1
|
Miller PN, Romero-Hernandez F, Calthorpe L, Wang JJ, Kim SS, Corvera CU, Hirose K, Kirkwood KS, Hirose R, Maker AV, Alseidi AA, Adam MA, Kim GE, Tempero MA, Ko AH, Nakakura EK. Long-Duration Neoadjuvant Therapy with FOLFIRINOX Yields Favorable Outcomes for Patients Who Undergo Surgery for Pancreatic Cancer. Ann Surg Oncol 2024; 31:6147-6156. [PMID: 38879670 PMCID: PMC11300478 DOI: 10.1245/s10434-024-15579-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/23/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND In 2023 alone, it's estimated that over 64,000 patients will be diagnosed with PDAC and more than 50,000 patients will die of the disease. Current guidelines recommend neoadjuvant therapy for patients with borderline resectable and locally advanced PDAC, and data is emerging on its role in resectable disease. Neoadjuvant chemotherapy may increase the number of patients able to receive complete chemotherapy regimens, increase the rate of microscopically tumor-free resection (R0) margin, and aide in identifying unfavorable tumor biology. To date, this is the largest study to examine surgical outcomes after long-duration neoadjuvant chemotherapy for PDAC. METHODS Retrospective analysis of single-institution data. RESULTS The routine use of long-duration therapy in our study (median cycles: FOLFIRINOX = 10; gemcitabine-based = 7) is unique. The majority (85%) of patients received FOLFIRINOX without radiation therapy; the R0 resection rate was 76%. Median OS was 41 months and did not differ significantly among patients with resectable, borderline-resectable, or locally advanced disease. CONCLUSIONS This study demonstrates that in patients who undergo surgical resection after receipt of long-duration neoadjuvant FOLFIRINOX therapy alone, survival outcomes are similar regardless of pretreatment resectability status and that favorable surgical outcomes can be attained.
Collapse
Affiliation(s)
- Phoebe N Miller
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of General Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Fernanda Romero-Hernandez
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Lucia Calthorpe
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Jaeyun Jane Wang
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Sunhee S Kim
- Department of Surgery, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Carlos U Corvera
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Adnan A Alseidi
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Grace E Kim
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Margaret A Tempero
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Andrew H Ko
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eric K Nakakura
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, University of California, San Francisco, San Francisco, CA, USA.
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
| |
Collapse
|
2
|
Miller PN, Nakakura EK. ASO Author Reflections: Total Neoadjuvant Therapy with Chemotherapy Alone for Pancreatic Cancer? Ann Surg Oncol 2024; 31:6203-6204. [PMID: 38909112 PMCID: PMC11300545 DOI: 10.1245/s10434-024-15660-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Phoebe N Miller
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Eric K Nakakura
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
| |
Collapse
|
3
|
Barreto SG, Shrikhande SV, Sirohi B. Neoadjuvant Therapy in Borderline Resectable Pancreatic Cancer. Indian J Surg Oncol 2024; 15:249-254. [PMID: 38817993 PMCID: PMC11133292 DOI: 10.1007/s13193-021-01361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/31/2021] [Indexed: 12/09/2022] Open
Abstract
In this perspective, we present our assessment of all of the known accumulated evidence on the role of neoadjuvant therapy in the management of borderline resectable pancreatic cancer highlighting the gaps in the data, the current regimens used and providing a brief insight into the way forward.
Collapse
Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia Australia
| | - Shailesh V. Shrikhande
- GI and HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra India
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu India
| |
Collapse
|
4
|
de la Pinta C. Stereotactic body radiotherapy in pancreatic adenocarcinoma. Hepatobiliary Pancreat Dis Int 2024; 23:14-19. [PMID: 36990839 DOI: 10.1016/j.hbpd.2023.03.002] [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: 04/14/2022] [Accepted: 02/28/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) in pancreatic cancer allows high delivery of radiation doses on tumors without affecting surrounding tissue. This review aimed at the SBRT application in the treatment of pancreatic cancer. DATA SOURCES We retrieved articles published in MEDLINE/PubMed from January 2017 to December 2022. Keywords used in the search included: "pancreatic adenocarcinoma" OR "pancreatic cancer" AND "stereotactic ablative radiotherapy (SABR)" OR "stereotactic body radiotherapy (SBRT)" OR "chemoradiotherapy (CRT)". English language articles with information on technical characteristics, doses and fractionation, indications, recurrence patterns, local control and toxicities of SBRT in pancreatic tumors were included. All articles were assessed for validity and relevant content. RESULTS Optimal doses and fractionation have not yet been defined. However, SBRT could be the standard treatment in patients with pancreatic adenocarcinoma in addition to CRT. Furthermore, the combination of SBRT with chemotherapy may have additive or synergic effect on pancreatic adenocarcinoma. CONCLUSIONS SBRT is an effective modality for patients with pancreatic cancer, supported by clinical practice guidelines as it has demonstrated good tolerance and good disease control. SBRT opens a possibility of improving outcomes for these patients, both in neoadjuvant treatment and with radical intent.
Collapse
Affiliation(s)
- Carolina de la Pinta
- Radiation Oncology Department, Ramón y Cajal University Hospital, IRYCIS, Alcalá University, 28034 Madrid, Spain.
| |
Collapse
|
5
|
Fossaert V, Mimmo A, Rhaiem R, Rached LJ, Brasseur M, Brugel M, Pegoraro F, Sanchez S, Bouché O, Kianmanesh R, Piardi T. Neoadjuvant chemotherapy for borderline resectable and upfront resectable pancreatic cancer increasing overall survival and disease-free survival? Front Oncol 2022; 12:980659. [PMID: 36387257 PMCID: PMC9640996 DOI: 10.3389/fonc.2022.980659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/06/2022] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic neoplasm. Surgery is the factual curative option, but most patients present with advanced disease. In order to increase resectability, results of neoadjuvant chemotherapy (NAC) on metastatic disease were extrapolated to the neoadjuvant setting by many centers. The aim of our study was to retrospectively evaluate the outcome of patients who underwent upfront surgery (US)-PDAC and borderline (BR)-PDAC, and those resected after NAC to determine prognostic factors that might affect the outcome in these resected patients. METHODS One hundred fifty-one patients between January 2012 and March 2021 in our department were reviewed. Epidemiological characteristics and pre-operative induction treatment were assessed. Pathological reports were analyzed to evaluate the quality of oncological resection (R0/R1). Post-operative mortality and morbidity and survival data were reviewed. RESULTS One hundred thirteen patients were addressed for US, and 38 were considered BR and referred for surgery after induction chemotherapy. The pancreatic resection R0 was 71.5% and R1 28.5%. pT3 rate was significantly higher in the US than BR (58,4% vs 34,2%, p= 0.005). The mean OS and DFS rates were 29.4 months 15.9 months respectively. There was no difference between OS and DFS of US vs BR patients. N0 patients had significantly longer OS and DFS (p=<0.001). R0 patients had significantly longer OS (p=0.03) and longer DFS (P=0.08). In the multivariate analysis, the presence of postoperative pancreatic fistula, R1 resection, N+ and not access to adjuvant chemotherapy were bad prognostic factors of OS. CONCLUSIONS Our study suggests the benefits of NAC for BR patients in downstaging tumors and rendering them amenable to resection, with same oncological result compared to US.
