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Head-to-head comparison of FOLFIRINOX versus gemcitabine plus nab-paclitaxel in advanced pancreatic cancer: a target trial emulation using real-world data. Ann Epidemiol 2023; 78:28-34. [PMID: 36563766 DOI: 10.1016/j.annepidem.2022.12.005] [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: 09/21/2022] [Revised: 11/29/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To emulate a hypothetical target trial assessing the effect of initiating 5-fluorouracil, folinic acid, irinotecan, and oxaliplatin (FOLFIRINOX) versus gemcitabine plus nab-paclitaxel (GN) within 8 weeks of diagnosis on overall survival. METHODS An observational cohort study was conducted using population-level data from Alberta, Canada. Individuals diagnosed with advanced pancreatic cancer between April 2015 and December 2019 were identified through the provincial cancer registry and followed until March 2021. Records were linked to other administrative databases containing information on relevant variables. Individuals were excluded if they did not have adequate hemoglobin, platelet, white blood cell, and serum creatinine measures or if they received prior therapy. The observational analog of the per-protocol effect was estimated using inverse probability weighted Kaplan-Meier curves with bootstrapped 95% confidence intervals. RESULTS Four hundred seven individuals were eligible. The weighted median overall survival was 8.3 months (95% CI, 5.7-11.9) for FOLFIRINOX and 5.1 months (95% CI: 4.3 to 5.8) for GN. The adjusted difference in median overall survival was 3.2 months (95% CI, 1.1-7.4) and the mortality hazard ratio was 0.78 (95% CI, 0.61-0.97). CONCLUSIONS Our estimates favored the initiation of FOLFIRINOX over GN with respect to overall survival.
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Noubissi Nzeteu GA, Gibbs BF, Kotnik N, Troja A, Bockhorn M, Meyer NH. Nanoparticle-based immunotherapy of pancreatic cancer. Front Mol Biosci 2022; 9:948898. [PMID: 36106025 PMCID: PMC9465485 DOI: 10.3389/fmolb.2022.948898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Pancreatic cancer (PC) has a complex and unique tumor microenvironment (TME). Due to the physical barrier formed by the desmoplastic stroma, the delivery of drugs to the tumor tissue is limited. The TME also contributes to resistance to various immunotherapies such as cancer vaccines, chimeric antigen receptor T cell therapy and immune checkpoint inhibitors. Overcoming and/or modulating the TME is therefore one of the greatest challenges in developing new therapeutic strategies for PC. Nanoparticles have been successfully used as drug carriers and delivery systems in cancer therapy. Recent experimental and engineering developments in nanotechnology have resulted in increased drug delivery and improved immunotherapy for PC. In this review we discuss and analyze the current nanoparticle-based immunotherapy approaches that are at the verge of clinical application. Particularly, we focus on nanoparticle-based delivery systems that improve the effectiveness of PC immunotherapy. We also highlight current clinical research that will help to develop new therapeutic strategies for PC and especially targeted immunotherapies based on immune checkpoint inhibitors.
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Affiliation(s)
- Gaetan Aime Noubissi Nzeteu
- University Hospital of General and Visceral Surgery, Department of Human Medicine, University of Oldenburg and Klinikum Oldenburg, Oldenburg, Germany
- *Correspondence: N. Helge Meyer, ; Gaetan Aime Noubissi Nzeteu,
| | - Bernhard F. Gibbs
- Department of Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Nika Kotnik
- Department of Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Achim Troja
- University Hospital of General and Visceral Surgery, Department of Human Medicine, University of Oldenburg and Klinikum Oldenburg, Oldenburg, Germany
| | - Maximilian Bockhorn
- University Hospital of General and Visceral Surgery, Department of Human Medicine, University of Oldenburg and Klinikum Oldenburg, Oldenburg, Germany
| | - N. Helge Meyer
- University Hospital of General and Visceral Surgery, Department of Human Medicine, University of Oldenburg and Klinikum Oldenburg, Oldenburg, Germany
- *Correspondence: N. Helge Meyer, ; Gaetan Aime Noubissi Nzeteu,
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Kerstjens M, Garrido Castro P, Pinhanços SS, Schneider P, Wander P, Pieters R, Stam RW. Irinotecan Induces Disease Remission in Xenograft Mouse Models of Pediatric MLL-Rearranged Acute Lymphoblastic Leukemia. Biomedicines 2021; 9:biomedicines9070711. [PMID: 34201500 PMCID: PMC8301450 DOI: 10.3390/biomedicines9070711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 01/27/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) in infants (<1 year of age) remains one of the most aggressive types of childhood hematologic malignancy. The majority (~80%) of infant ALL cases are characterized by chromosomal translocations involving the MLL (or KMT2A) gene, which confer highly dismal prognoses on current combination chemotherapeutic regimens. Hence, more adequate therapeutic strategies are urgently needed. To expedite clinical transition of potentially effective therapeutics, we here applied a drug repurposing approach by performing in vitro drug screens of (mostly) clinically approved drugs on a variety of human ALL cell line models. Out of 3685 compounds tested, the alkaloid drug Camptothecin (CPT) and its derivatives 10-Hydroxycamtothecin (10-HCPT) and 7-Ethyl-10-hydroxycamtothecin (SN-38: the active metabolite of the drug Irinotecan) appeared most effective at very low nanomolar concentrations in all ALL cell lines, including models of MLL-rearranged ALL (n = 3). Although the observed in vitro anti-leukemic effects of Camptothecin and its derivatives certainly were not specific to MLL-rearranged ALL, we decided to further focus on this highly aggressive type of leukemia. Given that Irinotecan (the pro-drug of SN-38) has been increasingly used for the treatment of various pediatric solid tumors, we specifically chose this agent for further pre-clinical evaluation in pediatric MLL-rearranged ALL. Interestingly, shortly after engraftment, Irinotecan completely blocked leukemia expansion in mouse xenografts of a pediatric MLL-rearranged ALL cell line, as well as in two patient-derived xenograft (PDX) models of MLL-rearranged infant ALL. Also, from a more clinically relevant perspective, Irinotecan monotherapy was able to induce sustainable disease remissions in MLL-rearranged ALL xenotransplanted mice burdened with advanced leukemia. Taken together, our data demonstrate that Irinotecan exerts highly potent anti-leukemia effects against pediatric MLL-rearranged ALL, and likely against other, more favorable subtypes of childhood ALL as well.
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Affiliation(s)
- Mark Kerstjens
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
- Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
| | - Patricia Garrido Castro
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
| | - Sandra S. Pinhanços
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
| | - Pauline Schneider
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
| | - Priscilla Wander
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
| | - Ronald W. Stam
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.K.); (P.G.C.); (S.S.P.); (P.S.); (P.W.); (R.P.)
- Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)88-9727672
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Chen K, Pan Y, Huang CJ, Chen QL, Zhang RC, Zhang MZ, Wang GY, Wang XF, Mou YP, Yan JF. Laparoscopic versus open pancreatic resection for ductal adenocarcinoma: separate propensity score matching analyses of distal pancreatectomy and pancreaticoduodenectomy. BMC Cancer 2021; 21:382. [PMID: 33836678 PMCID: PMC8034161 DOI: 10.1186/s12885-021-08117-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 03/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a leading causes of cancer mortality worldwide. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. The viability and safety of LPR for PDAC needs to be understood better. Laparoscopic distal pancreatectomy (LDP) and pancreaticoduodenectomy (LPD) are the two main surgical approaches for PDAC. We performed separate propensity score matching (PSM) analyses to assess the surgical and oncological outcomes of LPR for PDAC by comparing LDP with open distal pancreatectomy (ODP) as well as LPD with open pancreaticoduodenectomy (OPD). METHODS We assessed the data of patients who underwent distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) for PDAC between January 2004 and February 2020 at our hospital. A one-to-one PSM was applied to prevent selection bias by accounting for factors such as age, sex, body mass index, and tumour size. The DP group included 86 LDP patients and 86 ODP patients, whereas the PD group included 101 LPD patients and 101 OPD patients. Baseline characteristics, intraoperative effects, postoperative recovery, and survival outcomes were compared. RESULTS Compared to ODP, LDP was associated with shorter operative time, lesser blood loss, and similar overall morbidity. Of the 101 patients who underwent LPD, 10 patients (9.9%) required conversion to laparotomy. The short-term surgical advantage of LPD is not as apparent as that of LDP due to conversions. Compared with OPD, LPD was associated with longer operative time, lesser blood loss, and similar overall morbidity. For oncological and survival outcomes, there were no significant differences in tumour size, R0 resection rate, and tumour stage in both the DP and PD subgroups. However, laparoscopic procedures appear to have an advantage over open surgery in terms of retrieved lymph nodes (DP subgroup: 14.4 ± 5.2 vs. 11.7 ± 5.1, p = 0.03; PD subgroup 21.9 ± 6.6 vs. 18.9 ± 5.4, p = 0.07). These two groups did not show a significant difference in the pattern of recurrence and overall survival rate. CONCLUSIONS Laparoscopic DP and PD are feasible and oncologically safe procedures for PDAC, with similar postoperative outcomes and long-term survival among patients who underwent open surgery.
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Affiliation(s)
- Ke Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yu Pan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Chao-Jie Huang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Qi-Long Chen
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Ren-Chao Zhang
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Miao-Zun Zhang
- Department of Hepatopancreatobiliary Surgery, Ningbo Medical Center, Lihuili Hospital, Ningbo, 315100, Zhejiang Province, China
| | - Guan-Yu Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Xian-Fa Wang
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China
| | - Yi-Ping Mou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Jia-Fei Yan
- Department of Hepatopancreatobiliary Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016, Zhejiang Province, China.
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Adequate tissue sampling for the assessment of pathological tumor regression in pancreatic cancer. Sci Rep 2021; 11:6586. [PMID: 33753833 PMCID: PMC7985517 DOI: 10.1038/s41598-021-86152-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/09/2021] [Indexed: 01/23/2023] Open
Abstract
Standardized pathological evaluation of the regression assessment of neoadjuvant pancreatic cancer is necessary to improve prognostication and compare treatment outcomes in clinical trials. However, appropriate tissue sampling from surgically resected pancreatic cancer after neoadjuvant therapy has not been elucidated. We compared the tumor regression scores in the largest cancer slide determined macroscopically or histologically. We reviewed all slides and macroscopic photos of cut surfaces from resected pancreas of patients treated with neoadjuvant chemotherapy (n = 137; chemoradiotherapy or chemotherapy). The tumor regression scores (the Evans, College of American Pathologists, Japanese Pancreas Society grading systems, and Area of Residual Tumor [ART] score) were evaluated for the largest tumor slide determined by macroscopy or histologically as well as all slides from the resected pancreas. The largest cancer slides determined macroscopically and histologically were discrepant in 26% of the cases. Cancer cells were not detected in the largest macroscopically defined cut slides in 3%. Only ART scores assessed in the largest histological slides displayed significant difference in overall survival. We recommend obtaining the largest histological slides to provide adequate assessment for regression of neoadjuvant-treated pancreatic cancer. Sufficient sampling to detect the largest histological slides would be mandatory.
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FOLFIRINOX for Recurrent Pancreatic Cancer After Pancreatic Resection: A Secondary Analysis of the Nationwide Multicenter Observational Study Conducted by the Japan Adjuvant Study Group of Pancreatic Cancer 06. Pancreas 2020; 49:1372-1377. [PMID: 33122527 DOI: 10.1097/mpa.0000000000001692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The multidrug regimen with fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) is widely used for recurrent pancreatic cancer after pancreatic resection. However, there are concerns about severe toxicities and poor tolerability of FOLFIRINOX in these patients because some suffer from surgery-associated malnutrition, weight loss, and diabetes mellitus. We evaluated the toxicity and tolerability of FOLFIRINOX in these patients. METHODS This study was conducted as a secondary analysis of the Japan Adjuvant Study Group of Pancreatic Cancer 06 study, which was a multicenter observational study of FOLFIRINOX for pancreatic cancer in Japan. The toxicity and tolerability of FOLFIRINOX in recurrent disease correlated with those of both the locally advanced and the metastatic disease group. RESULTS The major grades 3 and 4 toxicities observed in the recurrent and locally advanced or metastatic disease groups were neutropenia (68% vs 63%), febrile neutropenia (4% vs 15%, P = 0.007), thrombocytopenia (4% vs 3%), diarrhea (4% vs 8%), and sensory neuropathy (0% vs 2%). The dose modification and relative dose intensity did not differ markedly between the groups. CONCLUSIONS The toxicity and tolerability of FOLFIRINOX for recurrence after pancreatic resection were similar to those for locally advanced or metastatic disease with appropriate patient selection and dose modifications.
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Sodergren MH, Mangal N, Wasan H, Sadanandam A, Balachandran VP, Jiao LR, Habib N. Immunological combination treatment holds the key to improving survival in pancreatic cancer. J Cancer Res Clin Oncol 2020; 146:2897-2911. [PMID: 32748119 PMCID: PMC7519893 DOI: 10.1007/s00432-020-03332-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/22/2020] [Indexed: 12/18/2022]
Abstract
Advances in surgery, peri-operative care and systemic chemotherapy have not significantly improved the prognosis of pancreatic cancer for several decades. Early clinical trials of immunotherapy have yielded disappointing results proposing other means by which the tumour microenvironment serves to decrease the immune response. Additionally, the emergence of various subtypes of pancreatic cancer has emerged as a factor for treatment responses with immunogenic subtypes carrying a better prognosis. Herein we discuss the reasons for the poor response to checkpoint inhibitors and outline a rationale why combination treatments are likely to be most effective. We review the therapies which could provide optimal synergistic effects to immunotherapy including chemotherapy, agents targeting the stroma, co-stimulatory molecules, vaccinations and methods of immunogenic tumour priming including radiofrequency ablation. Finally, we discuss reasons why peri-operative and in particular neoadjuvant combination treatments are likely to be most effective and should be considered for early clinical trials.
