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Nappo G, Donisi G, Zerbi A. Borderline resectable pancreatic cancer: Certainties and controversies. World J Gastrointest Surg 2021; 13:516-528. [PMID: 34194610 PMCID: PMC8223708 DOI: 10.4240/wjgs.v13.i6.516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Greta Donisi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
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Adjuvant chemotherapy versus observation following neoadjuvant therapy and surgery for resectable stages I–II pancreatic cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021; 21:383-392. [DOI: 10.1017/s1460396921000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Aim:
This National Cancer Database (NCDB) analysis was performed to evaluate the outcomes of adjuvant chemotherapy (AC) versus observation for resected pancreatic adenocarcinoma treated with neoadjuvant therapy (NT).
Materials and methods:
The NCDB was queried for primary stages I–II cT1-3N0-1M0 resected pancreatic adenocarcinoma treated with NT (2004–2015). Baseline patient, tumour and treatment characteristics were extracted. The primary end point was overall survival (OS). With a 6-month conditional landmark, Kaplan–Meier analysis, multivariable Cox proportional hazards method and 1:1 propensity score matching was used to analyse the data.
Results:
A total of 1,737 eligible patients were identified, of which 1,247 underwent post-operative observation compared to 490 with AC. The overall median follow-up was 34·7 months. The addition of AC showed improved survival on the multivariate analysis (HR 0·78, p < 0·001). AC remained statistically significant for improved OS, with a median OS of 26·3 months versus 22·3 months and 2-year OS of 63·9% versus 52·9% for the observation cohort (p < 0·001). Treatment interaction analysis showed OS benefit of AC for patients with smaller tumours.
Findings:
Our findings suggest a survival benefit for AC compared to observation following NT and surgery for resectable pancreatic adenocarcinoma, especially in patients with smaller tumours.
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Ettrich TJ, Berger AW, Perkhofer L, Daum S, König A, Dickhut A, Wittel U, Wille K, Geissler M, Algül H, Gallmeier E, Atzpodien J, Kornmann M, Muche R, Prasnikar N, Tannapfel A, Reinacher-Schick A, Uhl W, Seufferlein T. Neoadjuvant plus adjuvant or only adjuvant nab-paclitaxel plus gemcitabine for resectable pancreatic cancer - the NEONAX trial (AIO-PAK-0313), a prospective, randomized, controlled, phase II study of the AIO pancreatic cancer group. BMC Cancer 2018; 18:1298. [PMID: 30594153 PMCID: PMC6311014 DOI: 10.1186/s12885-018-5183-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Even clearly resectable pancreatic cancer still has an unfavorable prognosis. Neoadjuvant or perioperative therapies might improve the prognosis of these patients. Thus, evaluation of perioperative chemotherapy in resectable pancreatic cancer in a prospective, randomized trial is warranted. A substantial improvement in overall survival of patients with metastatic pancreatic cancer with FOLFIRINOX and nab-paclitaxel/gemcitabine vs standard gemcitabine has been demonstrated in phase III-trials. Indeed nab-paclitaxel/gemcitabine has a more favorable toxicity profile compared to the FOLFIRINOX protocol and appears applicable in a perioperative setting. Methods NEONAX is an interventional, prospective, randomized, controlled, open label, two sided phase II study with an unconnected analysis of the results in both experimental arms against a fixed survival probability (38% at 18 months with adjuvant gemcitabine), NCT02047513. NEONAX will enroll 166 patients with resectable pancreatic ductal adenocarcinoma (≤ cT3, N0 or N1, cM0) in two arms: Arm A (perioperative arm): 2 cycles nab-paclitaxel (125 mg/m2)/gemcitabine (1000 mg/m2, d1, 8 and 15 of an 28 day-cycle) followed by tumor surgery followed by 4 cycles nab-paclitaxel/gemcitabine, Arm B (adjuvant arm): tumor surgery followed by 6 cycles nab-paclitaxel/gemcitabine. The randomization (1:1) is eminent to avoid allocation bias between the groups. Randomization is stratified for tumor stage (ct1/2 vs. cT3) and lymph node status (cN0 vs. cN1). Primary objective is disease free survival (DFS) at 18 months after