Collapse
Affiliation(s)
- Violette Fossaert
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Antonio Mimmo
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Rami Rhaiem
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Linda J. Rached
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Mathilde Brasseur
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Mathias Brugel
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Francesca Pegoraro
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Stephane Sanchez
- Pôle Territorial Santé Publique et Performance des Hôpitaux Champagne Sud, University Reims Champagne-Ardenne, Troyes, France
| | - Olivier Bouché
- Department of Digestive Medical Oncology, University Reims Champagne-Ardenne, Reims, France
| | - Reza Kianmanesh
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
- Department of Surgery, Hepato-Bilio-Pancreatic and Metabolic Unit, University Reims Champagne-Ardenne, Troyes, France
| |
Collapse
|
6
|
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
|
7
|
Masuda H, Kotecha K, Maitra R, Gill AJ, Mittal A, Samra JS. Clinical suspicion of pancreatic cancer despite negative endoscopic ultrasound-guided fine-needle aspiration biopsy. ANZ J Surg 2021; 92:99-108. [PMID: 34636123 DOI: 10.1111/ans.17256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The early and accurate diagnosis of pancreatic ductal adenocarcinoma is vital for improving the efficacy of therapeutic interventions and to provide patients with the best chance of survival. While endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been demonstrated to be a reliable and accurate diagnostic tool for solid pancreatic neoplasms, the ongoing management of patients with a high clinical suspicion for malignancy but with a negative EUS-FNA biopsy result can prove a challenge. METHODS We describe five patients from a single centre who presented for further work-up of a pancreatic mass and/or imaging features concerning for a periampullary malignancy. RESULTS All patients had at least one EUS-FNA biopsy performed which returned no malignant cells on cytology. Despite these negative cytology results, all patients underwent further invasive investigation through upfront resection (pancreaticoduodenectomy) or extra-pancreatic biopsy (laparoscopic biopsy of peritoneal nodule) due to worrisome features on imaging, biochemical factors and clinical presentation culminating in a high degree of suspicion for malignancy. The final tissue histopathological diagnosis in all patients was pancreatic ductal adenocarcinoma. CONCLUSION This case series highlights the important clinical findings, imaging and biochemical features which need to be considered in patients who have high suspicion for malignancy despite having a negative EUS-FNA cytology result. In these patients with a high index of suspicion, surgical intervention through an upfront resection or further invasive investigation should not be delayed.
Collapse
Affiliation(s)
- Hiro Masuda
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Rudra Maitra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Janssen QP, van Dam JL, Kivits IG, Besselink MG, van Eijck CHJ, Homs MYV, Nuyttens JJME, Qi H, van Santvoort HJ, Wei AC, de Wilde RF, Wilmink JW, van Tienhoven G, Groot Koerkamp B. Added Value of Radiotherapy Following Neoadjuvant FOLFIRINOX for Resectable and Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 28:8297-8308. [PMID: 34142290 PMCID: PMC8591030 DOI: 10.1245/s10434-021-10276-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/09/2021] [Indexed: 12/30/2022]
Abstract
Background The added value of radiotherapy following neoadjuvant FOLFIRINOX chemotherapy in patients with resectable or borderline resectable pancreatic cancer ((B)RPC) is unclear. The objective of this meta-analysis was to compare outcomes of patients who received neoadjuvant FOLFIRINOX alone or combined with radiotherapy. Methods A systematic literature search was performed in Embase, Medline (ovidSP), Web of Science, Scopus, Cochrane, and Google Scholar. The primary endpoint was pooled median overall survival (OS). Secondary endpoints included resection rate, R0 resection rate, and other pathologic outcomes. Results We included 512 patients with (B)RPC from 15 studies, of which 7 were prospective nonrandomized studies. In total, 351 patients (68.6%) were treated with FOLFIRINOX alone (8 studies) and 161 patients (31.4%) were treated with FOLFIRINOX and radiotherapy (7 studies). The pooled estimated median OS was 21.6 months (range 18.4–34.0 months) for FOLFIRINOX alone and 22.4 months (range 11.0–37.7 months) for FOLFIRINOX with radiotherapy. The pooled resection rate was similar (71.9% vs. 63.1%, p = 0.43) and the pooled R0 resection rate was higher for FOLFIRINOX with radiotherapy (88.0% vs. 97.6%, p = 0.045). Other pathological outcomes (ypN0, pathologic complete response, perineural invasion) were comparable. Conclusions In this meta-analysis, radiotherapy following neoadjuvant FOLFIRINOX was associated with an improved R0 resection rate as compared with neoadjuvant FOLFIRINOX alone, but a difference in survival could not be demonstrated. Randomized trials are needed to determine the added value of radiotherapy following neoadjuvant FOLFIRINOX in patients with (B)PRC. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10276-8.
Collapse
Affiliation(s)
- Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Isabelle G Kivits
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hongchao Qi
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar J van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, Nieuwegein, The Netherlands
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| |
Collapse
|
9
|
Zhang Y, Huang ZX, Song B. Role of imaging in evaluating the response after neoadjuvant treatment for pancreatic ductal adenocarcinoma. World J Gastroenterol 2021; 27:3037-3049. [PMID: 34168406 PMCID: PMC8192284 DOI: 10.3748/wjg.v27.i22.3037] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/08/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy. Despite the development of multimodality treatments, including surgical resection, radiotherapy, and chemotherapy, the long-term prognosis of patients with PDAC remains poor. Recently, the introduction of neoadjuvant treatment (NAT) has made more patients amenable to surgery, increasing the possibility of R0 resection, treatment of occult micro-metastasis, and prolongation of overall survival. Imaging plays a vital role in tumor response evaluation after NAT. However, conventional imaging modalities such as multidetector computed tomography have limited roles in the assessment of tumor resectability after NAT for PDAC because of the similar appearance of tissue fibrosis and tumor infiltration. Perfusion computed tomography, using blood perfusion as a biomarker, provides added value in predicting the histopathologic response of PDAC to NAT by reflecting the changes in tumor matrix and fibrosis content. Other imaging technologies, including diffusion-weighted imaging of magnetic resonance imaging and positron emission tomography, can reveal the tumor response by monitoring the structural changes in tumor cells and functional metabolic changes in tumors after NAT. In addition, with the renewed interest in data acquisition and analysis, texture analysis and radiomics have shown potential for the early evaluation of the response to NAT, thus improving patient stratification to achieve accurate and intensive treatment. In this review, we briefly introduce the application and value of NAT in resectable and unresectable PDAC. We also summarize the role of imaging in evaluating the response to NAT for PDAC, as well as the advantages, limitations, and future development directions of current imaging techniques.