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Affiliation(s)
- M H Sodergren
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London, W12 0HS, UK.
| | - N Mangal
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London, W12 0HS, UK
| | - H Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London, W12 0HS, UK
| | - A Sadanandam
- Division of Molecular Pathology, Institute for Cancer Research, London, UK
- Centre for Molecular Pathology, Royal Marsden Hospital, London, UK
| | - V P Balachandran
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
- Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center, New York, USA
- David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, USA
| | - L R Jiao
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London, W12 0HS, UK
| | - N Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, DuCane Road, London, W12 0HS, UK
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Baimas-George M, Watson M, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc 2020; 34:3644-3649. [PMID: 32328825 DOI: 10.1007/s00464-020-07564-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods. RESULTS Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. CONCLUSIONS While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.
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Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
- Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28203, USA.
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Jung JP, Zenati MS, Dhir M, Zureikat AH, Zeh HJ, Simmons RL, Hogg ME. Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy. JAMA Surg 2019; 153:918-927. [PMID: 29998288 DOI: 10.1001/jamasurg.2018.2089] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy. Objective To determine if technical variables during RPD are associated with postoperative DGE. Design, Setting, and Participants A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016. Exposures Video review of gastrojejunal anastomosis during RPD. Main Outcomes and Measures Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined. Results Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04). Conclusions and Relevance This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.
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Affiliation(s)
- Jae Pil Jung
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mashaal Dhir
- Department of Surgery, State University of New York Upstate Medical University, Syracuse
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Division of Surgical Research, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Lei F, Xi X, Batra SK, Bronich TK. Combination Therapies and Drug Delivery Platforms in Combating Pancreatic Cancer. J Pharmacol Exp Ther 2019; 370:682-694. [PMID: 30796131 PMCID: PMC6806650 DOI: 10.1124/jpet.118.255786] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/21/2019] [Indexed: 12/14/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC), the fourth leading cause of cancer-related death in the United States, is highly aggressive and resistant to both chemo- and radiotherapy. It remains one of the most difficult-to-treat cancers, not only due to its unique pathobiological features such as stroma-rich desmoplastic tumors surrounded by hypovascular and hypoperfused vessels limiting the transport of therapeutic agents, but also due to problematic early detection, which renders most treatment options largely ineffective, resulting in extensive metastasis. To elevate therapeutic effectiveness of treatments and overt their toxicity, significant enthusiasm was generated to exploit new strategies for combating PDAC. Combination therapy targeting different barriers to mitigate delivery issues and reduce tumor recurrence and metastasis has demonstrated optimal outcomes in patients' survival and quality of life, providing possible approaches to overcome therapeutic challenges. This paper aims to provide an overview of currently explored multimodal therapies using either conventional therapy or nanomedicines along with rationale, up-to-date progress, as well as the key challenges that must be overcome. Understanding the future directions of the field may assist in the successful development of novel treatment strategies for enhancing therapeutic efficacy in PDAC.
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Affiliation(s)
- Fan Lei
- Department of Pharmaceutical Sciences and Center for Drug Delivery and Nanomedicine, College of Pharmacy (F.L., X.X., T.K.B.), and Department of Biochemistry and Molecular Biology (S.K.B.), University of Nebraska Medical Center, Omaha, Nebraska
| | - Xinyuan Xi
- Department of Pharmaceutical Sciences and Center for Drug Delivery and Nanomedicine, College of Pharmacy (F.L., X.X., T.K.B.), and Department of Biochemistry and Molecular Biology (S.K.B.), University of Nebraska Medical Center, Omaha, Nebraska
| | - Surinder K Batra
- Department of Pharmaceutical Sciences and Center for Drug Delivery and Nanomedicine, College of Pharmacy (F.L., X.X., T.K.B.), and Department of Biochemistry and Molecular Biology (S.K.B.), University of Nebraska Medical Center, Omaha, Nebraska
| | - Tatiana K Bronich
- Department of Pharmaceutical Sciences and Center for Drug Delivery and Nanomedicine, College of Pharmacy (F.L., X.X., T.K.B.), and Department of Biochemistry and Molecular Biology (S.K.B.), University of Nebraska Medical Center, Omaha, Nebraska
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Seufferlein T, Hammel P, Delpero JR, Macarulla T, Pfeiffer P, Prager GW, Reni M, Falconi M, Philip PA, Van Cutsem E. Optimizing the management of locally advanced pancreatic cancer with a focus on induction chemotherapy: Expert opinion based on a review of current evidence. Cancer Treat Rev 2019; 77:1-10. [PMID: 31163334 DOI: 10.1016/j.ctrv.2019.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/26/2019] [Indexed: 02/08/2023]
Abstract
Surgical resection of pancreatic cancer offers a chance of cure, but currently only 15-20% of patients are diagnosed with resectable disease, while 30-40% are diagnosed with non-metastatic, unresectable locally advanced pancreatic cancer (LAPC). Treatment for LAPC usually involves systemic chemotherapy, with the aim of controlling disease progression, reducing symptoms and maintaining quality of life. In a small proportion of patients with LAPC, primary chemotherapy may successfully convert unresectable tumours to resectable tumours. In this setting, primary chemotherapy is termed 'induction therapy' rather than 'neoadjuvant'. There is currently a lack of data from randomized studies to thoroughly evaluate the benefits of induction chemotherapy in LAPC, but Phase II and retrospective data have shown improved survival and high R0 resection rates. New chemotherapy regimens such as nab-paclitaxel + gemcitabine and FOLFIRINOX have demonstrated improvement in overall survival for metastatic disease and shown promise as neoadjuvant treatment in patients with resectable and borderline resectable disease. Prospective trials are underway to evaluate these regimens further as induction therapy in LAPC and preliminary data indicate a beneficial effect of FOLFIRINOX in this setting. Further research into optimal induction schedules is needed, as well as guidance on the patients who are most suitable for induction therapy. In this expert opinion article, a panel of surgeons, medical oncologists and gastrointestinal oncologists review the available evidence on management strategies for LAPC and provide their recommendations for patient care, with a particular focus on the use of induction chemotherapy.
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Affiliation(s)
| | - Pascal Hammel
- Hôpital Beaujon (AP-HP), Clichy, and Université Paris VII-Denis Diderot, France.
| | | | | | | | - Gerald W Prager
- Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University Vienna, Austria.
| | - Michele Reni
- Department of Medical Oncology, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Massimo Falconi
- Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy.
| | - Philip A Philip
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
| | - Eric Van Cutsem
- Digestive Oncology, University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven, Belgium.
