD, de Hingh IHJT, Hoogwater F, van Laarhoven HWM, Los M, Meijer GJ, de Meijer VE, Pande R, Roberts KJ, Stoker J, Stommel MWJ, van Tienhoven G, Verdonk RC, Verkooijen HM, Wessels FJ, Wilmink JW, Besselink MG, van Santvoort HC, Intven MPW, Molenaar IQ. Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design. Trials 2024; 25:401. [PMID: 38902836 PMCID: PMC11188210 DOI: 10.1186/s13063-024-08223-5] [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: 03/20/2024] [Accepted: 06/03/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial. METHODS This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment. DISCUSSION The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained. TRIAL REGISTRATION Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.
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Affiliation(s)
- L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
| | - V P Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - P C M Andel
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - L A A Brosens
- Department of Pathology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - O R Busch
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - G A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - H D Heerkens
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - F Hoogwater
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H W M van Laarhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Medical Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, St. Antonius Hospital Nieuwegein & Meander Medical Center, Utrecht University, Utrecht, the Netherlands
| | - G J Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - R Pande
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - K J Roberts
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - J Stoker
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Radiology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - G van Tienhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Radiation Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - R C Verdonk
- Department of Gastroenterology and Hepatology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - H M Verkooijen
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - F J Wessels
- Department of Radiology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, Department of Medical Oncology, Location University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
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13
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Mahawan T, Luckett T, Mielgo Iza A, Pornputtapong N, Caamaño Gutiérrez E. Robust and consistent biomarker candidates identification by a machine learning approach applied to pancreatic ductal adenocarcinoma metastasis. BMC Med Inform Decis Mak 2024; 24:175. [PMID: 38902676 PMCID: PMC11191155 DOI: 10.1186/s12911-024-02578-0] [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: 02/03/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Machine Learning (ML) plays a crucial role in biomedical research. Nevertheless, it still has limitations in data integration and irreproducibility. To address these challenges, robust methods are needed. Pancreatic ductal adenocarcinoma (PDAC), a highly aggressive cancer with low early detection rates and survival rates, is used as a case study. PDAC lacks reliable diagnostic biomarkers, especially metastatic biomarkers, which remains an unmet need. In this study, we propose an ML-based approach for discovering disease biomarkers, apply it to the identification of a PDAC metastatic composite biomarker candidate, and demonstrate the advantages of harnessing data resources. METHODS We utilised primary tumour RNAseq data from five public repositories, pooling samples to maximise statistical power and integrating data by correcting for technical variance. Data were split into train and validation sets. The train dataset underwent variable selection via a 10-fold cross-validation process that combined three algorithms in 100 models per fold. Genes found in at least 80% of models and five folds were considered robust to build a consensus multivariate model. A random forest model was constructed using selected genes from the train dataset and tested in the validation set. We also assessed the goodness of prediction by recalibrating a model using only the validation data. The biological context and relevance of signals was explored through enrichment and pathway analyses using QIAGEN Ingenuity Pathway Analysis and GeneMANIA. RESULTS We developed a pipeline that can detect robust signatures to build composite biomarkers. We tested the pipeline in PDAC, exploiting transcriptomics data from different sources, proposing a composite biomarker candidate comprised of fifteen genes consistently selected that showed very promising predictive capability. Biological contextualisation revealed links with cancer progression and metastasis, underscoring their potential relevance. All code is available in GitHub. CONCLUSION This study establishes a robust framework for identifying composite biomarkers across various disease contexts. We demonstrate its potential by proposing a plausible composite biomarker candidate for PDAC metastasis. By reusing data from public repositories, we highlight the sustainability of our research and the wider applications of our pipeline. The preliminary findings shed light on a promising validation and application path.
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Affiliation(s)
- Tanakamol Mahawan
- Program in Bioinformatics and Computational Biology, Graduate School, Chulalongkorn University, Bangkok, Thailand
- Department of Biochemistry & System Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
- Akkhraratchakumari Veterinary College, Walailak University, Nakhon Si Thammarat, Thailand
| | - Teifion Luckett
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Ainhoa Mielgo Iza
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Natapol Pornputtapong
- Department of Biochemistry and Microbiology, Faculty of Pharmaceutical Sciences, and Center of Excellence in Systems Biology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Eva Caamaño Gutiérrez
- Department of Biochemistry & System Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.
- Computational Biology Facility, LIV-SRF, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
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14
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Brown ZJ, Shannon AH, Cloyd JM. Neoadjuvant therapy for localized pancreatic ductal adenocarcinoma. Minerva Surg 2024; 79:315-325. [PMID: 38385797 DOI: 10.23736/s2724-5691.23.10150-x] [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: 02/23/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive tumor with poor prognosis and rising incidence globally. Multimodal therapy that includes surgical resection and chemotherapy with or without radiation offers the best chance for optimal outcomes. The development of established criteria for anatomic staging of local primary tumors into potentially resectable (PR), borderline resectable (BR), and locally advanced (LA) has greatly clarified the optimal treatment strategies. While upfront surgical resection was traditionally the recommended approach for localized PDAC, increasingly neoadjuvant therapy (NT) is recommended prior to surgery. Whereas NT can lead to downstaging that facilitates surgical resection for BR/LA cancers, NT also enhances patient selection for surgery, improves margin-negative resection rates, and increases the odds of completing multimodality therapy for all patients with PDAC. Herein, we review the rationale for NT for localized PDAC and summarize existing and ongoing literature.
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Affiliation(s)
- Zachary J Brown
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alexander H Shannon
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, USA -
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15
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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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16
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Wolfe AR, Feng H, Zuniga O, Rodrigues H, Eldridge DE, Yang L, Shen C, Williams TM. RAS-RAF-miR-296-3p signaling axis increases Rad18 expression to augment radioresistance in pancreatic and thyroid cancers. Cancer Lett 2024; 591:216873. [PMID: 38604313 PMCID: PMC11132429 DOI: 10.1016/j.canlet.2024.216873] [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: 11/08/2023] [Revised: 03/18/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
Oncogenic RAS and RAF signaling has been implicated in contributing to radioresistance in pancreatic and thyroid cancers. In this study, we sought to better clarify molecular mechanisms contributing to this effect. We discovered that miRNA 296-3p (miR-296-3p) is significantly correlated with radiosensitivity in a panel of pancreatic cancer cells, and miR-296-3p is highly expressed in normal cells, but low in cancer cell lines. Elevated expression of miR-296-3p increases radiosensitization while decreasing the expression of the DNA repair enzyme RAD18 in both pancreatic and thyroid cancer cells. RAD18 is overexpressed in both pancreatic and thyroid tumors compared to matched normal controls, and high expression of RAD18 in tumors is associated with poor prognostic features. Modulating the expression of mutant KRAS in pancreatic cancer cells or mutant BRAF in thyroid cancer cells demonstrates a tight regulation of RAD18 expression in both cancer types. Depletion of RAD18 results in DNA damage and radiation-induced cell death. Importantly, RAD18 depletion in combination with radiotherapy results in marked and sustained tumor regression in KRAS mutant pancreatic cancer orthotopic tumors and BRAF mutant thyroid heterotopic tumors. Overall, our findings identify a novel coordinated RAS/RAF-miR-296-3p-RAD18 signaling network in pancreatic and thyroid cancer cells, which leads to enhanced radioresistance.
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Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Haihua Feng
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Oscar Zuniga
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Henrique Rodrigues
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Daniel E Eldridge
- Department of Veterinary Medicine, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Linlin Yang
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Changxian Shen
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
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17
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Lun T, Palamuthusingam P, O’Rourke N. Isolated abdominal wall recurrence of pancreatic ductal adenocarcinoma: a rare case report. J Surg Case Rep 2024; 2024:rjae418. [PMID: 38912432 PMCID: PMC11190851 DOI: 10.1093/jscr/rjae418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/25/2024] [Accepted: 06/11/2024] [Indexed: 06/25/2024] Open
Abstract
A 76-year-old woman was investigated for epigastric pain on a background of a laparoscopic distal pancreatectomy and splenectomy for pancreatic ductal adenocarcinoma 4 years prior. Imaging revealed an isolated 32 mm fluorodeoxyglucose avid lesion contacting both the anterior abdominal wall and greater curvature of the stomach. Immunohistochemistry and fine needle biopsy confirmed a phenotype consistent with metastatic pancreatic adenocarcinoma. Laparoscopic excision of the mass and partial gastrectomy for clearance of margins was performed. Histopathology demonstrated a poorly differentiated pancreatic ductal adenocarcinoma, and the patient received adjuvant gemcitabine/capecitabine following an uncomplicated postoperative course. This article presents a rare case of isolated abdominal wall recurrence of pancreatic ductal adenocarcinoma, which was successfully treated with surgical resection and adjuvant chemotherapy.