Collapse
Affiliation(s)
- Yun Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Xing Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
10
|
Al-Sadairi AR, Mimmo A, Rhaiem R, Esposito F, Rached LJ, Tashkandi A, Zimmermann P, Memeo R, Sommacale D, Kianmanesh R, Piardi T. Laparoscopic hybrid pancreaticoduodenectomy: Initial single center experience. Ann Hepatobiliary Pancreat Surg 2021; 25:102-111. [PMID: 33649262 PMCID: PMC7952661 DOI: 10.14701/ahbps.2021.25.1.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is the gold standard for the treatment of periampullary tumors. Many specialized centers have adopted the totally laparoscopic or hybrid laparoscopic PD (LPD). However, this procedure has not yet been standardized and serious debate is taking place towards its safety and feasibility. Herein, we report our recent experience whit hybrid-LPD. Methods During 2019 in our department 56 PD were performed and 21 (37.5%) underwent hybrid-LPD. We have retrospectively reviewed the short-term outcomes of these patients. Results Main indication was pancreatic adenocarcinoma (71,4%). The median operative time and intraoperative blood loss were respectively 425 min (range, 226 to 576) and 317 ml (range 60 to 800 ml). Conversion to an open procedure was required in 4 patients (19%): 2 with suspected vein involvement, 1 for mesenteric panniculitis and 1 for biliary injury. The post-operative complication rate was 42.8% (9/21). Regarding post-operative pancreatic fistula, three patients (14.2%) had grade B and 1 grade C (4.7%). Median length of hospital stay was 14 days (range 9-23) and 90- days mortality was 4.7%. The mean number of harvested lymph nodes was 17.7 (range 12 to 26). The rate of margins R0 was 80%; R1 >0<1 mm was 10.5% and R1 0 mm was 9.5%. Conclusions Hydrid-LPD is safe and feasible. Careful patient selection and increasing experience can reduce the risk of post-operative complications.
Collapse
Affiliation(s)
- Abdul Rahman Al-Sadairi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Antonio Mimmo
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Rami Rhaiem
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Francesco Esposito
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Linda J Rached
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Ahmad Tashkandi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Perrine Zimmermann
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Daniele Sommacale
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, AP-HP, Université Paris-Est Créteil (UPEC), France
| | - Reza Kianmanesh
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France
| | - Tullio Piardi
- Department of Hepatobiliary, Pancreatic and Digestive Surgery, University Hospital Robert Debré of Reims, University of Champagne-Ardenne, Reims, France.,Hepato-Pancreato-Biliary Unit, General Surgery Department, Simone Veil Hospital, Troyes, University of Champagne-Ardenne, Reims, France
| |
Collapse
|
11
|
Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
Collapse
Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| |
Collapse
|
12
|
Neoadjuvant Phase II Trial of Chemoradiotherapy in Patients With Resectable and Borderline Resectable Pancreatic Cancer. Am J Clin Oncol 2020; 43:435-441. [PMID: 32251119 DOI: 10.1097/coc.0000000000000688] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is a largely incurable cancer. Surgical resection remains the only potential option for cure. Even in surgically resectable patients, only about 10% to 20% are long-term survivors. Emerging data suggest a role for neoadjuvant therapy to target occult micrometastatic disease. AIM To report our institutional experience with a novel neoadjuvant chemoradiation (CRT) regimen in resectable and borderline resectable pancreatic cancer. MATERIALS AND METHODS Patients were treated with 2 cycles of induction chemotherapy with FOLFOX and then received CRT with gemcitabine and intensity-modulated radiotherapy (IMRT). RESULTS From April 2014 to June 2017, 24 patients were enrolled. Eighteen patients were borderline resectable and 6 patients were resectable. All patients received induction chemotherapy with FOLFOX. Thirteen patients underwent pancreatectomy after CRT with a resection rate of 62%. R0 resection achieved in 11 patients (84.6%) and 2 patients had R1 resection (15.4%). For patients who underwent resection, the median progression-free survival (PFS) was 31 months, 1-year PFS rate was 69.2% (95% confidence interval [CI], 0.48-0.99), and 2-year PFS rate was 51.9% (95% CI, 0.3-0.89). Median overall survival (OS) was 34.8 months (95% CI, 1.045 to infinity), 1-year OS rate was 91.7% (95% CI, 0.77-1.0), and 2-year OS rate was 75% (95% CI, 0.54-1.0). Median CA 19-9 at screening for patients who underwent surgery was 659 (range, 18 to 2154), which decreased to 146.9 (range, 18 to 462) after CRT before resection. CONCLUSION Neoadjuvant therapy for borderline resectable and resectable pancreatic ductal adenocarcinoma with CRT facilitated R0 resection in 84% patients who underwent surgery.
Collapse
|
13
|
Heger U, Sun H, Hinz U, Klaiber U, Tanaka M, Liu B, Sachsenmaier M, Springfeld C, Michalski CW, Büchler MW, Hackert T. Induction chemotherapy in pancreatic cancer: CA 19-9 may predict resectability and survival. HPB (Oxford) 2020; 22:224-232. [PMID: 31375338 DOI: 10.1016/j.hpb.2019.06.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative/Neoadjuvant treatment (NT) is increasingly used in unresectable pancreatic cancer (PDAC). However, ∼40% of patients cannot be resected after NT and reliable preoperative response evaluation is currently lacking. We investigated CA 19-9 levels and their dynamics during NT for prediction of resectability and survival. METHODS We screened our institution's database for patients who underwent exploration or resection after NT with gemcitabine-based therapy (GEM) or FOLFIRINOX (FOL). Pre- and post-NT CA 19-9, resection rate and survival were analyzed. RESULTS Of 318 patients 165 (51.9%) were resected and 153 (48.1%) received exploration. In the FOL group (n = 103; 32.4%), a post-NT CA 19-9 cutoff at 91.8 U/ml had a sensitivity of 75.0% and a specificity of 76.9% for completing resection with an AUC of 0.783 in the ROC analysis (95% CI: 0.692-0.874; p < 0.001. PPV: 84.2%, NPV: 65.2%). Resected patients above the cutoff did not benefit from resection. Post-NT CA 19-9 <91.8 U/ml (OR 11.63, p < 0.001) and CA 19-9 ratio of <0.4 (OR 5.77, p = 0.001) were independent predictors for resectability in FOL patients. DISCUSSION CA 19-9 levels after neoadjuvant treatment with FOLFIRINOX predict resectability and survival of PDAC more accurately than dynamic values and should be incorporated into response evaluation and surgical decision-making.