randomization. Key secondary objectives are 3-year overall survival (OS) rate and DFS rate, progression during neoadjuvant therapy, R0 and R1 resection rate, quality of life and correlation of DFS, OS and tumor regression with pharmacogenomic markers, tumor biomarkers and molecular analyses (ctDNA, transcriptome, miRNA-arrays). In addition, circulating tumor-DNA will be analyzed in patients with the best and the worst responses to the neoadjuvant treatment. The study was initiated in March 2015 in 26 centers for pancreatic surgery in Germany. Discussion The NEONAX trial is an innovative study on resectable pancreatic cancer and currently one of the largest trials in this field of research. It addresses the question of the role of intensified perioperative treatment with nab-paclitaxel plus gemcitabine in resectable pancreatic cancers to improve disease-free survival and offers a unique potential for translational research. Trial registration ClinicalTrials.gov: NCT02047513, 08/13/2014. Electronic supplementary material The online version of this article (10.1186/s12885-018-5183-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Andreas W Berger
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Severin Daum
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité University Medicine Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Alexander König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Andreas Dickhut
- Department of Oncology/Hematology, Fulda Hospital, Pacelliallee 4, 36043, Fulda, Germany
| | - Uwe Wittel
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Kai Wille
- Department of Hematology and medical oncology, Johannes-Wesling-Klinikum Minden, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Hirschlandstr. 97, 73730 Esslingen, Esslingen, Germany
| | - Hana Algül
- Department of Internal Medicine II, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Eike Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Jens Atzpodien
- Department of Medical Oncology and Hematology, Niels-Stensen-Kliniken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Marko Kornmann
- Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89081, Ulm, Germany
| | - Nicole Prasnikar
- Department of Oncologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Andrea Tannapfel
- Department of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Internal Medicine, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Oncological Benefits of Neoadjuvant Chemoradiation With Gemcitabine Versus Upfront Surgery in Patients With Borderline Resectable Pancreatic Cancer. Ann Surg 2018; 268:215-222. [PMID: 29462005 DOI: 10.1097/sla.0000000000002705] [Citation(s) in RCA: 456] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
OPINION STATEMENT Pancreatic adenocarcinoma 2030 (PCa) is predicted to be the second leading cause of cancer death in USA by 2030. To date, attempts at early detection have been unsuccessful. Therapies for resectable PCa include surgery followed by adjuvant chemotherapy with or without radiotherapy. Unfortunately, most patients with PCa present with advanced disease and thus only 20% of patients are potentially resectable upon presentation. Improved surgical techniques along with adjuvant combination chemotherapy have improved outcomes for patients with resectable disease. The optimal treatment approach for borderline resectable and locally advanced unresectable PCa has not yet been defined. Despite significant advances in the palliative treatment of PCa, long-term survival of early stage disease continues to be sobering. The key to improving outcomes for this largely fatal disease is to identify multidisciplinary therapeutic interventions including surgical, medical, and radiation techniques tailored to the patient and their disease characteristics. The neoadjuvant approach provides an in vivo platform to test novel treatment options to help us understand tumor biology and surrounding microenvironment, which may ultimately help us achieve the goal of improvement in long-term survival. While the neoadjuvant approach remains popular as a way to optimally select patients that might benefit most from surgery, randomized trials utilizing adjuvant and neoadjuvant novel therapies hold the key to truly personalizing the ideal treatment strategy for localized PCa.