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Affiliation(s)
- Tegan Lun
- Department of Surgery, Townsville University Hospital, Townsville, 4814, QLD, Australia
| | - Pranavan Palamuthusingam
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane, 4006, QLD, Australia
- Department of Surgery, Wesley Hospital, Brisbane 4066, QLD, Australia
| | - Nicholas O’Rourke
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane, 4006, QLD, Australia
- Department of Surgery, Wesley Hospital, Brisbane 4066, QLD, Australia
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18
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Leonhardt CS, Gustorff C, Klaiber U, Le Blanc S, Stamm TA, Verbeke CS, Prager GW, Strobel O. Prognostic Factors for Early Recurrence After Resection of Pancreatic Cancer: A Systematic Review and Meta-Analysis. Gastroenterology 2024:S0016-5085(24)05004-2. [PMID: 38825047 DOI: 10.1053/j.gastro.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/17/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND & AIMS More than half of pancreatic ductal adenocarcinomas (PDACs) recur within 12 months after curative-intent resection. This systematic review and meta-analysis was conducted to identify all reported prognostic factors for early recurrence in resected PDACs. METHODS After a systematic literature search, a meta-analysis was conducted using a random effects model. Separate analyses were performed for adjusted vs unadjusted effect estimates as well as reported odds ratios (ORs) and hazard ratios (HRs). Risk of bias was assessed using the Quality in Prognostic Studies tool, and evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation recommendations. RESULTS After 2903 abstracts were screened, 65 studies were included. Of these, 28 studies (43.1%) defined early recurrence as evidence of recurrence within 6 months, whereas 34 (52.3%) defined it as evidence of recurrence within 12 months after surgery. Other definitions were uncommon. Analysis of unadjusted ORs and HRs revealed 41 and 5 prognostic factors for early recurrence within 6 months, respectively. When exclusively considering adjusted data, we identified 25 and 10 prognostic factors based on OR and HR, respectively. Using a 12-month definition, we identified 38 (OR) and 15 (HR) prognostic factors from unadjusted data and 38 (OR) and 30 (HR) prognostic factors from adjusted data, respectively. On the basis of frequency counts of adjusted data, preoperative carbohydrate antigen 19-9, N status, nondelivery of adjuvant therapy, grading, and tumor size based on imaging were identified as key prognostic factors for early recurrence. CONCLUSIONS Reported prognostic factors of early recurrence vary considerably. Identified key prognostic factors could aid in the development of a risk stratification framework for early recurrence. However, prospective validation is necessary.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria; Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom.
| | - Charlotte Gustorff
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulla Klaiber
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Solange Le Blanc
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Tanja A Stamm
- Institute of Outcomes Research, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Caroline S Verbeke
- Department of Pathology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gerald W Prager
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Strobel
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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19
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Ang A, Michaelides A, Chelala C, Ullah D, Kocher HM. Prognostication for recurrence patterns after curative resection for pancreatic ductal adenocarcinoma. Ann Hepatobiliary Pancreat Surg 2024; 28:248-261. [PMID: 38556877 PMCID: PMC11128784 DOI: 10.14701/ahbps.23-149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/02/2024] [Accepted: 02/10/2024] [Indexed: 04/02/2024] Open
Abstract
Backgrounds/Aims This study aimed to investigate patterns and factors affecting recurrence after curative resection for pancreatic ductal adenocarcinoma (PDAC). Methods Consecutive patients who underwent curative resection for PDAC (2011-21) and consented to data and tissue collection (Barts Pancreas Tissue Bank) were followed up until May 2023. Clinico-pathological variables were analysed using Cox proportional hazards model. Results Of 91 people (42 males [46%]; median age, 71 years [range, 43-86 years]) with a median follow-up of 51 months (95% confidence intervals [CIs], 40-61 months), the recurrence rate was 72.5% (n = 66; 12 loco-regional alone, 11 liver alone, 5 lung alone, 3 peritoneal alone, 29 simultaneous loco-regional and distant metastases, and 6 multi-focal distant metastases at first recurrence diagnosis). The median time to recurrence was 8.5 months (95% CI, 6.6-10.5 months). Median survival after recurrence was 5.8 months (95% CI, 4.2-7.3 months). Stratification by recurrence location revealed significant differences in time to recurrence between loco-regional only recurrence (median, 13.6 months; 95% CI, 11.7-15.5 months) and simultaneous loco-regional with distant recurrence (median, 7.5 months; 95% CI, 4.6-10.4 months; p = 0.02, pairwise log-rank test). Significant predictors for recurrence were systemic inflammation index (SII) ≥ 500 (hazard ratio [HR], 4.5; 95% CI, 1.4-14.3), lymph node ratio ≥ 0.33 (HR, 2.8; 95% CI, 1.4-5.8), and adjuvant chemotherapy (HR, 0.4; 95% CI, 0.2-0.7). Conclusions Timing to loco-regional only recurrence was significantly longer than simultaneous loco-regional with distant recurrence. Significant predictors for recurrence were SII, lymph node ration, and adjuvant chemotherapy.
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Affiliation(s)
- Andrew Ang
- The Royal London Hospital, Barts Health NHS Trust, London, UK
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London, UK
| | - Athena Michaelides
- The Royal London Hospital, Barts Health NHS Trust, London, UK
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London, UK
| | - Claude Chelala
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London, UK
| | - Dayem Ullah
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London, UK
| | - Hemant M. Kocher
- The Royal London Hospital, Barts Health NHS Trust, London, UK
- Barts Cancer Institute, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London, UK
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20
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Poiset SJ, Shah S, Cappelli L, Anné P, Mooney KE, Werner-Wasik M, Laufer TS, Posey JA, Lin D, Basu Mallick A, Lavu H, Bashir B, Yeo CJ, Mueller AC. Early outcomes of MR-guided SBRT for patients with recurrent pancreatic adenocarcinoma. Radiat Oncol 2024; 19:65. [PMID: 38812040 PMCID: PMC11138072 DOI: 10.1186/s13014-024-02457-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: 12/08/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Local treatment options for locally recurrent pancreatic adenocarcinoma (LR-PAC) are limited, with median survival time (MST) of 9-13 months (mos) following recurrence. MRI-guided stereotactic body radiation therapy (MRgSBRT) provides the ability to dose escalate while sparing normal tissue. Here we report on the early outcomes of MRgSBRT for LR-PAC. METHODS Patients with prior resection of pancreatic adenocarcinoma with local recurrence treated with MRgSBRT at a single tertiary referral center from 5-2021 to 2-2023 were identified from our prospective database. MRgSBRT was delivered to 40-50 Gy in 4-5 fractions with target and OAR delineation per institutional standards. Endpoints included local control per RECIST v1.1, distant failure, overall survival (OS), and acute and chronic toxicities per Common Terminology Criteria for Adverse Events, v5. RESULTS Fifteen patients with LR-PAC were identified with median follow-up of 10.6 mos (2.8-26.5 mos) from MRgSBRT. There were 8 females and 7 males, with a median age of 69 years (50-83). One patient underwent neoadjuvant radiation for 50.4 Gy in 28 fractions followed by resection, and one underwent adjuvant radiation for 45 Gy in 25 fractions prior to recurrence. MRgSBRT was delivered a median of 18.8 mos (3.5-52.8 mos) following resection. OS following recurrence at 6 and 12 mos were 87% and 51%, respectively, with a median survival time of 14.1 mos (3.2-27.4 mos). Three patients experienced local failure at 5.9, 7.8, and 16.6 months from MgSBRT with local control of 92.3% and 83.9% at 6 and 12 months. 10 patients experienced distant failure at a median of 2.9 mos (0.3-6.7 mos). Grade 1-2 acute GI toxicity was noted in 47% of patients, and chronic GI toxicity in 31% of patients. No grade > 3 toxicities were noted. CONCLUSIONS This is the first report on toxicity and outcomes of MRgSBRT for LR-PAC in the literature. MRgSBRT is a safe, feasible treatment modality with the potential for improved local control in this vulnerable population. Future research is necessary to better identify which patients yield the most benefit from MRgSBRT, which should continue to be used with systemic therapy as tolerated. TRIAL REGISTRATION Jefferson IRB#20976, approved 2/17/21.
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Affiliation(s)
- Spencer J Poiset
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Sophia Shah
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Louis Cappelli
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Pramila Anné
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - Talya S Laufer
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA
| | - James A Posey
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel Lin
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Atrayee Basu Mallick
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Harish Lavu
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Babar Bashir
- Department of Medical Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Cancer Center of Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center of Thomas Jefferson University, 111 S 11th St. Suite G301, Philadelphia, PA, 19107, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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21
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Tomić G, Sheridan C, Refermat AY, Baggelaar MP, Sipthorp J, Sudarshan B, Ocasio CA, Suárez-Bonnet A, Priestnall SL, Herbert E, Tate EW, Downward J. Palmitoyl transferase ZDHHC20 promotes pancreatic cancer metastasis. Cell Rep 2024; 43:114224. [PMID: 38733589 DOI: 10.1016/j.celrep.2024.114224] [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: 11/09/2023] [Revised: 03/04/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Metastasis is one of the defining features of pancreatic ductal adenocarcinoma (PDAC) that contributes to poor prognosis. In this study, the palmitoyl transferase ZDHHC20 was identified in an in vivo short hairpin RNA (shRNA) screen as critical for metastatic outgrowth, with no effect on proliferation and migration in vitro or primary PDAC growth in mice. This phenotype is abrogated in immunocompromised animals and animals with depleted natural killer (NK) cells, indicating that ZDHHC20 affects the interaction of tumor cells and the innate immune system. Using a chemical genetics platform for ZDHHC20-specific substrate profiling, a number of substrates of this enzyme were identified. These results describe a role for palmitoylation in enabling distant metastasis that could not have been detected using in vitro screening approaches and identify potential effectors through which ZDHHC20 promotes metastasis of PDAC.
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Affiliation(s)
- Goran Tomić
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Clare Sheridan
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | | | - Marc P Baggelaar
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK; Imperial College London, Department of Chemistry, Molecular Sciences Research Hub, 80 Wood Lane, London W12 0BZ, UK
| | - James Sipthorp
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK; Imperial College London, Department of Chemistry, Molecular Sciences Research Hub, 80 Wood Lane, London W12 0BZ, UK
| | | | - Cory A Ocasio
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Alejandro Suárez-Bonnet
- The Royal Veterinary College, Department of Pathobiology & Population Sciences, Hawkshead Lane, Hatfield AL9 7TA, UK; Experimental Histopathology, The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Simon L Priestnall
- The Royal Veterinary College, Department of Pathobiology & Population Sciences, Hawkshead Lane, Hatfield AL9 7TA, UK; Experimental Histopathology, The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Eleanor Herbert
- The Royal Veterinary College, Department of Pathobiology & Population Sciences, Hawkshead Lane, Hatfield AL9 7TA, UK; Experimental Histopathology, The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Edward W Tate
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK; Imperial College London, Department of Chemistry, Molecular Sciences Research Hub, 80 Wood Lane, London W12 0BZ, UK
| | - Julian Downward
- The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK.
