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Akita H, Takahashi H, Eguchi H, Asukai K, Hasegawa S, Wada H, Iwagami Y, Yamada D, Tomimaru Y, Noda T, Gotoh K, Kobayashi S, Doki Y, Sakon M. Difference between carbohydrate antigen 19-9 and fluorine-18 fluorodeoxyglucose positron emission tomography in evaluating the treatment efficacy of neoadjuvant treatment in patients with resectable and borderline resectable pancreatic ductal adenocarcinoma: Results of a dual-center study. Ann Gastroenterol Surg 2021; 5:381-389. [PMID: 34095729 PMCID: PMC8164457 DOI: 10.1002/ags3.12418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/19/2020] [Accepted: 11/27/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND An accurate evaluation of neoadjuvant treatment is important to maximize the prognostic benefit of this strategy in each individual patient. The main aim of the present study is to investigate the difference between carbohydrate antigen 19-9 and fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in evaluating the response to neoadjuvant treatment for resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Pancreatic ductal adenocarcinoma patients with positive standard uptake values (SUV) on FDG-PET before neoadjuvant chemoradiotherapy (NACRT) were enrolled (n = 141). In all patients, CA19-9 and FDG-PET were evaluated before the initiation of and after the completion of NACRT. The statuses of CA19-9 and FDG uptake alterations during NACRT were assessed in association with survival and tumor recurrence profiles. RESULTS A favorable response in each CA19-9 and FDG-PET was significantly related to better survival, respectively, than the unfavorable response (44.3% vs 19.5%, P < .001 and 45.8% vs 24.6%, P < .001). The status of CA19-9 was significantly associated with the incidence of distant recurrence whereas the status of FDG-PET was significantly associated with the incidence of local recurrence, and only patients with a favorable response in both CA19-9 and PET statuses showed a significantly better survival than the others (5-year survival: 56% vs 24%, P < .001), and those with unfavorable response in either of CA19-9 or PET status showed similar poor survival to those with unfavorable in both (P = .164). CONCLUSION CA19-9 and PET evaluation provided oncologically different risk assessments in terms of tumor recurrence profile, and favorable response in both CA19-9 and FDG-PET were necessary to achieve prognostic benefit from NACRT.
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Affiliation(s)
- Hirofumi Akita
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | | | - Hidetoshi Eguchi
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Kei Asukai
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | | | - Hiroshi Wada
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Yoshifumi Iwagami
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Daisaku Yamada
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Yoshito Tomimaru
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Takehiro Noda
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Kunihito Gotoh
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Shogo Kobayashi
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Masato Sakon
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
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Yamada D, Takahashi H, Hama N, Toshiyama R, Asukai K, Hasegawa S, Wada H, Sakon M, Ishikawa O. The clinical impact of splenic artery ligation on the occurrence of digestive varices after pancreaticoduodenectomy with combined portal vein resection: a retrospective study in two institutes. Langenbecks Arch Surg 2020; 406:1469-1479. [PMID: 33063227 DOI: 10.1007/s00423-020-02010-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Pancreaticoduodenectomy (PD) concomitant with portal vein resection (PVR) often develops into digestive varices with an occurrence rate of 30-50%, and the variceal bleeding is sometimes untreatable and results in fatality. Against this issue, splenic artery (SpA) ligation during PD-PVR is emerging as an easy and effective prophylactic surgical option. The aim of this study was to investigate the significance of SpA ligation in the development of digestive varices in patients undergoing PD-PVR. METHOD We retrospectively investigated 97 patients with PDAC who received PD-PVR in two hospitals. Vascular reconstruction of the splenic vein (SpV) was not performed in either hospital. We assessed the occurrence rate of digestive varices in these patients in association with the performance of SpA ligation. RESULTS The occurrence rate of digestive varices was 23%. SpA ligation was the only significant decreasing factor for the development of digestive varices (odds ratio 0.3, p = 0.035). Although SpV resection was not a significant risk factor for the development of digestive varices in all patients, SpV resection was a significant risk factor for the development of digestive varices in patients without SpA ligation, as demonstrated in previous reports. SpA ligation did not increase surgical complications or impair pancreatic function. CONCLUSION PD-PVR surgery was accompanied by a 23% incidence of digestive varices, and SpA ligation significantly decreased the development of digestive varices without causing clinically significant complications. TRIAL REGISTRATION No. 18196 (Osaka International Cancer Institute) and no. 19006 (National Hospital Organization Osaka National Hospital).