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Itchins M, Arena J, Nahm CB, Rabindran J, Kim S, Gibbs E, Bergamin S, Chua TC, Gill AJ, Maher R, Diakos C, Wong M, Mittal A, Hruby G, Kneebone A, Pavlakis N, Samra J, Clarke S. Retrospective cohort analysis of neoadjuvant treatment and survival in resectable and borderline resectable pancreatic ductal adenocarcinoma in a high volume referral centre. Eur J Surg Oncol 2017; 43:1711-1717. [PMID: 28688722 DOI: 10.1016/j.ejso.2017.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/28/2017] [Accepted: 06/09/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease. Neoadjuvant therapy (NA) with chemotherapy (NAC) and radiotherapy (RT) prior to surgery provides promise. In the absence of prospective data, well annotated clinical data from high-volume units may provide pilot data for randomised trials. METHODS Medical records from a tertiary hospital in Sydney, Australia, were analysed to identify all patients with resectable or borderline resectable PDAC. Data regarding treatment, toxicity and survival were collected. RESULTS Between January 1 2010 and April 1 2016, 220 sequential patients were treated: 87 with NA and 133 with upfront operation (UO). Forty-three NA patients (52%) and 5 UO patients (4%) were borderline resectable at diagnosis. Twenty-four borderline patients received NA RT, 22 sequential to NAC. The median overall survival (OS) in the NA group was 25.9 months (mo); 95% CI (21.1-43.0 mo) compared to 26.9 mo (19.7, 32.7) in the UO; HR 0.89; log-ranked p-value = 0.58. Sixty-nine NA patients (79%) were resected, mOS was 29.2 mo (22.27, not reached (NR)). Twenty-two NA (31%) versus 22 UO (17%) were node negative at operation (N0). In those managed with NAC/RT the mOS was 29.0 mo (17.3, NR). There were no post-operative deaths with NA within 90-days and three in the UO arm. DISCUSSION This is a hypothesis generating retrospective review of a selected real-world population in a high-throughput unit. Treatment with NA was well tolerated. The long observed survival in this group may be explained by lymph node sterilisation by NA, and the achievement of R0 resection in a greater proportion of patients.
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Affiliation(s)
- M Itchins
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia.
| | - J Arena
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - C B Nahm
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - J Rabindran
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - S Kim
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - E Gibbs
- National Health and Medical Research Council Clinical Trial Centre (NHMRC CTC), The University of Sydney, Australia
| | - S Bergamin
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - T C Chua
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - A J Gill
- Sydney Medical School (Northern), The University of Sydney, Australia; Cancer Diagnosis and Pathology, Kolling Institute, Royal North Shore Hospital, Sydney, Australia
| | - R Maher
- Department of Radiology, Royal North Shore Hospital, Australia
| | - C Diakos
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
| | - M Wong
- Department of Medical Oncology, Gosford Hospital, New South Wales, Australia
| | - A Mittal
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - G Hruby
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - A Kneebone
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - N Pavlakis
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
| | - J Samra
- Upper GI Surgical Unit, Department of Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia
| | - S Clarke
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School (Northern), The University of Sydney, Australia; Northern Cancer Institute, Sydney, NSW, Australia
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Perioperative chemotherapy is associated with a survival advantage in early stage adenocarcinoma of the pancreatic head. Surgery 2016; 160:714-24. [PMID: 27422328 DOI: 10.1016/j.surg.2016.05.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/28/2016] [Accepted: 05/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The value of neoadjuvant chemotherapy in the treatment of early stage pancreatic cancer is not yet clear. METHODS We evaluated patients from the National Cancer Data Base who underwent pancreaticoduodenectomy for clinical stage I and II pancreatic adenocarcinoma between 2006 and 2012. RESULTS In total, 7,881 patients were identified. Of these, 27.5% received no chemotherapy, 57.4% received adjuvant chemotherapy, 10.2% received neoadjuvant chemotherapy alone, and 4.9% received perioperative chemotherapy, both preoperative and postoperative chemotherapy. Neoadjuvant chemotherapy use (neoadjuvant chemotherapy alone and perioperative chemotherapy) increased from 12.0% in 2006 to 20.2% in 2012. Patients who received chemotherapy prior to the operation (neoadjuvant chemotherapy alone and perioperative chemotherapy) had greater rates of margin negative (80.2% vs 73.0%, P < .001) and node negative (58.2% vs 28.7%, P < .001) resections and shorter mean durations of stay (12.0 vs 11.1 days, P = .012) than those receiving either adjuvant chemotherapy or no chemotherapy at all. There were no differences in 30-day unplanned readmissions (P = .074) and 90-day mortality (P = .227). On Cox survival analysis, adjusted for clinical variables including age and comorbid disease, patients undergoing perioperative chemotherapy, adjuvant chemotherapy, and neoadjuvant chemotherapy alone demonstrated significantly improved overall survival relative to that of patients undergoing resection alone (all P < .001). Patients receiving perioperative chemotherapy demonstrated a significant overall survival advantage compared with those receiving adjuvant chemotherapy (hazard ratio 0.75; 95% confidence interval, 0.65-0.85). Neoadjuvant chemotherapy alone had a marginal overall survival benefit compared with adjuvant chemotherapy (hazard ratio 0.89; 95% confidence interval, 0.81-0.98). CONCLUSION Early stage pancreatic cancer patients who receive perioperative chemotherapy have better overall survival than those receiving no chemotherapy, adjuvant chemotherapy, or neoadjuvant chemotherapy alone. Patterns of postoperative morbidity are similar regardless of the sequence of therapy. Neoadjuvant chemotherapy should be considered for patients presenting with early stage pancreatic cancer.