Collapse
Affiliation(s)
- Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Huihui Sun
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Bing Liu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Milena Sachsenmaier
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Springfeld
- Department of Medical Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph W Michalski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
| |
Collapse
|
14
|
Comparison of Tumor Regression Grading of Residual Pancreatic Ductal Adenocarcinoma Following Neoadjuvant Chemotherapy Without Radiation: Would Fewer Tier-Stratification Be Favorable Toward Standardization? Am J Surg Pathol 2020; 43:334-340. [PMID: 30211728 DOI: 10.1097/pas.0000000000001152] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To assess whether the College of American Pathologists (CAP) and the Evans grading systems for neoadjuvant chemotherapy without radiation-treated pancreatectomy specimens are prognostic, and if a 3-tier stratification scheme preserves data granularity. Conducted retrospective review of 32 patients with ordinary pancreatic ductal adenocarcinoma treated with neoadjuvant therapy without radiation followed by surgical resection. Final pathologic tumor category (AJCC eighth edition) was 46.9% ypT1, 34.4% ypT2, and 18.7% ypT3. Median follow-up time was 29.8 months, median disease-free survival (DFS) was 19.6 months, and median overall survival (OS) was 34.2 months. CAP score 1, 2, 3 were present in 5 (15.6%), 18 (56.3%), and 9 (28.1%) patients, respectively. Evans grade III, IIb, IIa, and I were present in 10 (31.2%), 8 (25.0%), 7 (21.9%), and 7 (21.9%) patients, respectively. OS (CAP: P=0.005; Evans: P=0.001) and DFS (CAP: P=0.003; Evans: P=0.04) were statistically significant for both CAP and Evans. Stratified CAP scores 1 and 2 versus CAP score 3 was statistically significant for both OS (P=0.002) and DFS (P=0.002). Stratified Evans grades I, IIa, and IIb versus Evans grade III was statistically significant for both OS (P=0.04) and DFS (P=0.02). CAP, Evans, and 3-tier stratification are prognostic of OS and DFS.
Collapse
|
15
|
Pathologic Response to Primary Systemic Therapy With FOLFIRINOX in Patients With Resectable Pancreatic Cancer. Am J Clin Oncol 2019; 42:761-766. [PMID: 31569128 DOI: 10.1097/coc.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Primary systemic therapy in resectable pancreatic cancer is currently under investigation. FOLFIRINOX has been shown to be effective in both the adjuvant and metastatic settings and is increasingly being used on and off study in the neoadjuvant setting. The objective pathologic response elicited by this regimen in truly resectable disease has not as yet been widely reported. METHODS This analysis focuses on 14 patients with resectable pancreatic cancer who were treated in a pilot study of primary systemic therapy, using 4 cycles of neoadjuvant FOLFIRINOX before surgery. A dedicated pancreatic pathologist reviewed all of the subsequent surgical specimens to assess the degree of tumor regression elicited by this approach, according to the scoring system proposed by Evans. RESULTS Four patients (28.6%) had Evans grade I, 4 (28.6%) Evans grade IIa, 2 (14.2%) Evans grade IIb, and 4 (28.6%) Evans grade III response to the primary systemic therapy. There were no Evans grade IV responses. CONCLUSIONS The results are intriguing with 28% of the specimens showing destruction of <10% of tumor cells, and only 28% achieving >90% destruction of tumor cells. The significant variation in response once again confirms the known heterogeneity in the biology of this cancer and clearly FOLFIRINOX is not equally effective in all patients. Future studies evaluating primary systemic therapy in pancreatic cancer should examine the optimal duration of therapy before surgery and should include a standardized pathologic grading scheme to better enable comparison of results.
Collapse
|
16
|
Janssen QP, Buettner S, Suker M, Beumer BR, Addeo P, Bachellier P, Bahary N, Bekaii-Saab T, Bali MA, Besselink MG, Boone BA, Chau I, Clarke S, Dillhoff M, El-Rayes BF, Frakes JM, Grose D, Hosein PJ, Jamieson NB, Javed AA, Khan K, Kim KP, Kim SC, Kim SS, Ko AH, Lacy J, Margonis GA, McCarter MD, McKay CJ, Mellon EA, Moorcraft SY, Okada KI, Paniccia A, Parikh PJ, Peters NA, Rabl H, Samra J, Tinchon C, van Tienhoven G, van Veldhuisen E, Wang-Gillam A, Weiss MJ, Wilmink JW, Yamaue H, Homs MYV, van Eijck CHJ, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in Patients With Borderline Resectable Pancreatic Cancer: A Systematic Review and Patient-Level Meta-Analysis. J Natl Cancer Inst 2019; 111:782-794. [PMID: 31086963 PMCID: PMC6695305 DOI: 10.1093/jnci/djz073] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 12/19/2018] [Accepted: 04/22/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. METHODS We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. RESULTS We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n = 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] = 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI = 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patient-level survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI = 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI = 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI = 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI = 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI = 8.1 to 14.2). No deaths were attributed to FOLFIRINOX. CONCLUSIONS This patient-level meta-analysis of BRPC patients treated with neoadjuvant FOLFIRINOX showed a favorable median OS, resection rate, and R0-resection rate. These results need to be assessed in a randomized trial.
Collapse
Affiliation(s)
| | - Stefan Buettner
- See the Notes section for the full list of authors’ affiliations
| | - Mustafa Suker
- See the Notes section for the full list of authors’ affiliations
| | - Berend R Beumer
- See the Notes section for the full list of authors’ affiliations
| | - Pietro Addeo
- See the Notes section for the full list of authors’ affiliations
| | | | - Nathan Bahary
- See the Notes section for the full list of authors’ affiliations
| | | | - Maria A Bali
- See the Notes section for the full list of authors’ affiliations
| | - Marc G Besselink
- See the Notes section for the full list of authors’ affiliations
| | - Brian A Boone
- See the Notes section for the full list of authors’ affiliations
| | - Ian Chau
- See the Notes section for the full list of authors’ affiliations
| | - Stephen Clarke
- See the Notes section for the full list of authors’ affiliations
| | - Mary Dillhoff
- See the Notes section for the full list of authors’ affiliations
| | | | - Jessica M Frakes
- See the Notes section for the full list of authors’ affiliations
| | - Derek Grose
- See the Notes section for the full list of authors’ affiliations
| | - Peter J Hosein
- See the Notes section for the full list of authors’ affiliations
| | - Nigel B Jamieson
- See the Notes section for the full list of authors’ affiliations
| | - Ammar A Javed
- See the Notes section for the full list of authors’ affiliations
| | - Khurum Khan
- See the Notes section for the full list of authors’ affiliations
| | - Kyu-Pyo Kim
- See the Notes section for the full list of authors’ affiliations
| | - Song Cheol Kim
- See the Notes section for the full list of authors’ affiliations
| | - Sunhee S Kim
- See the Notes section for the full list of authors’ affiliations
| | - Andrew H Ko