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12
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Wang ZQ, Zhang F, Deng T, Zhang L, Feng F, Wang FH, Wang W, Wang DS, Luo HY, Xu RH, Ba Y, Li YH. The efficacy and safety of modified FOLFIRINOX as first-line chemotherapy for Chinese patients with metastatic pancreatic cancer. Cancer Commun (Lond) 2019; 39:26. [PMID: 31068222 PMCID: PMC6507030 DOI: 10.1186/s40880-019-0367-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 04/15/2019] [Indexed: 12/21/2022] Open
Abstract
Background Oxaliplatin, irinotecan, 5-fluorouracil, and l-leucovorin (FOLFIRINOX) has become one of the first-line treatment options for advanced pancreatic cancer (PC). However, the relatively high rate of grade 3 or 4 adverse events associated with the standard dosage of FOLFIRINOX limits its widespread use in clinical practice. In this study, we were to evaluate the efficacy and safety of a modified FOLFIRINOX regimen as a first-line chemotherapy for Chinese patients with metastatic PC. Methods Patients with histologically confirmed primary metastatic pancreatic adenocarcinoma with an Eastern Cooperative Oncology Group (ECOG) performance status score of 0–2 were recruited to receive the modified FOLFIRINOX regimen (intravenous infusion of oxaliplatin, 65 mg/m2; irinotecan, 150 mg/m2; l-leucovorin, 200 mg/m2; and 5-fluorouracil, 2400 mg/m2, repeated every 2 weeks). The treatment was continued for 12 cycles unless the patient had progressive disease (PD), stable disease (SD) with symptom deterioration, unacceptable adverse events, or requested to terminate the treatment prematurely. The primary endpoint was objective response rate (ORR). Results Sixty-five patients were enrolled from July 2012 to April 2017 in three institutions, and they all received at least one cycle of chemotherapy, with a median of 8 cycles (range 1–12 cycles). No complete response was observed. Twenty-one (32.3%) patients had partial responses, and 27 (41.5%) had SD. The ORR and disease control rate of the study cohort was 32.3% and 73.8%. The estimated median overall survival and progression-free survival were 11.60 (95% confidence interval [CI] 8.76–14.44) and 5.77 (95% CI 5.00–6.54) months. Major grade 3 or 4 adverse events included neutropenia (12.3%) and diarrhea (6.2%). No treatment-related death was observed. Conclusions Modified FOLFIRINOX was well-tolerated and might be a promising option as first-line therapy for Chinese patients with metastatic PC. Trial registration ClinicalTrials.gov, NCT02028806. Registered 7 January 2014, https://clinicaltrials.gov/ct2/show/NCT02028806
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Affiliation(s)
- Zhi-Qiang Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Fei Zhang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Ting Deng
- Department of Gastrointestinal Medical Oncology, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, People's Republic of China
| | - Le Zhang
- Department of Gastrointestinal Medical Oncology, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, People's Republic of China
| | - Fen Feng
- Cancer Center, The First People's Hospital of Foshan, Foshan, 528000, Guangdong, People's Republic of China
| | - Feng-Hua Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Wei Wang
- Cancer Center, The First People's Hospital of Foshan, Foshan, 528000, Guangdong, People's Republic of China
| | - De-Shen Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Hui-Yan Luo
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Rui-Hua Xu
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China
| | - Yi Ba
- Department of Gastrointestinal Medical Oncology, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, 300060, People's Republic of China.
| | - Yu-Hong Li
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, People's Republic of China.
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13
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Yamamoto KN, Nakamura A, Liu LL, Stein S, Tramontano AC, Kartoun U, Shimizu T, Inoue Y, Asakuma M, Haeno H, Kong CY, Uchiyama K, Gonen M, Hur C, Michor F. Computational modeling of pancreatic cancer patients receiving FOLFIRINOX and gemcitabine-based therapies identifies optimum intervention strategies. PLoS One 2019; 14:e0215409. [PMID: 31026288 PMCID: PMC6485645 DOI: 10.1371/journal.pone.0215409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/01/2019] [Indexed: 01/03/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) exhibits a variety of phenotypes with regard to disease progression and treatment response. This variability complicates clinical decision-making despite the improvement of survival due to the recent introduction of FOLFIRINOX (FFX) and nab-paclitaxel. Questions remain as to the timing and sequence of therapies and the role of radiotherapy for unresectable PDAC. Here we developed a computational analysis platform to investigate the dynamics of growth, metastasis and treatment response to FFX, gemcitabine (GEM), and GEM+nab-paclitaxel. Our approach was informed using data of 1,089 patients treated at the Massachusetts General Hospital and validated using an independent cohort from Osaka Medical College. Our framework establishes a logistic growth pattern of PDAC and defines the Local Advancement Index (LAI), which determines the eventual primary tumor size and predicts the number of metastases. We found that a smaller LAI leads to a larger metastatic burden. Furthermore, our analyses ascertain that i) radiotherapy after induction chemotherapy improves survival in cases receiving induction FFX or with larger LAI, ii) neoadjuvant chemotherapy improves survival in cases with resectable PDAC, and iii) temporary cessations of chemotherapies do not impact overall survival, which supports the feasibility of treatment holidays for patients with FFX-associated adverse effects. Our findings inform clinical decision-making for PDAC patients and allow for the rational design of clinical strategies using FFX, GEM, GEM+nab-paclitaxel, neoadjuvant chemotherapy, and radiation.
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Affiliation(s)
- Kimiyo N. Yamamoto
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, United States of America
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Akira Nakamura
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Lin L. Liu
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Shayna Stein
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Uri Kartoun
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, United States of America
| | - Tetsunosuke Shimizu
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Yoshihiro Inoue
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Mitsuhiro Asakuma
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Hiroshi Haeno
- Mathematical Biology Laboratory, Department of Biology, Faculty of Sciences, Kyushu University, Fukuoka, Japan
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kazuhisa Uchiyama
- Departments of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, United States of America
| | - Franziska Michor
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, United States of America
- Center for Cancer Evolution, Dana-Farber Cancer Institute, Boston, MA, United States of America
- The Broad Institute of Harvard and MIT, Cambridge, MA, United States of America
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14
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Madani Tonekaboni SA, Soltan Ghoraie L, Manem VSK, Haibe-Kains B. Predictive approaches for drug combination discovery in cancer. Brief Bioinform 2019; 19:263-276. [PMID: 27881431 DOI: 10.1093/bib/bbw104] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Indexed: 02/07/2023] Open
Abstract
Drug combinations have been proposed as a promising therapeutic strategy to overcome drug resistance and improve efficacy of monotherapy regimens in cancer. This strategy aims at targeting multiple components of this complex disease. Despite the increasing number of drug combinations in use, many of them were empirically found in the clinic, and the molecular mechanisms underlying these drug combinations are often unclear. These challenges call for rational, systematic approaches for drug combination discovery. Although high-throughput screening of single-agent therapeutics has been successfully implemented, it is not feasible to test all possible drug combinations, even for a reduced subset of anticancer drugs. Hence, in vitro and in vivo screening of a large number of drug combinations are not practical. Therefore, devising computational methods to efficiently explore the space of drug combinations and to discover efficacious combinations has attracted a lot of attention from the scientific community in the past few years. Nevertheless, in the absence of consensus regarding the computational approaches used to predict efficacious drug combinations, a plethora of methods, techniques and hypotheses have been developed to date, while the research field lacks an elaborate categorization of the existing computational methods and the available data sources. In this manuscript, we review and categorize the state-of-the-art computational approaches for drug combination prediction, and elaborate on the limitations of these methods and the existing challenges. We also discuss about the recent pan-cancer drug combination data sets and their importance in revising the available methods or developing more performant approaches.