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Abstract
OBJECTIVES Despite pancreatic cancer being the fifth highest cause of cancer death in developed regions, there is a paucity of population-based management details for patients with pancreatic cancer. The objective of this study was to reflect on current practice and outcomes to facilitate future improvement. METHODS A comprehensive population-based patterns-of-care study in 2 Australian states was conducted. Patients diagnosed with pancreatic adenocarcinoma between July 2009 and June 2011 were identified by cancer registries, and detailed clinical data were collected from medical records. RESULTS Data were collected for 1863 patients, 96% of those eligible. The majority resided in major cities; their median age was 72 years, and 54% were men. Over half of the cases (58%) had metastatic disease at diagnosis. Resection was attempted for 20% of patients but only completed in 15%. The uptake of adjuvant chemotherapy (76%) and the proportion alive at 1-year (22%) were higher than reported in previous population-based reports. Of those with no complete surgical resection, 43% received palliative chemotherapy. CONCLUSIONS This population-based overview of the management of patients with pancreatic cancer suggests that, despite evidence that the proportion surviving and the use of adjuvant chemotherapy has increased, there may still be underutilization of cancer-directed therapies.
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Desai NV, Sliesoraitis S, Hughes SJ, Trevino JG, Zlotecki RA, Ivey AM, George TJ. Multidisciplinary neoadjuvant management for potentially curable pancreatic cancer. Cancer Med 2015; 4:1224-39. [PMID: 25766842 PMCID: PMC4559034 DOI: 10.1002/cam4.444] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 12/24/2022] Open
Abstract
Pancreatic adenocarcinoma remains the fourth leading cause of cancer mortality in the U.S. Despite advances in surgical technique, radiotherapy technologies, and chemotherapeutics, the 5-year survival rate remains approximately 20% for the 15% of patients who are eligible for surgical resection. The majority of this group suffers metastatic recurrence. However, despite advances in therapies for patients with advanced pancreatic cancer, only surgery has consistently proven to improve long-term survival. Various combinations of chemotherapy, biologic-targeted therapy, and radiotherapy have been evaluated in different settings to improve outcomes. In this context, a neoadjuvant (preoperative) treatment strategy offers numerous potential benefits: (1) ensuring delivery of early, systemic therapy, (2) improving selection of patients for surgical therapy with truly localized disease, (3) potential downstaging of the neoplasm facilitating a negative margin resection in patients with locally advanced disease, and (4) providing a superior clinical trial mechanism capable of rapid assessment of the efficacy of novel therapeutics. This article reviews the recent trends in the management of pancreatic adenocarcinoma, with a particular emphasis on a multidisciplinary neoadjuvant approach to treatment.
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Affiliation(s)
- Neelam V Desai
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Sarunas Sliesoraitis
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Jose G Trevino
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Robert A Zlotecki
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Alison M Ivey
- University of Florida Health Cancer Center, Gainesville, Florida
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
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Sutton JM, Abbott DE. Neoadjuvant therapy for pancreas cancer: Past lessons and future therapies. World J Gastroenterol 2014; 20:15564-15579. [PMID: 25400440 PMCID: PMC4229521 DOI: 10.3748/wjg.v20.i42.15564] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/21/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma remains a most deadly malignancy, with an overall 5-year survival of 5%. A subset of patients will be diagnosed with potentially resectable disease, and while complete surgical resection provides the only chance at cure, data from trials of postoperative chemoradiation and/or chemotherapy demonstrate a modest survival advantage over those patients who undergo resection alone. As such, most practitioners believe that completion of multimodality therapy is the optimal treatment. However, the sequence of surgery, chemotherapy and radiation therapy is frequently debated, as patients may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to resection. Here we review the rationale for neoadjuvant therapy, which includes a higher rate of completion of multimodality therapy, minimizing the risk of unnecessary surgical resection for patients who develop early metastatic disease, improved surgical outcomes and the potential for longer overall survival. However, there are no prospective, randomized studies of the neoadjuvant approach compared to a surgery-first strategy; the established and ongoing investigations of neoadjuvant therapy for pancreatic cancer are discussed in detail. Lastly, as the future of therapeutic regimens is likely to entail patient-specific genetic and molecular analyses, and the treatment that is best applied based on those data, a review of clinically relevant biomarkers in pancreatic cancer is also presented.