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan.
| | - Naoki Hama
- Department of Surgery, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
| | - Reishi Toshiyama
- Department of Surgery, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
| | - Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Osamu Ishikawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
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Eguchi H, Takeda Y, Takahashi H, Nakahira S, Kashiwazaki M, Shimizu J, Sakai D, Isohashi F, Nagano H, Mori M, Doki Y. A Prospective, Open-Label, Multicenter Phase 2 Trial of Neoadjuvant Therapy Using Full-Dose Gemcitabine and S-1 Concurrent with Radiation for Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2019; 26:4498-4505. [PMID: 31440928 DOI: 10.1245/s10434-019-07735-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neoadjuvant therapy reportedly shows only marginal clinical benefit in pancreatic ductal adenocarcinoma (PDAC), especially in resectable cases. However, with more effective regimens, neoadjuvant therapy may become a standard of care for resectable cases. A prospective, open-label, multicenter phases 1 and 2 trial of neoadjuvant therapy was conducted using full-dose gemcitabine and S-1 concurrently with 50.4 Gy of radiation therapy (GSRT) for resectable PDAC. This report describes the phase 2 results. METHODS The phase 2 part of this study enrolled 57 patients with cytologically or histologically proven PDAC deemed resectable based on imaging before neoadjuvant therapy. These patients received GSRT. After reevaluation by computed tomography scan, surgical exploration was performed, followed by adjuvant therapy. According to the prescribed protocol of the clinical trial, statistical analyses included 57 phase 2 patients and 6 phase 1 patients who received the same dosage as in phase 2. RESULTS This trial enrolled 63 patients (42 men and 21 women) with a median age of 70 years. Leukopenia or neutropenia of grade 3 or higher occurred for 79% of the patients, but no other severe adverse events were observed. Among the 63 patients, 54 underwent surgical resection. Intention-to-treat analysis of the 63 patients showed an excellent median survival time lasting as long as 55.3 months. The patients who completed neoadjuvant therapy, surgery, and adjuvant therapy had a 5-year survival rate of 56.6%. CONCLUSIONS This regimen showed outstanding clinical efficacy with acceptable tolerability for patients with resectable PDAC.
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Affiliation(s)
- Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan.
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Hidenori Takahashi
- Department of Surgery, Osaka International Cancer Institute, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Shin Nakahira
- Department of Surgery, Sakai City Medical Center, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Masaki Kashiwazaki
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Junzo Shimizu
- Department of Surgery, Osaka Rosai Hospital, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Daisuke Sakai
- Department of Frontier Science for Cancer and Chemotherapy, Graduate School of Medicine, Osaka University, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Fumiaki Isohashi
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
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4
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Yamada D, Takahashi H, Asukai K, Hasegawa S, Tomokuni A, Wada H, Akita H, Yasui M, Miyata H, Ishikawa O. Pathological complete response (pCR) with or without the residual intraductal carcinoma component following preoperative treatment for pancreatic cancer: Revisiting the definition of "pCR" from the prognostic standpoint. Ann Gastroenterol Surg 2019; 3:676-685. [PMID: 31788656 PMCID: PMC6875936 DOI: 10.1002/ags3.12288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/15/2019] [Accepted: 09/04/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIM There are no previous reports describing the prognostic significance of the residual intraductal carcinoma component (carcinoma in situ [CIS]) following preoperative treatment for pancreatic ductal adenocarcinoma (PDAC). The aim of the present study was to investigate the prognostic significance of a minimal residual CIS in cases with complete absence of an invasive component after preoperative treatment for PDAC. METHODS Eighty-one of 594 PDAC patients with preoperative treatment and subsequent surgery in our institute showed remarkable remission in the invasive component, which included 48 patients with the minimal residual invasive component (Min-inv group) and 33 with absence of an invasive component (No-inv group). We assessed the survival of these patients in association with the presence or absence of an invasive component and intraductal CIS. RESULTS Five-year overall survival in the No-inv group patients was significantly better than that of the Min-inv group patients (82%/66%, P = .041). Among the 33 patients in the No-inv group, residual CIS was observed in 16 patients (CIS-positive group), and the remaining 17 patients had no residual CIS (CIS-negative group). There was no significant difference in survival between patients in the CIS-positive and CIS-negative groups (92%/78%, P = .31). CONCLUSIONS Residual CIS in the absence of an invasive component after preoperative treatment does not yield a prognostic impact after receiving perioperative treatment for PDAC. It might be reasonable to define pathological complete response (pCR) from the prognostic standpoint as follows: pCR is the complete absence of an invasive carcinoma component regardless of residual CIS.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Shinichiro Hasegawa
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Akira Tomokuni
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Wada
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Hirofumi Akita
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayohi Yasui
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
| | - Osamu Ishikawa
- Department of Gastroenterological surgeryOsaka International Cancer InstituteOsakaJapan
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Otsuru T, Kobayashi S, Wada H, Takahashi T, Gotoh K, Iwagami Y, Yamada D, Noda T, Asaoka T, Serada S, Fujimoto M, Eguchi H, Mori M, Doki Y, Naka T. Epithelial-mesenchymal transition via transforming growth factor beta in pancreatic cancer is potentiated by the inflammatory glycoprotein leucine-rich alpha-2 glycoprotein. Cancer Sci 2019; 110:985-996. [PMID: 30575211 PMCID: PMC6398893 DOI: 10.1111/cas.13918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 12/15/2022] Open
Abstract
We previously showed that an inflammation‐related, molecule leucine‐rich alpha‐2 glycoprotein (LRG) enhances the transforming growth factor (TGF)‐β1‐induced phosphorylation of Smad proteins and is elevated in patients with pancreatic ductal adenocarcinoma (PDAC). As TGF‐β/Smad signaling is considered to play a key role in epithelial‐mesenchymal transition (EMT), we attempted to clarify the mechanism underlying LRG‐related EMT in relation to metastasis in PDAC. We cultured LRG‐overexpressing PDAC cells (Panc1/LRG) and evaluated the morphology, EMT‐related molecules and TGF‐β/Smad signaling pathway in these cells. We also assessed the LRG levels in plasma and resected specimens from patients with PDAC. Inflammatory cytokines induced LRG production in PDAC cells. A spindle‐like shape was visualized more frequently than other shapes in Panc1/LRG with TGF‐β1 exposure. The expression of E‐cadherin in Panc1/LRG was decreased with TGF‐β1 exposure. Invasion increased with TGF‐β1 stimulation of Panc1/LRG. The phosphorylation of smad2 in Panc1/LRG was increased in comparison with parental Panc1 under TGF‐β1 stimulation. In the plasma LRG‐high group, the recurrence rate tended to be higher and the recurrence‐free survival (RFS) tended to be worse in comparison with the plasma LRG‐low group. LRG enhanced EMT induced by TGF‐β signaling, thus indicating that LRG has a significant effect on the metastasis of PDAC.
