1
|
Jethwa KR, Kim E, Berlin J, Anker CJ, Tchelebi L, Abood G, Hallemeier CL, Jabbour S, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Williams V, Russo S. Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma: Systematic Review and Guidelines. Am J Clin Oncol 2024; 47:185-199. [PMID: 38131628 DOI: 10.1097/coc.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and "Preferred Reporting Items for Systematic Reviews and Meta-analyses" 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.
Collapse
Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jordan Berlin
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Christopher J Anker
- Department of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, VT
| | - Leila Tchelebi
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
| | | | | | | | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, NJ
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Sibley Memorial Hospital, Washington DC
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, PA
| | - William Small
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, IL
| | - Vonetta Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, NY
| | - Suzanne Russo
- Department of Radiation Oncology, University Hospitals Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
2
|
Coveler AL, Pillarisetty VG, Koh WJ, Zhen DB, Park JO, King GG, Sham JG, Hannan LM, Mann GN, Baker KK, Redman MW, Swanson PE, Chiorean EG, Whiting SH. Perioperative Chemotherapy and Chemoradiotherapy for Patients With Resectable and Borderline Resectable Pancreatic Adenocarcinoma. Pancreas 2023; 52:e282-e287. [PMID: 37782886 DOI: 10.1097/mpa.0000000000002253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
OBJECTIVES Pancreatic ductal adenocarcinoma (PDA) is the third most common cause of cancer death in the United States. Most patients who undergo resection develop recurrence. Standard treatment confers a median overall survival (OS) of 24 months. Exposure to alternate regimens may prevent chemoresistance. This study evaluated multiagent perioperative therapy for potentially resectable PDA patients to improve OS. METHODS A single center, phase 2, trial of patients with resectable or borderline resectable PDA. Patients received neoadjuvant therapy with induction chemotherapy (gemcitabine, docetaxel, capecitabine) for 3 cycles, chemoradiation (intensity-modulated radiation therapy with capecitabine and oxaliplatin) followed by surgery, and 2 months of adjuvant gemcitabine and oxaliplatin and 2 months of gemcitabine. The primary endpoint was OS. The secondary endpoint was recurrence-free survival (RFS). RESULTS Thirty-two eligible patients were enrolled. Twenty-two patients underwent surgical resection. After a median follow-up of 56.8 months, mOS was 31.6 months (95% confidence interval [CI], 14.2-58.1) for all patients, 58.1 months (95% CI, 31.6 to NR) for those who completed surgery. The mRFS was 31.3 months (95% CI, 12.5 to NR). CONCLUSIONS Perioperative therapy with GTX, chemoradiotherapy, and adjuvant GemOx/Gem resulted in promising survival of 58 months for patients who underwent resection and may represent another treatment option for PDA.
Collapse
Affiliation(s)
| | | | - Wui-Jin Koh
- National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA
| | | | - James O Park
- Department of Surgery, University of Washington, Seattle, WA
| | | | - Jonathan G Sham
- Department of Surgery, University of Washington, Seattle, WA
| | - Lindsay M Hannan
- From the Department of Medicine, University of Washington, Seattle, WA
| | - Gary N Mann
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | - Paul E Swanson
- Department of Pathology, University of Washington, Seattle, WA
| | | | | |
Collapse
|
3
|
Yeh C, Zhou M, Sigel K, Jameson G, White R, Safyan R, Saenger Y, Hecht E, Chabot J, Schreibman S, Juzyna B, Ychou M, Conroy T, Fojo T, Manji GA, Von Hoff D, Bates SE. Tumor Growth Rate Informs Treatment Efficacy in Metastatic Pancreatic Adenocarcinoma: Application of a Growth and Regression Model to Pivotal Trial and Real-World Data. Oncologist 2022; 28:139-148. [PMID: 36367377 PMCID: PMC9907043 DOI: 10.1093/oncolo/oyac217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/26/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Methods for screening agents earlier in development and strategies for conducting smaller randomized controlled trials (RCTs) are needed. METHODS We retrospectively applied a tumor growth model to estimate the rates of growth of pancreatic cancer using radiographic tumor measurements or serum CA 19-9 values from 3033 patients with stages III-IV PDAC who were enrolled in 8 clinical trials or were included in 2 large real-world data sets. RESULTS g correlated inversely with OS and was consistently lower in the experimental arms than in the control arms of RCTs. At the individual patient level, g was significantly faster for lesions metastatic to the liver relative to those localized to the pancreas. Regardless of regimen, g increased toward the end of therapy, often by over 3-fold. CONCLUSIONS Growth rates of PDAC can be determined using radiographic tumor measurement and CA 19-9 values. g is inversely associated with OS and can differentiate therapies within the same trial and across trials. g can also be used to characterize changes in the behavior of an individual's PDAC, such as differences in the growth rate of lesions based on metastatic site, and the emergence of chemoresistance. We provide examples of how g can be used to benchmark phase II and III clinical data to a virtual reference arm to inform go/no go decisions and consider novel trial designs to optimize and accelerate drug development.
Collapse
Affiliation(s)
- Celine Yeh
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mengxi Zhou
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Keith Sigel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gayle Jameson
- Department of Medical Oncology/Hematology, HonorHealth Research Institute, Scottsdale, AZ, USA
| | - Ruth White
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Rachael Safyan
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Yvonne Saenger
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Elizabeth Hecht
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - John Chabot
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Stephen Schreibman
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Béata Juzyna
- R&D UNICANCER, Fédération Nationale des Centres de Lutte Contre le Cancer, Paris, France
| | - Marc Ychou
- Department of Medical Oncology, Institut Régional du Cancer de Montpellier (ICM), Montpellier, France
| | - Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy Cedex, France
| | - Tito Fojo
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA,Hematology/Oncology, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Gulam A Manji
- Department of Medicine, Division of Hematology/Oncology, Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Daniel Von Hoff
- Virginia G. Piper Cancer Center Clinical Trials, HonorHealth Research Institute, Scottsdale, AZ, USA,Translational Genomics Research Institute, Clinical Translational Research Division, Phoenix, AZ, USA
| | - Susan E Bates
- Corresponding author: Susan E. Bates, MD, Columbia University Herbert Irving Comprehensive Cancer Center, 161 Fort Washington Avenue, Herbert Irving Pavilion, 9th Floor, New York, NY 10032, USA. Tel: +1 212 305 9422.
| |
Collapse
|
4
|
Puleo A, Malla M, Boone BA. Defining the Optimal Duration of Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Time for a Personalized Approach? Pancreas 2022; 51:1083-1091. [PMID: 37078929 PMCID: PMC10144367 DOI: 10.1097/mpa.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/03/2022] [Indexed: 04/21/2023]
Abstract
ABSTRACT Despite recent advances, pancreatic ductal adenocarcinoma (PDAC) continues to be associated with dismal outcomes, with a cure evading most patients. While historic treatment for PDAC has been surgical resection followed by 6 months of adjuvant therapy, there has been a recent shift toward neoadjuvant treatment (NAT). Several considerations support this approach, including the characteristic early systemic spread of PDAC, and the morbidity often surrounding pancreatic resection, which can delay recovery and preclude patients from starting adjuvant treatment. The addition of NAT has been suggested to improve margin-negative resection rates, decrease lymph node positivity, and potentially translate to improved survival. Conversely, complications and disease progression can occur during preoperative treatment, potentially eliminating the chance of curative resection. As NAT utilization has increased, treatment durations have been found to vary widely between institutions with an optimal duration remaining undefined. In this review, we assess the existing literature on NAT for PDAC, reviewing treatment durations reported across retrospective case series and prospective clinical trials to establish currently used approaches and seek the optimal duration. We also analyze markers of treatment response and review the potential for personalized approaches that may help clarify this important treatment question and move NAT toward a more standardized approach.