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Differentiation of noncalculous periampullary obstruction: comparison of CT with negative-contrast CT cholangiopancreatography versus MRI with MR cholangiopancreatography. Eur Radiol 2014; 25:391-401. [DOI: 10.1007/s00330-014-3430-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/18/2014] [Accepted: 09/03/2014] [Indexed: 01/16/2023]
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Tachezy M, Gebauer F, Petersen C, Arnold D, Trepel M, Wegscheider K, Schafhausen P, Bockhorn M, Izbicki JR, Yekebas E. Sequential neoadjuvant chemoradiotherapy (CRT) followed by curative surgery vs. primary surgery alone for resectable, non-metastasized pancreatic adenocarcinoma: NEOPA- a randomized multicenter phase III study (NCT01900327, DRKS00003893, ISRCTN82191749). BMC Cancer 2014; 14:411. [PMID: 24906700 PMCID: PMC4057592 DOI: 10.1186/1471-2407-14-411] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/29/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Median OS after surgery in curative intent for non-metastasized pancreas cancer ranges under study conditions from 17.9 months to 23.6 months. Tumor recurrence occurs locally, at distant sites (liver, peritoneum, lungs), or both. Observational and autopsy series report local recurrence rates of up to 87% even after potentially "curative" R0 resection. To achieve better local control, neoadjuvant CRT has been suggested for preoperative tumour downsizing, to elevate the likelihood of curative, margin-negative R0 resection and to increase the OS rate. However, controlled, randomized trials addressing the impact of neoadjuvant CRT survival do not exist. METHODS/DESIGN The underlying hypothesis of this randomized, two-armed, open-label, multicenter, phase III trial is that neoadjuvant CRT increases the three-year overall survival by 12% compared to patients undergoing upfront surgery for resectable pancreatic cancer. A rigorous, standardized technique of histopathologically handling Whipple specimens will be applied at all participating centers. Overall, 410 patients (n=205 in each study arm) will be enrolled in the trial, taking into regard an expected drop out rate of 7% and allocated either to receive neoadjuvant CRT prior to surgery or to undergo surgery alone. Circumferential resection margin status, i.e. R0 and R1 rates, respectively, surgical resectability rate, local and distant disease-free and global survival, and first site of tumor recurrence constitute further essential endpoints of the trial. DISCUSSION For the first time, the NEOPA study investigates the impact of neoadjuvant CRT on survival of resectable pancreas head cancer in a prospectively randomized manner. The results of the study have the potential to change substantially the treatment regimen of pancreas cancer. TRIAL REGISTRATION Clinical Trial gov: NCT01900327, DRKS00003893, ISRCTN82191749.
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Affiliation(s)
- Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Florian Gebauer
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | | | - Dirk Arnold
- Clinic for Medical Oncology, Tumor Biology Center- Freiburg im Breisgau, Breisgau, Germany
| | - Martin Trepel
- University Cancer Center Hamburg (UCCH) - Hubertus Wald Tumor Center, Hamburg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Phillipe Schafhausen
- University Cancer Center Hamburg (UCCH) - Hubertus Wald Tumor Center, Hamburg, Germany
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jakob Robert Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Emre Yekebas
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- Departement of General, Visceral and Thoracic Surgery, Darmstadt Clinic, Darmstadt, Germany
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Sahora K, Schindl M, Kuehrer I, Werba G, Fitzal F, Goetzinger P, Gnant M. Gemcitabine-based neoadjuvant chemotherapy for locally advanced pancreatic cancer does not affect mortality and morbidity after pancreatic resection. Eur Surg 2013. [DOI: 10.1007/s10353-013-0213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Trakul N, Koong AC, Maxim PG, Chang DT. Modern radiation therapy techniques for pancreatic cancer. Gastroenterol Clin North Am 2012; 41:223-35. [PMID: 22341260 DOI: 10.1016/j.gtc.2011.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Radiation therapy is a rapidly evolving field, and recent technical advances have spurred an increasing number of new treatments as well as marked improvements in previously existing treatments. Despite a growing body of published evidence demonstrating that radiotherapy for the treatment of pancreatic cancer is improving in efficacy and safety, the ultimate effect on patient outcomes remains to be seen. It is an unfortunate fact that the majority of pancreatic cancer patients will ultimately have metastases and succumb to distant disease. Thus, improvements in local tumor control engendered by these recent advances will have little impact on overall survival without the coincident development of better systemic treatment regimens.