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Affiliation(s)
- Toru Otsuru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Satoshi Serada
- Center for Intractable Immune Disease, Kochi University, Kochi, Japan
| | - Minoru Fujimoto
- Center for Intractable Immune Disease, Kochi University, Kochi, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Testuji Naka
- Center for Intractable Immune Disease, Kochi University, Kochi, Japan
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Shinke G, Yamada D, Eguchi H, Iwagami Y, Asaoka T, Noda T, Wada H, Kawamoto K, Gotoh K, Kobayashi S, Takeda Y, Tanemura M, Mori M, Doki Y. Role of histone deacetylase 1 in distant metastasis of pancreatic ductal cancer. Cancer Sci 2018; 109:2520-2531. [PMID: 29917299 PMCID: PMC6113427 DOI: 10.1111/cas.13700] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/12/2018] [Indexed: 12/22/2022] Open
Abstract
Current therapies for pancreatic ductal cancer (PDAC) do not sufficiently control distant metastasis. Thus, new therapeutic targets are urgently needed. Numerous studies have suggested that the epithelial-mesenchymal transition (EMT) is pivotal for metastasis of carcinomas. The fact that the EMT is reversible suggests the possibility that it is induced by an epigenetic mechanism. In this study, we aimed to investigate the role of histone deacetylase 1 (HDAC1), which is an epigenetic mechanism on distant metastasis of PDAC. We investigated the HDAC1 expression in 103 resected PDAC specimens obtained from patients who were treated with/without preoperative therapy using immunohistochemistry. To validate the findings in the clinical samples, we evaluated the HDAC1 activity, the EMT-associated genes and the migration/invasion ability in vitro, and performed an HDAC1 inhibitor assay. The high expression of HDAC1 in clinical samples was significantly associated with poor progression-free survival, especially distant metastasis-free survival. In vitro, HDAC1 inhibitors decreased the invasion ability and reversed the EMT change; the only factor to show a concomitant decrease was the expression of SNAIL. We confirmed that the HDAC1 expression was associated with the SNAIL expression in clinical samples. Moreover, the resistant cells and parental cells did not show any significant differences in the expression of HDAC1; this was consistent with the finding that preoperative therapy did not alter the HDAC1 expression in clinical samples. The targeting of HDAC1, which could suppress metastasis by inhibiting the EMT, is a promising treatment option for PDAC.
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Affiliation(s)
- Go Shinke
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.,Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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7
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Mukai Y, Yamada D, Eguchi H, Iwagami Y, Asaoka T, Noda T, Kawamoto K, Gotoh K, Kobayashi S, Takeda Y, Tanemura M, Mori M, Doki Y. Vitamin D Supplementation is a Promising Therapy for Pancreatic Ductal Adenocarcinoma in Conjunction with Current Chemoradiation Therapy. Ann Surg Oncol 2018; 25:1868-1879. [PMID: 29675761 DOI: 10.1245/s10434-018-6431-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND The cancer-associated fibroblasts (CAFs) in pancreatic ductal adenocarcinoma (PDAC) are well known to play a dominant role in distant metastasis. Nevertheless, the effect on CAFs with current chemoradiation therapies remains uncertain. OBJECTIVE This study aimed to reveal the role of CAFs under current chemoradiation therapy (CRT) and investigate the factors regulating CAFs. METHODS α-SMA-positive cells in 86 resected PDAC specimens with/without preoperative CRT were evaluated by immunohistochemistry. Various factors, including the plasma levels of vitamin D, were investigated for association with the number of CAFs or distant metastasis-free survival (DMFS). Human pancreatic satellite cells (hPSCs) extracted from clinical specimens were used to validate the factors. RESULTS All PDAC samples contained CAFs but the number varied widely. Multivariate analysis for DMFS indicated a larger number of CAFs was a significant risk factor. Univariate analysis for the number of CAFs identified two clinical factors: preoperative CRT and lower plasma levels of vitamin D. In subgroup analysis, the higher plasma level of vitamin D was a dominant factor for longer DMFS in PDAC patients after preoperative CRT. These results were validated by using extracted hPSCs. Irradiation activated stromal cells into CAFs facilitating malignant characteristics of PDAC and the change was inhibited by vitamin D supplementation in vitro. CONCLUSION In conjunction with established current therapies, vitamin D supplementation may be an effective treatment for PDAC patients by inactivating CAFs.