- See the Notes section for the full list of authors’ affiliations
| | - Jill Lacy
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Colin J McKay
- See the Notes section for the full list of authors’ affiliations
| | - Eric A Mellon
- See the Notes section for the full list of authors’ affiliations
| | | | - Ken-Ichi Okada
- See the Notes section for the full list of authors’ affiliations
| | | | - Parag J Parikh
- See the Notes section for the full list of authors’ affiliations
| | - Niek A Peters
- See the Notes section for the full list of authors’ affiliations
| | - Hans Rabl
- See the Notes section for the full list of authors’ affiliations
| | - Jaswinder Samra
- See the Notes section for the full list of authors’ affiliations
| | | | | | | | | | - Matthew J Weiss
- See the Notes section for the full list of authors’ affiliations
| | | | - Hiroki Yamaue
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Matthew H G Katz
- See the Notes section for the full list of authors’ affiliations
| | | |
Collapse
|
17
|
Swords DS, Francis SR, Lloyd S, Garrido-Laguna I, Mulvihill SJ, Gruhl JD, Christensen MC, Stoddard GJ, Firpo MA, Scaife CL. Lymph Node Ratio in Pancreatic Adenocarcinoma After Preoperative Chemotherapy vs. Preoperative Chemoradiation and Its Utility in Decisions About Postoperative Chemotherapy. J Gastrointest Surg 2019; 23:1401-1413. [PMID: 30187332 DOI: 10.1007/s11605-018-3953-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Single-center studies in pancreatic adenocarcinoma have suggested that preoperative chemotherapy (PCT) is associated with higher lymph node ratio (LNR) than preoperative chemoradiation (PCRT). The association of postoperative chemotherapy with overall survival (OS) in patients treated with PCT and PCRT remains unclear. Our objectives were to investigate whether (1) PCT is associated with higher LNR than PCRT and (2) postoperative chemotherapy is associated with longer OS after PCT and PCRT in LNR-stratified cohorts. METHODS A retrospective cohort study was performed of patients with pancreatic adenocarcinoma treated with PCT or PCRT followed by resection between 2006 and 2014 in the National Cancer Database. Temporal trends were evaluated with Cuzick's test. OS was evaluated with multivariable Cox regression and inverse probability weighted (IPW) Cox regression. RESULTS Of 4187 patients, 1993 (47.6%) received PCT. PCT rates were stable at approximately 30% in 2006-2010 (p = 0.33) but increased to 64.9% by 2014 (p < 0.001). Node positivity rates were higher after PCT than PCRT (62.7 vs. 41.8%, P < 0.001) and mean LNR was higher (0.10 [95% CI 0.096, 0.11] vs. 0.058 [95% CI 0.052, 0.063], P < 0.001). Postoperative chemotherapy was associated with longer OS in patients with LNR 0.01-0.149 after PCT by univariate analysis (median OS 34.5 vs. 26.5 months, P = 0.002), multivariable Cox regression (HR 0.64, 95% CI 0.48, 0.84), and IPW Cox regression (HR 0.72, 95% CI 0.55, 0.94). Postoperative chemotherapy was not associated with longer OS for patients who were node-negative or who had LNR ≥ 0.15 after PCT or for any patient subgroups after PCRT. CONCLUSIONS PCT is associated with a higher LNR and higher rates of node positivity than PCRT. Postoperative chemotherapy is associated with longer OS than observation in patients with a LNR of 0.01-0.149 after PCT.
Collapse
Affiliation(s)
- Douglas S Swords
- Division of General Surgery, Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - Samual R Francis
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA
| | - Ignacio Garrido-Laguna
- Division of Medical Oncology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Sean J Mulvihill
- Division of General Surgery, Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Joshua D Gruhl
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA
| | - Miles C Christensen
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Matthew A Firpo
- Division of General Surgery, Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Courtney L Scaife
- Division of General Surgery, Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| |
Collapse
|
18
|
Conversion surgery for initially unresectable pancreatic cancer: current status and unresolved issues. Surg Today 2019; 49:894-906. [PMID: 30949842 DOI: 10.1007/s00595-019-01804-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/17/2019] [Indexed: 12/16/2022]
Abstract
Pancreatic cancer is one of the most lethal of all malignancies. One of the reasons for the dismal prognosis is that most diagnoses are made when the disease is either locally advanced or metastatic. Recent advances in chemotherapy and chemoradiotherapy (CRT) enable "conversion surgery" to be performed for selected patients with initially unresectable pancreatic cancer following favorable responses to preoperative treatment. Using FOLFIRINOX as preoperative treatment, the resection rate was reported as 6-44% of patients with locally advanced cancer and the prognosis of these patients was favorable. Even for metastasized cancer, recent reports show the effectiveness of conversion surgery, which has achieved 27-56 months of median overall survival. However, there are many unanswered questions about conversion surgery. The optimal regimen and duration of preoperative treatment remain unclear and there is still debate regarding the safety and effectiveness of vascular resection, which is often required for curative resection of locally advanced cancer. Accumulation of more data on conversion surgery is required to establish the safety and effectiveness of this treatment. In this review, we summarize the current status and unresolved issues about conversion surgery for initially unresectable pancreatic cancer.
Collapse
|
19
|
Advances of pathological complete response after neoadjuvant therapy for pancreatic cancer. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
|
20
|
Chemotherapy Versus Chemoradiation as Preoperative Therapy for Resectable Pancreatic Ductal Adenocarcinoma: A Propensity Score Adjusted Analysis. Pancreas 2019; 48:216-222. [PMID: 30629022 DOI: 10.1097/mpa.0000000000001231] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although the use of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma is increasing, the optimal preoperative treatment regimen remains poorly defined. METHODS All patients with resectable pancreatic ductal adenocarcinoma who received preoperative chemotherapy alone (12%) or chemoradiation therapy (CRT) alone (88%) before pancreatectomy between 1999 and 2014 were included. Propensity score matching with inverse probability weighting was conducted based on age, baseline carbohydrate antigen 19-9, and procedure type. RESULTS Patients who received preoperative CRT were more likely to undergo a margin negative (91% vs 79%, P < 0.01) and node negative (53% vs 23%, P < 0.01) resection and experience less locoregional recurrence (LR; 16% vs 33%, P < 0.01) but similar median overall survival (OS; 33.6 vs 26.4 months, P = 0.09). On multivariate analysis, carbohydrate antigen 19-9 (hazard ratio, 1.2; 95% confidence interval [CI], 1.1-1.3) and positive lymph nodes (hazard ratio, 1.5; 95% CI, 1.0-2.2) were associated with OS, whereas tumor size (odds ratio [OR], 1.5; 95% CI, 1.3-1.8), positive lymph nodes (OR, 3.1; 95% CI, 1.8-5.6), and preoperative chemotherapy (OR, 1.8; 95% CI, 1.1-2.9) were associated with LR. CONCLUSIONS Preoperative CRT is associated with less margin and lymph node positivity, reduced LR, and similar OS compared with preoperative chemotherapy.