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22
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Abdalla TSA, Duhn J, Klinkhammer-Schalke M, Zeissig SR, Kleihues-van Tol K, Honselmann KC, Braun R, Kist M, Bolm L, von Fritsch L, Lapshyn H, Litkevych S, Hummel R, Zemskov S, Wellner UF, Keck T, Deichmann S. Oncological Outcomes and Patterns of Recurrence after the Surgical Resection of an Invasive Intraductal Papillary Mucinous Neoplasm versus Primary Pancreatic Ductal Adenocarcinoma: An Analysis from the German Cancer Registry Group of the Society of German Tumor Centers. Cancers (Basel) 2024; 16:2016. [PMID: 38893136 PMCID: PMC11171342 DOI: 10.3390/cancers16112016] [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: 04/30/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are premalignant cystic neoplasms of the pancreas (CNPs), which can progress to invasive IPMN and pancreatic cancer. The available literature has shown controversial results regarding prognosis and clinical outcomes after the resection of invasive IPMN. AIMS This study aims to characterize the oncologic outcomes and metastatic progression pattern after the resection of non-metastatic invasive IPMN. METHODS Data were obtained from 24 clinical cancer registries participating in the German Cancer Registry Group of the Society of German Tumor Centers (ADT). Patients with invasive IPMN (n = 217) as well as PDAC (n = 5794) between 2000 and 2021 were included and compared regarding oncological outcomes. RESULTS Invasive IPMN was significantly smaller in size (p < 0.001) and of a lower tumor grade (p < 0.001), with fewer lymph node metastases (p < 0.001), lymphangiosis (p < 0.001), and consequently a higher R0 resection rate (88 vs. 74%) compared to PDAC. Moreover, invasive IPMN was associated with fewer local (11 vs. 15%) and distant recurrences (29 vs. 46%) and metastasized more frequently in the lungs only (26% vs. 14%). Invasive IPMN was associated with a longer median OS (29 vs. 19 months) and DFS (31 vs. 15 months) compared to PDAC and stayed independently prognostic in multivariable analyses. These survival differences were most pronounced in early tumor stages. Interestingly, postoperative chemotherapy was not associated with improved overall survival in surgically resected invasive IPMN. CONCLUSIONS Invasive IPMN is a rare pancreatic entity with increasing incidence in Germany. It is associated with favorable histopathological features at the time of resection and longer OS and DFS compared to PDAC, particularly before the locoregional spread has occurred. Invasive IPMNs are associated with lung-only metastasis. The benefit of postoperative chemotherapy after the resection of invasive IPMN remains uncertain.
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Affiliation(s)
- Thaer S. A. Abdalla
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Jannis Duhn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Monika Klinkhammer-Schalke
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Sylke Ruth Zeissig
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
- Institute of Clinical Epidemiology and Biometry (ICE-B), University of Würzburg, 97974 Würzburg, Germany
| | - Kees Kleihues-van Tol
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Kim C. Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Markus Kist
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Lennart von Fritsch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Stanislav Litkevych
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
| | - Richard Hummel
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
- Department of Surgery, University Medical Center Greiswald, 17489 Greifswald, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical University, 01601 Kiev, Ukraine
| | - Ulrich Friedrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Network for Care, Quality and Research in Oncology (ADT), German Cancer Registry Group of the Society of German Tumor Centers, 14057 Berlin, Germany
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23
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Mittelstädt A, Anthuber A, David P, Podolska M, Bénard A, Brunner M, Krautz C, Jacobsen A, Denz A, Weber K, Merkel S, Hackner D, Buniatov T, Roßdeutsch L, Klösch B, Swierzy I, Hansen FJ, Strobel D, Zopf Y, Baur JO, Van Deun J, Immanuel Geppert C, Gießl A, Lettmaier S, Semrau S, Grützmann R, Kouhestani D, Weber GF. Exosomal ROR1 in peritoneal fluid identifies peritoneal disseminated PDAC and is associated with poor survival. Front Immunol 2024; 15:1253072. [PMID: 38846943 PMCID: PMC11153717 DOI: 10.3389/fimmu.2024.1253072] [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: 07/04/2023] [Accepted: 05/07/2024] [Indexed: 06/09/2024] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest forms of cancer and peritoneal dissemination is one major cause for this poor prognosis. Exosomes have emerged as promising biomarkers for gastrointestinal cancers and can be found in all kinds of bodily fluids, also in peritoneal fluid (PF). This is a unique sample due to its closeness to gastrointestinal malignancies. The receptor tyrosine kinase-like orphan receptor 1 (ROR1) has been identified as a potential biomarker in human cancers and represents a promising target for an immunotherapy approach, which could be considered for future treatment strategies. Here we prospectively analyzed the exosomal surface protein ROR1 (exo-ROR1) in PF in localized PDAC patients (PER-) on the one hand and peritoneal disseminated tumor stages (PER+) on the other hand followed by the correlation of exo-ROR1 with clinical-pathological parameters. Methods Exosomes were isolated from PF and plasma samples of non-cancerous (NC) (n = 15), chronic pancreatitis (CP) (n = 4), localized PDAC (PER-) (n = 18) and peritoneal disseminated PDAC (PER+) (n = 9) patients and the surface protein ROR1 was detected via FACS analysis. Additionally, soluble ROR1 in PF was analyzed. ROR1 expression in tissue was investigated using western blots (WB), qPCR, and immunohistochemistry (IHC). Exosome isolation was proven by Nano Tracking Analysis (NTA), WB, Transmission electron microscopy (TEM), and BCA protein assay. The results were correlated with clinical data and survival analysis was performed. Results PDAC (PER+) patients have the highest exo-ROR1 values in PF and can be discriminated from NC (p <0.0001), PDAC (PER-) (p <0.0001), and CP (p = 0.0112). PDAC (PER-) can be discriminated from NC (p = 0.0003). In plasma, exo-ROR1 is not able to distinguish between the groups. While there is no expression of ROR1 in the exocrine pancreatic tissue, PDAC and peritoneal metastasis show expression of ROR1. High exo-ROR1 expression in PF is associated with lower overall survival (p = 0.0482). Conclusion With exo-ROR1 in PF we found a promising diagnostic and prognostic biomarker possibly discriminating between NC, PDAC (PER-) and PDAC (PER+) and might shed light on future diagnostic and therapeutic concepts in PDAC.
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Affiliation(s)
- Anke Mittelstädt
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Anna Anthuber
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Paul David
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Alan Bénard
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Christian Krautz
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Anne Jacobsen
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Axel Denz
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Danilo Hackner
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Timur Buniatov
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Lotta Roßdeutsch
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Bettina Klösch
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Izabella Swierzy
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Deike Strobel
- Department of Gastroenterology, University Hospital Erlangen, Erlangen, Germany
| | - Yurdagül Zopf
- Department of Gastroenterology, University Hospital Erlangen, Erlangen, Germany
| | - Jan-Ole Baur
- Department of Internal Medicine 5, University Hospital Erlangen, Erlangen, Germany
| | - Jan Van Deun
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | | | - Andreas Gießl
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Comprehensive Cancer Center, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Dina Kouhestani
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Georg F. Weber
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Comprehensive Cancer Center, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany
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24
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Phillips ME, Robertson MD, Bennett-Eastley K, Rowe L, Frampton AE, Hart KH. Standard Nutritional Assessment Tools Are Unable to Predict Loss of Muscle Mass in Patients Due to Undergo Pancreatico-Duodenectomy: Highlighting the Need for Detailed Nutritional Assessment. Nutrients 2024; 16:1269. [PMID: 38732516 PMCID: PMC11085118 DOI: 10.3390/nu16091269] [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: 03/30/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND AND METHODS Pancreatico-duodenectomy (PD) carries significant morbidity and mortality, with very few modifiable risk factors. Radiological evidence of sarcopenia is associated with poor outcomes. This retrospective study aimed to analyse the relationship between easy-to-use bedside nutritional assessment techniques and radiological markers of muscle loss to identify those patients most likely to benefit from prehabilitation. RESULTS Data were available in 184 consecutive patients undergoing PD. Malnutrition was present in 33-71%, and 48% had a high visceral fat-to-skeletal muscle ratio, suggestive of sarcopenic obesity (SO). Surgical risk was higher in patients with obesity (OR 1.07, 95%CI 1.01-1.14, p = 0.031), and length of stay was 5 days longer in those with SO (p = 0.006). There was no correlation between skeletal muscle and malnutrition using percentage weight loss or the malnutrition universal screening tool (MUST), but a weak correlation between the highest hand grip strength (HGS; 0.468, p < 0.001) and the Global Leadership in Malnutrition (GLIM) criteria (-0.379, p < 0.001). CONCLUSIONS Nutritional assessment tools give widely variable results. Further research is needed to identify patients at significant nutritional risk prior to PD. In the meantime, those with malnutrition (according to the GLIM criteria), obesity or low HGS should be referred to prehabilitation.