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Affiliation(s)
- Yosuke Mukai
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Surgery, Osaka Police Hospital, Tennoji, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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The investigation of the survival time after recurrence in patients with pancreatic ductal adenocarcinoma for individualization of adjuvant chemotherapy. Surg Today 2018; 48:952-962. [PMID: 29770847 DOI: 10.1007/s00595-018-1674-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/27/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease; however, the frequency of recurrence can be reduced if curative surgery following adjuvant chemotherapy is applied. At present, adjuvant chemotherapy is uniformly performed in all patients, as it is unclear which tumor types are controlled best or worst. We investigated patients with recurrence to establish the optimum treatment strategy. METHODS Of 138 patients who underwent curative surgery for PDAC, 85 developed recurrence. Comprehensive clinicopathological factors were investigated for their association with the survival time after recurrence (SAR). RESULTS The median SAR was 12.6 months. Treatments for recurrence included best supportive care, GEM-based therapy and S-1. The performance status [hazard ratio (HR) 0.12, P < 0.001], histological invasion of lymph vessels (HR 0.27, P < 0.001), kind of treatment for recurrence (HR 5.0, P < 0.001) and initial recurrence site (HR 2.9, P < 0.001) were independent significant risk factors for the SAR. The initial recurrence sites were the liver (n = 21, median SAR 8.8 months), lung (n = 10, 14.9 months), peritoneum (n = 6, 1.7 months), lymph nodes (n = 6, 14.7 months), local site (n = 17, 13.9 months) and multiple sites (n = 25, 10.1 months). A shorter recurrence-free survival (< 1 year) and higher postoperative CA19-9 level were significantly associated with critical recurrence (peritoneal/liver). CONCLUSIONS Several risk factors for SAR were detected in this study. Further investigations are needed to individualize the adjuvant chemotherapy for each patient with PDAC.
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9
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A practical approach to pancreatic cancer immunotherapy using resected tumor lysate vaccines processed to express α-gal epitopes. PLoS One 2017; 12:e0184901. [PMID: 29077749 PMCID: PMC5659602 DOI: 10.1371/journal.pone.0184901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 09/03/2017] [Indexed: 12/23/2022] Open
Abstract
Objectives Single-agent immunotherapy is ineffective against poorly immunogenic cancers, including pancreatic ductal adenocarcinoma (PDAC). The aims of this study were to demonstrate the feasibility of production of novel autologous tumor lysate vaccines from resected PDAC tumors, and verify vaccine safety and efficacy. Methods Fresh surgically resected tumors obtained from human patients were processed to enzymatically synthesize α-gal epitopes on the carbohydrate chains of membrane glycoproteins. Processed membranes were analyzed for the expression of α-gal epitopes and the binding of anti-Gal, and vaccine efficacy was assessed in vitro and in vivo. Results Effective synthesis of α-gal epitopes was demonstrated after processing of PDAC tumor lysates from 10 different patients, and tumor lysates readily bound an anti-Gal monoclonal antibody. α-gal(+) PDAC tumor lysate vaccines elicited strong antibody production against multiple tumor-associated antigens and activated multiple tumor-specific T cells. The lysate vaccines stimulated a robust immune response in animal models, resulting in tumor suppression and a significant improvement in survival without any adverse events. Conclusions Our data suggest that α-gal(+) PDAC tumor lysate vaccination may be a practical and effective new immunotherapeutic approach for treating pancreatic cancer.
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10
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Dhir M, Malhotra GK, Sohal DP, Hein NA, Smith LM, O’Reilly EM, Bahary N, Are C. Neoadjuvant treatment of pancreatic adenocarcinoma: a systematic review and meta-analysis of 5520 patients. World J Surg Oncol 2017; 15:183. [PMID: 29017581 PMCID: PMC5634869 DOI: 10.1186/s12957-017-1240-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent years have seen standardization of the anatomic definitions of pancreatic adenocarcinoma, and increasing utilization of neoadjuvant therapy (NAT). The aim of the current review was to summarize the evidence for NAT in pancreatic adenocarcinoma since 2009, when consensus criteria for resectable (R), borderline resectable (BR), and locally advanced (LA) disease were endorsed. METHODS PubMed search was undertaken along with extensive backward search of the references of published articles to identify studies utilizing NAT for pancreatic adenocarcinoma. Abstracts from ASCO-GI 2014 and 2015 were also searched. RESULTS A total of 96 studies including 5520 patients were included in the final quantitative synthesis. Pooled estimates revealed 36% grade ≥ 3 toxicities, 5% biliary complications, 21% hospitalization rate and low mortality (0%, range 0-16%) during NAT. The majority of patients (59%) had stable disease. On an intention-to-treat basis, R0-resection rates varied from 63% among R patients to 23% among LA patients. R0 rates were > 80% among all patients who were resected after NAT. Among R and BR patients who underwent resection after NAT, median OS was 30 and 27.4 months, respectively. CONCLUSIONS The current study summarizes the recent literature for NAT in pancreatic adenocarcinoma and demonstrates improving outcomes after NAT compared to those historically associated with a surgery-first approach for pancreatic adenocarcinoma.