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Affiliation(s)
- Seyed Ali Madani Tonekaboni
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Laleh Soltan Ghoraie
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Venkata Satya Kumar Manem
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Haibe-Kains
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Computer Science, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute of Cancer Research, Toronto, Ontario, Canada
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15
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Deyme L, Barbolosi D, Gattacceca F. Population pharmacokinetics of FOLFIRINOX: a review of studies and parameters. Cancer Chemother Pharmacol 2018; 83:27-42. [DOI: 10.1007/s00280-018-3722-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/01/2018] [Indexed: 02/08/2023]
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16
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Tsuboya A, Fujita KI, Kubota Y, Ishida H, Taki-Takemoto I, Kamei D, Iwai S, Sasaki Y. Coadministration of cytotoxic chemotherapeutic agents with irinotecan is a risk factor for irinotecan-induced cholinergic syndrome in Japanese patients with cancer. Int J Clin Oncol 2018; 24:222-230. [DOI: 10.1007/s10147-018-1347-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/16/2018] [Indexed: 12/01/2022]
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17
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Irreversible Electroporation in pancreatic ductal adenocarcinoma: Is there a role in conjunction with conventional treatment? Eur J Surg Oncol 2018; 44:1486-1493. [PMID: 30146253 DOI: 10.1016/j.ejso.2018.07.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/09/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The incidence of pancreatic ductal adenocarcinoma (PDAC) is rapidly increasing. Up to 30% of patients present with locally advanced disease and therefore are not candidates for surgery. Locally advanced pancreatic cancer (LAPC) is an emerging entity lacking in level III evidence-based recommendations for its treatment. Currently, systemic chemotherapy is the main treatment for LAPC. However, due to lack of response or disease progression, downsizing of the tumour, making it resectable is successful in only a small proportion of patients. Radiotherapy is often advocated to improve local disease control if there is stability following chemotherapy. Recently, Irreversible Electroporation (IRE), a novel non-thermal ablation technique, has been proposed for the treatment of LAPC. AIMS AND METHODS This narrative review aims to explore the potential role and timing for the use of IRE in patients with LAPC. RESULTS To date, there is limited and inconsistent level I and II evidence available in the literature regarding the use of IRE for the treatment of PDAC. DISCUSSION Although some of the preliminary experience of the use of IRE in patients with LAPC is encouraging, it should only be used after conventional evidence-based treatments and/or within the research context.
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18
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Salzwedel AO, Han J, LaRocca CJ, Shanley R, Yamamoto M, Davydova J. Combination of interferon-expressing oncolytic adenovirus with chemotherapy and radiation is highly synergistic in hamster model of pancreatic cancer. Oncotarget 2018; 9:18041-18052. [PMID: 29719589 PMCID: PMC5915056 DOI: 10.18632/oncotarget.24710] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/06/2018] [Indexed: 01/05/2023] Open
Abstract
Recent clinical trials utilizing Interferon-alpha (IFN) in combination with chemoradiation have demonstrated significant improvements in the survival of patients with pancreatic cancer. However, efficacy was limited by the systemic toxicity of IFN and low intratumoral levels of the cytokine. We sought to address these drawbacks by using an Oncolytic Adenovirus expressing IFN (OAd-hamIFN) in combination with chemotherapy and/or radiation in regimens mimicking the IFN-based therapies used in clinical trials. IFN expressed from OAd-hamIFN potentiated the cytotoxicity of radiation and chemotherapy (5-FU, Gemcitabine, and Cisplatin), and enhanced pancreatic cancer cell death in both in vitro and in vivo experimental settings. Notably, synergism was demonstrated in therapeutic groups that combined the interferon-expressing oncolytic virus with chemotherapy and radiation. In an in vivo immunocompetent hamster model, treatment regimens combining oncolytic virus therapy with 5-FU and radiation demonstrated significant tumor growth inhibition and enhanced survival. This is the first study to report synergism between an IFN-expressing oncolytic adenovirus and chemoradiation-based therapies. When combined with an IFN-expressing OAd, there is a significant enhancement of radiation and especially chemoradiation, which may broaden the application of this new therapeutic approach to the pancreatic cancer patients who cannot tolerate existing chemotherapy regimens.
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Affiliation(s)
| | - Joohee Han
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
| | | | - Ryan Shanley
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Masato Yamamoto
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
- Institute of Molecular Virology, University of Minnesota, Minneapolis, MN 55455, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Julia Davydova
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
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19
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Systematic review on the role of serum tumor markers in the detection of recurrent pancreatic cancer. HPB (Oxford) 2018; 20:297-304. [PMID: 29366815 DOI: 10.1016/j.hpb.2017.11.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biomarker testing can be helpful to monitor disease progression after resection of pancreatic cancer. This systematic review aims to give an overview of the literature on the diagnostic value of serum tumor markers for the detection of recurrent pancreatic cancer during follow-up. METHODS A systematic search was performed to 2 October 2017. All studies reporting on the diagnostic value of postoperatively measured serum biomarkers for the detection of pancreatic cancer recurrence were included. Data on diagnostic accuracy of tumor markers were extracted. Forest plots and pooled values of sensitivity and specificity were calculated. RESULTS Four articles described test results of CA 19-9. A pooled sensitivity and specificity of respectively 0.73 (95% CI 0.66-0.80) and 0.83 (95% CI 0.73-0.91) were calculated. One article reported on CEA, showing a sensitivity of 50% and specificity of 65%. No other serum tumor markers were discussed for surveillance purposes in the current literature. CONCLUSION Although testing of serum CA 19-9 has considerable limitations, CA 19-9 remains the most used serum tumor marker for surveillance after surgical resection of pancreatic cancer. Further studies are needed to assess the role of serum tumor marker testing in the detection of recurrent pancreatic cancer and to optimize surveillance strategies.
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20
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Manji GA, Olive KP, Saenger YM, Oberstein P. Current and Emerging Therapies in Metastatic Pancreatic Cancer. Clin Cancer Res 2018; 23:1670-1678. [PMID: 28373365 DOI: 10.1158/1078-0432.ccr-16-2319] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/03/2017] [Accepted: 02/03/2017] [Indexed: 02/06/2023]
Abstract
Targeted therapies and immunotherapy have changed the face of multiple solid malignancies, including metastatic melanoma and lung cancer, but no such therapies exist for pancreatic ductal adenocarcinoma (PDAC) despite the knowledge of key mutations and an increasing understanding of the tumor microenvironment. Until now, most clinical studies have not been biomarker driven in this highly immunosuppressive and heterogeneous cancer. Ongoing basic and translational studies are better classifying the disease in hopes of identifying critical pathways that distinguish the unique PDAC subtypes, which will lead to personalized therapies. In this review, we discuss the current treatment options for metastatic pancreatic cancer and highlight current ongoing clinical trials, which aim to target the stroma and the immune microenvironment either alone or in combination with standard chemotherapy. Identifying biomarkers and key resistance pathways and targeting these pathways in a personalized manner in combination with chemotherapy are likely to yield a more immediate and durable clinical benefit. Clin Cancer Res; 23(7); 1670-8. ©2017 AACRSee all articles in this CCR Focus section, "Pancreatic Cancer: Challenge and Inspiration."