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Affiliation(s)
- Mary E. Phillips
- Department of Nutrition and Dietetics, Royal Surrey NHS Foundation Trust, Guildford GU2 7XX, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - M. Denise Robertson
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Kate Bennett-Eastley
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Lily Rowe
- Department of Nutrition and Dietetics, Royal Surrey NHS Foundation Trust, Guildford GU2 7XX, UK
| | - Adam E. Frampton
- Department of Nutrition and Dietetics, Royal Surrey NHS Foundation Trust, Guildford GU2 7XX, UK
- HPB Surgical Unit, Royal Surrey NHS Foundation Trust, Guildford GU2 7XX, UK
- Section of Oncology, Department of Clinical and Experimental Medicine, FHMS, University of Surrey, Guildford GU2 7XH, UK
| | - Kathryn H. Hart
- Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
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25
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Martos MP, Amirian H, Dickey EM, Box EW, Merchant NB, Hosein PJ, Hester CA, Datta J. Improving patient stratification and selection for curative-intent treatment in localized pancreatic cancer. Hepatobiliary Surg Nutr 2024; 13:325-328. [PMID: 38617473 PMCID: PMC11007343 DOI: 10.21037/hbsn-23-668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/01/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Mary P. Martos
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Haleh Amirian
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin M. Dickey
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Edmond W. Box
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B. Merchant
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J. Hosein
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Caitlin A. Hester
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jashodeep Datta
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, Miami, FL, USA
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26
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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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27
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Hang HX, Cai ZH, Yang YF, Fu X, Qiu YD, Cheng H. Comparison of prognosis and postoperative morbidities between standard pancreaticoduodenectomy and the TRIANGLE technique for resectable pancreatic ductal adenocarcinoma. World J Gastrointest Surg 2024; 16:689-699. [PMID: 38577093 PMCID: PMC10989349 DOI: 10.4240/wjgs.v16.i3.689] [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: 12/19/2023] [Revised: 01/17/2024] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Radical surgery combined with systemic chemotherapy offers the possibility of long-term survival or even cure for patients with pancreatic ductal adenocarcinoma (PDAC), although tumor recurrence, especially locally, still inhibits the treatment efficacy. The TRIANGLE technique was introduced as an extended dissection procedure to improve the R0 resection rate of borderline resectable or locally advanced PDAC. However, there was a lack of studies concerning postoperative complications and long-term outcomes of this procedure on patients with resectable PDAC. AIM To compare the prognosis and postoperative morbidities between standard pancreaticoduodenectomy (PD) and the TRIANGLE technique for resectable PDAC. METHODS Patients with resectable PDAC eligible for PD from our hospital between June 2018 and December 2021 were enrolled in this retrospective cohort study. All the patients were divided into PDstandard and PDTRIANGLE groups according to the surgical procedure. Baseline characteristics, surgical data, and postoperative morbidities were recorded. All of the patients were followed up, and the date and location of tumor recurrence, and death were recorded. The Kaplan-Meier method and log-rank test were used for the survival analysis. RESULTS There were 93 patients included in the study and 37 underwent the TRIANGLE technique. Duration of operation was longer in the PDTRIANGLE group compared with the PDstandard group [440 (410-480) min vs 320 (265-427) min] (P = 0.001). Intraoperative blood loss [700 (500-1200) mL vs 500 (300-800) mL] (P = 0.009) and blood transfusion [975 (0-1250) mL vs 400 (0-800) mL] (P = 0.009) were higher in the PDTRIANGLE group. There was a higher incidence of surgical site infection (43.2% vs 12.5%) (P = 0.001) and postoperative diarrhea (54.1% vs 12.5%) (P = 0.001) in the PDTRIANGLE group. The rates of R0 resection and local recurrence, overall survival, and disease-free survival did not differ significantly between the two groups. CONCLUSION The TRIANGLE technique is safe, with acceptable postoperative morbidities compared with standardized PD, but it does not improve prognosis for patients with resectable PDAC.
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Affiliation(s)
- He-Xing Hang
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Zheng-Hua Cai
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Yi-Fei Yang
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Xu Fu
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Yu-Dong Qiu
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Hao Cheng
- Division of Pancreatic Surgery, Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, Jiangsu Province, China
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28
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Wu CY, Kuo TC, Lin HW, Yang JT, Chen WH, Cheng WF, Tien YW, Chan KC. Immunocyte profiling changes in patients received epidural versus intravenous analgesia after pancreatectomy: A randomized controlled trial. J Formos Med Assoc 2024:S0929-6646(24)00148-7. [PMID: 38494360 DOI: 10.1016/j.jfma.2024.03.003] [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: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Perioperative immunosuppressants, such as surgical stress and opioid use may downregulate anti-cancer immunocytes for patients undergoing pancreatectomy. Thoracic epidural analgesia (TEA) may attenuate these negative effects and provide better anti-cancer immunocyte profile change than intravenous analgesia using opioid. METHODS We randomly assigned 108 adult patients undergoing pancreatectomy to receive one of two 72-h postoperative analgesia protocols: one was TEA, and the other was intravenous patient-controlled analgesia (IV-PCA). The perioperative proportional changes of immunocytes relevant to anticancer immunity-namely natural killer (NK) cells, cytotoxic T cells, helper T cells, mature dendritic cells, and regulatory T (Treg) cells were determined at 1 day before surgery, at the end of surgery and on postoperative day 1,4 and 7 using flow cytometry. In addition, the progression-free survival and overall survival between the two groups were compared. RESULTS After surgery, the proportions of NK cells and cytotoxic T cells were significantly decreased; the proportion of B cells and mature dendritic cells and Treg cells were significantly increased. However, the proportions of helper T cells exhibited no significant change. These results were comparable between the two groups. Furthermore, there were no significant differences in progression-free survival (52.75 [39.96] and 57.48 [43.66] months for patients in the TEA and IV-PCA groups, respectively; p = 0.5600) and overall survival (62.71 [35.48] and 75.11 [33.10] months for patients in the TEA and IV-PCA groups, respectively; p = 0.0644). CONCLUSIONS TEA was neither associated with favorable anticancer immunity nor favorable oncological outcomes for patients undergoing pancreatectomy.
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Affiliation(s)
- Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital, Hsinchu branch, Hsinchu, Taiwan
| | - Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Wei Lin
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Ting Yang
- Department of Health Services, University of Washington, Seattle, United States
| | - Wen-Hsiu Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Fang Cheng
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
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29
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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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30
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Wang G, Lei W, Duan S, Cao A, Shi H. Preoperative evaluating early recurrence in resectable pancreatic ductal adenocarcinoma by using CT radiomics. Abdom Radiol (NY) 2024; 49:484-491. [PMID: 37955726 DOI: 10.1007/s00261-023-04074-x] [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: 07/10/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE To investigate the feasibility of a radiomics model based on contrast-enhanced CT for preoperatively predicting early recurrence after curative resection in patients with resectable pancreatic ductal adenocarcinoma (PDAC). METHODS One hundred and eighty-six patients with resectable PDAC who underwent curative resection were included and allocated to training set (131 patients) and validation set (55 patients). Radiomics features were extracted from arterial phase and portal venous phase images. The Mann-Whitney U test and least absolute shrinkage and selection operator (LASSO) regression were used for feature selection and radiomics signature construction. The radiomics model based on radiomics signature and clinical features was developed by the multivariate logistic regression analysis. Performance of the radiomics model was investigated by the area under the receiver operating characteristic (ROC) curve. RESULTS The radiomics signature, consisting of three arterial phase and three venous phase features, showed optimal prediction performance for early recurrence in both training (AUC = 0.73) and validation sets (AUC = 0.66). Multivariate logistic analysis identified the radiomics signature (OR, 2.58; 95% CI 2.36-3.17; p = 0.002) and clinical stage (OR, 1.60; 95% CI 1.15-2.30; p = 0.007) as independent predictors. The AUC values for risk evaluation of early recurrence using the radiomics model incorporating clinical stage were 0.80 (training set) and 0.75 (validation set). CONCLUSION The radiomics-based model integrating with clinical stage can predict early recurrence after upfront surgery in patients with resectable PDAC.
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Affiliation(s)
- Gang Wang
- Department of Radiotherapy, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Xuzhou, People's Republic of China
| | - Weijie Lei
- Department of Radiotherapy, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Xuzhou, People's Republic of China
| | - Shaofeng Duan
- GE Healthcare, Pudong New Town, 1 Huatuo Road, Shanghai, People's Republic of China
| | - Aihong Cao
- Department of Radiology, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Xuzhou, People's Republic of China.
| | - Hongyuan Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, People's Republic of China.
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31
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Rompen IF, Habib JR, Wolfgang CL, Javed AA. Anatomical and Biological Considerations to Determine Resectability in Pancreatic Cancer. Cancers (Basel) 2024; 16:489. [PMID: 38339242 PMCID: PMC10854859 DOI: 10.3390/cancers16030489] [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: 11/14/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains associated with poor outcomes with a 5-year survival of 12% across all stages of the disease. These poor outcomes are driven by a delay in diagnosis and an early propensity for systemic dissemination of the disease. Recently, aggressive surgical approaches involving complex vascular resections and reconstructions have become more common, thus allowing more locally advanced tumors to be resected. Unfortunately, however, even after the completion of surgery and systemic therapy, approximately 40% of patients experience early recurrence of disease. To determine resectability, many institutions utilize anatomical staging systems based on the presence and extent of vascular involvement of major abdominal vessels around the pancreas. However, these classification systems are based on anatomical considerations only and do not factor in the burden of systemic disease. By integrating the biological criteria, we possibly could avoid futile resections often associated with significant morbidity. Especially patients with anatomically resectable disease who have a heavy burden of radiologically undetected systemic disease most likely do not derive a survival benefit from resection. On the contrary, we could offer complex resections to those who have locally advanced or oligometastatic disease but have favorable systemic biology and are most likely to benefit from resection. This review summarizes the current literature on defining anatomical and biological resectability in patients with pancreatic cancer.
