Adjuvant radiotherapy and chemotherapy improve survival in patients with pancreatic adenocarcinoma receiving surgery: adjuvant chemotherapy alone is insufficient in the era of intensity modulation radiation therapy

Phase 1 Study of Adjuvant Allogeneic Granulocyte-Macrophage Colony-Stimulating Factor-Transduced Pancreatic Tumor Cell Vaccine, Low-Dose Cyclophosphamide, and Stereotactic Body Radiation Therapy Followed by FOLFIRINOX in High-Risk Resected Pancreatic Ductal Adenocarcinoma

PURPOSE

Local and distant progression remains common following resection of resectable pancreatic ductal adenocarcinoma (PDAC) despite adjuvant multiagent chemotherapy. We report a prospective institutional phase 1 trial incorporating adjuvant GVAX vaccine, low-dose cyclophosphamide (Cy), and stereotactic body radiation therapy (SBRT) followed by FOLFIRINOX (FFX) among patients who underwent resection of high-risk PDAC.

PATIENTS AND METHODS

The study design was a modified 3+3. Cohort 1 received 5-fraction SBRT to 33 Gy to the tumor bed and 25 Gy to elective nodes followed by 6 cycles of full-dose FFX. After toxicity review, cohort 2 had SBRT and was switched to modified FFX (mFFX). Cohort 3 had 1 cycle of Cy/GVAX followed by SBRT, mFFX, and 4 cycles of maintenance Cy/GVAX with 6-month Cy/GVAX boosts until progression.

RESULTS

Nineteen patients were enrolled with a median follow-up of 36.2 months. To be eligible, patients were required to have close/positive margins (within ≤1 mm) (71%) and/or lymph node metastasis (79%). Overall, 63% of patients had both. In cohort 1, 67% of patients received 6 cycles of FFX; in cohort 2, 75% received 6 cycles of modified FFX. In cohort 3, 12 patients received the first dose of Cy/GVAX and SBRT with 10 individuals (83%) receiving 6 cycles of mFFX. Cohort 3 had acceptable levels of grade ≥3 thrombocytopenia, neutropenia, and diarrhea after 2 cycles of mFFX. Median overall survival (OS)/disease-free survival (DFS) for the overall cohort and cohort 3 was 36.2/18.2 months and 61.3/24.1 months, respectively. One- and 2-year OS for cohort 3 was 83%/75%, respectively. At the last follow-up (median = x), 5 patients were alive (42%) in cohort 3.

CONCLUSIONS

This is the first prospective trial to evaluate adjuvant GVAX, Cy, SBRT, and mFFX in resected PDAC patients with high-risk features. This combination regimen was well tolerated with limited toxicity and promising survival outcomes, warranting future studies to validate this regimen in the adjuvant setting.

Correlation of maintenance chemotherapy and improved survival in patients with locally advanced unresectable pancreatic head adenocarcinoma receiving neoadjuvant chemotherapy and concurrent chemoradiotherapy

To assess the efficacy of maintenance chemotherapy in the management of unresectable locally advanced pancreatic head adenocarcinoma (PHA) cancer after neoadjuvant chemotherapy and concurrent chemoradiation therapy (CCRT). This study, a large-scale head-to-head propensity score matching (PSM) cohort study, employed real-world data. PSM was used to evaluate the impact of maintenance chemotherapy on overall survival and cancer-specific survival in patients with unresectable locally advanced PHA who underwent neoadjuvant chemotherapy and CCRT. A total of 148 patients with locally advanced pancreatic head adenocarcinoma were included in the study after PSM. These patients were equally divided into two groups, those receiving maintenance chemotherapy and those who did not. Confounding factors were balanced between the groups. The adjusted hazard ratios for all-cause mortality and cancer-specific mortality were 0.56 (95% CI: 0.40-0.77; P = 0.0005) and 0.56 (95% CI: 0.40-0.78; P = 0.0007), respectively, in patients receiving maintenance chemotherapy compared to those who did not. Our large-scale, real-world study demonstrates that maintenance chemotherapy may enhance survival outcomes for patients with unresectable locally advanced pancreatic head adenocarcinoma who underwent neoadjuvant chemotherapy and concurrent chemoradiation therapy.