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Affiliation(s)
- Gulam Abbas Manji
- Division of Medical Oncology, Columbia University Medical Center, and New York Presbyterian Hospital, Herbert Irving Pavilion, New York, New York.
| | - Kenneth P Olive
- Department of Pathology and Cell Biology, Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York
| | - Yvonne M Saenger
- Division of Medical Oncology, Columbia University Medical Center, and New York Presbyterian Hospital, Herbert Irving Pavilion, New York, New York
| | - Paul Oberstein
- Division of Medical Oncology, Columbia University Medical Center, and New York Presbyterian Hospital, Herbert Irving Pavilion, New York, New York
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21
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Cho IR, Kang H, Jo JH, Lee HS, Chung MJ, Park JY, Park SW, Song SY, Chung JB, An C, Park MS, Jung SY, Bang S. Efficacy and treatment-related adverse events of gemcitabine plus nab-paclitaxel for treatment of metastatic pancreatic cancer "in a Korean" population: A single-center cohort study. Semin Oncol 2018; 44:420-427. [PMID: 29935903 DOI: 10.1053/j.seminoncol.2018.01.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/27/2017] [Accepted: 01/01/2018] [Indexed: 12/13/2022]
Abstract
Pancreatic cancer has poor prognosis because of its rapid progression and treatment resistance. Based on the results of the Metastatic Pancreatic Adenocarcinoma Clinical Trial (MPACT), a combination regimen of gemcitabine with nab-paclitaxel is currently used as standard therapy for the treatment of metastatic pancreatic cancer. However, because studies in Asian populations are lacking, we investigated the treatment efficacy and safety of this combination therapy in Korean population. Patients with metastatic pancreatic cancer (n=81) treated with gemcitabine and nab-paclitaxel (1,000 and 125 mg/m2, respectively) as the first-line chemotherapy from January 2016 were identified using the Severance Hospital Pancreatic Cancer Cohort Registry. Treatment efficacy and treatment-related adverse events (AEs) were analyzed. The median follow-up period was 10.7 months (range, 1.5-23.3 months). Median overall survival, progression-free survival, and objective response rates were 12.1 months (95% confidence interval [CI], 10.7-not estimable), 8.4 months (95% CI, 5.0-11.8), and 46.9%, respectively. The incidence of grade ≥3 neurotoxicity and neutropenia were 18.5% and 46.9%, respectively. Febrile neutropenia and grade ≥3 gastrointestinal AEs occurred in 13 (16.0%) and 16 (19.8%) patients, respectively. Dose reductions because of AEs were required in 60.5% of patients. The combination of gemcitabine with nab-paclitaxel is an effective anti-cancer regimen in Korean population of patients with metastatic pancreatic adenocarcinoma. However, careful monitoring and management are required because of occurrence of treatment-related AEs.
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Affiliation(s)
- In Rae Cho
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Huapyong Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Jo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Bock Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Chansik An
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Mi-Suk Park
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - So Young Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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22
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Smigiel JM, Parameswaran N, Jackson MW. Targeting Pancreatic Cancer Cell Plasticity: The Latest in Therapeutics. Cancers (Basel) 2018; 10:cancers10010014. [PMID: 29320425 PMCID: PMC5789364 DOI: 10.3390/cancers10010014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/27/2017] [Accepted: 01/04/2018] [Indexed: 02/07/2023] Open
Abstract
Mortality remains alarmingly high for patients diagnosed with pancreatic ductal adenocarcinoma (PDAC), with 93% succumbing to the disease within five years. The vast majority of PDAC cases are driven by activating mutations in the proto-oncogene KRAS, which results in constitutive proliferation and survival signaling. As efforts to target RAS and its downstream effectors continue, parallel research aimed at identifying novel targets is also needed in order to improve therapeutic options and efficacy. Recent studies demonstrate that self-renewing cancer stem cells (CSCs) contribute to metastatic dissemination and therapy failure, the causes of mortality from PDAC. Here, we discuss current challenges in PDAC therapeutics, highlight the contribution of mesenchymal/CSC plasticity to PDAC pathogenesis, and propose that targeting the drivers of plasticity will prove beneficial. Increasingly, intrinsic oncogenic and extrinsic pro-growth/survival signaling emanating from the tumor microenvironment (TME) are being implicated in the de novo generation of CSC and regulation of tumor cell plasticity. An improved understanding of key regulators of PDAC plasticity is providing new potential avenues for targeting the properties associated with CSC (including enhanced invasion and migration, metastatic outgrowth, and resistance to therapy). Finally, we describe the growing field of therapeutics directed at cancer stem cells and cancer cell plasticity in order to improve the lives of patients with PDAC.
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Affiliation(s)
- Jacob M Smigiel
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Neetha Parameswaran
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Mark W Jackson
- Department of Pathology, Case Western Reserve University, Cleveland, OH 44106, USA.
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH 44106, USA.
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23
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Ngo-Huang A, Parker NH, Wang X, Petzel MQB, Fogelman D, Schadler KL, Bruera E, Fleming JB, Lee JE, Katz MHG. Home-based exercise during preoperative therapy for pancreatic cancer. Langenbecks Arch Surg 2017; 402:1175-1185. [PMID: 28710540 PMCID: PMC8372869 DOI: 10.1007/s00423-017-1599-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/25/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Exercise concurrent with neoadjuvant chemotherapy and/or chemoradiation for pancreatic adenocarcinoma (PDAC) may mitigate the decline in function that may occur as a result of the disease or its treatment in the preoperative period. The primary objective of this single-arm prospective trial was to determine adherence to a home-based exercise program administered during preoperative therapy. METHODS Twenty patients from a quaternary cancer center with potentially resectable PDAC were enrolled. Patients were prescribed a minimum of 120 min of moderate-intensity exercise weekly: at least 60 min of aerobic exercise and 60 min of resistance exercise. Self-reported exercise was recorded in daily logs. Functional and survey measures were collected upon enrollment, following preoperative therapy, and 1 month after surgery. RESULTS Fifteen out of 20 patients participated in the program. They reported a mean (standard deviation (SD)) of 98.6 (69.8) min of aerobic exercise weekly and 57.4 (36.0) min of strengthening exercise weekly over a median of 17 weeks (range, 5-35 weeks) of preoperative therapy, for a mean (SD) of 156.0 (64.5) min of total exercise weekly. Eighty percent reported a mean of least 120 min of total exercise weekly during preoperative therapy. Patients with low baseline physical activity based on the International Physical Activity Questionnaire significantly increased their preoperative physical activity (p = .01). There were no adverse events associated with the exercise program. CONCLUSIONS Patients with PDAC will participate in a home-based exercise program of aerobic and strengthening exercise and will increase physical activity, concurrent with preoperative chemotherapy and/or chemoradiation.