Collapse
Affiliation(s)
- Amanda Puleo
- From the Division of Surgical Oncology, Department of Surgery
| | - Midhun Malla
- Section of Hematology/Oncology, Department of Medicine
| | - Brian A. Boone
- From the Division of Surgical Oncology, Department of Surgery
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
| |
Collapse
|
5
|
Ingram MA, Lauren BN, Pumpalova Y, Park J, Lim F, Bates SE, Kastrinos F, Manji GA, Kong CY, Hur C. Cost-effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab-paclitaxel in borderline resectable/locally advanced pancreatic cancer patients. Cancer Rep (Hoboken) 2022; 5:e1565. [PMID: 35122419 PMCID: PMC9458514 DOI: 10.1002/cnr2.1565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/11/2021] [Accepted: 09/21/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The 2020 National Comprehensive Cancer Network guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab-paclitaxel (G-nP) for borderline resectable/locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC). AIM The purpose of our study was to compare treatment outcomes, toxicity profiles, costs, and quality-of-life measures between these two treatments to further inform clinical decision-making. METHODS AND RESULTS We developed a decision-analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G-nP over 12 years. The model inputs were estimated using clinical trial data and published literature. The primary endpoint was incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted-life-year (QALY). Secondary endpoints included overall (OS) and progression-free survival (PFS), total cost of care, QALYs, PDAC resection rate, and monthly treatment-related adverse events (TRAE) costs (USD). FOLFIRINOX was the cost-effective strategy, with an ICER of $60856.47 per QALY when compared to G-nP. G-nP had an ICER of $44639.71 per QALY when compared to natural history. For clinical outcomes, more patients underwent an "R0" resection with FOLFIRINOX compared to G-nP (84.9 vs. 81.0%), but FOLFIRINOX had higher TRAE costs than G-nP ($10905.19 vs. $4894.11). A one-way sensitivity analysis found that the ICER of FOLFIRINOX exceeded the threshold when TRAE costs were higher or PDAC recurrence rates were lower. CONCLUSION Our modeling analysis suggests that FOLFIRNOX is the cost-effective treatment compared to G-nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow-up are needed to confirm our findings.
Collapse
Affiliation(s)
- Myles A. Ingram
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Brianna N. Lauren
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Yoanna Pumpalova
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Jiheum Park
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Francesca Lim
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Susan E. Bates
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Fay Kastrinos
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Division of Digestive and Liver DiseasesColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Gulam A. Manji
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Chung Yin Kong
- Division of General MedicineMount Sinai School of MedicineNew YorkNew YorkUSA
| | - Chin Hur
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Division of Digestive and Liver DiseasesColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| |
Collapse
|
6
|
Hill C, Sehgal S, Fu W, Hu C, Reddy A, Thompson E, Hacker‐Prietz A, Le D, De Jesus‐Acosta A, Lee V, Zheng L, Laheru DA, Burns W, Weiss M, Wolfgang C, He J, Herman JM, Meyer J, Narang A. High local failure rates despite high margin-negative resection rates in a cohort of borderline resectable and locally advanced pancreatic cancer patients treated with stereotactic body radiation therapy following multi-agent chemotherapy. Cancer Med 2022; 11:1659-1668. [PMID: 35142085 PMCID: PMC8986142 DOI: 10.1002/cam4.4527] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) for patients with borderline resectable and locally advanced pancreatic adenocarcinoma (BRPC/LAPC) remains controversial. Herein, we report on surgical, pathologic, and survival outcomes in BRPC/LAPC patients treated at a high-volume institution with induction chemotherapy (CTX) followed by 5-fraction SBRT. METHODS BRPC/LAPC patients treated between 2016 and 2019 were retrospectively reviewed. Surgical and pathological outcomes were descriptively characterized. Overall survival (OS) and progression-free survival (PFS) were analyzed using Cox proportional hazard regression. Locoregional failure and distant failure were analyzed with Fine-Gray competing risk model. RESULTS Of 155 patients, 91 (59%) had LAPC and 64 (41%) had BRPC. Almost all were treated with induction multi-agent CTX with either FOLFIRINOX (75%) or gemcitabine and nab-paclitaxel (24%) for a median duration of 4.0 months (1-18 months). All received SBRT to a median dose of 33 Gy. Among 64 BRPC patients, 50 (78%) underwent resection, of whom 48 (96%) achieved margin-negative (R0) resection. Among 91 LAPC patients, 57 (63%) underwent resection, of whom 50 (88%) achieved R0 resection. Despite the high R0 rate, 33% of patients experienced locoregional failure, which was a component of 44% of all failures. After SBRT, median OS and PFS were 18.7 and 7.7 months, respectively. After SBRT, 1- and 2-year OS probabilities were 70% and 45%, whereas, from diagnosis, they were 93% and 51%. CONCLUSIONS Although a high proportion of BRPC/LAPC patients treated with induction multi-agent CTX followed by SBRT successfully achieved R0 resection, locoregional failure remained common, highlighting the need to continue to optimize radiation delivery in this context.
Collapse
Affiliation(s)
- Colin Hill
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Shuchi Sehgal
- Philadelphia College of Osteopathic MedicinePhiladelphiaPennsylvaniaUSA
| | - Wei Fu
- Department of Biostatistics and BioinformaticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Chen Hu
- Department of Biostatistics and BioinformaticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Abhinav Reddy
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elizabeth Thompson
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amy Hacker‐Prietz
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Dung Le
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Ana De Jesus‐Acosta
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Valerie Lee
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Lei Zheng
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Daniel A. Laheru
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - William Burns
- Department of Medical OncologyThe Sidney Kimmel Comprehensive Cancer CenterBloomberg‐Kimmel Institute for Cancer Immunotherapy at Johns HopkinsBaltimoreMarylandUSA
| | - Matthew Weiss
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Christopher Wolfgang
- Department of SurgeryZucker School of Medicine at Hofstra/NorthwellLake SuccessNew YorkUSA
| | - Jin He
- Department of Medical OncologyThe Sidney Kimmel Comprehensive Cancer CenterBloomberg‐Kimmel Institute for Cancer Immunotherapy at Johns HopkinsBaltimoreMarylandUSA
| | - Joseph M. Herman
- Department of SurgeryNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| |
Collapse
|
7
|
Reddy AV, Hill CS, Sehgal S, He J, Zheng L, Herman JM, Meyer J, Narang AK. High neutrophil-to-lymphocyte ratio following stereotactic body radiation therapy is associated with poor clinical outcomes in patients with borderline resectable and locally advanced pancreatic cancer. J Gastrointest Oncol 2022; 13:368-379. [PMID: 35284125 PMCID: PMC8899739 DOI: 10.21037/jgo-21-513] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/24/2021] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The purpose of this study is to report on the prognostic role of pre- and post-stereotactic body radiation therapy (SBRT) neutrophil-to-lymphocyte ratio (NLR) in a cohort of patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) who was treated with multi-agent induction chemotherapy followed by five-fraction SBRT. METHODS Patients treated with multi-agent induction chemotherapy followed by SBRT from August 2016 to January 2019 and who had laboratory values available for review were included in the study. Univariate (UVA) and multivariate analyses (MVA) were performed to determine associations between pre-/post-SBRT NLR and overall survival (OS), local progression-free survival (LPFS), distant metastasis-free survival (DMFS), and progression-free survival (PFS). RESULTS A total of 156 patients were treated with multi-agent induction chemotherapy followed by SBRT and had laboratory values available for review. On UVA, chemotherapy duration ≥4 months, poorly differentiated disease, inability to undergo resection, pre-SBRT ANC ≥3.7 No./µL, pre-SBRT NLR ≥2.3, and post-SBRT NLR ≥2.6 were associated with worse OS. Patients with post-SBRT NLR ≥2.6 had a median OS of 16.7 months versus median OS not yet reached in patients with post-SBRT <2.6 (P=0.009). On MVA, poorly differentiated disease [hazard ratio (HR) =1.82, 95% CI: 1.04-3.18, P=0.035], inability to undergo resection (HR =2.17, 95% CI: 1.25-3.70, P=0.006), and post-SBRT NLR ≥2.6 (HR =2.55, 95% CI: 1.20-5.45, P=0.015) were associated with inferior OS. On UVA, baseline CA 19-9 ≥219 U/mL, pre-SBRT platelet count ≥157×1,000/µL, and post-SBRT NLR ≥2.6 were associated with inferior LPFS. Patients with post-SBRT NLR ≥2.6 had a median LPFS of 18.3 months versus median LPFS not yet reached in patients with post-SBRT <2.6 (P=0.028). On MVA, only post-SBRT NLR ≥2.6 was associated with worse LPFS (HR =3.22, 95% CI: 1.04-9.98, P=0.043). CONCLUSIONS Post-SBRT NLR ≥2.6 predicted for inferior OS and LPFS in BRPC/LAPC patients treated with multi-agent chemotherapy and SBRT. These findings highlight the importance of further elucidating the immunologic effects of radiation therapy in this setting, which may have significant implications on both radiation design as well as combination strategies.