Recent Developments in the Treatment of Pancreatic Cancer

Pancreatic duct adenocarcinoma is currently the sixth-leading cause of cancer death worldwide and the fourth in Europe, with a continuous increase in annual lethality in Portugal during the last two decades. Surgical en-bloc resection of the tumor with microscopic-negative margins and an adequate lymphadenectomy is the only possibility of long-term survival. As this type of cancer is a systemic disease, there is a high rate of recurrence even after curative resection, turning systemic therapy the core of its management, mostly based on chemotherapy. Neoadjuvant strategies for nonmetastatic disease showed significant improvement in overall survival compared with upfront surgery, namely in borderline resectable disease. Moreover, these strategies provided downstaging in several situations allowing R0 resections. Under these new oncologic strategies, several recent surgical issues were introduced, namely more aggressive vascular resections and even tumor resections in oligometastatic disease. This review revisits the state-of-the-art of surgical and oncological interventions in pancreatic duct adenocarcinoma and highlights recent advances in the field aiming to achieve higher survival rates.

The In Vitro and In Vivo Anticancer Effect of Photomed for Photodynamic Therapy: Comparison with Photofrin and Radachlorin

To overcome the limitation of conventional cancer treatments, photodynamic therapy (PDT) has been introduced as another treatment option. PDT provides a non-invasive, non-surgical way with reduced toxicity. To improve the antitumor efficacy of PDT, we synthesized a novel photosensitizer, a 3-substituted methyl pyropheophorbide-a derivative (Photomed). The purpose of the study was to evaluate the antitumor effect of PDT with Photomed comparing with the clinically approved photosensitizers Photofrin and Radachlorin. The cytotoxicity assay against SCC VII cells (murine squamous cell carcinoma) was performed to determine whether Photomed is safe without PDT and whether Photomed is effective against cancer cells with PDT. An in vivo anticancer efficacy study was also performed using SCC VII tumor-bearing mice. The mice were divided into small-tumor and large-tumor groups to identify whether Photomed-induced PDT is effective for not only small tumors but also large tumors. From in vitro and in vivo studies, Photomed was confirmed to be (1) a safe photosensitizer without laser irradiation, (2) the most effective photosensitizer with PDT against cancers compared to Photofrin and Radachlorin and (3) effective with PDT in treating not only small tumors but also large tumors. In conclusion, Photomed may contribute as a novel, potential photosensitizer for use in PDT cancer treatment.

Survival and prognostic factors among hospitalized pancreatic cancer patients in northwestern Iran

Background

Pancreatic cancer (PC) is associated with a poor prognosis, with various modifiable risk factors affecting the survival of patients. Our aim was to evaluate the survival rate and the prognostic factors influencing survival in PC patients in northwestern Iran.

Materials and Methods

All the PC patients admitted to the Imam Reza Hospital of Tabriz, Iran, from 2016 to 2020, were enrolled in this study. The survival rate and time were calculated, and the risk factors related to survival were evaluated by Cox regressions. The data were analyzed using the Cox proportional hazards model using STATA software.

Results

Of 110 patients, 12-, 24-, 36-, and 48-month survival rates were 29.1%, 19.8%, 14.1%, and 8.5%, respectively, with the median survival time of seven months. The mean age was 65.5 years. The results showed that a higher age (hazard ratio [HR] [95% confidence interval (CI)] = 2.04 [1.20-3.46]), lower education (1.72 [1.03-2.89]), delayed diagnosis (1.03 [1.02-1.05]), hypertension (1.53 [1.01-2.31]), concomitant heart disorders (2.67 [1.50-4.74]), COPD (4.23 [1.01-17.69]), consanguineous marriage (1.59 [1.01-2.50]), and the presence of icterus complications (adjusted HR = 3.64 [1.56-8.49]) were directly associated with a worse survival. On the contrary, radiotherapy (0.10 [0.01-0.85]), chemotherapy (0.57 [0.36-0.89]), and surgical therapy (AHR = 0.48 [0.23-0.99]) were directly related to a good prognosis.

Conclusion

Surgery, chemotherapy, and radiotherapy were the best predictors of survival in PC patients. Moreover, it seems that resolving jaundice can improve survival in these patients. It seems that increasing social awareness, treating underlying diseases, and employing an appropriate therapeutic method may promise a better outlook, improve the survival rate of patients, and reduce PC risk.