Collapse
|
21
|
Nagakawa Y, Sahara Y, Hosokawa Y, Murakami Y, Yamaue H, Satoi S, Unno M, Isaji S, Endo I, Sho M, Fujii T, Takishita C, Hijikata Y, Suzuki S, Kawachi S, Katsumata K, Ohta T, Nagakawa T, Tsuchida A. Clinical Impact of Neoadjuvant Chemotherapy and Chemoradiotherapy in Borderline Resectable Pancreatic Cancer: Analysis of 884 Patients at Facilities Specializing in Pancreatic Surgery. Ann Surg Oncol 2019; 26:1629-1636. [PMID: 30610555 DOI: 10.1245/s10434-018-07131-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The efficacy of neoadjuvant therapy (NAT), including neoadjuvant chemotherapy (NAC) and neoadjuvant chemo-radiotherapy (NACRT), for patients with borderline resectable pancreatic cancer (BRPC) has not been elucidated. This study aimed to clarify the efficacy of NAC and NACRT for patients with BRPC. METHODS The study analyzed the treatment outcomes of 884 patients treated for BRPC from 2011 to 2013. Treatment results were compared between upfront surgery and NAT and between NAC and NACRT using propensity score-matching analysis. Overall survival (OS) was calculated via intention-to-treat analyses. RESULTS The overall resection rates for the patients who underwent NAT were significantly lower than for the patients who underwent upfront surgery (75.1% vs 93.3%; p < 0.001). However, the R0 resection rate was significantly higher for NAT than for upfront surgery (p < 0.001). Additionally, the OS for the patients who received NAT was significantly longer than for those who underwent upfront surgery (median survival time [MST], 25.7 vs 19.0 months; p = 0.015). The lymph node rate for the patients with NACRT was significantly lower than for those who underwent NAC (p < 0.001). However, the resection rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.041). The local recurrence rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.002). However, OS did not differ significantly between NAC and NACRT (MST, 29.2 vs 22.5 months; p = 0.130). CONCLUSIONS The study showed that NAT has potential benefit for patients with BRPC. Compared with NAC, NACRT decreased the rates for lymph node metastasis and local recurrence but did not improve the prognosis.
Collapse
Affiliation(s)
- Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan.
| | - Yatsuka Sahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Yuichi Hosokawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroki Yamaue
- Department of Gastroenterological Surgery, Wakayama Medical University, Wakayama, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Moriguchi, Osaka, Japan
| | - Michiaki Unno
- Department of Hepatobiliary-Pancreatic Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Yosuke Hijikata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Shuji Suzuki
- Department of Gastroenterological Surgery, Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, Japan
| | - Shigeyuki Kawachi
- Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Takukazu Nagakawa
- Department of Gastroenterological Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Shinjuku, Tokyo, Japan
| |
Collapse
|
22
|
Choi JG, Nipp RD, Tramontano A, Ali A, Zhan T, Pandharipande P, Dowling EC, Ferrone CR, Hong TS, Schrag D, Fernandez-Del Castillo C, Ryan DP, Kong CY, Hur C. Neoadjuvant FOLFIRINOX for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer: Results of a Decision Analysis. Oncologist 2018; 24:945-954. [PMID: 30559125 PMCID: PMC6656457 DOI: 10.1634/theoncologist.2018-0114] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022] Open
Abstract
Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial between competing strategies. This article analyzes a mathematical decision‐analytic model to estimate the long‐term clinical outcomes and cost‐effectiveness of neoadjuvant FOLFIRINOX compared with surgery followed by adjuvant gemcitabine monotherapy or gemcitabine/capecitabine for patients with potentially resectable pancreatic ductal adenocarcinoma. Background. The effectiveness and cost‐effectiveness of using neoadjuvant FOLFIRINOX (nFOLFIRINOX) for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC) are unknown. Our objective was to determine whether nFOLFIRINOX is more effective or cost‐effective for patients with BR/LA PDAC compared with upfront resection surgery and adjuvant gemcitabine plus capecitabine (GEM/CAPE) or gemcitabine monotherapy (GEM). Materials and Methods. We performed a decision‐analysis to assess the value of nFOLFIRINOX versus GEM/CAPE or GEM using a mathematical simulation model. Model transition probabilities were estimated using published and institutional clinical data. Model outcomes included overall and disease‐free survival, quality‐adjusted life‐years (QALYs), cost in U.S. dollars, and cost‐effectiveness expressed as an incremental cost‐effectiveness ratio. Deterministic and probabilistic sensitivity analyses explored the uncertainty of model assumptions. Results. Model results found median overall survival (34.5/28.0/22.0 months) and disease‐free survival (15.0/14.0/13.0 months) were better for nFOLFIRINOX compared with GEM/CAPE and GEM. nFOLFIRINOX was the optimal strategy on an efficiency frontier, resulting in an additional 0.35 life‐years, or 0.30 QALYs, at a cost of $46,200/QALY gained compared with GEM/CAPE. Sensitivity analysis found that cancer recurrence and complete resection rates most affected model results, but were otherwise robust. Probabilistic sensitivity analyses found that nFOLFIRINOX was cost‐effective 92.4% of the time at a willingness‐to‐pay threshold of $100,000/QALY. Conclusion. Our modeling analysis suggests that nFOLFIRINOX is preferable to upfront surgery for patients with BR/LA PDAC from both an effectiveness and cost‐effectiveness standpoint. Additional clinical data that further define the long‐term effectiveness of nFOLFIRINOX are needed to confirm our results. Implications for Practice. Increasingly, neoadjuvant FOLFIRINOX has been used for borderline resectable and locally advanced pancreatic cancer with the goal of rendering them resectable and decreasing risk of recurrence. Despite many efforts to show the benefits of neoadjuvant over adjuvant therapies, clinical evidence to guide this decision is largely lacking. Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial. This modeling analysis suggests that neoadjuvant FOLFIRINOX is preferable to upfront surgery and adjuvant therapies by various outcome metrics including quality‐adjusted life years, overall survival, and incremental cost‐effectiveness ratio.
Collapse
Affiliation(s)
- Jin G Choi
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Health Innovations Research and Evaluations Unit, Columbia University Medical Center, New York, NY, USA
| | - Ryan D Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Tramontano
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ayman Ali
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tiannan Zhan
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pari Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Emily C Dowling
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Schrag
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlos Fernandez-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chin Hur
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
23
|
Glinka J, Diaz F, Alva A, Mazza O, Sanchez Claria R, Ardiles V, de Santibañes E, Pekolj J, de Santibañes M. Use of radiotherapy in patients with palliative double bypass for locally advanced pancreatic adenocarcinoma. Radiat Oncol J 2018; 36:210-217. [PMID: 30309212 PMCID: PMC6226143 DOI: 10.3857/roj.2018.00206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/17/2018] [Indexed: 12/14/2022] Open
Abstract
Purpose Pancreatic cancer (PC) has not changed overall survival in recent years despite therapeutic efforts. Surgery with curative intent has shown the best long-term oncological results. However, 80%–85% of patients with these tumors are unresectable at the time of diagnosis. In those patients, first therapeutic attempts are minimally invasive or surgical procedures to alleviate symptoms. The addition of radiotherapy (RT) to standard chemotherapy, ergo chemoradiation, in patients with locally advanced pancreatic cancer (LAPC) is still controversial. The study aims to compare outcomes in patients with a double bypass surgery due to LAPC treated or not with RT. Materials and Methods A retrospective cohort study of patients with double bypass for LAPC were registered and divided into two groups: treated or not with postoperative RT. Baseline characteristics, postoperative complications, those related to RT and their relation to the main event (mortality) were compared. Results Seventy-four patients were included. Surgical complications between the groups did not offer significant differences. Complications related to RT were mostly mild, and 86% of patients completed the treatment. Overall survival at 1 and 2 years for patients in the exposed group was 64% and 35% vs. 50% and 28% in the non-exposed group, respectively (p = 0.11; power 72%; hazard ratio = 0.53; 95% confidence interval, 0.24–1.18). Conclusion We observed a tendency for survival improvement in patients with postoperative RT. However, we’ve not had enough power to demonstrate this difference, possibly due to the small sample size. It is indispensable to develop randomized and prospective trials to guide more specific treatment lines in this patients.