Collapse
Affiliation(s)
- Abhinav V. Reddy
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Colin S. Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Shuchi Sehgal
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health, New Hyde Park, NY, USA
| | - Jeffrey Meyer
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Amol K. Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| |
Collapse
|
8
|
Yang L, Bai Y, Li Q, Chen J, Liu F, Weng X, Xu F. Analysis of the Curative Effect of Neoadjuvant Therapy on Pancreatic Cancer. Front Oncol 2021; 11:695645. [PMID: 34485131 PMCID: PMC8416459 DOI: 10.3389/fonc.2021.695645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/30/2021] [Indexed: 12/24/2022] Open
Abstract
The prevalence of pancreatic cancer is sharply increasing recently, which significantly increases the economic burden of the population. At present, the primary treatment of resectable pancreatic cancer is surgical resection, followed by chemotherapy with or without radiation. However, the recurrence rates remain high even after R0 resection. This treatment strategy does not distinguish undetected metastatic disease, and it is prone to postoperative complications. Neoadjuvant therapies, including neoadjuvant chemotherapy and radiotherapy, is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer. This review summarized and discussed clinical trials of neoadjuvant therapy for pancreatic cancer, comparing resection rates, outcome measures, and adverse reactions between neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy.
Collapse
Affiliation(s)
- Liqiong Yang
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Yun Bai
- Department of Public Health, Chengdu Medical College, Chengdu, China
| | - Qing Li
- Department of Anesthesiology, Gulinxian People's Hospital of Sichuan Province, Luzhou, China
| | - Jie Chen
- Department of Digestive Surgery, School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.,Department of Orthopedics, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fangfang Liu
- Department of Art, Art College, Southwest Minzu University, Chengdu, China
| | - Xiechuan Weng
- Department of Neuroscience, Beijing Institute of Basic Medical Sciences, Beijing, China
| | - Fan Xu
- Department of Public Health, Chengdu Medical College, Chengdu, China
| |
Collapse
|
9
|
Hani U, Osmani RAM, Siddiqua A, Wahab S, Batool S, Ather H, Sheraba N, Alqahtani A. A systematic study of novel drug delivery mechanisms and treatment strategies for pancreatic cancer. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
10
|
Kim SS, Lee S, Lee HS, Bang S, Park MS. Prognostic factors in patients with locally advanced or borderline resectable pancreatic ductal adenocarcinoma: chemotherapy vs. chemoradiotherapy. Abdom Radiol (NY) 2021; 46:655-666. [PMID: 32748250 DOI: 10.1007/s00261-020-02661-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To identify common and unique pre-treatment prognostic factors in patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC), treated with chemotherapy (CTx) or concurrent chemoradiotherapy (CRT). METHODS We enrolled 215 patients with BR/LA PDAC, who were treated with either CTx (n = 82) or CRT (n = 133) as a first-line treatment between 2013 and 2016. Clinical data and CT imaging findings for predicting overall survival (OS) and progression-free survival (PFS) were analyzed using Cox regression analysis. RESULTS Carbohydrate antigen (CA) 19-9 > 1000 U/mL (hazard ratio [HR] 1.91; p = 0.001) and non-homogeneous enhancement (HR 1.95; p < 0.001) were associated with shorter OS in all study populations. There was no significant difference in median OS (15.3 vs 16.8 months, p = 0.297) and PFS (10.0 vs 11.7 months, p = 0.321) between the CTx and CRT groups. Non-homogeneous enhancement (HR 2.04; p = 0.006) and presence of positive lymph node on CT (HR 2.38; p = 0.036) were associated with poor OS in the CTx group, while CA 19-9 > 1000 U/mL (HR 2.38; p = 0.001) and non-homogeneous enhancement (HR 1.73; p = 0.006) were independent predictors for poor OS in the CRT group. CONCLUSION Enhancement pattern on CT was a common prognostic factor for patients with PDAC treated with either CTx or CRT. Presence of positive lymph nodes on CT was a poor prognostic factor for the CTx group only, whereas CA 19-9 > 1000 U/mL was a poor prognostic factor for the CRT group only.
Collapse
Affiliation(s)
- Seung-Seob Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sunyoung Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi-Suk Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| |
Collapse
|
11
|
Ishido K, Hakamada K, Kimura N, Miura T, Wakiya T. Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2021; 5:7-23. [PMID: 33532676 PMCID: PMC7832965 DOI: 10.1002/ags3.12379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is highly malignant. While cancers in other organs have shown clear improvements in 5-year survival, the 5-year survival rate of pancreatic cancer is approximately 10%. Early relapse and metastasis are not uncommon, making it difficult to achieve an acceptable prognosis even after complete surgical resection of the pancreas. Studies have been performed on various treatments to improve the prognosis of PDAC, and multidisciplinary approaches including non-surgical treatments have led to gradual improvement. In the present literature review, we have described the significance of anatomical and biological resectability criteria, the concept of R0 resection in surgical treatment, the feasibility of minimally invasive surgery, the remarkable development of perioperative chemotherapy, the effectiveness of conversion surgery for unresectable PDAC, and ongoing challenges in PDAC treatment. We also provide an essential update on these subjects by focusing on recent trends and topics.
Collapse
Affiliation(s)
- Keinosuke Ishido
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Kenichi Hakamada
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Norihisa Kimura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Takuya Miura
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| | - Taiichi Wakiya
- Department of Gastroenterological SurgeryHirosaki University Graduate School of MedicineHirosakiJapan
| |
Collapse
|
12
|
Laura A, Anna C, Cinquepalmi M, Giovanni M, Sole MM, Nava AK, Niccolò P, Giuseppe N, Stefano V, Paolo A, Francesco D, Giovanni R. Is Complete Pathologic Response in Pancreatic Cancer Overestimated? A Systematic Review of Prospective Studies. J Gastrointest Surg 2020; 24:2336-2348. [PMID: 32583324 DOI: 10.1007/s11605-020-04697-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/11/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In literature, percentages of pathologic complete response (pCR) in patients presenting with resectable (RES), borderline resectable (BLR) or locally advanced (LA) pancreatic cancer (PaC) after neoadjuvant treatment (NADT) are variable, ranging 0-33%. Those data come mostly from retrospective reviews of single centres. The objective of this systematic review is to assess the incidence of pCR. METHODS Following the criteria of the PRISMA statement, a literature search was conducted looking for prospective papers focusing on neoadjuvant treatment in PaC. Retrospective papers, other than ductal carcinoma histologies and trials including metastatic patients, were excluded from the present review. Data extraction was carried out by 3 independent investigators. Meta-analysis was performed with ProMeta3 Software (Internovi, 2015). PROSPERO registry: CRD42018095641. RESULTS The literature search of Embase, Cochrane and Medline with the terms "neoadjuvant OR preoperative", "pancreatic OR pancreas" and "cancer OR adenocarcinoma OR tumor" led to the identification of 3128 papers. We restricted the search to humans, last 10 years and English language articles resulting in 1158 eligible articles to review. Extended paper revision led to the inclusion of 27 papers. Complete pathologic response ranged 0-11.11%, at the meta-analysis 4% (95% CI 3-5%), in prospective studies 0-9.09% and in prospective databases 1.63-11.11%. CONCLUSIONS Pathologic complete response in pancreatic cancer is actually infrequent: high-quality studies provide a more reliable picture of neoadjuvant effects, high rates of pCR are reported in selected retrospective studies but it is overestimated.
Collapse
Affiliation(s)
- Antolino Laura
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Crovetto Anna
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Matteo Cinquepalmi
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy.
| | - Moschetta Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Mattei Maria Sole
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Andrea Kazemi Nava
- Hepatopancreaticobiliary Group, Saint Vincent's University Hospital, Dublin, Ireland
| | - Petrucciani Niccolò
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Nigri Giuseppe
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Valabrega Stefano
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Aurello Paolo
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - D'Angelo Francesco
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Ramacciato Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| |
Collapse
|
13
|
Oba A, Ho F, Bao QR, Al-Musawi MH, Schulick RD, Del Chiaro M. Neoadjuvant Treatment in Pancreatic Cancer. Front Oncol 2020; 10:245. [PMID: 32185128 PMCID: PMC7058791 DOI: 10.3389/fonc.2020.00245] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Thanks to the development of modern chemotherapeutic regimens, survival after surgery for pancreatic ductal adenocarcinoma (PDAC) has improved and pancreatologists worldwide agree that the treatment of PDAC demands a multidisciplinary approach. Neoadjuvant treatment (NAT) plays a major role in the treatment of PDAC since only about 20% of patients are considered resectable at the time of diagnosis. Moreover, increasing data demonstrating the benefits of NAT for borderline resectable/locally advanced PDAC are driving a shift from up-front surgery to NAT in the multidisciplinary treatment of even resectable PDAC. Our understanding of the role of NAT in PDAC has evolved from tumor shrinkage to controlling potential micrometastases and selecting patients who may benefit from radical resection. The present review gives an overview on the current literature of NAT concepts for BR/LA PDAC and resectable PDAC.