Cancer drug screening with an on-chip multi-drug dispenser in digital microfluidics

Microfluidics has been the most promising platform for drug screening with a limited number of cells. However, convenient on-chip preparation of a wide range of drug concentrations remains a large challenge and has restricted wide acceptance of microfluidics in precision medicine. In this paper, we report a digital microfluidic system with an innovative control structure and chip design for on-chip drug dispensing to generate concentrations that span three to four orders of magnitude, enabling single drug or combinatorial multi-drug screening with simple electronic control. Specifically, we utilize droplet ejection from a drug drop sitting on a special electrode, named a drug dispenser, under high-voltage pulse actuation to deliver the desired amount of drugs to be picked up by a cell suspension drop driven by low-voltage sine wave actuation. Our proof-of-principle validation for this technique as a convenient single and multi-drug screening involved testing of the drug toxicity of two chemotherapeutics, cisplatin (Cis) and epirubicin (EP), towards MDA-MB-231 breast cancer cells and MCF-10A normal breast cells. The results are consistent with those screened based on traditional 96-well plates. These findings demonstrate the reliability of the drug screening system with an on-chip drug dispenser. This system with fewer cancer cells, less drug consumption, a small footprint, and high scalability with regard to concentration could pave the way for drug screening on biopsied primary tumor cells for precision medicine or any concentration-related research.

Current and emerging therapeutic strategies in pancreatic cancer: Challenges and opportunities

Pancreatic carcinoma (PC) is one of the leading causes of cancer-related deaths worldwide. Despite early detection and advances in therapeutics, the prognosis remains dismal. The outcome and therapeutic approach are dependent on the stage of PC at the time of diagnosis. The standard of care is surgery, followed by adjuvant chemotherapy. The advent of newer drugs has changed the landscape of adjuvant therapy. Moreover, recent trials have highlighted the role of neoadjuvant therapy and chemoradiotherapy for resectable and borderline resectable PC. As we progress towards a better understanding of tumor biology, genetics, and microenvironment, novel therapeutic strategies and targeted agents are now on the horizon. We have described the current and emerging therapeutic strategies in PC.

Prognostic Factors and Effect of Adjuvant Chemoradiation Following Chemotherapy in Resected Pancreatic Cancer Patients With Lymph Node Metastasis or R1 Resection

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with a poor prognosis. In resectable PDAC, the recurrence rate is still high even when surgery and adjuvant chemotherapy (CT) are applied. Regional lymph node metastasis and positive margins are associated with higher recurrence risk and worse survival. Adjuvant radiotherapy has been explored, but its efficacy remains controversial. In recent years, some characteristics have been reported to stratify patients who may benefit from adjuvant chemoradiation (CRT), such as lymph node metastasis and margin status. Adjuvant chemotherapy followed by chemoradiation (CT-CRT) was also proposed. A total of 266 patients with resectable PDAC who have lymph node metastasis or R1 resection after surgery were enrolled. In multivariate Cox regression analyses, pancreatic body or tail tumor location (HR 0.433, p<0.0001, compared with pancreatic head) and adjuvant CT predicted a better survival, while there were no significant differences among the different CT regimens. Higher T stage indicated poor survival (stage I: reference; stage II: HR 2.178, p=0.014; stage III: HR 3.581, p=0.001). Propensity score matching was applied in 122 patients to explore the role of CRT. A cohort of 51 patients (31 and 20 patients in the CT and CT-CRT groups, respectively) was generated by matching. Further analyses revealed adjuvant CT-CRT was associated with prolonged survival compared with CT alone (HR 0.284, p=0.014) and less frequent local recurrences (56.5% vs. 21.4% in the CT and CT-CRT group, respectively). However, no significant differences in disease-free survival among these two groups were observed.

Adjuvant Treatment in Pancreatic Cancer: Shaping the Future of the Curative Setting

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease even in the early stages, despite progresses in surgical and pharmacological treatment in recent years. High potential for metastases is the main cause of therapeutic failure in localized disease, highlighting the current limited knowledge of underlying pathological processes. However, nowadays research is focusing on the search for personalized approaches also in the adjuvant setting for PDAC, by implementing the use of biomarkers and investigating new therapeutic targets. In this context, the aim of this narrative review is to summarize the current treatment scenario and new potential therapeutic approaches in early stage PDAC, from both a preclinical and clinical point of view. Additionally, the review examines the role of target therapies in localized PDAC and the influence of neoadjuvant treatments on survival outcomes.