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Affiliation(s)
- Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210 USA
| | - Gautam K. Malhotra
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 98198 USA
| | - Davendra P.S. Sohal
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Nicholas A. Hein
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Eileen M. O’Reilly
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA
| | - Nathan Bahary
- Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232 USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE 98198 USA
- Department of Surgery/Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198 USA
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11
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Yamada D, Eguchi H, Iwagami Y, Mukai Y, Hashimoto Y, Asaoka T, Noda T, Kawamoto K, Gotoh K, Kobayashi S, Takeda Y, Tanemura M, Mori M, Doki Y. Patients Treated with Preoperative Chemoradiation for Pancreatic Ductal Adenocarcinoma have Impaired Bone Density, a Predictor of Distant Metastasis. Ann Surg Oncol 2017; 24:3715-3724. [PMID: 28849575 DOI: 10.1245/s10434-017-6040-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a lethal neoplasm that spreads to surrounding tissue or distant sites. This study investigated distant metastases in PDAC patients with or without preoperative chemoradiation therapy (CRT), focusing on vitamin D levels and bone density. METHODS This study included 146 patients with PDAC who underwent surgery from 2007 to 2014. Bone density was evaluated using computed tomography, and the preoperative vitamin D level was calculated by enzyme-linked immunosorbent assay (ELISA) for patients with available plasma (48 cases). RESULTS When the patients were divided into two groups according to the change in bone density, the group with decreased bone density had a shorter distant metastasis-free survival time (DMFS) after surgery than the other group (p < 0.05). Low vitamin D was a weak predictor of DMFS, but the difference was not significant (p = 0.08), perhaps because of the sample size. Multivariate analysis indicated three significant factors associated with distant metastasis: a decrease in bone density (hazard ratio [HR], 2.17; p = 0.04), normalization of the Dupan-2 value after surgery (hazard ratio [HR], 0.39; p = 0.02), and completion of adjuvant chemotherapy (HR, 0.29; p < 0.01). Univariate analysis showed that a low vitamin D concentration (<20 pg/ml) was a risk factor (p = 0.04) for bone density change. Multivariate analysis found that preoperative CRT was the only factor associated (±, OR, 5.8; p = 0.04) with bone density change, suggesting that preoperative CRT significantly decreases bone density in patients with insufficient vitamin D. CONCLUSION Patients treated with preoperative CRT tend to have impaired bone density, which is a predictor of distant metastasis. Thus, vitamin D supplementation may decrease distant metastasis.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan.
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Yosuke Mukai
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Yasuji Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan.,Department of Surgery, Yao Municipal Hospital, Ryugecho 1-3-1, Yao, Osaka, 581-0069, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan.,Department of Surgery, Kansai Rosai Hospital, Inabasou 3-1-69, Amagasaki, Hyogo, 660-8511, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan.,Department of Surgery, Osaka Police Hospital, Tennoji-ku Kitayamacho 10-31, Osaka, Osaka, 543-0035, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, Osaka, 565-0871, Japan
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12
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Zhan HX, Xu JW, Wu D, Wu ZY, Wang L, Hu SY, Zhang GY. Neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of prospective studies. Cancer Med 2017; 6:1201-1219. [PMID: 28544758 PMCID: PMC5463082 DOI: 10.1002/cam4.1071] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/13/2022] Open
Abstract
There is a strong rationale and many theoretical advantages for neoadjuvant therapy in pancreatic cancer (PC). However, study results have varied significantly. In this study, a systematic review and meta‐analysis of prospective studies were performed in order to evaluate safety and effectiveness of neoadjuvant therapy in PC. Thirty‐nine studies were selected (n = 1458 patients), with 14 studies focusing on patients with resectable disease (group 1), and 19 studies focusing on patients with borderline resectable and locally advanced disease (group 2). Neoadjuvant chemotherapy was administered in 97.4% of the studies, in which 76.9% was given radiotherapy and 74.4% administered with chemoradiation. The complete and partial response rate was 3.8% and 20.9%. The incidence of grade 3/4 toxicity was 11.3%. The overall resection rate after neoadjuvant therapy was 57.7% (group 1: 73.0%, group 2: 40.2%). The R0 resection rate was 84.2% (group 1: 88.2%, group 2: 79.4%). The overall survival for all patients was 16.79 months (resected 24.24, unresected 9.81; group 1: 17.76, group 2: 16.20). Our results demonstrate that neoadjuvant therapy has not been proven to be beneficial and should be considered with caution in patients with resectable PC. Patients with borderline resectable or locally advanced disease may benefit from neoadjuvant therapy, but further research is needed.