Collapse
Affiliation(s)
- Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Felix Ho
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Quoc Riccardo Bao
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Mohammed H Al-Musawi
- Clinical Trials Office, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| |
Collapse
|
14
|
Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
Collapse
Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
| |
Collapse
|
15
|
Groot VP, Blair AB, Gemenetzis G, Ding D, Burkhart RA, Yu J, Borel Rinkes IH, Molenaar IQ, Cameron JL, Weiss MJ, Wolfgang CL, He J. Recurrence after neoadjuvant therapy and resection of borderline resectable and locally advanced pancreatic cancer. Eur J Surg Oncol 2019; 45:1674-1683. [DOI: 10.1016/j.ejso.2019.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/14/2019] [Accepted: 04/04/2019] [Indexed: 12/19/2022] Open
|
16
|
Tanaka M, Mihaljevic AL, Probst P, Heckler M, Klaiber U, Heger U, Büchler MW, Hackert T. Meta-analysis of recurrence pattern after resection for pancreatic cancer. Br J Surg 2019; 106:1590-1601. [DOI: 10.1002/bjs.11295] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/06/2019] [Accepted: 06/04/2019] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Initial recurrence mapping of resected pancreatic ductal adenocarcinoma (PDAC) could help in stratifying patient subpopulations for optimal postoperative follow-up. The aim of this systematic review and meta-analysis was to investigate the initial recurrence patterns of PDAC and to correlate them with clinicopathological factors.
Methods
MEDLINE and Web of Science databases were searched systematically for studies reporting first recurrence patterns after PDAC resection. Data were extracted from the studies selected for inclusion. Pooled odds ratios (ORs) and 95 per cent confidence intervals were calculated to determine the clinicopathological factors related to the recurrence sites. The weighted average of median overall survival was calculated.
Results
Eighty-nine studies with 17 313 patients undergoing PDAC resection were included. The weighted median rates of initial recurrence were 20·8 per cent for locoregional sites, 26·5 per cent for liver, 11·4 per cent for lung and 13·5 per cent for peritoneal dissemination. The weighted median overall survival times were 19·8 months for locoregional recurrence, 15·0 months for liver recurrence, 30·4 months for lung recurrence and 14·1 months for peritoneal dissemination. Meta-analysis revealed that R1 (direct) resection (OR 2·21, 95 per cent c.i. 1·12 to 4·35), perineural invasion (OR 5·19, 2·79 to 9·64) and positive peritoneal lavage cytology (OR 5·29, 3·03 to 9·25) were significantly associated with peritoneal dissemination as initial recurrence site. Low grade of tumour differentiation was significantly associated with liver recurrence (OR 4·15, 1·71 to 10·07).
Conclusion
Risk factors for recurrence patterns after surgery could be considered for specific surveillance and treatments for patients with pancreatic cancer.
Collapse
Affiliation(s)
- M Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - A L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - U Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| |
Collapse
|
17
|
Pathologic tumor response to neoadjuvant therapy in borderline resectable pancreatic cancer. Hepatobiliary Pancreat Dis Int 2019; 18:373-378. [PMID: 31176601 DOI: 10.1016/j.hbpd.2019.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy (NAT). The aim of this study was to determine the incidence of significant pathologic response to NAT in borderline resectable pancreatic cancer (BRPC), and association of NAT regimen and other clinico-pathologic characteristics with pathologic response. METHODS Patients with BRPC who underwent NAT and pancreatic resection between January 2012 and June 2017 were included. Pathologic response was assessed on a qualitative scale based on the College of American Pathologists grading system. Demographics and baseline characteristics, oncologic treatment, pathology, and survival outcomes were compared. RESULTS Seventy-one patients were included for analysis. Four patients had complete pathologic responses (tumor regression score 0), 12 patients had marked responses (score 1), 42 had moderate responses (score 2), and 13 had minimal responses (score 3). Patients with complete or marked responses were more likely to have received neoadjuvant gemcitabine chemoradiation (62.5%, 38.1%, and 23.1% of the complete/marked, moderate, and minimal response groups, respectively; P = 0.04). Of the complete/marked, moderate, and minimal response groups, margins were negative in 75.0%, 78.6%, and 46.2% (P = 0.16); node negative disease was observed in 87.5%, 54.8%, and 15.4% (P < 0.01); and median overall survival was 50.0 months, 31.7 months, and 23.2 months (P = 0.563). Of the four patients with pathologic complete responses, three were disease-free at 66.1, 41.7 and 31.4 months, and one was deceased with metastatic liver disease at 16.9 months. CONCLUSIONS A more pronounced pathologic tumor response to NAT in BRPC is correlated with node negative disease, but was not associated with a statistically significant survival benefit in this study.
Collapse
|
18
|
Clinical Characteristics of Patients Experiencing Pathologic Complete Response Following Neoadjuvant Therapy for Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma. Am J Clin Oncol 2019; 41:982-985. [PMID: 28968257 DOI: 10.1097/coc.0000000000000409] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The purpose of this study is to describe clinical characteristics and outcomes of patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) who achieved pathologic complete response (pCR) following neoadjuvant therapy. MATERIALS AND METHODS A single institution clinical database for patients with pancreatic ductal adenocarcinoma was queried. Between 2008 and 2014 patients were identified with BRPC and LAPC, who underwent surgical resection after receiving neoadjuvant treatment. Clinical and pathologic features of the patients who achieved pCR were acquired retrospectively. RESULTS Six patients were identified to have pCR on pathology of the postoperative specimen. On the basis of pretreatment clinical staging, 2 patients were considered to have BRPC and 4 LAPC. Four patients received gemcitabine-based chemotherapy and 2 patients received FOLFIRINOX (5-fluorouracil, oxaliplatin, irinotecan, and leucovorin). Five of 6 patients received radiation therapy before operative resection. Operative procedures included distal pancreatectomy (n=3) and pancreatoduodenectomy (n=3). Pancreatic intraepithelial neoplasia 1 to 2 was present in 3 cases, and pancreatic intraepithelial neoplasia 3 in 1 case. During a median follow-up of 21.3 months, 2 patients died, with a median survival of 11.0 months (range, 10.4 to 11.6 mo). Four patients are alive and continue to follow-up with median survival of 28.7 months (range, 20.1 to 42.4 mo). CONCLUSIONS Multimodality neoadjuvant therapy may lead to complete pathologic response in a small number of patients with borderline resectable/locally advanced pancreatic adenocarcinoma. pCR to neoadjuvant therapy does not lead to cure in most cases, and the majority of patients appear to relapse locally or systemically.
Collapse
|
19
|
Bradley A, Van Der Meer R. Neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer: A Markov decision analysis. PLoS One 2019; 14:e0212805. [PMID: 30817807 PMCID: PMC6394923 DOI: 10.1371/journal.pone.0212805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. In the absence of large randomized controlled trials offering a direct comparison, this study aims to use Markov decision analysis to compare efficacy of traditional surgery first (SF) and neoadjuvant treatment (NAT) pathways for potentially resectable pancreatic cancer. Methods An advanced Markov decision analysis model was constructed to compare SF and NAT pathways for potentially resectable pancreatic cancer. Transition probabilities were calculated from randomized control and Phase II/III trials after comprehensive literature search. Utility outcomes were measured in overall and quality-adjusted life months (QALMs) on an intention-to-treat basis as the primary outcome. Markov cohort analysis of treatment received was the secondary outcome. Model uncertainties were tested with one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Results SF gave 23.72 months (18.51 QALMs) versus 20.22 months (16.26 QALMs). Markov Cohort Analysis showed that where all treatment modalities were received NAT gave 35.05 months (29.87 QALMs) versus 30.96 months (24.86QALMs) for R0 resection and 34.08 months (29.87 QALMs) versus 25.85 months (20.72 QALMs) for R1 resection. One-way deterministic sensitivity analysis showed that NAT was superior if the resection rate was greater than 51.04% or below 75.68% in SF pathway. Two-way sensitivity analysis showed that pathway superiority depended on obtaining multimodal treatment in either pathway. Conclusion Whilst NAT is a viable alternative to traditional SF approach, superior pathway selection depends on the individual patient’s likelihood of receiving multimodal treatment in either pathway.