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Affiliation(s)
- Nicholas Trakul
- Department of Radiation Oncology, Stanford University School of Medicine and Cancer Center, Stanford, CA 94305, USA.
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Oberic L, Viret F, Baey C, Ychou M, Bennouna J, Adenis A, Peiffert D, Mornex F, Pignon JP, Celier P, Berille J, Ducreux M. Docetaxel- and 5-FU-concurrent radiotherapy in patients presenting unresectable locally advanced pancreatic cancer: a FNCLCC-ACCORD/0201 randomized phase II trial's pre-planned analysis and case report of a 5.5-year disease-free survival. Radiat Oncol 2011; 6:124. [PMID: 21943032 PMCID: PMC3191360 DOI: 10.1186/1748-717x-6-124] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 09/26/2011] [Indexed: 02/08/2023] Open
Abstract
Background To explore possible improvement in the treatment of locally advanced pancreatic carcinoma (LAPC) we performed a randomized, non-comparative phase II study evaluating docetaxel - plus either daily continuous 5 FU or weekly cisplatin concurrent to radiotherapy. We report here the results of the docetaxel plus 5 FU regimen stopped according to the interim analysis. The docetaxel plus cisplatin arm was continued. Methods Forty (40) chemotherapy-naive patients with unresectable LAPC were randomly assigned (1:1) to either continuous fluorouracil (5-FU) 200 mg/m2/day (protracted IV) and docetaxel (DCT) 20 mg/m2/week or DCT 20 mg/m2 and cisplatin (CDDP) 20 mg/m2, plus concurrent radiotherapy for a period of 6 weeks. The radiation dose to the primary tumor was 54 Gy in 30 fractions. The trial's primary endpoint was the 6-month crude non-progression rate (NPR). Secondary endpoints were tolerance, objective response rate, and overall survival. Accrual was to be stopped if at 6 months more than 13 disease progressions were observed in 20 patients. Results Eighteen (18) progressions occurred at 6 months in the 5-FU-DCT arm. Six-month NPR was 10% (95%CI: 0-23). Six and 12-month survivals were 85% (95%CI: 64-95) and 40% (95%CI: 22-61); median overall survival was 10.1 months. Median progression-free survival was 4.3 months. We report the case of one patient who was amenable to surgery and has been in complete response (CR) for 5.5 years. Toxicities grade ≥ 3 were reported in 75% of patients; no treatment-related death occurred. Severe toxicities were mainly vomiting (35%), abdominal pain (10%) and fatigue (10%). Conclusions Combination of 5-FU, docetaxel and radiotherapy has inadequate efficacy in the treatment of LAPC despite good tolerance for the 5-FU-DCT regimen. Trial Registration ClinicalTrials.gov: NCT00112697
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O'Reilly EM. Adjuvant therapy for pancreas adenocarcinoma: where are we going? Expert Rev Anticancer Ther 2011; 11:173-7. [PMID: 21342036 DOI: 10.1586/era.10.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Evaluation of: Neoptolemos JP, Stocken DD, Bassi C et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs. gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304(10), 1073-1081 (2010). Over the last decade, adjuvant therapy in the treatment of resected pancreas adenocarcinoma has had its value established. Such treatment incrementally increases 5-year survivorship and delays time to tumor recurrence. The backbone of adjuvant therapy is the single-agent gemcitabine, based primarily on results from the Charité Onkologie Clinical (CONKO)-001 study. Based on the combined results of the European Study Group for Pancreas Cancer (ESPAC)-1 and ESPAC-3 trials, Neoptolemos and colleagues have established both bolus 5-fluorouracil and leucovorin and gemcitabine as standard options for resected pancreatic cancer. Gemcitabine remains the main standard therapy based on its ease of administration and a more favorable toxicity profile; however, there is now a clearly validated alternate option of 5-fluororuacil and leucovorin based on the results of ESPAC-3. Moving forward, the integration of novel cytotoxic and targeted agents into adjuvant therapy, along with refining the role of neoadjuvant therapy for patients with resectable pancreas cancer, will hopefully accrue a more substantial improvement in outcome for patients with resected pancreas adenocarcinoma.