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Affiliation(s)
- Han-Xiang Zhan
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Jian-Wei Xu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Dong Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Zhi-Yang Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Lei Wang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - San-Yuan Hu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Guang-Yong Zhang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
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13
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Tomihara H, Yamada D, Eguchi H, Iwagami Y, Noda T, Asaoka T, Wada H, Kawamoto K, Gotoh K, Takeda Y, Tanemura M, Mori M, Doki Y. MicroRNA-181b-5p, ETS1, and the c-Met pathway exacerbate the prognosis of pancreatic ductal adenocarcinoma after radiation therapy. Cancer Sci 2017; 108:398-407. [PMID: 28064436 PMCID: PMC5378264 DOI: 10.1111/cas.13159] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 12/20/2022] Open
Abstract
Preoperative chemoradiation therapy (CRT) for pancreatic ductal adenocarcinoma (PDAC) has emerged as a reasonable strategy that shows good prognostic impact. However, after preoperative CRT, resected specimens show remnant tumor cells, which indicate that some tumor cells had acquired or were selected for resistance to CRT. Recently, two oncological mechanisms, the EMT and the presence of CSCs, were reported to be associated with resistance in various cancers. Previous reports showed that HGF could induce EMT in PDAC cells; moreover, the HGF receptor, c‐Met, was identified as a dominant pancreatic CSC marker. However, the clinical significance of c‐Met expression remains unclear. So, we hypothesized that remnant PDAC tissue after CRT might harbor cells with high c‐Met expression, and these cells may exacerbate patients’ prognosis. In the immunohistochemical analysis, we showed that preoperative CRT was significantly associated with high c‐Met expression; moreover, high c‐Met expression was a significant marker of a dismal prognosis. Next, we investigated mechanisms of c‐Met upregulation in PDAC cells. We established GEM‐resistant and radioresistant PDAC cells to analyze the transcriptome involved in c‐Met expression. The microarray data for the established radiation‐resistant PDAC cells indicated miR‐181b‐5p downregulation, which targets ETS1, one of the transcription factors for c‐Met, and it was shown that radiation exposure induced c‐Met expression through ETS1 increase by the suppression of miR‐181b‐5p. These results suggested that targeting these mechanisms may promote the development of a novel multidisciplinary treatment strategy for improving preoperative CRT efficiency.
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Affiliation(s)
- Hideo Tomihara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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14
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Yamada D, Eguchi H, Asaoka T, Tomihara H, Noda T, Wada H, Kawamoto K, Gotoh K, Takeda Y, Tanemura M, Mori M, Doki Y. The basal nutritional state of PDAC patients is the dominant factor for completing adjuvant chemotherapy. Surg Today 2017; 47:1361-1371. [PMID: 28421348 DOI: 10.1007/s00595-017-1522-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/13/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) is highly lethal, and several clinical trials have shown that adjuvant chemotherapy after curative resection can improve the prognosis of these patients. However, the adjuvant chemotherapy completion rate is less than satisfactory. If this rate could be increased then the overall prognosis of PDAC might be improved; however, reports addressing this problem are insufficient. To elucidate the factors, we retrospectively investigated PDAC patients. METHODS Various factors of 121 PDAC patients undergoing R0 resection, including preoperatively treated patients, were investigated. Univariate and multivariate analyses were performed to investigate the factors that were associated with the completion of adjuvant chemotherapy. RESULTS The analysis identified age and the prognostic nutritional index (PNI) as significant independent factors. A receiver operating characteristic curve analysis of age yielded a cutoff value of 67 years (sensitivity, 64%; specificity, 78%). Univariate and multivariate analyses of the 61 patients who were over 67 years of age revealed that the PNI (odds ratio, 0.85; P = 0.048) and Evans grade (odds ratio, 0.041; P = 0.0010) were significant factors for the completion of chemotherapy. CONCLUSIONS The results of our investigation suggest that nutrition should be controlled in older PDAC patients to facilitate the completion of adjuvant chemotherapy.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan.
| | - Tadafumi Asaoka
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Hideo Tomihara
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan.,Department of Surgery, Kansai Rosai Hospital, Inabasou 3-1-69, Amagasaki, Hyogo, 660-8511, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan.,Department of Surgery, Osaka Police Hospital, Tennoji-ku Kitayamacho 10-31, Osaka, Osaka, 543-0035, Japan
| | - Masaki Mori
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Dr.surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2 (E2), Suita, 565-0871, Osaka, Japan
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15
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A novel preoperative predictor of pancreatic fistula using computed tomography after distal pancreatectomy with staple closure. Surg Today 2017; 47:1180-1187. [PMID: 28265770 DOI: 10.1007/s00595-017-1495-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/24/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE A thick pancreas has proven to be a conspicuous predictor of pancreatic fistula (PF) following distal pancreatectomy (DP) using staples. Other predictors for this serious surgical complication currently remain obscure. This study sought to identify novel predictors of PF following DP. METHODS One hundred and twenty-two patients were retrospectively assessed to determine the correlation between PF occurrence and the clinicopathological findings and radiologic data from preoperative computed tomography (CT). CT assessments included the thickness of the pancreas (TP) and pancreatic CT number (pancreatic index; PI), calculated by dividing the pancreatic CT by the splenic CT density. RESULTS Twenty-four patients (19.7%) developed a clinically relevant PF. TP was identified as an independent risk factor for PF in multivariate analyses (odds ratio 1.17; P = 0.0095). In subgroup analyses, a lower PI in a thick pancreas was a significant predictor of PF (P = 0.032). The combination of these two prediction parameters, known as the TP-to-PI ratio (TPIR), showed a significantly better prediction ability than TP alone (area under the receiver operating characteristic curve for the incidence of PF, TPIR 0.80 vs. TP 0.69; P = 0.037). CONCLUSION Combining the CT number with TP substantially improves the prediction ability for the incidence of PF following DP with staple use.