Adjuvant Pancreatic Cancer Management: Towards New Perspectives in 2021

Adjuvant chemotherapy is currently used in all patients with resected pancreatic cancer who are able to begin treatment within 3 months after surgery. Since the recent publication of the PRODIGE 24 trial results, modified FOLFIRINOX has become the standard-of-care in the non-Asian population with localized pancreatic adenocarcinoma following surgery. Nevertheless, there is still a risk of toxicity, and feasibility may be limited in heavily pre-treated patients. In more frail patients, gemcitabine-based chemotherapy remains a suitable option, for example gemcitabine or 5FU in monotherapy. In Asia, although S1-based chemotherapy is the standard of care it is not readily available outside Asia and data are lacking in non-Asiatic patients. In patients in whom resection is not initially possible, intensified schemes such as FOLFIRINOX or gemcitabine-nabpaclitaxel have been confirmed as options to enhance the response rate and resectability, promoting research in adjuvant therapy. In particular, should oncologists prescribe adjuvant treatment after a long sequence of chemotherapy +/- chemoradiotherapy and surgery? Should oncologists consider the response rate, the R0 resection rate alone, or the initial chemotherapy regimen? And finally, should they take into consideration the duration of the entire sequence, or the presence of limited toxicities of induction treatment? The aim of this review is to summarize adjuvant management of resected pancreatic cancer and to raise current and future concerns, especially the need for biomarkers and the best holistic care for patients.

Comparison of efficacy between adjuvant chemotherapy and chemoradiation therapy for pancreatic cancer: AJCC stage-based approach

BACKGROUND

The adjuvant treatment for patients with resected pancreatic cancer (PC) is not yet standardized. Because the prognosis differs according to the American Joint Committee on Cancer (AJCC) stage, a tailored approach to establish more aggressive treatment plans in high-risk patients is necessary. However, studies comparing the efficacy of adjuvant treatment modalities according to the AJCC stage are largely lacking.

AIM

To compare the efficacy of chemotherapy and chemoradiation therapy according to AJCC 8th staging system in patients with PC who underwent surgical resection.

METHODS

A total of 335 patients who underwent surgical resection and adjuvant treatment for PC were included. Patients were divided into three groups: Chemoradiation therapy (CRT) group, systemic chemotherapy (SCT) group and combined treatment of chemoradiation plus chemotherapy therapy (CRT-SCT) group. The primary outcomes were differences in overall survival (OS) between the three groups. The secondary outcomes were differences in recurrence-free survival, recurrence pattern and adverse events between the three groups.

RESULTS

Patients received CRT (n = 65), SCT (n = 62) and CRT-SCT (n = 208). Overall median OS was 33.3 mo (95% confidence interval (CI): 27.4-38.6). In patients with stage I/II, the median OS was 27.0 mo (95%CI: 2.06-89.6) in the CRT group, 35.8 mo (95%CI: 26.9-NA) in the SCT group and 38.6 mo (95%CI: 33.3-55.7) in the CRT-SCT group. Among them, there was no significant difference in OS between the three groups. In 59 patients with stage III, median OS in the SCT group [19.0 mo (95%CI: 12.6-NA)] and the CRT-SCT group [23.4 mo (95%CI: 22.0-44.4)] was significantly longer than that in the CRT group [17.7 mo (95%CI: 6.8-NA); P = 0.011 and P < 0.001, respectively]. There were no significant differences in incidence of locoregional and distant recurrences between the three groups (P = 0.158 and P = 0.205, respectively). Incidences of grade 3 or higher hematologic adverse events were higher in the SCT and CRT-SCT groups than in the CRT group.

CONCLUSION

SCT and CRT-SCT showed significantly longer OS and recurrence-free survival than CRT in patients with AJCC stage III, while there was no significant difference in OS between the CRT, SCT and CRT-SCT groups in patients with AJCC stage I/II. Different adjuvant therapy according to AJCC stage can be applied in patients with PC.

Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study

Background

To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy.

Methods

We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index.

Results

We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores.

Conclusions

Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.