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Affiliation(s)
- Ingmar F. Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Joseph R. Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christopher L. Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Ammar A. Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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Lee JH, Shin J, Min JH, Jeong WK, Kim H, Choi SY, Lee J, Hong S, Kim K. Preoperative prediction of early recurrence in resectable pancreatic cancer integrating clinical, radiologic, and CT radiomics features. Cancer Imaging 2024; 24:6. [PMID: 38191489 PMCID: PMC10775464 DOI: 10.1186/s40644-024-00653-3] [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: 07/26/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES To use clinical, radiographic, and CT radiomics features to develop and validate a preoperative prediction model for the early recurrence of pancreatic cancer. METHODS We retrospectively analyzed 190 patients (150 and 40 in the development and test cohort from different centers) with pancreatic cancer who underwent pancreatectomy between January 2018 and June 2021. Radiomics, clinical-radiologic (CR), and clinical-radiologic-radiomics (CRR) models were developed for the prediction of recurrence within 12 months after surgery. Performance was evaluated using the area under the curve (AUC), Brier score, sensitivity, and specificity. RESULTS Early recurrence occurred in 36.7% and 42.5% of the development and test cohorts, respectively (P = 0.62). The features for the CR model included carbohydrate antigen 19-9 > 500 U/mL (odds ratio [OR], 3.60; P = 0.01), abutment to the portal and/or superior mesenteric vein (OR, 2.54; P = 0.054), and adjacent organ invasion (OR, 2.91; P = 0.03). The CRR model demonstrated significantly higher AUCs than the radiomics model in the internal (0.77 vs. 0.73; P = 0.048) and external (0.83 vs. 0.69; P = 0.038) validations. Although we found no significant difference between AUCs of the CR and CRR models (0.83 vs. 0.76; P = 0.17), CRR models showed more balanced sensitivity and specificity (0.65 and 0.87) than CR model (0.41 and 0.91) in the test cohort. CONCLUSIONS The CRR model outperformed the radiomics and CR models in predicting the early recurrence of pancreatic cancer, providing valuable information for risk stratification and treatment guidance.
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Affiliation(s)
- Jeong Hyun Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jaeseung Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Hye Min
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Honsoul Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro Gangnam-gu, Seoul, 06351, Republic of Korea
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Jisun Lee
- Department of Radiology, College of Medicine, Chungbuk National University, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sungjun Hong
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Kyunga Kim
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [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: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Leonhardt CS, Hank T, Pils D, Gustorff C, Sahora K, Schindl M, Verbeke CS, Strobel O, Klaiber U. Prognostic impact of resection margin status on survival after neoadjuvant treatment for pancreatic cancer: systematic review and meta-analysis. Int J Surg 2024; 110:453-463. [PMID: 38315795 PMCID: PMC10793837 DOI: 10.1097/js9.0000000000000792] [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: 07/04/2023] [Accepted: 09/10/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND A greater than 1 mm tumour-free resection margin (R0 >1 mm) is a prognostic factor in upfront-resected pancreatic ductal adenocarcinoma. After neoadjuvant treatment (NAT); however, the prognostic impact of resection margin (R) status remains controversial. METHODS Randomised and non-randomised studies assessing the association of R status and survival in resected pancreatic ductal adenocarcinoma after NAT were sought by systematic searches of MEDLINE, Web of Science and CENTRAL. Hazard ratios (HR) and their corresponding 95% CI were collected to generate log HR using the inverse-variance method. Random-effects meta-analyses were performed and the results presented as weighted HR. Sensitivity and meta-regression analyses were conducted to account for different surgical procedures and varying length of follow-up, respectively. RESULTS Twenty-two studies with a total of 4929 patients were included. Based on univariable data, R0 greater than 1 mm was significantly associated with prolonged overall survival (OS) (HR 1.76, 95% CI 1.57-1.97; P<0.00001) and disease-free survival (DFS) (HR 1.66, 95% CI 1.39-1.97; P<0.00001). Using adjusted data, R0 greater than 1 mm was significantly associated with prolonged OS (HR 1.65, 95% CI 1.39-1.97; P<0.00001) and DFS (HR 1.76, 95% CI 1.30-2.39; P=0.0003). Results for R1 direct were comparable in the entire cohort; however, no prognostic impact was detected in sensitivity analysis including only partial pancreatoduodenectomies. CONCLUSION After NAT, a tumour-free margin greater than 1 mm is independently associated with improved OS as well as DFS in patients undergoing surgical resection for pancreatic cancer.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Hank
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Dietmar Pils
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Charlotte Gustorff
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Caroline S. Verbeke
- Department of Pathology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Oliver Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulla Klaiber
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
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Adekolujo OS, Wahab A, Akanbi MO, Oyasiji T, Hrinczenko B, Alese OB. Isolated pulmonary metastases in pancreatic ductal adenocarcinoma: a review of current evidence. Cancer Biol Ther 2023; 24:2198479. [PMID: 37526431 PMCID: PMC10395259 DOI: 10.1080/15384047.2023.2198479] [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: 06/30/2022] [Accepted: 03/24/2023] [Indexed: 08/02/2023] Open
Abstract
Despite recent advances in cancer therapeutics, pancreatic ductal adenocarcinoma (PDAC) remains a lethal disease with a 5-year overall survival of only 10%. Since either at or within a few months of diagnosis, most patients with PDAC will present with metastatic disease, a more individualized approach to select patients who may benefit from more aggressive therapy has been suggested. Although studies have reported improved survival in PDAC and isolated pulmonary metastasis (ISP) compared to extrapulmonary metastases, such findings remain controversial. Furthermore, the added benefit of pulmonary metastasectomy and other lung-directed therapies remains unclear. In this review, we discuss the metastatic pattern of PDAC, evaluate the available evidence in the literature for improved survival in PDAC and ISP, evaluate the evidence for the added benefit of pulmonary metastasectomy and other lung-directed therapies, identify prognostic factors for survival, discuss the biological basis for the reported improved survival and identify areas for further research.
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Affiliation(s)
- Orimisan Samuel Adekolujo
- Department of Medicine, Michigan State University, East Lansing, MI, USA
- Medical Oncology, Karmanos Cancer Institute at McLaren Greater Lansing, Lansing, MI, USA
| | - Ahsan Wahab
- Department of Medicine, Prattville Baptist Hospital, Prattville, AL, USA
| | - Maxwell Oluwole Akanbi
- Department of Medicine, Michigan State University, East Lansing, MI, USA
- Department of Medicine, McLaren Flint, Flint, MI, USA
| | - Tolutope Oyasiji
- Department of Oncology, Barbara Ann Karmanos Cancer Institute at McLaren Flint, Wayne State University, Flint, MI, USA
| | - Borys Hrinczenko
- Department of Medicine, Michigan State University, East Lansing, MI, USA
- Medical Oncology, Karmanos Cancer Institute at McLaren Greater Lansing, Lansing, MI, USA
| | - Olatunji Boladale Alese
- Department of Hematology & Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Blomstrand H, Olsson H, Green H, Björnsson B, Elander NO. Impact of resection margins and para-aortic lymph node metastases on recurrence patterns and prognosis in resectable pancreatic cancer - a long-term population-based cohort study. HPB (Oxford) 2023; 25:1531-1544. [PMID: 37659905 DOI: 10.1016/j.hpb.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/11/2023] [Accepted: 08/10/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Pancreatic cancer remains a leading cause of cancer-related death. To individualise management and improve survival, more accurate prognostic models are needed. METHODS All patients resected for pancreatic ductal adenocarcinoma in a tertiary Swedish centre during 2009-2019 were thoroughly analysed with regards to pathological and clinical parameters including tumour grade, resection margin status, para-aortic lymph node engagement (node station 16), and systemic treatment. RESULTS The study cohort included 275 patients. Overall median survival was 21.2 months (95% CI 17.5-24.8). Year of resection, margin status (R1 subdivided into R11mm/R1ink), perineural invasion, differentiation grade, TNM stage, and adjuvant therapy were independent factors with significant impact on survival. Margin status also significantly affected recurrence-free survival and relapse patterns, with local and peritoneal relapses being associated with R1-status (p < 0.001 and p = 0.007). Presence of para-aortic lymph node metastases was associated with shorter recurrence-free survival as compared to N1 status only. CONCLUSION Survival in resected pancreatic cancer is improving over time. Resection margin status is a key factor affecting recurrence patterns and prognosis. Given the poor recurrence-free survival in node station 16 metastasised patients, the rational for resection remains in doubt, and improved treatment strategies for this patient group is necessary.
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Affiliation(s)
- Hakon Blomstrand
- Department of Clinical Pathology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Hans Olsson
- Department of Clinical Pathology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Henrik Green
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden
| | - Bergthor Björnsson
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nils O Elander
- Department of Biomedical and Clinical Sciences, Linköping University, Sweden; Clatterbridge Cancer Centre NHS FT, Liverpool, United Kingdom
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Hong S, Ren J, Zhang S, Yan Y, Liu S, Qi F. Comparison of clinical outcomes and prognosis between total pancreatectomy and pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. ANZ J Surg 2023; 93:2820-2827. [PMID: 37614050 DOI: 10.1111/ans.18653] [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: 06/15/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND To compare the clinical outcomes and prognosis of total pancreatectomy (TP) and pancreaticoduodenectomy (PD) for the treatment of pancreatic ductal adenocarcinoma (PDAC), and to explore the safety and indications of TP. METHODS A systematic search was conducted on PubMed, Web of Science, and Embase databases from January 1943 to March 2023 for literatures comparing TP and PD in the treatment of PDAC. The primary outcome was postoperative overall survival (OS), and secondary outcomes included surgery time, blood loss, readmission, hospital stay, perioperative mortality, and overall morbidity. Fixed-effect or random-effect models were selected based on heterogeneity, and odds ratio (OR), mean difference (MD), or hazard ratio (HR) with 95% confidence intervals (CI) were calculated. RESULTS A total of six studies involving 8396 patients were included in the meta-analysis. There was no statistically significant difference in OS after surgery between the two groups (HR = 1.08, 95% CI: 0.91-1.27; P = 0.38). The TP group had a longer surgery time (MD = 13.66, 95% CI: 4.57-22.75; P = 0.003) and more blood loss (MD = 133.17, 95% CI: 8.00-258.33; P = 0.04) than the PD group. There were no significant differences between the two groups in terms of hospital stay (MD = 0.09, 95% CI: -2.04 to 2.22; P = 0.93), readmission rate (OR = 1.39; 95% CI: 1.00-1.92; P = 0.05), perioperative mortality (OR = 1.29, 95% CI: 0.98-1.69; P = 0.07), and overall morbidity (OR = 0.80, 95% CI: 0.50-1.26; P = 0.33). CONCLUSION The surgical process of TP is relatively complex, but there is no difference in short-term clinical outcomes and OS compared to PD, making it a safe and reliable procedure. Indications and treatment outcomes for planned TP and salvage TP may differ, and more research is needed in the future for further classification and verification.