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16
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Two cases of resectable pancreatic cancer diagnosed by open surgical biopsy after endoscopic ultrasound fine-needle aspiration failed to yield diagnosis: case reports. Surg Case Rep 2017; 3:39. [PMID: 28238191 PMCID: PMC5326629 DOI: 10.1186/s40792-017-0314-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Tumor biopsy for histological diagnosis is required preoperatively and before initiating chemotherapy or radiation therapy for patients with pancreatic cancer (Cancer of the Pancreas: Clinical Practice Guidelines, European Society for Medical Oncology). Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is widely applied to obtain tissue samples for histological examination. However, in some cases, EUS-FNA cannot be performed safely or tissue samples are insufficient to establish a definitive diagnosis. We present two cases of pancreatic cancer diagnosed by open surgical biopsy after EUS-FNA failed to yield a diagnosis. Case presentation Case 1 was a 50-year-old man. Computed tomography showed a hypovascular lesion in the uncus of the pancreas. Although EUS-FNA was conducted twice, we could not collect enough quantity of tissue samples to establish a definitive diagnosis. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by curative operation. Case 2 was a 68-year-old man. Computed tomography showed a hypovascular tumor in the uncus of the pancreas. EUS revealed a 14-mm hypoechoic lesion, but we could not perform EUS-FNA because the superior mesenteric vein was located in the puncture line. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by pancreaticoduodenectomy. Conclusions EUS-FNA is the first choice in the diagnostic modalities of pancreatic neoplasm, but open surgical biopsy is an effective diagnostic method if EUS-FNA is unsuccessful.
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17
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Preoperative chemoradiotherapy does not compromise the feasibility of adjuvant chemotherapy for patients with pancreatic ductal adenocarcinoma. Surg Today 2016; 47:218-226. [PMID: 27586014 DOI: 10.1007/s00595-016-1405-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/10/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Preoperative chemoradiotherapy (CRT) is a novel, emerging treatment strategy for pancreatic ductal adenocarcinoma (PDAC), but it remains unclear whether post-surgery adjuvant chemotherapy is feasible following preoperative CRT. This retrospective study evaluates the feasibility of adjuvant therapy after preoperative CRT. METHODS The subjects of this study were 99 consecutive patients who underwent pancreatectomy for PDAC between January, 2007 and February, 2013 in our hospital. Sixty patients received preoperative CRT: as gemcitabine (GEM) and 40 Gy radiation in 28 (G-CRT group), and as GEM, S-1, and 50.4 Gy radiation in 32 (GS-CRT group). We also evaluated 39 patients who underwent surgery alone (SA group). We investigated adjuvant chemotherapy induction and completion rates and the frequency of adverse events rated ≥grade 3, based on Common Terminology Criteria for Adverse Events (version 4.0) in all three groups. RESULTS In the G-CRT, GS-CRT, and SA groups, the induction rates were 78 % (22/28), 78 % (25/32), and 72 % (28/39), respectively; completion rates were 86 % (19/22), 88 % (22/25), and 82 % (23/28), respectively; and adverse event frequencies were 36 % (8/22), 28 % (7/25), and 43 % (12/28), respectively. No significant difference was found among the three groups. CONCLUSION Preoperative CRT was demonstrated to be safe and did not compromise the feasibility of adjuvant chemotherapy.
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18
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Hasegawa S, Eguchi H, Tomokuni A, Tomimaru Y, Asaoka T, Wada H, Hama N, Kawamoto K, Kobayashi S, Marubashi S, Konnno M, Ishii H, Mori M, Doki Y, Nagano H. Pre-treatment neutrophil to lymphocyte ratio as a predictive marker for pathological response to preoperative chemoradiotherapy in pancreatic cancer. Oncol Lett 2015; 11:1560-1566. [PMID: 26893780 DOI: 10.3892/ol.2015.4057] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 07/07/2015] [Indexed: 12/15/2022] Open
Abstract
An elevated neutrophil to lymphocyte ratio (NLR) has been reported to be associated with the pathological response to neoadjuvant therapies in numerous types of cancer. The aim of the current study was to clarify the association between pre-treatment NLR and the pathological response to preoperative chemoradiotherapy in pancreatic cancer patients. This retrospective analysis included data from 56 consecutive patients whose tumors were completely surgically resected. All patients received preoperative therapy, consisting of gemcitabine-based chemotherapy (alone or in combination with S-1) combined with 40 or 50.4 Gy irradiation, prior to surgery. Predictive factors, including NLR, platelet to lymphocyte ratio (PLR), modified Glasgow prognostic score and prognostic nutrition index, were measured prior to treatment. A comparison was made between those who responded well pathologically (good response group, Evans classification IIb/III) and those with a poor response (Evans I/IIa). NLR was determined to be significantly higher in the poor response group. Multivariate analysis identified an elevated NLR as an independent risk factor for the poor pathological response [odds ratio (OR), 5.35; P=0.0257]. The pre-treatment NLR (≥2.2/<2.2) was found to be a statistically significant predictive indicator of pathological response (P=0.00699). The results demonstrate that pre-treatment NLR may be a useful predictive marker for the pathological response to preoperative therapy in pancreatic cancer patients.