Collapse
Affiliation(s)
- Juan Glinka
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico Diaz
- Department of Radiation Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Augusto Alva
- Department of Radiation Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Oscar Mazza
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Sanchez Claria
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martín de Santibañes
- Department of General Surgery, Hepato-Bilio-Pancreatic Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
24
|
Prognostic factors for actual long-term survival in the era of multidisciplinary treatment for pancreatic ductal adenocarcinoma. Langenbecks Arch Surg 2018; 403:693-700. [PMID: 30218193 DOI: 10.1007/s00423-018-1709-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Recent advances in multidisciplinary treatments are improving the postoperative prognosis of pancreatic ductal adenocarcinoma (PDAC). However, the prognosis even after potentially curative resection remains poor. The aim of this study was to identify the clinical and pathological features of actual 5-year survivors under current circumstances. METHODS A total of 128 patients who underwent pancreatectomy for PDAC at our institution between January 2006 and December 2011 were retrospectively analyzed. RESULTS The actual 5-year overall survival rate for all patients was 30.9%, with a median survival time of 33.1 months. Of 128 patients, 25 (19.5%) survived for 5 years after surgery without disease recurrence. A univariate analysis showed that the pretreatment serum CA19-9 value, tumor depth, lymph node metastasis, and UICC stage at resection were significant predictive factors for the actual long-term survival. A multivariate analysis showed that a pretreatment serum CA19-9 value ≥ 110 U/mL was a significant unfavorable prognostic indicator. In addition, all subjects in the 5-year survival group completed adjuvant chemotherapy. The recurrence rate in the liver was significantly lower and that in the lung significantly higher in the long-term survival group than in the short-term survival group. CONCLUSIONS The factors contributing to the long-term survival of PDAC were the pretreatment CA19-9 value and the completion of adjuvant chemotherapy. To achieve the actual long-term survival and cure after pancreatectomy for pancreatic cancer, further treatment strategies enhancing the completion rate of adjuvant chemotherapy are required.
Collapse
|
25
|
Lee RC, Kanhere H, Trochsler M, Broadbridge V, Maddern G, Price TJ. Pancreatic, periampullary and biliary cancer with liver metastases: Should we consider resection in selected cases? World J Gastrointest Oncol 2018; 10:211-220. [PMID: 30147847 PMCID: PMC6107475 DOI: 10.4251/wjgo.v10.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/14/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To analyse the safety and efficacy of curative intent surgery in biliary and pancreatic cancer.
METHODS An extensive literature review was performed using MEDLINE, Google Scholar and EMBASE to identify articles regarding hepato-pancreatoduodenectomy or resection of liver metastasis in patients with pancreatic, biliary tract, periampullary and gallbladder cancers.
RESULTS A total of 19 studies were identified and reviewed. Major hepatectomy was undertaken in 391 patients. The median overall survival for pancreatic cancer ranged from 5-36 mo and for biliary tract/gallbladder cancer, it was 8-38 mo. The 30 d mortality rate was only 1%-9%. Overall Survival was significantly better for patients, who had good response to neoadjuvant chemotherapy, underwent metachronous liver resection and who had intestinal type tumours.
CONCLUSION Resection of liver metastases in pancreatic and biliary cancers may provide survival benefit without compromising safety and quality of life in a very select group of patients. These data may be utilised to formulate selection criteria that may allow future investigation of resection in the era of more effective systemic therapy.
Collapse
Affiliation(s)
- Rachael Chang Lee
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
| | - Harsh Kanhere
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Markus Trochsler
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Vy Broadbridge
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
| | - Guy Maddern
- Department of Surgery, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| | - Timothy J Price
- Department of Medical Oncology, the Queen Elizabeth Hospital, Adelaide 5011, Australia
- School of Medicine, University of Adelaide, Adelaide 5000, Australia
| |
Collapse
|
26
|
A phase II trial of gemcitabine, S-1 and LV combination (GSL) neoadjuvant chemotherapy for patients with borderline resectable and locally advanced pancreatic cancer. Med Oncol 2018; 35:100. [PMID: 29846849 DOI: 10.1007/s12032-018-1158-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 12/11/2022]
Abstract
There has been a pressing need to develop optimal regimen for neoadjuvant chemotherapy (NAC) for pancreatic cancer (PC). The safety and efficacy of gemcitabine, S-1, and LV combination (GSL) therapy as NAC for borderline resectable (BR) and locally advanced (LA) PC was evaluated in this phase II study. Patients with pathologically proven BR or LA PC were enrolled and gemcitabine 1000 mg/m2 by 30-min infusion on day 1, S-1 40 mg/m2 orally twice daily, and LV 25 mg orally twice daily on days 1-7 every 2 weeks were provided, and evaluation by CT every 2 courses was performed. The primary end point was R0 resection rate, and the secondary endpoints were resection rate, response rate, adverse events, surgical outcomes, and survival. Twenty-four patients with PC (21 BR and 3 LA) were enrolled. Response rate and disease control rate of NAC were 17.4 and 87.0%. Grade 3 and 4 toxicities involved neutropenia (34.8%), anorexia (17.4%), and mucositis (17.4%). Serum CA19-9 level decreased by 52.2%. Resection rate was 60.9% after the median of 4 cycles and R0 resection rate was 76.5% in patients undergoing laparotomy. NAC-GSL is a feasible treatment option for BR and LAPC.
Collapse
|
27
|
Toesca DAS, Koong AJ, Poultsides GA, Visser BC, Haraldsdottir S, Koong AC, Chang DT. Management of Borderline Resectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2018; 100:1155-1174. [PMID: 29722658 DOI: 10.1016/j.ijrobp.2017.12.287] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/07/2017] [Accepted: 12/27/2017] [Indexed: 12/13/2022]
Abstract
With the rapid development of imaging modalities and surgical techniques, the clinical entity representing tumors that are intermediate between resectable and unresectable pancreatic adenocarcinoma has been identified has been termed "borderline resectable" (BR). These tumors are generally amenable for resection but portend an increased risk for positive margins after surgery and commonly necessitate vascular resection and reconstruction. Although there is a lack of consensus regarding the appropriate definition of what constitutes a BR pancreatic tumor, it has been demonstrated that this intermediate category carries a particular prognosis that is in between resectable and unresectable disease. In order to downstage the tumor and increase the probability of clear surgical margins, neoadjuvant therapy is being increasingly utilized and studied. There is a lack of high-level evidence to establish the optimal treatment regimen for BR tumors. When resection with negative margins is achieved after neoadjuvant therapy, the prognosis for BR tumors approaches and even exceeds that for resectable disease. This review presents the current definitions, different treatment approaches, and the clinical outcomes of BR pancreatic cancer.