Toxicity Profiles of Fractionated Radiotherapy, Contemporary Stereotactic Radiosurgery, and Transsphenoidal Surgery in Nonfunctioning Pituitary Macroadenomas

Background: Here, we compared the toxicity profiles of contemporary stereotactic radiosurgery (SRS), modern fractionated radiotherapy (FRT), and transsphenoidal surgery used to treat nonfunctioning pituitary macroadenomas. Methods: We included the data of patients with nonfunctioning pituitary macroadenomas. To compare treatment outcomes, the patients were categorized groups 1 (those receiving modern FRT), 2 (those receiving contemporary SRS), and 3 (those receiving transsphenoidal surgery). The multivariable Cox proportional hazards regression analysis was performed to yielded adjusted hazard ratios (aHRs) and their 95% CIs for local recurrence in groups 2 and 3 compared with group 1. Results: We included the data of 248 patients with nonfunctioning pituitary macroadenomas. The analytical results revealed no significant differences in second primary brain or head and neck cancer, hypopituitarism, or optic nerve injury between the three cohorts. The multivariable Cox proportional hazards regression analysis revealed that compared with group 1, the aHRs (95% CIs) for stroke risk in groups 2 and 3 were 0.37 (0.14–0.99) and 0.51 (0.31–0.84), respectively. Conclusion: Contemporary SRS and transsphenoidal surgery for nonfunctioning pituitary macroadenoma treatment have equivalent toxicity profiles. However, modern FRT for nonfunctioning pituitary macroadenoma treatment might considerably increase stroke risk.

Is There a Standard Adjuvant Therapy for Resected Pancreatic Cancer?

Surgical resection remains the only treatment that offers a potential chance of long-term survival. Unfortunately, about 80% of patients treated with curative intent will develop recurrence. Since 2001, adjuvant therapy with gemcitabine or 5-fluorouracyle was recommended. This approach allows a median overall survival (OS) of around 23 months, and 5-year survival of 22%. In recent years, two phase-3 trials investigating new chemotherapy regimens resulted in considerably improved survival times. The doublet gemcitabine-capecitabine has shown improvement in OS from 25.5 to 28 months (p = 0.032) compared to gemcitabine, in the ESPAC-4 trial. Later, preliminary results of PRODIGE 24 trial presented at the 2018 ASCO meeting showed a superiority of a combination chemotherapy regimen with fluorouracil, leucovorin, irinotecan, and oxaliplatin (mFOLFIRINOX) when compared to gemcitabine alone, both in terms of median disease-free survival (21.6 vs. 12.8 months, p < 0.0001) and OS (54.4 vs. 35 months, p = 0.003). Contrary to chemotherapy, the role of adjuvant radiotherapy is still controversial, even in the case of R1 surgery. A randomized trial exploring the role of chemoradiotherapy in this setting is now ongoing in the US (RTOG-0848). Overall, the management of localized pancreatic adenocarcinoma is evolving. In this review, we summarize the current status and the most up-to-date developments in adjuvant treatment.

Optimal treatments for cervical adenocarcinoma

To compare the effects of curative surgery and curative definitive concurrent chemoradiotherapy (CCRT) on cervical adenocarcinoma (AC) by conducting a national cohort study with a large sample size, we enrolled women with cervical AC and categorized them into two groups according to treatment modality to compare treatment outcomes: group 1, comprising patients who received curative surgery, and group 2, comprising patients who received curative definitive CCRT. Data of 1,621 patients with cervical AC were extracted from the Taiwan Cancer Registry database. Univariate and multivariate Cox regression analysis results indicated that high American Society of Anesthesiologists scores, advanced American Joint Committee on Cancer (AJCC) clinical stage, and curative definitive CCRT were significant independent poor prognostic factors. The adjusted hazard ratio (aHR; 95% confidence interval [CI]) for overall mortality in early invasive clinical stages (IB-IIA) was 1.27 (0.77-2.69) in group 2 compared with group 1, whereas that for overall mortality at AJCC clinical stage IIB was 2.46 (1.34-4.53) in group 2 compared with group 1. The aHR (95% CI) for overall mortality at advanced clinical stages (III and IV) was 1.47 (1.09-1.97) in group 2 compared with group 1. Curative surgery improves survival in cervical AC at advanced clinical stages. Either curative surgery or definitive CCRT is an option in the early invasive clinical stages of cervical AC.

Results of Treatment with Modern Fractionated Radiotherapy, Contemporary Stereotactic Radiosurgery, and Transsphenoidal Surgery in Nonfunctioning Pituitary Macroadenoma

BACKGROUND

To compare the effects of contemporary stereotactic radiosurgery (SRS), modern fractionated radiotherapy (FRT), and transsphenoidal surgery on nonfunctioning pituitary macroadenoma.