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Affiliation(s)
- Eileen M O'Reilly
- Department of Medicine, Gastrointestinal Oncology Service, 1275 York Avenue, Box 324, New York, NY 10065, USA.
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Kanda M, Fujii T, Nagai S, Kodera Y, Kanzaki A, Sahin TT, Hayashi M, Yamada S, Sugimoto H, Nomoto S, Takeda S, Morita S, Nakao A. Pattern of lymph node metastasis spread in pancreatic cancer. Pancreas 2011; 40:951-5. [PMID: 21441841 DOI: 10.1097/mpa.0b013e3182148342] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We aimed to clarify the detailed pattern of lymph node (LN) metastasis spread in patients with pancreatic cancer. METHODS This retrospective study enrolled 429 patients who underwent pancreatectomy with extended lymphadenectomy for pancreatic cancer. The prognostic implications of LN metastasis were evaluated, and the position, frequency, and association with other clinicopathologic factors were investigated. RESULTS Lymph node metastasis was confirmed pathologically in 289 patients (67.4%). The prognosis of patients with LN metastasis was significantly poorer than that of patients without LN metastasis (P < 0.001). Distant LN metastasis occurred frequently, regardless of the tumor site. Patients classified with T1 or T2 only had regional LN metastasis, whereas there was a high rate of distant LN metastasis, including the para-aortic LNs, in patients with T3 or higher-stage tumors. Para-aortic LN metastasis was significantly associated with arterial and perineural invasion (P = 0.006 and P < 0.001, respectively). Lymph node metastasis in the hepatic portal region was a strong predictor of para-aortic LN metastasis in pancreatic head cancer. CONCLUSIONS Pancreatic cancer frequently metastasized to distant LNs via a complex pathway and developed into systemic disease. Aggressive multimodality therapy, including neoadjuvant therapy, is essential to improve the long-term survival of patients at substantial risk of distant LN metastasis.
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Affiliation(s)
- Mitsuro Kanda
- Department of Surgery II, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Glazer ES, Zhu C, Massey KL, Thompson CS, Kaluarachchi WD, Hamir AN, Curley SA. Noninvasive radiofrequency field destruction of pancreatic adenocarcinoma xenografts treated with targeted gold nanoparticles. Clin Cancer Res 2011; 16:5712-21. [PMID: 21138869 DOI: 10.1158/1078-0432.ccr-10-2055] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Pancreatic carcinoma is one of the deadliest cancers with few effective treatments. Gold nanoparticles (AuNP) are potentially therapeutic because of the safety demonstrated thus far and their physiochemical characteristics. We used the astounding heating rates of AuNPs in nonionizing radiofrequency (RF) radiation to investigate human pancreatic xenograft destruction in a murine model. EXPERIMENTAL DESIGN Weekly, Panc-1 and Capan-1 human pancreatic carcinoma xenografts in immunocompromised mice were exposed to an RF field 36 hours after treatment (intraperitoneal) with cetuximab- or PAM4 antibody-conjugated AuNPs, respectively. Tumor sizes were measured weekly, whereas necrosis and cleaved caspase-3 were investigated with hematoxylin-eosin staining and immunofluorescence, respectively. In addition, AuNP internalization and cytotoxicity were investigated in vitro with confocal microscopy and flow cytometry, respectively. RESULTS Panc-1 cells demonstrated increased apoptosis with decreased viability after treatment with cetuximab-conjugated AuNPs and RF field exposure (P = 0.00005). Differences in xenograft volumes were observed within 2 weeks of initiating therapy. Cetuximab- and PAM4-conjugated AuNPs demonstrated RF field-induced destruction of Panc-1 and Capan-1 pancreatic carcinoma xenografts after 6 weeks of weekly treatment (P = 0.004 and P = 0.035, respectively). There was no evidence of injury to murine organs. Cleaved caspase-3 and necrosis were both increased in treated tumors. CONCLUSIONS This study demonstrates a potentially novel cancer therapy by noninvasively inducing intracellular hyperthermia with targeted AuNPs in an RF field. While the therapy is dependent on the specificity of the targeting antibody, normal tissues were without toxicity despite systemic therapy and whole-body RF field exposure.