Collapse
Affiliation(s)
- Alison Bradley
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
- West of Scotland Pancreatic Cancer Unit, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Robert Van Der Meer
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
| |
Collapse
|
20
|
Raufi AG, Manji GA, Chabot JA, Bates SE. Neoadjuvant Treatment for Pancreatic Cancer. Semin Oncol 2019; 46:19-27. [DOI: 10.1053/j.seminoncol.2018.12.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
|
21
|
Hajatdoost L, Sedaghat K, Walker EJ, Thomas J, Kosari S. Chemotherapy in Pancreatic Cancer: A Systematic Review. ACTA ACUST UNITED AC 2018; 54:medicina54030048. [PMID: 30344279 PMCID: PMC6122094 DOI: 10.3390/medicina54030048] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023]
Abstract
Background and Aim: Pancreatic cancer is one of the most fatal cancers. Cytotoxic chemotherapy remains the mainstream treatment for unresectable pancreatic cancer. This systematic review evaluated and compared the overall survival (OS) and progression-free survival (PFS) outcomes obtained from recent phase 2 and 3 clinical trials of pancreatic cancer chemotherapy. Materials and methods: Thirty-two studies were included and compared based on chemotherapy agents or combinations used. Additionally, outcomes of first-line versus second-line chemotherapy in pancreatic cancer were compared. Results: In studies that investigated the treatments in adjuvant settings, the highest OS reported was for S-1 in patients, who received prior surgical resection (46.5 months). In neoadjuvant settings, the combination of gemcitabine, docetaxel, and capecitabine prior to the surgical resection had promising outcomes (OS of 32.5 months). In non-adjuvant settings, the highest OS reported was for the combination of temsirolimus plus bevacizumab (34.0 months). Amongst studies that investigated second-line treatment, the highest OS reported was for the combination of gemcitabine plus cisplatin (35.5 months), then temsirolimus plus bevacizumab (34.0 months). Conclusions: There is a need to develop further strategies besides chemotherapy to improve the outcomes in pancreatic cancer treatment. Future studies should consider surgical interventions, combination chemotherapy, and individualized second-line treatment based on the prior chemotherapy.
Collapse
Affiliation(s)
- Leva Hajatdoost
- Department of Pharmaceutical Sciences, Baha'i Institute for Higher Education (BIHE), Tehran 11369, Iran.
| | - Keyvan Sedaghat
- Department of Pharmaceutical Sciences, Baha'i Institute for Higher Education (BIHE), Tehran 11369, Iran.
| | - Erin J Walker
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
| | - Jackson Thomas
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, Canberra 2617 ACT, Australia.
| |
Collapse
|
22
|
Wang L, Cheng CS, Chen L, Chen Z. Benefit from the inclusion of surgery in the treatment of patients with stage III pancreatic cancer: a propensity-adjusted, population-based SEER analysis. Cancer Manag Res 2018; 10:1907-1918. [PMID: 30013397 PMCID: PMC6038853 DOI: 10.2147/cmar.s167103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose In the past 20 years, surgical resection has been a secure and applicable procedure for pancreatic cancer (PC), but it remains controversial for stage III PC with data evaluating its efficacy mostly derived from small randomized trials. Hence, we designed this study to further evaluate its benefit using surveillance, epidemiology, and end results dataset. Patients and methods Patients with stage III PC were identified in the surveillance, epidemiology, and end results registries from 2004 to 2014. The effect of surgery on cancer-specific survival was assessed by risk-adjusted Cox proportional hazard regression modeling and propensity score matching. Results Overall, 6,138 patients with stage III PC were included. Of these, 608 patients underwent primary tumor surgery. On multivariable analyses, surgery was independently associated with improved cancer-specific survival (HR=0.580; 95% CI=0.523–0.643, p<0.001). The survival benefit with surgery was also observed in the propensity score-matched cohort (HR=0.501; 95% CI=0.438–0.573, p<0.001). Conclusion Primary tumor surgery is associated with improved survival in stage III PC. Prospective randomized trials are needed to confirm these results, and further efforts are required to address patient selection.
Collapse
Affiliation(s)
- Lai Wang
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China, .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,
| | - Chien-Shan Cheng
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China, .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,
| | - Lianyu Chen
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China, .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,
| | - Zhen Chen
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai, China, .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China,
| |
Collapse
|
23
|
Intraoperative Radiotherapy in the Era of Intensive Neoadjuvant Chemotherapy and Chemoradiotherapy for Pancreatic Adenocarcinoma. Am J Clin Oncol 2018; 41:607-612. [DOI: 10.1097/coc.0000000000000336] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
24
|
Quan K, Sutera P, Xu K, Bernard ME, Burton SA, Wegner RE, Zeh H, Bahary N, Stoller R, Heron DE. Results of a prospective phase 2 clinical trial of induction gemcitabine/capecitabine followed by stereotactic ablative radiation therapy in borderline resectable or locally advanced pancreatic adenocarcinoma. Pract Radiat Oncol 2018; 8:95-106. [PMID: 29291966 DOI: 10.1016/j.prro.2017.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 09/22/2017] [Accepted: 10/03/2017] [Indexed: 01/18/2023]
Abstract
PURPOSE Stereotactic ablative radiation therapy's (SABR's) great conformity and short duration has become an attractive treatment modality. We report a phase 2 clinical trial to evaluate efficacy and safety of induction chemotherapy (ICT) followed by SABR in patient with borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). METHODS AND MATERIALS Patients with biopsy-proven BR or LA PDAC were treated with four 21-day cycles of intravenous gemcitabine and oral capecitabine. Patients were restaged within 4 weeks after ICT by computed tomography and treated by 3-fraction SABR if no metastasis or progressive disease was identified. Patients were restaged 4 weeks following SABR to determine resectability. Tumor response was assessed with carbohydrate antigen 19-9. RESULTS Thirty-five patients (19 BR/16 LA) were enrolled. The median age was 71.8 years (range, 50.6-81.1). ICT was completed in 91.4% (n = 32) of patients. All patients who completed ICT completed SABR. Of those 32 patients, 34.3% (n = 12: 10 BR, 2 LA) underwent pancreaticoduodenectomy and 11 of 12 (91.7%) received R0 resection. Median overall survival was 18.8, 28.3, and 14.3 months for the entire cohort, BR, and LA, respectively. The 2-year local progression-free survival (LPFS) was 44.9%, 40%, and 52% for the entire cohort, BR, and LA, respectively. For BR patients, multivariate analysis showed surgery was associated with better overall survival and LPFS. One-year LPFS for patients with surgery was 80% and 44% without surgery. Within the 15.4-month follow-up, no grade 3+ toxicity from SABR was observed. No significant quality of life change was observed before and after ICT, SABR, or surgery for BR or LA patients. CONCLUSIONS This is the first prospective phase 2 study to investigate the feasibility and efficacy of a 12-week gemcitabine/capecitabine ICT followed by SABR for BR or LA PDAC. The results suggest excellent tolerability, high R0 resection rates, and acceptable posttreatment complications.
Collapse
Affiliation(s)
- Kimmen Quan
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Philip Sutera
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Karen Xu
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Mark E Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Steven A Burton
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Rodney E Wegner
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Herbert Zeh
- Department of Surgical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Ronald Stoller
- Department of Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
| |
Collapse
|
25
|
Kluger MD, Rashid MF, Rosario VL, Schrope BA, Steinman JA, Hecht EM, Chabot JA. Resection of Locally Advanced Pancreatic Cancer without Regression of Arterial Encasement After Modern-Era Neoadjuvant Therapy. J Gastrointest Surg 2018; 22:235-241. [PMID: 28895032 DOI: 10.1007/s11605-017-3556-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/17/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Modern-era systemic therapy for locally advanced pancreatic adenocarcinoma (LAPC) offers improved survival relative to historical regimens but not necessarily improved radiographic downstaging to allow more patients to undergo resection. The aim of this study was to evaluate the survival, progression, and pathologic outcomes after resection of LAPC that did not regress from > 180 degrees arterial encasement after neoadjuvant therapy. METHODS Sixty-one LAPC patients were brought to the operating room after neoadjuvant therapy for NCCN-defined unresectable pancreatic cancer between 2012 and 2017. Pts were explored with intent of pancreatectomy and irreversible electroporation for margin extension; 5 (8%) had metastatic lesions on exploratory laparoscopy and were excluded from analyses. Imaging was re-examined to confirm LAPC prior to surgery. Data were analyzed from a prospective pancreatic cancer database. RESULTS Patients had arterial involvement of the celiac axis (37.5%) and/or superior mesenteric artery (42.9%) and/or an extended length of the common hepatic (n = 44.6%) artery. Twenty-nine males and 27 females, median 65 years of age, received neoadjuvant gemcitabine-based (58.9%) or FOLFIRINOX (35.7%) chemotherapy and stereotactic body (42.9%) or intensity-modulated (51.8%) radiation therapy. Median months from initiation of neoadjuvant therapy to surgery was 7.5. Sixty-one percent underwent Whipple, 21% distal, and 18% modified Appleby procedures; 57% patients underwent venous reconstruction. Ninety-day mortality was 2%. An R0 margin was achieved in 80%, and 53% were N0. Median overall and progression-free survival was 18.5 (95%CI 12.27-32.33) and 8.5 months (95%CI 6.0-15.0), respectively. One- and 3-year survival from surgery was 68.5% (95%CI 53.0-79.7) and 39.0% (95%CI 23.7-53.8), respectively. CONCLUSION With modern-era neoadjuvant therapy, R0 resections can be achieved in a majority of non-metastatic patients with locally advanced, unresectable disease based on cross-sectional imaging.