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Affiliation(s)
- An Ngo-Huang
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX, 77030, USA.
| | - Nathan H Parker
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Q B Petzel
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Clinical Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keri L Schadler
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1414, Houston, TX, 77030, USA
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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24
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de W Marsh R, Talamonti MS, Baker MS, Posner M, Roggin K, Matthews J, Catenacci D, Kozloff M, Polite B, Britto M, Wang C, Kindler H. Primary systemic therapy in resectable pancreatic ductal adenocarcinoma using mFOLFIRINOX: A pilot study. J Surg Oncol 2017; 117:354-362. [PMID: 29044544 DOI: 10.1002/jso.24872] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/11/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgery followed by gemcitabine and/or a fluoropyrimidine is standard therapy for resectable PDAC. mFOLFIRINOX (oxaliplatin 85 mg/m2 , irinotecan 180 mg/m2 , leucovorin 400 mg/m2 Day 1, 5-FU 2400 mg/m2 × 48 h IV, peg-filgrastim 6 mg SQ day 3, every 14 days) has substantial activity in metastatic PDAC. We wished to determine the tolerability/efficacy of peri-operative mFOLFIRINOX in resectable PDAC. METHODS Patients with resectable PDAC (ECOG PS 0/1) received four cycles of mFOLFIRINOX pre- and post-surgery. The primary endpoint was completion of preoperative chemotherapy plus resection. Secondary endpoints included completion of all therapy, R0 resection, treatment related toxicity, PFS, and OS. RESULTS Twenty-one patients enrolled: median age 62 (47-78); 20/21 (95%) completed four cycles of preoperative mFOLFIRINOX; response by RECIST was 1 CR, 3 PR, 16 SD; 17/21 (81%) completed resection, 16/21 (76%) R0; 14/21 (66%) completed four cycles of postoperative mFOLFIRINOX. Grade 3 and 4 toxicity occurred in 23% and 14% patients pre-operatively, 26% and 6.0% post-operatively. Nine patients are alive with median follow-up of 27.7 (3.1-47.1) months. CONCLUSIONS PST using mFOLFIRINOX in resectable PDAC is feasible and tolerable. R0 resection rate is high and survival promising, requiring longer follow-up and larger studies for definitive assessment.
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Affiliation(s)
- Robert de W Marsh
- Department of Medicine, Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, Illinois
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Mitchell Posner
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Kevin Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Jeffrey Matthews
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Daniel Catenacci
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Mark Kozloff
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Blase Polite
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michele Britto
- Department of Medicine, Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, Illinois
| | - Chi Wang
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Hedy Kindler
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
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25
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Labori KJ, Brudvik KW. Follow-up After Surgery for Pancreatic Ductal Adenocarcinoma: Steps Toward an International Consensus. Pancreas 2017; 46:e2-e3. [PMID: 27977631 DOI: 10.1097/mpa.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo, Norway
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26
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Stein SM, James ES, Deng Y, Cong X, Kortmansky JS, Li J, Staugaard C, Indukala D, Boustani AM, Patel V, Cha CH, Salem RR, Chang B, Hochster HS, Lacy J. Final analysis of a phase II study of modified FOLFIRINOX in locally advanced and metastatic pancreatic cancer. Br J Cancer 2016; 114:737-43. [PMID: 27022826 PMCID: PMC4984865 DOI: 10.1038/bjc.2016.45] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/22/2016] [Accepted: 02/08/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Modifications of FOLFIRINOX are widely used despite the absence of prospective data validating efficacy in metastatic disease (metastatic pancreatic cancer (MPC)) or locally advanced pancreatic cancer (LAPC). We conducted a multicentre phase II study of modified FOLFIRINOX in advanced pancreatic cancer to assess the impact of dose attenuation in MPC and efficacy in LAPC. METHODS Patients with untreated MPC or LAPC received modified FOLFIRINOX (irinotecan and bolus 5-fluorouracil reduced by 25%). Adverse events (AEs) were compared with full-dose FOLFIRINOX. Response rate (RR), median progression-free survival (PFS) and median overall survival (OS) were determined. RESULTS In total, 31 and 44 patients with LAPC and MPC were enrolled, respectively. In MPC, efficacy of modified FOLFIRINOX was comparable with FOLFIRINOX with RR 35.1%, OS 10.2 months (95% CI 7.65-14.32) and PFS 6.1 months (95% CI 5.19-8.31). In LAPC, efficacy was notable with RR 17.2%, resection rate 41.9%, PFS 17.8 months (95% CI 11.0-23.9) and OS 26.6 months (95% CI 16.7, NA). Neutropenia (P<0.0001), vomiting (P<0.001) and fatigue (P=0.01) were significantly decreased. [(18)F]-Fluorodeoxyglucose positron emission tomography imaging response did not correlate with PFS or OS. CONCLUSIONS In this first prospective study of modified FOLFIRINOX in MPC and LAPC, we observed decreased AEs compared with historical control patients. In MPC, the efficacy appears comparable with FOLFIRINOX. In LAPC, PFS and OS were prolonged and support the continued use of FOLFIRINOX in this setting.
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Affiliation(s)
- Stacey M Stein
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Edward S James
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Yanhong Deng
- Yale School of Public Health, 300 George Street, New Haven, CT 06510, USA
| | - Xiangyu Cong
- Yale School of Public Health, 300 George Street, New Haven, CT 06510, USA
| | - Jeremy S Kortmansky
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Jia Li
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA.,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Carol Staugaard
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Doddamane Indukala
- Department of Diagnostic Radiology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Ann Marie Boustani
- Department of Diagnostic Radiology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Vatsal Patel
- Department of Diagnostic Radiology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Charles H Cha
- Department of Surgery, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Ronald R Salem
- Department of Surgery, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Bryan Chang
- Department of Therapeutic Radiology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Howard S Hochster
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Jill Lacy
- Department of Medicine, Section of Medical Oncology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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28
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Mantripragada KC, Safran H. Optimizing initial chemotherapy for metastatic pancreatic cancer. Future Oncol 2016; 12:1125-33. [PMID: 26939741 DOI: 10.2217/fon-2015-0006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The two combination chemotherapy regimens FOLFIRINOX and gemcitabine plus nab-paclitaxel represent major breakthroughs in the management of metastatic pancreatic cancer. Both regimens showed unprecedented survival advantage in the setting of front-line therapy. However, their application for treatment of patients in the community is challenging because of significant toxicities, thus limiting potential benefits to a narrow population of patients. Modifications to the dose intensity or schedule of those regimens improve their tolerability, while likely retaining survival advantage over single-agent chemotherapy. Newer strategies to optimize these two active regimens in advanced pancreatic cancer are being explored that can help personalize treatment to individual patients.