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Affiliation(s)
- Shengqian Hong
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Jiao Ren
- Department of Radiology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Sufang Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Yulou Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Shiqi Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Fuzhen Qi
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
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Ahuja M, Pandé R, Chugtai S, Brown RM, Cain O, Bartlett DC, Dasari BVM, Marudanayagam R, Roberts KJ, Isaac J, Sutcliffe RP, Chatzizacharias N. Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma. Diagnostics (Basel) 2023; 13:3465. [PMID: 37998601 PMCID: PMC10670022 DOI: 10.3390/diagnostics13223465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Pancreaticoduodenectomy (PD) with vein resection is the only potentially curative option for patients with pancreatic ductal adenocarcinoma (PDAC) with venous involvement. The aim of our study was to assess the oncological prognostic significance of the different variables of venous involvement in patients undergoing PD for resectable and borderline-resectable with venous-only involvement (BR-V) PDAC. We performed a retrospective analysis of prospectively acquired data over a 10-year period. Of the 372 patients included, 105 (28%) required vein resection and vein wall involvement was identified in 37% of those. A multivariable analysis failed to identify the vein-related resection margins as independent predictors for OS, DFS or LR. Vein wall tumour involvement was an independent predictor of OS (risk x1.7-2) and DFS (risk x1.9-2.2) in all models, while it replaced overall surgical margin positivity as the only parameter independently predicting LR during an analysis of separate resection margins (risk x2.4). Vein wall tumour invasion may be a more reliable predictor of oncological outcomes compared to traditionally reported parameters. Future studies should focus on possible pre-operative investigations that could identify these cases and management pathways that could yield a survival benefit, such as the use of neoadjuvant treatments.
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Affiliation(s)
- Manish Ahuja
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rupaly Pandé
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Shafiq Chugtai
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rachel M. Brown
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - Owen Cain
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - David C. Bartlett
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Bobby V. M. Dasari
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Keith J. Roberts
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2SQ, UK
| | - John Isaac
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Robert P. Sutcliffe
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Nikolaos Chatzizacharias
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
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Stoecklein NH, Fluegen G, Guglielmi R, Neves RPL, Hackert T, Birgin E, Cieslik SA, Sudarsanam M, Driemel C, van Dalum G, Franken A, Niederacher D, Neubauer H, Fehm T, Rox JM, Böhme P, Häberle L, Göring W, Esposito I, Topp SA, Coumans FAW, Weitz J, Knoefel WT, Fischer JC, Bork U, Rahbari NN. Ultra-sensitive CTC-based liquid biopsy for pancreatic cancer enabled by large blood volume analysis. Mol Cancer 2023; 22:181. [PMID: 37957606 PMCID: PMC10641981 DOI: 10.1186/s12943-023-01880-1] [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: 06/26/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023] Open
Abstract
The limited sensitivity of circulating tumor cell (CTC) detection in pancreatic adenocarcinoma (PDAC) stems from their extremely low concentration in the whole circulating blood, necessitating enhanced detection methodologies. This study sought to amplify assay-sensitivity by employing diagnostic leukapheresis (DLA) to screen large blood volumes. Sixty patients were subjected to DLA, with a median processed blood volume of ~ 2.8 L and approximately 5% of the resulting DLA-product analyzed using CellSearch (CS). Notably, DLA significantly increased CS-CTC detection to 44% in M0-patients and 74% in M1-patients, yielding a 60-fold increase in CS-CTC enumeration. DLA also provided sufficient CS-CTCs for genomic profiling, thereby delivering additional genomic information compared to tissue biopsy samples. DLA CS-CTCs exhibited a pronounced negative prognostic impact on overall survival (OS), evidenced by a reduction in OS from 28.6 to 8.5 months (univariate: p = 0.002; multivariable: p = 0.043). Additionally, a marked enhancement in sensitivity was achieved (by around 3-4-times) compared to peripheral blood (PB) samples, with positive predictive values for OS being preserved at around 90%. Prognostic relevance of CS-CTCs in PDAC was further validated in PB-samples from 228 PDAC patients, consolidating the established association between CTC-presence and reduced OS (8.5 vs. 19.0 months, p < 0.001). In conclusion, DLA-derived CS-CTCs may serve as a viable tool for identifying high-risk PDAC-patients and aiding the optimization of multimodal treatment strategies. Moreover, DLA enables comprehensive diagnostic profiling by providing ample CTC material, reinforcing its utility as a reliable liquid-biopsy approach. This high-volume liquid-biopsy strategy presents a potential pathway for enhancing clinical management in this malignancy.
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Affiliation(s)
- Nikolas H Stoecklein
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Georg Fluegen
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Rosa Guglielmi
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Rui P L Neves
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Emrullah Birgin
- Department of Surgery, Medical Faculty Mannheim, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefan A Cieslik
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Monica Sudarsanam
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christiane Driemel
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Guus van Dalum
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - André Franken
- Department of Obstetrics and Gynecology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Dieter Niederacher
- Department of Obstetrics and Gynecology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Hans Neubauer
- Department of Obstetrics and Gynecology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Tanja Fehm
- Department of Obstetrics and Gynecology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jutta M Rox
- Department of Transplantation Diagnostics and Cell Therapeutics, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Petra Böhme
- Institute of Forensic Medicine Düsseldorf, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lena Häberle
- Institute of Pathology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Wolfgang Göring
- Institute of Pathology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Irene Esposito
- Institute of Pathology, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefan A Topp
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Frank A W Coumans
- Decisive Science, Ertskade 10, 1019 BB, Amsterdam, The Netherlands
- Current Affiliation: Department for General and Visceral Surgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Jürgen Weitz
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Wolfram T Knoefel
- General, Visceral and Pediatric Surgery, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Johannes C Fischer
- Department of Transplantation Diagnostics and Cell Therapeutics, University Hospital and Medical Faculty of the Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus of the Technical University Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Nuh N Rahbari
- Department of Surgery, Medical Faculty Mannheim, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- Current Affiliation: Department for General and Visceral Surgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Bernhardt M, Rühlmann F, Azizian A, Kölling MA, Beißbarth T, Grade M, König AO, Ghadimi M, Gaedcke J. Impact of Portal Vein Resection (PVR) in Patients Who Underwent Curative Intended Pancreatic Head Resection. Biomedicines 2023; 11:3025. [PMID: 38002027 PMCID: PMC10669675 DOI: 10.3390/biomedicines11113025] [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: 08/20/2023] [Revised: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
The oncological impact of portal vein resection (PVR) in pancreatic cancer surgery remains contradictory. Different variables might have an impact on the outcome. The aim of the present study is the retrospective assessment of the frequency of PVR, histological confirmation of tumor infiltration, and comparison of oncological outcomes in PVR patients. We retrieved n = 90 patients from a prospectively collected data bank who underwent pancreas surgery between 2012 and 2019 at the University Medical Centre Göttingen (Germany) and showed a histologically confirmed pancreatic ductal adenocarcinoma (PDAC). While 50 patients (55.6%) underwent pancreatic resection combined with PVR, 40 patients (44.4%) received standard pancreatic surgery. Patients with distal pancreatectomy or a tumor other than PDAC were excluded. PVR was performed either as local excision or circular resection of the portal vein. Clinical/patient data and follow-ups were retrieved. The median follow-up period was 20.5 months. Regarding the oncological outcome, a statistically poorer CSS (p = 0.04) was observed in PVR patients. There was no difference (p = 0.18) in patients' outcomes between tangential and complete PVR, while n = 21 (42% of PVR patients) showed portal vein infiltration. The correlation between performed PVR and resection status was statistically significant: 48.6% of PVR patients achieved R0 resections compared to 75% in non-PVR patients (p = 0.03). Patients who underwent PDAC surgery with PVR show a significantly poorer outcome regardless of PVR type. Tumor size and R-status remain two important variables significantly associated with outcome. Since there is a lack of standardization for the indication of PVR, it remains unknown if the need for resection of vein structures during pancreatic resection represents the biological aggressiveness of the tumor or is biased by the experience of the surgeon.