METHODS

We enrolled patients with nonfunctioning pituitary macroadenoma. To compare treatment outcomes, the patients were categorized into three groups according to the treatment modality: group 1, patients receiving modern FRT; group 2, patients receiving contemporary SRS; and group 3, patients receiving transsphenoidal surgery.

RESULTS

In total, 548 patients with nonfunctioning pituitary macroadenoma were selected for our study. Univariate and multivariate Cox regression analysis results indicated that the treatment modalities were significant independent prognostic factors. In multivariable Cox proportional hazard regression analysis, the adjusted hazard ratios (aHR; 95% confidence interval (CI)) of local recurrence were 0.27 (0.10-0.91) and 1.95 (1.25-2.37) for the SRS and transsphenoidal surgery cohorts, respectively, in comparison with the FRT cohort. The aHR (95% CI) of all-cause mortality was 1.03 (0.68-1.56) for the transsphenoidal surgery cohort in comparison with the FRT cohort, without statistical significance. However, the aHR (95% CI) of all-cause mortality was 0.36 (0.15-0.85) for the SRS cohort in comparison with the FRT cohort.

CONCLUSION

Contemporary SRS has optimal effects on local recurrence and survival compared with modern FRT and transsphenoidal surgery. Modern FRT is associated with more favorable local control and equal survival compared with transsphenoidal surgery.

Diagnostic and therapeutic recommendations in pancreatic ductal adenocarcinoma. Recommendations of the Working Group of the Polish Pancreatic Club

These recommendations refer to the current management in pancreatic ductal adenocarcinoma (PDAC), a neoplasia characterised by an aggressive course and extremely poor prognosis. The recommendations regard diagnosis, surgical, adjuvant and palliative treatment, with consideration given to endoscopic and surgical methods. A vast majority of the statements are based on data obtained in clinical studies and experts' recommendations on PDAC management, including the following guidelines: International Association of Pancreatology/European Pancreatic Club (IAP/EPC), American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) and Polish Society of Gastroenterology (PSG) and The National Institute for Health and Care Excellence (NICE). All recommendations were voted on by members of the Working Group of the Polish Pancreatic Club. Results of the voting and brief comments are provided with each recommendation.

Treatment outcomes for unresectable intrahepatic cholangiocarcinoma: Nationwide, population-based, cohort study based on propensity score matching with the Mahalanobis metric

PURPOSE

No prospective randomized trials have been conducted to date to evaluate the efficacy of palliation of pain or jaundice without treatment, definitive concurrent chemoradiotherapy (CCRT), sequential chemotherapy and radiotherapy (CTRT), or chemotherapy (CT) alone for treating unresectable intrahepatic cholangiocarcinoma (ICC). We designed a nationwide, population-based, cohort study to determine the effects of different treatments on patients with unresectable ICC using propensity score matching (PSM) with the Mahalanobis metric.

PATIENTS AND METHODS

We classified patients with unresectable ICC from the Taiwan Cancer Registry database into the following 4 treatment groups: group 1, definitive CCRT; group 2, sequential CTRT; group 3, no treatment (palliative therapy for relief of pain, pruritus, or jaundice); and group 4, CT alone. Confounding factors among the 4 treatment groups were minimized through propensity score matching (PSM).

RESULTS

After PSM, the final cohort consisted of 844 patients (211 patients in each of the 4 groups). In both univariable and multivariable Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) derived for groups 1 and 2 compared with group 4 were 0.65 (0.59-0.71) and 0.95 (0.83-1.48), respectively. Furthermore, an aHR (95% CI) of 2.25 (1.89-2.67) was derived for significant independent prognostic risk factors for poor overall survival for group 3 compared with group 4.

CONCLUSIONS

Definitive CCRT is the optimal therapy for patients with unresectable ICC without distant metastasis.

Differentiation of atypical pancreatic neuroendocrine tumors from pancreatic ductal adenocarcinomas: Using whole-tumor CT texture analysis as quantitative biomarkers

Background

To explore the application value of computed tomography (CT) texture analysis in differentiating atypical pancreatic neuroendocrine tumors (pNET) from pancreatic ductal adenocarcinomas (PDAC).