Collapse
Affiliation(s)
- Diego A S Toesca
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - Amanda J Koong
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | | | - Brendan C Visser
- Department of Surgery, Stanford Cancer Institute, Stanford, California
| | | | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California.
| |
Collapse
|
28
|
Cloyd JM, Wang H, Egger ME, Tzeng CWD, Prakash LR, Maitra A, Varadhachary GR, Shroff R, Javle M, Fogelman D, Wolff RA, Overman MJ, Koay EJ, Das P, Herman JM, Kim MP, Vauthey JN, Aloia TA, Fleming JB, Lee JE, Katz MHG. Association of Clinical Factors With a Major Pathologic Response Following Preoperative Therapy for Pancreatic Ductal Adenocarcinoma. JAMA Surg 2017; 152:1048-1056. [PMID: 28700784 DOI: 10.1001/jamasurg.2017.2227] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance We previously demonstrated that a major pathologic response to preoperative therapy, defined histopathologically by the presence of less than 5% viable cancer cells in the surgical specimen, is an important prognostic factor for patients with pancreatic ductal adenocarcinoma. However, to our knowledge, the patients most likely to experience a significant response to therapy are undefined. Objective To identify clinical factors associated with major pathologic response in a large cohort of patients who underwent preoperative therapy and pancreatectomy for pancreatic ductal adenocarcinoma. Design, Setting, and Participants Retrospective review of a prospectively maintained database at University of Texas MD Anderson Cancer Center. The study included 583 patients with histopathologically confirmed pancreatic ductal adenocarcinoma who received preoperative therapy prior to pancreatectomy between 1990 and 2015. Exposures Preoperative therapy consisted of systemic chemotherapy alone (n = 38; 6.5%), chemoradiation alone (n = 261; 44.8%), or both (n = 284; 48.7%) prior to pancreatoduodenectomy (n = 514; 88.2%), distal pancreatectomy (n = 62; 10.6%), or total pancreatectomy (n = 7; 1.2%). Main Outcomes and Measures Clinical variables associated with a major pathologic response (pathologic complete response or <5% residual cancer cells) were evaluated using logistic regression. Results Among all patients, the mean (SD) age was 63.7 (9.2) years, and 53.0% were men. A major pathologic response was seen in 77 patients (13.2%) including 23 (3.9%) who had a complete pathologic response. The median overall survival duration was significantly longer for patients who had a major response than for those who did not (73.4 months vs 32.2 months, P < .001). On multivariate logistic regression, only age younger than 50 years, baseline serum cancer antigen 19-9 level less than 200 U/mL, and gemcitabine as a radiosensitizer were associated with a major response. The number of these positive factors was associated with the likelihood of a major response in a stepwise fashion (0, 7.5%; 1, 12.7%; 2, 16.9%; 3, 35.7%; P = .009). Conclusions and Relevance Although a major pathologic response occurs infrequently following preoperative therapy for pancreatic ductal adenocarcinoma, it is associated with a significantly improved prognosis. Of the patient- and treatment-related factors we analyzed, only young age, low baseline cancer antigen 19-9, and gemcitabine as a radiosensitizer were associated with a major pathologic response. Given its association with long-term survival, better predictors of response and more effective preoperative regimens should be aggressively sought.
Collapse
Affiliation(s)
- Jordan M Cloyd
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Huamin Wang
- Department of Pathology; University of Texas MD Anderson Cancer Center, Houston
| | - Michael E Egger
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Laura R Prakash
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Anirban Maitra
- Department of Pathology; University of Texas MD Anderson Cancer Center, Houston
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Rachna Shroff
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Eugene J Koay
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Prajnan Das
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Joseph M Herman
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Michael P Kim
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Thomas A Aloia
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Jason B Fleming
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Jeffrey E Lee
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| | - Matthew H G Katz
- Department of Surgical Oncology; University of Texas MD Anderson Cancer Center, Houston
| |
Collapse
|
29
|
Abstract
Local recurrence of pancreatic cancer (PC) can occur in the pancreatic remnant. In addition, new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this review was to describe the characteristics and therapeutic strategy regarding remnant PC. A literature search was performed using Medline published in English according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The incidence of remnant PC has been reported to be 3% to 5%. It is difficult to distinguish local recurrence from new primary PC. Genetic diagnosis such as Kirsten rat sarcoma viral oncogene homolog mutation may resolve this problem. For patients with remnant PC, repeated pancreatectomy can be performed. Residual total pancreatectomy is the most common procedure. Recent studies have described the safety of the operation because of recent surgical progress and perioperative care. The patients with remnant PC without distant metastasis have shown good long-term outcomes, especially those who underwent repeated pancreatectomy. Adjuvant chemotherapy may contribute to longer survival. In conclusion, this review found that both local recurrence and new primary PC can develop in the pancreatic remnant. Repeated pancreatectomy for the remnant PC is a feasible procedure and can prolong patient survival.
Collapse
|
30
|
Rosati LM, Kumar R, Herman JM. Integration of Stereotactic Body Radiation Therapy into the Multidisciplinary Management of Pancreatic Cancer. Semin Radiat Oncol 2017; 27:256-267. [PMID: 28577833 DOI: 10.1016/j.semradonc.2017.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although most patients with pancreatic cancer die of metastatic disease, an autopsy study showed that up to one-third of patients die of predominantly local disease. This patient population stands to benefit the most from radiation, surgery, or both. Unfortunately, however, single-agent chemotherapy has had minimal benefit in pancreatic cancer, and most patients progress distantly before receiving radiation therapy (RT). With the addition of multiagent chemotherapy, patients are living longer, and RT has emerged as an important modality in preventing local progression. Standard chemoradiation delivered over 5-6 weeks has been shown to improve local control, but this approach delays full-dose systemic therapy and increases toxicity when compared to chemotherapy alone. Stereotactic body RT (SBRT) delivered in 3-5 fractions can be used to accurately target the pancreatic tumor with small margins and limited acute treatment-related toxicity. Given the favorable toxicity profile, SBRT can easily be integrated with other therapies in all stages of pancreatic cancer. However, future studies are necessary to determine optimal dose or fractionation regimens and sequencing with targeted therapies and immunotherapy. The purpose of this review is to discuss our current understanding of SBRT in the multidisciplinary management of patients with pancreatic cancer and future implications.
Collapse
Affiliation(s)
- Lauren M Rosati
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachit Kumar
- Division of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Joseph M Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|