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Affiliation(s)
- Markus Bernhardt
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Felix Rühlmann
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Azadeh Azizian
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Max Alexander Kölling
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Tim Beißbarth
- Institute of Medical Bioinformatics, University Medical Center, D-37075 Goettingen, Germany
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Alexander Otto König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, D-37075 Goettingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Jochen Gaedcke
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
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Xie T, Xie X, Liu W, Chen L, Liu K, Zhou Z. Prediction of postoperative recurrence in resectable pancreatic body/tail adenocarcinoma: a novel risk stratification approach using a CT-based nomogram. Eur Radiol 2023; 33:7782-7793. [PMID: 37624415 DOI: 10.1007/s00330-023-10047-x] [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: 10/25/2022] [Revised: 05/28/2023] [Accepted: 06/20/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVES To identify prognostic CT features that predict recurrence in patients with resectable pancreatic body/tail adenocarcinoma (PBTA) and construct a CT-based nomogram for preoperative risk stratification. METHODS A total of 258 patients with resectable PBTA who underwent upfront surgery were retrospectively enrolled (development cohort, n = 172; validation cohort, n = 86), and their clinical and CT features were analyzed. Stepwise Cox proportional hazard analysis was performed to identify prognostic features and construct a predictive nomogram for recurrence-free survival (RFS). The prognostic performance of the CT-based nomogram was validated and compared to the 8th American Joint Committee on Cancer (AJCC) pathological staging system. RESULTS In the development cohort, the following five CT features for predicting recurrence were identified to construct the nomogram: tumor density in the venous phase, tumor necrosis, adjacent organ invasion, splenic vein invasion, and superior mesenteric vein/portal vein abutment. In the validation cohort, the CT-based nomogram showed a concordance index of 0.65 (95% confidence interval: 0.58-0.73), which was higher than the 8th AJCC staging system. The area under the curves of the nomogram for predicting recurrence at 0.5, 1, and 2 years were 0.66, 0.71, and 0.72, respectively. Patients were categorized into high- and low-risk groups with 1-year recurrence probabilities of 0.73 and 0.43, respectively. CONCLUSIONS The proposed nomogram provided accurate recurrence risk stratification for patients with resectable PBTA in a preoperative setting and may be used to facilitate clinical decision-making. CLINICAL RELEVANCE STATEMENT The proposed CT-based nomogram, based on easily available CT features, may serve as an effective and convenient tool for stratifying further the recurrence risk of patients with pancreatic body/tail adenocarcinoma. KEY POINTS • The CT-based nomogram, incorporating five commonly used CT features, successfully preoperatively stratified patients with resectable PBTA into distinct prognosis groups. • Tumor density in the venous phase, tumor necrosis, splenic vein invasion, adjacent organ invasion, and superior mesenteric vein/portal vein abutment were associated with RFS in patients with resectable PBTA. • The CT-based nomogram exhibited better predictive performance for recurrence than the 8th AJCC staging system.
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Affiliation(s)
- Tiansong Xie
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xuebin Xie
- Medical Imaging Center, Kiang Wu Hospital, Macau, China
| | - Wei Liu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Chen
- Department of Radiology, Fudan University Shanghai Cancer Center (Minhang Campus), Shanghai, China
| | - Kefu Liu
- Department of Radiology, the Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China.
| | - Zhengrong Zhou
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
- Department of Radiology, Fudan University Shanghai Cancer Center (Minhang Campus), Shanghai, China.
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Miyazaki Y, Oda T, Shimomura O, Hashimoto S, Doi M, Takahashi K, Owada Y, Furuya K, Ogawa K, Ohara Y, Akashi Y, Enomoto T. Total Superior Mesenteric Artery Nerve Plexus Preservation During Pancreaticoduodenectomy for Pancreatic Cancer. World J Surg 2023; 47:2816-2824. [PMID: 37501009 DOI: 10.1007/s00268-023-07111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Superior mesenteric artery (SMA) nerve plexus (PLsma) dissection has been performed to achieve R0 resection in pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) in high-volume centers. However, full-extent PLsma preservation in PD is employed in our institution. The feasibility of the PLsma preservation strategy was investigated. METHODS Between January 2010 and December 2020, 156 patients underwent PLsma preservation PD for PDAC at our institution. Of these, 118 patients had resectable PDAC (R group) and 38 patients had borderline resectable artery (BR-A group). Clinical and oncological outcomes focusing on local recurrence, patient prognoses, and morbidities (including postoperative refractory diarrhea) were retrospectively analyzed and our postoperative outcomes were compared with those of other institutions. RESULTS Pathological R0 resection by PLsma preservation PD was achieved in 96 R group patients (81.4%) and 27 BR-A group patients (71.1%). The median postoperative hospital stay was 15.0 days in both groups. Local site-only recurrence was observed in 10.2% (12/118) of R-group and 10.5% (4/38) of BR-A-group patients, whereas distant site-only recurrence occurred in 21.2% (25/118) of R-group and 28.9% (11/38) of BR-A-group patients. Median survival times were 64.3 months (R group) and 35.4 months (BR-A group, p = 0.07). Median disease-free survival (DFS) times were 31.0 months (R group) and 12.0 months (BR-A group). No diarrhea requiring opioids was observed in either group. These results were equal or superior to those of PLsma dissection PD in other institutions. CONCLUSIONS PLsma preservation in PD was feasible compared to PLsma dissection in recurrence and overall survival.
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Affiliation(s)
- Yoshihiro Miyazaki
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Manami Doi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kinji Furuya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
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Pedrazzoli S. Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor. J Clin Med 2023; 12:6461. [PMID: 37892599 PMCID: PMC10607532 DOI: 10.3390/jcm12206461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality. METHODS This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients. RESULTS Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available. CONCLUSION In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.
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Eijkelenkamp H, Grimbergen G, Daamen LA, Heerkens HD, van de Ven S, Mook S, Meijer GJ, Molenaar IQ, van Santvoort HC, Paulson E, Erickson BA, Verkooijen HM, Hall WA, Intven MPW. Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac. Front Oncol 2023; 13:1040673. [PMID: 37854684 PMCID: PMC10579578 DOI: 10.3389/fonc.2023.1040673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT. Methods We evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3-12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan-Meier analysis to calculate the cumulative overall survival. Results A total of 80 patients were assessed with a median FU of 8 months (range 1-39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3-4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3-4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%. Conclusion Online adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3-4 toxicity and a stable QoL at 3 months of FU.
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Affiliation(s)
- Hidde Eijkelenkamp
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Guus Grimbergen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A. Daamen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D. Heerkens
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
- Department of Radiotherapy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia van de Ven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Stella Mook
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J. Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Izaak Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, Netherlands
| | | | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Ann Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - William Adrian Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Martijn P. W. Intven
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
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Sickels A, Jain T, Dudeja V. Peritoneal Cell-Free DNA: A Novel Biomarker for Recurrence in Pancreatic Cancer. Ann Surg Oncol 2023; 30:6308-6310. [PMID: 37482596 DOI: 10.1245/s10434-023-13947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Angela Sickels
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tejeshwar Jain
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Akkaya H, Özdemir S, Dilek O, Topaloglu AC, Bayhan AZ, Taş ZA, Gökler C, Gülek B. Evaluation of the performance of and interobserver agreement on postoperative baseline CT findings in the identification of locoregional recurrence in patients with pancreatic ductal adenocarcinoma. Abdom Radiol (NY) 2023; 48:3135-3146. [PMID: 37517056 DOI: 10.1007/s00261-023-04012-x] [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: 05/26/2023] [Revised: 07/13/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To evaluate interobserver agreement on the findings of baseline contrast-enhanced multidetector computed tomography (CE-MDCT) performed at the postoperative third month in patients who underwent surgery due to ductal adenocarcinoma of the pancreatic head and investigate the value of these findings in predicting locoregional recurrence. MATERIAL AND METHODS The baseline CE-MDCT images of 198 patients who underwent the Whipple procedure due to pancreatic head tumors were evaluated independently by three radiologists at the postoperative third month. The radiologists were asked to note suspicious findings in terms of locoregional recurrence, including postoperative fat stranding, the presence of perivascular contrast-enhanced solid tissue, short diameter of solid tissue if present, the shape of solid tissue (convex/concave), presence of peritoneal implants, diameter (mm) of pancreatic duct dilatation if present, the presence of lymph nodes larger than 5 mm, portal vein stenosis (≥50 and <50%), the presence of ascites, and the presence of distant metastases, as specified by the Society of Abdominal Radiology in October 2022. The agreement between the radiologists and the value of these parameters in predicting locoregional recurrence were investigated. RESULTS Among the CE-MDCT findings evaluated, the radiologists had a moderate-to-high level of agreement concerning the presence of perivascular contrast-enhanced solid tissue. However, there was a poor interobserver agreement on the shape of solid tissue. A very high level of agreement was found among the radiologists in the evaluation of pancreatic duct dilatation, peritoneal implants, ascites, and the presence of distant metastases. According to the univariate analysis, the rates of portal vein stenosis had a 1.419 -fold effect [odds ratio (OR)=1.419, [95% confidence interval (CI)= 0.548-3.679, p=0.041], lymph node presence had a 2.337 -fold effect [odds ratio (OR)=2.337, [95% confidence interval (CI)= 1.165-4.686, p=0.015], perivascular contrast-enhanced solid tissue had 2.241 -fold effect [odds ratio (OR)=2.241, [95% confidence interval (CI)= 1.072-4.684, p=0.005]. In the multivariate analysis, perivascular contrast-enhanced solid tissue had 2.241 -fold effect [odds ratio (OR)=2.519, [95% confidence interval (CI)= 1.132-5.605, p=0.024]. CONCLUSION In the postoperative baseline CE-MDCT examination, the presence of solid tissue, lymph node presence, and portal vein stenosis in the surgical bed are among the findings that may indicate early locoregional recurrence in patients with pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Hüseyin Akkaya
- Department of Radiology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey.