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Affiliation(s)
- Kalyan C Mantripragada
- The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI 02903, USA
| | - Howard Safran
- The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI 02903, USA
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29
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Frontline nilotinib in patients with chronic myeloid leukemia in chronic phase: results from the European ENEST1st study. Leukemia 2015; 30:57-64. [PMID: 26437782 PMCID: PMC4705425 DOI: 10.1038/leu.2015.270] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 12/20/2022]
Abstract
The Evaluating Nilotinib Efficacy and Safety in Clinical Trials as First-Line Treatment (ENEST1st) study included 1089 patients with newly diagnosed chronic myeloid leukemia in chronic phase. The rate of deep molecular response (MR4 (BCR-ABL1⩽0.01% on the International Scale or undetectable BCR-ABL1 with ⩾10 000 ABL1 transcripts)) at 18 months was evaluated as the primary end point, with molecular responses monitored by the European Treatment and Outcome Study network of standardized laboratories. This analysis was conducted after all patients had completed 24 months of study treatment (80.9% of patients) or discontinued early. In patients with typical BCR-ABL1 transcripts and ⩽3 months of prior imatinib therapy, 38.4% (404/1052) achieved MR4 at 18 months. Six patients (0.6%) developed accelerated or blastic phase, and 13 (1.2%) died. The safety profile of nilotinib was consistent with that of previous studies, although the frequencies of some nilotinib-associated adverse events were lower (for example, rash, 21.4%). Ischemic cardiovascular events occurred in 6.0% of patients. Routine monitoring of lipid and glucose levels was not mandated in the protocol. These results support the use of frontline nilotinib, particularly when achievement of a deep molecular response (a prerequisite for attempting treatment-free remission in clinical trials) is a treatment goal.
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30
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Wei Q, Yu W, Rosati LM, Herman JM. Advances of stereotactic body radiotherapy in pancreatic cancer. Chin J Cancer Res 2015; 27:349-57. [PMID: 26361404 DOI: 10.3978/j.issn.1000-9604.2015.04.12] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/22/2015] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer (PCA) is one of the most aggressive tumors with few effective treatment modalities. It is the 4th and 7th leading cause of cancer death in the United States and China, respectively. At the time of diagnosis, only 20% of cases present with a resectable tumor, and about 40% with a locally advanced tumor that is considered unresectable. Even resected patients still have a poor prognosis, with an incidence of local recurrence ranging from 20% to 60%. It is also reported that up to 30% of PCA patients die from locally obstructive disease with few or no distant metastases. These findings have highlighted the importance of local radiation therapy in the treatment of PCA. As the role of conventional chemoradiotherapy remains controversial, the dawn of the pancreas stereotactic body radiation therapy (SBRT) era represents a potential paradigm shift in the management of PCA. SBRT delivers a higher biological effective dose to the tumor with sharp dose escalation in a shorter treatment time course. Pancreas SBRT is a novel therapeutic option to achieve local tumor control with minimal toxicity. Herein, we review the advancement of SBRT for PCA patients with different stages of pancreatic adenocarcinoma.
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Affiliation(s)
- Qichun Wei
- 1 Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China ; 2 Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wei Yu
- 1 Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China ; 2 Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lauren M Rosati
- 1 Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China ; 2 Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph M Herman
- 1 Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China ; 2 Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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31
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Vietsch EE, van Eijck CHJ, Wellstein A. Circulating DNA and Micro-RNA in Patients with Pancreatic Cancer. PANCREATIC DISORDERS & THERAPY 2015; 5:156. [PMID: 26161297 PMCID: PMC4494744 DOI: 10.4172/2165-7092.1000156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Collecting repeat samples of blood ("liquid biopsies") is a broadly used clinical approach for serial monitoring of disease or response to treatments. In patients with cancer the most distinct molecular feature are somatic mutations acquired by cancer cells present in the diseased tissue. Indeed, mutant DNA derived from dying or lysed cancer cells can be isolated from patient serum samples, subjected to DNA sequencing and to analysis of abundance as a measure of tumor burden. Also, changes in the DNA mutation patterns in serum samples collected over time can indicate altered pathways or clonal evolution of the disease and altered abundance of mutant DNA suggests an altered disease burden. In addition, during the course of treatment, changes in circulating DNA mutation patterns can indicate the emergence of resistant clones and prompt changes in treatment. In contrast to mutant DNA, microRNAs (miR) are transcribed, processed, packaged and released from cells in normal and in diseased tissues as part of the extracellular crosstalk between cells. Interestingly, released miR can function in cell-to-cell communication and as hormone-like signals that operate at a distance through their release into the circulation and subsequent uptake into cells in distant tissues. Circulating miR expression patterns can be established from serial serum samples and monitored for alterations over time. Circulating miR provide a readout of the organism's steady state and serial analyses will indicate changes in the response to therapy or an altered physiologic or disease state. Furthermore, changes in circulating miR patterns can indicate treatment efficacy or resistance as well as adverse effects associated with the respective intervention. Thus, the combined serial analysis of mutant DNA and miR in the circulation has the potential to provide a molecular footprint of pancreatic cancer and can be used to monitor treatment responses or resistance to treatment in real time with a minimally invasive procedure.
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Affiliation(s)
- Eveline E Vietsch
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | | | - Anton Wellstein
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
- Corresponding author: Anton Wellstein, Georgetown University Medical School, Lombardi, Comprehensive Cancer Center, Research Building; Room E311, 3970 Reservoir Road, Washington DC, Tel: +1202687-3672,
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32
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Quinn BA, Lee NA, Kegelman TP, Bhoopathi P, Emdad L, Das SK, Pellecchia M, Sarkar D, Fisher PB. The Quest for an Effective Treatment for an Intractable Cancer: Established and Novel Therapies for Pancreatic Adenocarcinoma. Adv Cancer Res 2015; 127:283-306. [PMID: 26093904 DOI: 10.1016/bs.acr.2015.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
With therapies that date back to the 1950s, and few newly approved treatments in the last 20 years, pancreatic cancer remains a significant challenge for the development of novel therapeutics. Current regimens have successfully extended patient survival, although they still lead to prognoses measured in months rather than years. The genetic diversity inherent in pancreatic tumors forms the roadblocks that must be overcome in future therapeutics. Recent insight into the genetic patterns found in tumor cells may provide clues leading to better understanding of the challenges hindering the development of treatments. Here, we review currently used drugs and established combination therapies that comprise the standard of care for a highly recalcitrant disease. Novel approaches can improve upon current therapies in a variety of ways. Enhancing specificity, such that growth inhibition and cytotoxic effects act preferentially on tumor cells, is one approach to advance treatments. This can be accomplished through the targeting of extracellular markers specific to cancer cells. Additionally, enlisting natural defenses and overcoming tumor-driven immune suppression could prove to be a useful tactic. Recent studies utilizing these approaches have yielded promising results and could contribute to an ongoing effort battling a particularly difficult cancer.
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Affiliation(s)
- Bridget A Quinn
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Nathaniel A Lee
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; Department of Surgery, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Timothy P Kegelman
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Praveen Bhoopathi
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Luni Emdad
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Massey Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Swadesh K Das
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Massey Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | | | - Devanand Sarkar
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Massey Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Paul B Fisher
- Department of Human and Molecular Genetics, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Institute of Molecular Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA; VCU Massey Cancer Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA.
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