Collapse
Affiliation(s)
- Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - M Farzan Rashid
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Vilma L Rosario
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Jonathan A Steinman
- Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA. .,Division of GI & Endocrine Surgery, Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, 161 Fort Washington Ave-8th Floor, New York, NY, 10032, USA.
| |
Collapse
|
26
|
Sherman WH, Hecht E, Leung D, Chu K. Predictors of Response and Survival in Locally Advanced Adenocarcinoma of the Pancreas Following Neoadjuvant GTX with or Without Radiation Therapy. Oncologist 2017; 23:4-e10. [PMID: 29212734 PMCID: PMC5759824 DOI: 10.1634/theoncologist.2017-0208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/15/2017] [Indexed: 12/13/2022] Open
Abstract
LESSONS LEARNED There is no presenting parameter that predicts the success of neoadjuvant therapy for pancreatic cancer.Despite the images on scans following neoadjuvant therapy, all patients should be evaluated, because inflammation following radiation therapy (RT) may overstate the extent of tumor and vascular involvement. BACKGROUND In patients presenting with locally advanced pancreatic adenocarcinoma deemed unresectable by two pancreatic cancer surgeons, we analyzed presenting tumor size, extent of vascular involvement, tumor markers, response to neoadjuvant gemcitabine (G), docetaxel (T), and capecitabine (X) with or without additional chemoradiotherapy with GX on R0 resection rates (≥2 mm margins), and survival. METHODS All patients had baseline magnetic resonance imaging (MRI) and/or computed tomography (CT) scans and endoscopic ultrasound. A baseline positron emission tomography-computed tomography (PET-CT) was performed in 39 patients. The scans were reviewed by two radiologists.GTX (gemcitabine 750 mg/m2 and docetaxel 30 mg/m2 on days 4 and 11 with capecitabine 1,500 mg/m2 days 1-14) was administered on a 3-week schedule for 6 cycles to patients with both arterial and venous-only involvement. Patients in the arterial arm received GX/RT before surgery, and those in the venous arm received GX/RT after R1 resection. Standard-dose RT was delivered by intensity-modulated radiation therapy (IMRT) or conformal fields to 5040 cGy along with capecitabine for 5 days and gemcitabine on day 5 of weeks 1, 2, 4, and 5 of RT, starting with the first full week of RT.A cancer antigen test 19-9 (CA 19-9) was obtained at baseline and days 4 and 11 of each cycle. The rate of change in CA 19-9 was calculated using the formula: (Log10 CA 19-9 time 0) - (Log10 CA 19-9 at 9 weeks)/9 weeks. This was derived based on the observation that the fall in CA 19-9 following effective chemotherapy is a second-order function. RESULTS Of the 34 patients with arterial involvement and 11 with extensive venous involvement who met the eligibility criteria and began GTX, only 5 patients in the arterial arm did not undergo subsequent resection. The remaining 40 patients were included in this analysis of presenting parameters with respect to R0 resection, disease-free survival (DFS), and overall survival (OS). R0 resection was achieved in 28 of 40 patients (70%), and R1 resection in the remaining 12 (30%). The OS after R0 resection was a median 37 months (95% confidence interval [CI]: 29.3-44.7) compared with 29 months (95% CI: 28.5-41.5) for those with R1 resection.Excluding four postoperative deaths, median DFS for the 25 (71%) with R0 resection was 31 months (95% CI: 11.3-51.1), and the median DFS for R1 resection was only 14 months (95% CI: 11.1-17). Eleven of the twenty-eight (39%) patients achieving R0 resection have not relapsed (median = 45 months, range = 25-71 months). CONCLUSION R0 resection, the goal of neoadjuvant treatment, can be achieved in 70% of patients presenting with locally advanced pancreatic cancer. The median DFS was 31 months (95% CI: 11. 3-51.1). No relationship was found with tumor size, degree of vascular involvement, carcinoembryonic antigen test (CEA), CA 19-9, degree of tumor regression on scan, fall in CA 19-9, or SUV on PET scan and subsequent survival.
Collapse
Affiliation(s)
| | | | - David Leung
- Bristol-Meyers Squibb, New York, New York, USA
| | - Kyung Chu
- Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
27
|
Dhir M, Malhotra GK, Sohal DP, Hein NA, Smith LM, O’Reilly EM, Bahary N, Are C. Neoadjuvant treatment of pancreatic adenocarcinoma: a systematic review and meta-analysis of 5520 patients. World J Surg Oncol 2017; 15:183. [PMID: 29017581 PMCID: PMC5634869 DOI: 10.1186/s12957-017-1240-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent years have seen standardization of the anatomic definitions of pancreatic adenocarcinoma, and increasing utilization of neoadjuvant therapy (NAT). The aim of the current review was to summarize the evidence for NAT in pancreatic adenocarcinoma since 2009, when consensus criteria for resectable (R), borderline resectable (BR), and locally advanced (LA) disease were endorsed. METHODS PubMed search was undertaken along with extensive backward search of the references of published articles to identify studies utilizing NAT for pancreatic adenocarcinoma. Abstracts from ASCO-GI 2014 and 2015 were also searched. RESULTS A total of 96 studies including 5520 patients were included in the final quantitative synthesis. Pooled estimates revealed 36% grade ≥ 3 toxicities, 5% biliary complications, 21% hospitalization rate and low mortality (0%, range 0-16%) during NAT. The majority of patients (59%) had stable disease. On an intention-to-treat basis, R0-resection rates varied from 63% among R patients to 23% among LA patients. R0 rates were > 80% among all patients who were resected after NAT. Among R and BR patients who underwent resection after NAT, median OS was 30 and 27.4 months, respectively. CONCLUSIONS The current study summarizes the recent literature for NAT in pancreatic adenocarcinoma and demonstrates improving outcomes after NAT compared to those historically associated with a surgery-first approach for pancreatic adenocarcinoma.
Collapse
Affiliation(s)
- Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210 USA
| | - Gautam K. Malhotra
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 98198 USA
| | - Davendra P.S. Sohal
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Nicholas A. Hein
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Eileen M. O’Reilly
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA
| | - Nathan Bahary
- Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232 USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE 98198 USA
- Department of Surgery/Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198 USA
| |
Collapse
|
28
|
Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
Collapse
|
29
|
Zhan HX, Xu JW, Wu D, Wu ZY, Wang L, Hu SY, Zhang GY. Neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of prospective studies. Cancer Med 2017; 6:1201-1219. [PMID: 28544758 PMCID: PMC5463082 DOI: 10.1002/cam4.1071] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/13/2022] Open
Abstract
There is a strong rationale and many theoretical advantages for neoadjuvant therapy in pancreatic cancer (PC). However, study results have varied significantly. In this study, a systematic review and meta‐analysis of prospective studies were performed in order to evaluate safety and effectiveness of neoadjuvant therapy in PC. Thirty‐nine studies were selected (n = 1458 patients), with 14 studies focusing on patients with resectable disease (group 1), and 19 studies focusing on patients with borderline resectable and locally advanced disease (group 2). Neoadjuvant chemotherapy was administered in 97.4% of the studies, in which 76.9% was given radiotherapy and 74.4% administered with chemoradiation. The complete and partial response rate was 3.8% and 20.9%. The incidence of grade 3/4 toxicity was 11.3%. The overall resection rate after neoadjuvant therapy was 57.7% (group 1: 73.0%, group 2: 40.2%). The R0 resection rate was 84.2% (group 1: 88.2%, group 2: 79.4%). The overall survival for all patients was 16.79 months (resected 24.24, unresected 9.81; group 1: 17.76, group 2: 16.20). Our results demonstrate that neoadjuvant therapy has not been proven to be beneficial and should be considered with caution in patients with resectable PC. Patients with borderline resectable or locally advanced disease may benefit from neoadjuvant therapy, but further research is needed.