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Affiliation(s)
- Evan S Glazer
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Ottenhof NA, de Wilde RF, Maitra A, Hruban RH, Offerhaus GJA. Molecular characteristics of pancreatic ductal adenocarcinoma. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2011:620601. [PMID: 21512581 PMCID: PMC3068308 DOI: 10.4061/2011/620601] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Revised: 12/07/2010] [Accepted: 01/10/2011] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is an almost universally lethal disease and despite extensive research over the last decades, this has not changed significantly. Nevertheless, much progress has been made in understanding the pathogenesis of pancreatic ductal adenocarcinoma (PDAC) suggesting that different therapeutic strategies based on these new insights are forthcoming. Increasing focus exists on designing the so-called targeted treatment strategies in which the genetic characteristics of a tumor guide therapy. In the past, the focus of research was on identifying the most frequently affected genes in PDAC, but with the complete sequencing of the pancreatic cancer genome the focus has shifted to defining the biological function that the altered genes play. In this paper we aimed to put the genetic alterations present in pancreatic cancer in the context of their role in signaling pathways. In addition, this paper provides an update of the recent advances made in the development of the targeted treatment approach in PDAC.
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Affiliation(s)
- Niki A. Ottenhof
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Roeland F. de Wilde
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Anirban Maitra
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Ralph H. Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - G. Johan A. Offerhaus
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- *G. Johan A. Offerhaus:
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Mohr A, Albarenque SM, Deedigan L, Yu R, Reidy M, Fulda S, Zwacka RM. Targeting of XIAP combined with systemic mesenchymal stem cell-mediated delivery of sTRAIL ligand inhibits metastatic growth of pancreatic carcinoma cells. Stem Cells 2011; 28:2109-20. [PMID: 20882532 DOI: 10.1002/stem.533] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Disseminating tumors are one of the gravest medical problems. Here, we combine the tumor-specific apoptosis-inducing activity of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) with the ability of mesenchymal stem cells (MSCs) to infiltrate both tumor and lymphatic tissues to target primary tumors as well as disseminated cancer cells in a human pancreatic cancer mouse model. Furthermore, we targeted X-linked inhibitor of apoptosis protein (XIAP) by RNA interference (RNAi) inside the cancer cells to make use of the apoptosis sensitization as well the antimetastatic effect that is afforded by XIAP silencing. We generated MSCs, termed MSC.sTRAIL, that express and secrete a trimeric form of soluble TRAIL (sTRAIL). MSC.sTRAIL triggered limited apoptosis in human pancreatic carcinoma cells that were resistant to soluble recombinant TRAIL, which is most likely due to the enhanced effect of the direct, cell-mediated delivery of trimeric TRAIL. MSC.sTRAIL-mediated cell death was markedly increased by concomitant knockdown of XIAP by RNAi in the cancer cells. These findings were confirmed in xenograft models, in which tumors from the parental pancreatic carcinoma cells showed only growth retardation on treatment with MSC.sTRAIL, whereas tumors with silenced XIAP that were treated with MSC.sTRAIL went into remission. Moreover, animals with XIAP-negative xenografts treated with MSC.sTRAIL were almost free of lung metastasis, whereas animals treated with control MSCs showed substantial metastatic growth in the lungs. In summary, this is the first demonstration that a combined approach using systemic MSC-mediated delivery of sTRAIL together with XIAP inhibition suppresses metastatic growth of pancreatic carcinoma.
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Affiliation(s)
- Andrea Mohr
- National University of Ireland, Galway, National Centre for Biomedical Engineering Science and Apoptosis Research Centre, Molecular Therapeutics Group, Galway, Ireland
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