| | - Selim Özdemir
- Department of Radiology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Okan Dilek
- Department of Radiology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Ali Can Topaloglu
- Department of Radiology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Ahmet Ziya Bayhan
- Department of Medical Oncology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Zeynel Abidin Taş
- Department of Pathology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Cihan Gökler
- Department of Surgical Oncology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
| | - Bozkurt Gülek
- Department of Radiology, Adana City Training and Research Hospital, University of Health Sciences, Kışla District, Dr. Mithat Özsan Boulevard, 4522. Street No. 1, 01230, Yüreğir, Adana, Turkey
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Hagerty BL, Oshi M, Endo I, Takabe K. High Mesothelin expression in pancreatic adenocarcinoma is associated with aggressive tumor features but not prognosis. Am J Cancer Res 2023; 13:4235-4245. [PMID: 37818071 PMCID: PMC10560932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/08/2023] [Indexed: 10/12/2023] Open
Abstract
Mesothelin is a cell surface marker expressed on most pancreatic cancers and has been associated with aggressive biology. Despite its popularity as a drug target, clinical relevance of Mesothelin expression in pancreatic cancer is unclear. We set out to define transcriptomic signatures associated with high Mesothelin expression and identify its role in tumor biology and its clinical relevance. We analyzed pancreatic adenocarcinomas in the cancer genome atlas (TCGA), (n = 145) and the results were validated using GSE62452 cohort (n = 69). We divided the cohorts into high and low Mesothelin expression by the median. High Mesothelin was not associated with progression-free, disease-free, disease specific, nor overall survival in TCGA cohort. Despite this, high Mesothelin expression was associated with high Ki67 expression and enriched all five cell proliferation-related Hallmark gene sets, but not with previously investigated pathways: TNF-alpha, PI3K, nor angiogenesis. Mesothelin expression did not correlate with MUC16 expression. The high Mesothelin pancreatic cancers demonstrated higher homologous recombination deficiency, fraction altered, and silent and non-silent mutation rates (all P < 0.001) that indicate aggressive cancer biology. However, lymphocyte infiltration score, TIL regional fraction, TCR richness, infiltration of CD8 T-cells, and cytolytic activity were all significantly lower in Mesothelin high tumors (all P < 0.015). Finally, we found that Mesothelin expression significantly correlated with sensitivity to cytotoxic chemotherapy in pancreatic cancer cell lines. In conclusion, high Mesothelin expression is associated with enhanced proliferation, depressed immune response, and sensitivity to cytotoxic chemotherapy, which may explain there was no difference in survival in pancreatic cancer patients.
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Affiliation(s)
- Brendan L Hagerty
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer CenterBuffalo, NY, USA
| | - Masanori Oshi
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer CenterBuffalo, NY, USA
- Department of Gastroenterological Surgery, Yokohama City University School of MedicineYokohama, Kanagawa, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of MedicineYokohama, Kanagawa, Japan
| | - Kazuaki Takabe
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer CenterBuffalo, NY, USA
- Department of Gastroenterological Surgery, Yokohama City University School of MedicineYokohama, Kanagawa, Japan
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New YorkBuffalo, NY, USA
- Department of Surgery, Niigata University Graduate School of Medical and Dental SciencesNiigata, Japan
- Department of Breast Surgery and Oncology, Tokyo Medical UniversityTokyo, Japan
- Department of Breast Surgery, Fukushima Medical UniversityFukushima, Japan
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Liu S, Li H, Xue Y, Yang L. Prognostic value of neoadjuvant therapy for resectable and borderline resectable pancreatic cancer: A meta-analysis of randomized controlled trials. PLoS One 2023; 18:e0290888. [PMID: 37672511 PMCID: PMC10482298 DOI: 10.1371/journal.pone.0290888] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE To investigate the prognostic value of preoperative neoadjuvant therapy (NT) compared to upfront surgery (US) in patients with resectable and borderline resectable pancreatic cancer. METHODS PubMed, Embase, Web of Science were searched to collect randomized controlled trials on preoperative neoadjuvant therapy versus upfront surgery for resectable and borderline resectable pancreatic cancer before April 7, 2023, and data were extracted after screening according to inclusion and exclusion criteria, and HRs were obtained indirectly using enguage software; Stata 12.0 software was used for data analysis. RESULTS A total of 8 randomized controlled trials (RCTs) were included in this study, comprising a total of 1058 cases, including 503 cases in the NT group and 555 cases in the US group. Using an intention-to-treat population (ITT) analysis, the results showed that neoadjuvant treatment improved the R0 resection rate (RR 2.71, 95% CI 1.59-4.62; P = 0.000; I2 = 46.20%) and overall survival (HR 0.66, 95% CI 0.54-0.82; P = 0.000; I2 = 0.00%). In the subgroup of patients with resectable pancreatic cancer, the R0 resection rate in the NT group versus the US group (RR 1.14, 95% CI 0.93-1.39; P = 0.196; I2 = 0.00%) and overall survival (HR 0.89, 95% CI 0.64-1.24; P = 0.489; I2 = 0.00%) were not statistically significant. CONCLUSIONS Preoperative neoadjuvant treatment is of prognostic value in patients with borderline resectable pancreatic cancer, as it increases the R0 resection rate and improves overall survival compared to upfront surgery.
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Affiliation(s)
- Shangtong Liu
- Medical College, Jishou University, Jishou City, Xiangxi Tujia and Miao Autonomous Prefecture, Hunan Province, China
| | - Hui Li
- Medical College, Jishou University, Jishou City, Xiangxi Tujia and Miao Autonomous Prefecture, Hunan Province, China
| | - Yuhui Xue
- Medical College, Jishou University, Jishou City, Xiangxi Tujia and Miao Autonomous Prefecture, Hunan Province, China
| | - Liang Yang
- Medical College, Jishou University, Jishou City, Xiangxi Tujia and Miao Autonomous Prefecture, Hunan Province, China
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van Oosten AF, Daamen LA, Groot VP, Biesma NC, Habib JR, van Goor IWJM, Kinny-Köster B, Burkhart RA, Wolfgang CL, van Santvoort HC, He J, Molenaar IQ. Predicting post-recurrence survival for patients with pancreatic cancer recurrence after primary resection: A Bi-institutional validated risk classification. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106910. [PMID: 37173152 DOI: 10.1016/j.ejso.2023.04.009] [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: 09/12/2022] [Revised: 03/07/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Over 80% of patients will develop disease recurrence after radical resection of pancreatic ductal adenocarcinoma (PDAC). This study aims to develop and validate a clinical risk score predicting post-recurrence survival (PRS) at time of recurrence. METHODS All patients who had recurrence after undergoing pancreatectomy for PDAC at the Johns Hopkins Hospital or at the Regional Academic Cancer Center Utrecht during the study period were included. Cox proportional hazard model was used to develop the risk model. Performance of the final model was assessed in a test set after internal validation. RESULTS Of 718 resected PDAC patients, 72% had recurrence after a median follow-up of 32 months. The median overall survival was 21 months and the median PRS was 9 months. Prognostic factors associated with shorter PRS were age (hazard ratio [HR] 1.02; 95% confidence interval [95%CI] 1.00-1.04), multiple-site recurrence (HR 1.57; 95%CI 1.08-2.28), and symptoms at time of recurrence (HR 2.33; 95%CI 1.59-3.41). Recurrence-free survival longer than 12 months (HR 0.55; 95%CI 0.36-0.83), FOLFIRINOX and gemcitabine-based adjuvant chemotherapy (HR 0.45; 95%CI 0.25-0.81; HR 0.58; 95%CI 0.26-0.93, respectively) were associated with a longer PRS. The resulting risk score had a good predictive accuracy (C-index: 0.73). CONCLUSION This study developed a clinical risk score based on an international cohort that predicts PRS in patients who underwent surgical resection for PDAC. This risk score will become available on www.evidencio.com and can help clinicians with patient counseling on prognosis.
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Affiliation(s)
- A Floortje van Oosten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands; Division of Imaging and Oncology, University Medical Center Utrecht Cancer Center, Utrecht University, Utrecht, the Netherlands
| | - Vincent P Groot
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Nanske C Biesma
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Joseph R Habib
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iris W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Benedict Kinny-Köster
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, New York University Langone Medical Center, New York City, NY, USA
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Langone Medical Center, New York City, NY, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands.
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50
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Sina N, Olkhov-Mitsel E, Chen L, Karanicolas P, Sun L, Roopchand P, Rowsell C, Truong T. Utility of intraoperative pathology consultations of whipple resection specimens and their impact on final margin status. Heliyon 2023; 9:e20238. [PMID: 37810002 PMCID: PMC10560021 DOI: 10.1016/j.heliyon.2023.e20238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/06/2023] [Accepted: 09/14/2023] [Indexed: 10/10/2023] Open
Abstract
The resection margin status is a significant surgical prognostic factor for the long-term outcomes of patients undergoing pancreaticoduodenectomy (Whipple procedure). As a result, surgeons frequently rely on intraoperative consults (IOCs) involving frozen sections to evaluate margin clearance during these resections. Nevertheless, the impact of this practice on final margin status and long-term outcomes remains a topic of debate. This study aimed to assess the impact of IOCs on the clearance rate of resection margins following Whipple procedure and distal pancreatectomy. A retrospective database review of all patients who underwent Whipple procedure or distal pancreatectomy at our institution between 2018 and 2020 was performed to evaluate the utility of IOCs by gastrointestinal surgeons and its correlation with final postoperative surgical margin status. A significant variation in the frequency of IOC requests for margins among surgeons was noted. However, the use of frozen section analysis for intraoperative margin assessment was not significantly associated with the clearance rate of final post-operative margins. More frequent use of IOC did not result in higher final margin clearance rate, an important prognostic factor following Whipple procedure.
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Affiliation(s)
- Niloofar Sina
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Ekaterina Olkhov-Mitsel
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - Lina Chen
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Paul Karanicolas
- Department of Surgery, Sunnybrook Health Science Center, Toronto, Ontario, M4N 3M5, Canada
| | - Laibao Sun
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - Preeya Roopchand
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - Corwyn Rowsell
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
- Department of Laboratory Medicine & Pathobiology, St. Michael's Hospital, Toronto, Ontario, M5B 1W8, Canada
| | - Tra Truong
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
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