Collapse
Affiliation(s)
- Han-Xiang Zhan
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Jian-Wei Xu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Dong Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Zhi-Yang Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Lei Wang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - San-Yuan Hu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Guang-Yong Zhang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| |
Collapse
|
30
|
Palmarocchi MC, Balzarotti Canger RC, Saletti P. Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report. Oncol Lett 2017; 13:4445-4452. [PMID: 28588713 DOI: 10.3892/ol.2017.6026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/11/2017] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer mortality and is associated with a poor overall survival even when diagnosed early and considered resectable. Complete surgical removal with negative histological margins is an independent predictor of survival and remains the only potential curative treatment. In borderline resectable pancreatic adenocarcinoma (BRPAC), preoperative systemic therapy may increase resectability and margin-negative resection rate. There is no current consensus on the optimal chemotherapy regimen for BRPAC. The present case describes a patient with BRPAC who achieved a pathological complete response to neoadjuvant FOLFIRINOX (folinic acid, fluorouracil, irinotecan and oxaliplatin), but early relapse following a pancreaticoduodenectomy without vascular resection, with an uneventful postoperative course, except for a pulmonary embolism.
Collapse
Affiliation(s)
| | | | - Piercarlo Saletti
- Medical Oncology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
| |
Collapse
|
31
|
Kondo N, Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakagawa N, Takahashi S, Ohge H, Sueda T. A phase 1 study of gemcitabine/nab-paclitaxel/S-1 (GAS) combination neoadjuvant chemotherapy for patients with locally advanced pancreatic adenocarcinoma. Cancer Chemother Pharmacol 2017; 79:775-781. [DOI: 10.1007/s00280-017-3274-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/01/2017] [Indexed: 01/11/2023]
|
32
|
Glazer ES, Rashid OM, Klapman JB, Harris CL, Hodul PJ, Pimiento JM, Malafa MP. Endoscopic ultrasonography complements computed tomography in predicting portal or superior mesenteric vein resection in patients with borderline resectable pancreatic carcinoma. Pancreatology 2016; 17:130-134. [PMID: 28043760 DOI: 10.1016/j.pan.2016.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/30/2016] [Accepted: 12/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines recommend computed tomographic (CT) scans for vascular staging of patients with pancreatic carcinoma; however, endoscopic ultrasonography (EUS) in these patients is not required and its utility in combination with CT scan is less well-defined. The purpose of this study is to explore the utility of EUS in addition to CT in identifying patients with borderline resectable pancreatic carcinoma (BRPC). METHODS We reviewed our database of patients with BRPC who went to surgery with curative intent. Inclusion criteria were preoperative staging with CT scan and EUS, completion of neoadjuvant chemotherapy and radiotherapy, and surgical resection. RESULTS We identified 62 patients (average age of 65 ± 9 years, 60% male); 97% of patients underwent R0 resections. We found that 29% of patients were classified as BRPC by EUS alone, 23% by CT alone, and 48% by both modalities. Of 34 patients who required vein resection, EUS alone preoperatively identified 88% of these patients while CT alone identified 67%. EUS identified 11 patients who required vein resection that CT did not identify as BRPC, whereas CT identified 4 patients that EUS did not identify as BRPC. On multivariate analysis, EUS was associated with vein resection (P < 0.02), but CT scan findings, tumor size, and CA19-9 values were not associated (each P > 0.1). CONCLUSIONS EUS complemented CT in identifying BRPC patients requiring vein resection, with nearly one-third of patients identified with EUS alone, supporting EUS use in addition to CT scan for vascular staging of patients with pancreatic carcinoma.
Collapse
Affiliation(s)
- Evan S Glazer
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Omar M Rashid
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jason B Klapman
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Cynthia L Harris
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| |
Collapse
|
33
|
Benzing C, Hau HM, Atanasov G, Broschewitz J, Krenzien F, Bartels M, Wiltberger G. Outcome and complications of combined liver and pancreas resections: a retrospective analysis. Acta Chir Belg 2016; 116:340-345. [PMID: 27471834 DOI: 10.1080/00015458.2016.1186962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Combined resections of the liver and pancreas are related to high complication and mortality rates. The present study assessed the outcome of these procedures and identified specific risk factors for morbidity and mortality. METHODS Between January 2001 and April 2012, 28 combined liver/pancreas resections were performed at our institution. All patients were retrospectively analysed using a database with regards to baseline characteristics, surgical procedures, complications and survival. RESULTS Among the pancreatic resections, there were 12 (42.9%) Kausch-Whipple (KW), 9 (32.1%) pylorus-preserving pancreaticoduodenectomy (PPPD), 6 (21.4%) distal pancreatectomies (DP) and 1 (3.6%) total pancreaticoduodenectomy (TPD). In 12 (48.9%) cases, major complications (grade IIIb-V) were observed. Overall survival was 35 months (SD = 40.5) and the 3-year survival rate was 35.7% (1-year survival rate: 50%). DISCUSSION Combined resections of the liver and pancreas are associated with high complication rates, especially if major liver resections are performed. Therefore, it is mandatory to do a thorough evaluation of potential patients.
Collapse
Affiliation(s)
- Christian Benzing
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Georgi Atanasov
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Johannes Broschewitz
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Felix Krenzien
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Michael Bartels
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Georg Wiltberger
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| |
Collapse
|
34
|
Phase 1B trial of Nab-paclitaxel plus gemcitabine, capecitabine, and cisplatin (PAXG regimen) in patients with unresectable or borderline resectable pancreatic adenocarcinoma. Br J Cancer 2016; 115:290-6. [PMID: 27404453 PMCID: PMC4973162 DOI: 10.1038/bjc.2016.209] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/23/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nab-paclitaxel-gemcitabine combination significantly improved overall survival over gemcitabine in metastatic pancreatic adenocarcinoma. A phase 1b trial was performed (ClinicalTrials.gov number, NCT01730222) to determine the recommended phase 2 dose (RP2D) of nab-paclitaxel in combination with cisplatin, capecitabine, and gemcitabine at fixed dose (800, 30, and 1250 mg m(-2) every 2 weeks, respectively; PAXG regimen). METHODS Nab-paclitaxel doses were escalated from 100 (level one) to 125 (level two) and 150 mg m(-2) (level three) every 2 weeks in cohorts of 3-6 patients with pathologically confirmed unresectable or borderline resectable pancreatic adenocarcinoma. RESULTS Between Dec 2012 and Apr 2014, 24 patients were enroled (3 at level one, 5 at level two, 16 at level three) and received 117 cycles of PAXG. No dose-limiting toxicity occurred and level three was the RP2D. At this dose, nab-paclitaxel dose-intensity was 91%. Worse per patient grade 3/4 toxicity were neutropenia 25/31%; fatigue 19%; anaemia and hand-foot syndrome 12%, nausea 6%, and febrile neutropenia 6%. A partial response (PR) was observed in 16 (67%) and stable disease (SD) in 8 patients (33%). Among 21 patients with a baseline positive positron emission tomography (PET) scan, a complete metabolic response was observed in 9 (43%), PR in 10 (48%), SD in 2. CA19-9 decreased by ⩾49% in all the 19 patients with elevated basal value. Six patients were resected after chemotherapy. Progression-free survival at 6 months (PFS-6) was 96%. CONCLUSIONS The RP2D of nab-paclitaxel in the PAXG regimen was 150 mg m(-2) every 2 weeks. The preliminary results are promising and warrant further exploration.
Collapse
|
35
|
Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
|
36
|
Spadi R, Brusa F, Ponzetti A, Chiappino I, Birocco N, Ciuffreda L, Satolli MA. Current therapeutic strategies for advanced pancreatic cancer: A review for clinicians. World J Clin Oncol 2016; 7:27-43. [PMID: 26862489 PMCID: PMC4734936 DOI: 10.5306/wjco.v7.i1.27] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/22/2015] [Accepted: 11/23/2015] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) would become the second leading cause of cancer death in the near future, despite representing only 3% of new cancer diagnosis. Survival improvement will come from a better knowledge of risk factors, earlier diagnosis, better integration of locoregional and systemic therapies, as well as the development of more efficacious drugs rising from a deeper understanding of disease biology. For patients with unresectable, non-metastatic disease, combined strategies encompassing primary chemotherapy and radiation seems to be promising. In fit patients, new polychemotherapy regimens can lead to better outcomes in terms of slight but significant survival improvement associated with a positive impact on quality of life. The upfront use of these regimes can also increase the rate of radical resections in borderline resectable and locally advanced PC. Second line treatments showed to positively affect both overall survival and quality of life in fit patients affected by metastatic disease. At present, oxaliplatin-based regimens are the most extensively studied. Nonetheless, other promising drugs are currently under evaluation. Presently, in addition to surgery and conventional radiation therapy, new locoregional treatment techniques are emerging as alternative options in the multimodal approach to patients or diseases not suitable for radical surgery. As of today, in contrast with other types of cancer, targeted therapies failed to show relevant activity either alone or in combination with chemotherapy and, thus, current clinical practice does not include them. Up to now, despite the fact of extremely promising results in different tumors, also immunotherapy is not in the actual therapeutic armamentarium for PC. In the present paper, we provide a comprehensive review of the current state of the art of clinical practice and research in PC aiming to offer a guide for clinicians on the most relevant topics in the management of this disease.