Materials and methods

This single‐center retrospective study was approved by local institutional review board, and the requirement for informed consent was waived. We retrospectively analyzed 127 patients with 50 PDACs and 77 pNETs in pathology database between January 2012 and May 2017.These patients successfully finished preoperative contrast‐enhanced CT test. Texture parameters (mean, median, 5th, 10th, 25th, 75th, 90th percentiles, skewness, kurtosis and entropy) were extracted from portal images and compared between PDAC and 77 pNET groups using proper statistical method. The optimal parameters for differentiating PDACs and atypical pNETs were gained through receiver operating characteristic (ROC) curves.

Results

On the basis of arterial enhancement, 52 pNETs (67%, 52/77) were typical hypervascular and 25 pNETs (32%, 25/77) were atypical hypovascular. Compared with PDACs, atypical pNETs had statistically higher mean, median, 5th, 10th, and 25th percentiles (P = 0.006, 0.024, 0.000, 0.001, 0.021, respectively) and statistically lower skewness (P = 0.017). However, there were no difference for 75th, 90th percentiles, kurtosis and entropy between these two tumors (P = 0.232, 0.415, 0.143, 0.291, respectively). For differentiating PDACs and atypical pNETs, 5th percentile and 5th+skewness were optimal parameters for alone and combined diagnosis, respectively.

Conclusion

Volumetric CT texture features, especially combined diagnosis of 5th+skewness can be used as a quantitative tool to distinguish atypical pNETs from PDACs.

Effect of marital status on survival in glioblastoma multiforme by demographics, education, economic factors, and insurance status

The relationship between marital status and glioblastoma multiforme (GBM) has not been addressed in depth. Here, we aimed to investigate the association between marital status and survival in GBM. We searched the Surveillance, Epidemiology, and End Results (SEER) database and extracted the data of eligible patients diagnosed with GBM after 2004. Marital status was classified as married, divorced/separated, widowed, and single. A Kaplan-Meier test was conducted to compare the survival curves of different groups. Multivariate Cox regression was performed to evaluate overall survival (OS) and cause-specific survival (CSS) in different groups. Subgroup analysis was applied according to demographics, typical education and income levels in the locale, and insurance status. A total of 30 767 eligible patients were included. The median OS values were 9, 7, 3, 9 months in married, divorced/separated, widowed, and single patients, respectively. After adjustment for other covariates, married patients had better OS and CSS than other patients had. In addition to marital status, demographic factors, disease progression factors, local educational level, and insurance status were also associated with survival in GBM. Furthermore, subgroup analyses revealed the protective effect of marriage in most of the comparisons. Notably, the protective effect of marriage becomes more and more apparent as time goes on. The advantageous effect of marriage on GBM survival is especially prominent in patients who are male, older than 60 years of age, White, or living in middle-income counties. In conclusion, marital status is an independent prognostic factor for GBM.

Adjuvant radiotherapy and chemotherapy improve survival in patients with pancreatic adenocarcinoma receiving surgery: adjuvant chemotherapy alone is insufficient in the era of intensity modulation radiation therapy

In the era of intensity modulation radiation therapy (IMRT), no prospective randomized trial has evaluated the efficacy of adjuvant therapies such as adjuvant concurrent chemoradiotherapy (CCRT), adjuvant sequential chemotherapy and radiotherapy (CT-RT), and adjuvant CT alone in resectable pancreatic adenocarcinoma (PA). Through propensity score matching, we designed a nationwide, population-based, head-to-head cohort study to determine the effects of dissimilar adjuvant treatments on resectable PA. We minimized the confounding of various adjuvant treatment outcomes among the following resectable PA groups of patients from the Taiwan Cancer Registry database: group 1, adjuvant CCRT; group 2, adjuvant sequential CT-RT; and group 3, adjuvant CT alone. All the studied techniques are IMRTs. The matching process yielded a final cohort of 588 patients (196, 196, and 196 patients in groups 1, 2, and 3, respectively). In both univariate and multivariate Cox regression analyses, adjusted hazard ratios (aHRs; 95% confidence interval [CI]) of death derived for the adjuvant CCRT and adjuvant sequential CT-RT cohorts compared with the adjuvant CT alone cohort were 0.398 (0.314-0.504) and 0.307 (0.235-0.402), respectively. A combination of adjuvant IMRT and CT for resectable PA treatment improves survival to a greater extent than does adjuvant CT alone.