Collapse
|
37
|
Chand S, O'Hayer K, Blanco FF, Winter JM, Brody JR. The Landscape of Pancreatic Cancer Therapeutic Resistance Mechanisms. Int J Biol Sci 2016; 12:273-82. [PMID: 26929734 PMCID: PMC4753156 DOI: 10.7150/ijbs.14951] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic cancer (pancreatic ductal adenocarcinoma, PDA) is infamously moving to the top of the list as one of the most lethal cancers with an overall 5 year survival rate of 7%. Multiple genomic-based and molecular characterization studies of PDA specimens and established animal models have provided the field with multiple targets and a progression model of this disease. Still, to date, the best therapeutic options are surgery and combination cytotoxic therapies. In general, even in the best case scenario (i.e., an early stage diagnosis and a response to a specific therapy), most of these fortunate patients' PDA cells acquire or exert resistance mechanisms and eventually kill the patient. Herein, we touch on a growing field of investigation that focuses on PDA cell therapeutic resistance mechanisms. We examine extrinsic elements (i.e., the tumor microenvironment, hypoxia) to the intrinsic processes within the cell (i.e., post-transcriptional gene regulation and somatic mutations) that are important for therapeutic efficacy and resistance. Even as better targeted and personalized approaches move through the clinical trial pipeline the discussed resistance mechanisms will most likely play a role in the management of this deadly disease.
Collapse
Affiliation(s)
- Saswati Chand
- 1. Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center
| | - Kevin O'Hayer
- 1. Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center;; 2. Department of Medical Oncology, and the; 3. Department of Pharmacology & Experimental Therapeutics, Division of Clinical Pharmacology, Thomas Jefferson University, Philadelphia PA
| | - Fernando F Blanco
- 1. Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center;; 3. Department of Pharmacology & Experimental Therapeutics, Division of Clinical Pharmacology, Thomas Jefferson University, Philadelphia PA
| | - Jordan M Winter
- 1. Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center
| | - Jonathan R Brody
- 1. Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center
| |
Collapse
|
38
|
Kluger MD, Epelboym I, Schrope BA, Mahendraraj K, Hecht EM, Susman J, Weintraub JL, Chabot JA. Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients. Ann Surg Oncol 2015; 23:1736-43. [PMID: 26714959 DOI: 10.1245/s10434-015-5034-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.
Collapse
Affiliation(s)
- Michael D Kluger
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
| | - Irene Epelboym
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Krishnaraj Mahendraraj
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth M Hecht
- Division of Abdominal Imaging, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Jonathan Susman
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Joshua L Weintraub
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
39
|
Treatment of 200 locally advanced (stage III) pancreatic adenocarcinoma patients with irreversible electroporation: safety and efficacy. Ann Surg 2015; 262:486-94; discussion 492-4. [PMID: 26258317 DOI: 10.1097/sla.0000000000001441] [Citation(s) in RCA: 273] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Ablative therapies have been increasingly utilized in the treatment of locally advanced pancreatic cancer (LAPC). Irreversible electroporation (IRE) is an energy delivery system, effective in ablating tumors by inducing irreversible membrane destruction of cells. We aimed to demonstrate efficacy of treatment with IRE as part of multimodal treatment of LAPC. METHODS From July 2010 to October 2014, patients with radiographic stage III LAPC were treated with IRE and monitored under a multicenter, prospective institutional review board-approved registry. Perioperative 90-day outcomes, local failure, and overall survival were recorded. RESULTS A total of 200 patients with LAPC underwent IRE alone (n = 150) or pancreatic resection plus IRE for margin enhancement (n = 50). All patients underwent induction chemotherapy, and 52% received chemoradiation therapy as well for a median of 6 months (range, 5-13 months) before IRE. IRE was successfully performed in all patients. Thirty-seven percent of patients sustained complications, with a median grade of 2 (range, 1-5). Median length of stay was 6 days (range, 4-36 days). With a median follow-up of 29 months, 6 patients (3%) have experienced local recurrence. Median overall survival was 24.9 months (range: 4.9-85 months). CONCLUSIONS For patients with LAPC (stage III), the addition of IRE to conventional chemotherapy and radiation therapy results in substantially prolonged survival compared with historical controls. These results suggest that ablative control of the primary tumor may prolong survival.
Collapse
|
40
|
Liu Z, Du R, Long J, Guo K, Ge C, Bi S, Xu Y. microRNA-218 promotes gemcitabine sensitivity in human pancreatic cancer cells by regulating HMGB1 expression. Chin J Cancer Res 2015; 27:267-78. [PMID: 26157323 DOI: 10.3978/j.issn.1000-9604.2015.04.06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/24/2015] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The purpose of this study was to examine the effect of gemcitabine (GEM) on microRNA-218 (miR-218) expression in human pancreatic cancer cells. METHODS Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed to examine the differences in miR-218 expression between the GEM-sensitive BxPC-3 pancreatic cancer cells and GEM-resistant PANC-1 cells. The effect of GEM on the expression of miR-218 in PANC-1 cells was also investigated. PANC-1 cells were transfected either with HMGB1 siRNA to knock down the expression of HMGB1 or with the recombinant HMGB1 expression vector (pcDNA3.1-HMGB1) to overexpress HMGB1. The effect of ectopic expression of HMGB1 on the apoptosis of miR-218-transfected and GEM-treated PANC-1 cells was examined by flow cytometric analysis. RESULTS The miR-218 expression level was lower in GEM-resistant PANC-1 cells compared to GEM-sensitive BxPC-3 cells (P<0.05). The percentage of apoptotic PANC-1 cells was significantly increased in the miR-218 mimic + GEM group compared to the mimic ctrl + GEM group and the normal control group (P<0.01). The HMGB1 expression level was markedly decreased in PANC-1 cells transfected with HMGB1 siRNA but was significantly increased in PANC-1 cells transfected with the recombinant HMGB1 expression vector, pcDNA3.1-HMGB1 (P<0.01). The proportion of apoptotic PANC-1 cells was significantly lower in the miR-218 mimic + GEM + pcDNA3.1-HMGB1 group compared to the miR-218 mimic + GEM + HMGB1 siRNA group (P<0.01). CONCLUSIONS The expression level of miR-218 was downregulated in the GEM-resistant cell line. miR-218 promoted the sensitivity of PANC-1 cells to GEM, which was achieved mainly through regulating the expression of HMGB1 in PANC-1 cells.
Collapse
Affiliation(s)
- Zhe Liu
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Ruixia Du
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Jin Long
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Kejian Guo
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Chunlin Ge
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Shulong Bi
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| | - Yuanhong Xu
- 1 Department of Pancreatic Surgery, First Hospital of China Medical University, Shenyang 110001, China ; 2 Department of Otorhinolaryngology, Fengtian Hospital, Shenyang Medical University, Shenyang 110024, China
| |
Collapse
|
41
|
Sho M, Akahori T, Tanaka T, Kinoshita S, Nagai M, Tamamoto T, Ohbayashi C, Hasegawa M, Kichikawa K, Nakajima Y. Importance of resectability status in neoadjuvant treatment for pancreatic cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:563-70. [PMID: 25921623 DOI: 10.1002/jhbp.258] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/29/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Much attention has been paid to neoadjuvant treatment (NAT) as a new strategy especially for borderline resectable pancreatic cancer (BRPC). However, the optimal indication of NAT remains undetermined. METHODS We analyzed 248 patients with pancreatic cancer (PC). One hundred resectable tumors were classified as R group. Sixty-nine tumors with venous involvement were classified as BR-P group, while 31 tumors with arterial involvement were classified as BR-A group. Ninety-nine patients received NAT. Furthermore, 48 unresectable locally advanced PC served as controls (LAPC group). Among them, 11 patients received adjuvant surgery afterwards (Ad-surg group). RESULTS The overall median survival time in the R, BR-P and BR-A groups was 45.3, 24.8 and 16.8 months. In the R and BR-P groups, patients treated with NAT had a better prognosis than those without. In contrast, NAT had no impact on prognosis in the BR-A group. Patients treated with NAT in the BR-P, but not BR-A group, had a better prognosis than patients in the LAPC group. Furthermore, patients in the Ad-surg group had a significantly better prognosis than patients in the BR-A group. CONCLUSIONS Borderline resectable pancreatic cancer with venous involvement, but without arterial involvement, may be a good indication for NAT. Our data highlight the importance of preoperative resectability assessment to evaluate the indication and efficacy of NAT.
Collapse
Affiliation(s)
- Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoichi Kinoshita
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuro Tamamoto
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Chiho Ohbayashi
- Department of Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | | |
Collapse
|