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Affiliation(s)
- Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan; Department of Frontier Science for Cancer and Chemotherapy, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Akira Tomokuni
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Naoki Hama
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shigeru Marubashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Masamitsu Konnno
- Department of Frontier Science for Cancer and Chemotherapy, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Hideshi Ishii
- Department of Frontier Science for Cancer and Chemotherapy, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan; Department of Cancer Profiling Discovery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
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Asaoka T, Miyamoto A, Maeda S, Tsujie M, Hama N, Yamamoto K, Miyake M, Haraguchi N, Nishikawa K, Hirao M, Ikeda M, Sekimoto M, Nakamori S. Prognostic impact of preoperative NLR and CA19-9 in pancreatic cancer. Pancreatology 2015; 16:434-40. [PMID: 26852169 DOI: 10.1016/j.pan.2015.10.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 10/22/2015] [Accepted: 10/25/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently, several preoperative proinflammatory markers and nutritional factors such as neutrophil-to-lymphocyte ratio (NLR) and prognostic nutrition index (PNI) have been reported as significant predictor for poor prognosis of various malignant tumors. In this study, we evaluated the prognostic values of these preoperative parameters in patients with resectable pancreatic head cancer. METHODS We retrospectively reviewed consecutive patients who underwent PD for pancreatic head cancer between 2007 and 2012. A total of 46 patients were enrolled in this analysis. Preoperative parameters such as CRP, CA19-9, NLR and PNI at the time of presentation were recorded as well as overall survival. Cancer specific survival was assessed using Kaplan-Meier method. Univariate and multivariate Cox regression models were applied to evaluate the prognostic relevance of preoperative parameters. The correlations between CA19-9 values, NLR and pathological findings, first recurrence site were respectively reviewed. RESULTS In multivariable analysis preoperative high NLR (≧2.7) and high CA19-9 (≧230) were independent prognostic factors for poor survival (P value: 0.03 and 0.025, respectively). Kaplan-Meier survival analysis demonstrated the overall 2-year survival rate in patients with high NLR or high CA19-9 were 37.5% compared with 89.9% in patients with low NLR and low CA19-9. CONCLUSION Preoperative NLR and serum CA19-9 offer significant prognostic information associated with overall survival following PD in the patients with pancreatic head cancer.
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Affiliation(s)
- Tadafumi Asaoka
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan; Department of Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Atsushi Miyamoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Sakae Maeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Masanori Tsujie
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Naoki Hama
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Kazuyoshi Yamamoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Kazuhiro Nishikawa
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Motohiro Hirao
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Masataka Ikeda
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Shoji Nakamori
- Department of Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
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20
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Goji T, Kimura T, Miyamoto H, Takehara M, Kagemoto K, Okada Y, Okazaki J, Takaoka Y, Miyamoto Y, Mitsui Y, Matsumoto S, Sueuchi T, Tanaka K, Fujino Y, Takaoka T, Kitamura S, Okamoto K, Kimura M, Sogabe M, Muguruma N, Okahisa T, Sato Y, Sagawa T, Fujikawa K, Sato Y, Ikushima H, Takayama T. A phase I/II study of fixed-dose-rate gemcitabine and S-1 with concurrent radiotherapy for locally advanced pancreatic cancer. Cancer Chemother Pharmacol 2015. [PMID: 26220846 DOI: 10.1007/s00280-015-2835-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE This study was conducted to identify the maximum-tolerated dose (MTD) of fixed-dose-rate gemcitabine (FDR-gem) administered concurrently with S-1 and radical radiation for locally advanced pancreatic cancer (LAPC) and to provide efficacy and safety data. METHODS Patients with unrespectable pancreatic cancer confined to the pancreatic region were treated with FDR-gem (300-400 mg/m(2), 5 mg/m(2)/min) on days 1, 8, 22, and 29 and 60 mg/m(2) of S-1 orally on days 1-14, 22-35. A total radiation dose of 50.4 Gy (1.8 Gy/day, 28 fractions) was delivered concurrently. RESULTS Twenty-five patients were enrolled; all were evaluable for toxicity assessment. In phase I, eight patients were treated in sequential cohorts of three to five patients per dose level. The MTD was reached at level 2, and dose-limiting toxicities were neutropenia and thrombocytopenia. The recommended doses were 300 mg/m(2) of gemcitabine and 60 mg/m(2) of S-1 daily. The overall response rate was 25% and disease control rate (partial response plus stable disease) was 92%. The progression-free survival was 11.0 months. The median overall survival and 1-year survival rates were 16.0 months and 73%, respectively. CONCLUSION The combination of FDR-gem and S-1 with radiation is a feasible regimen that shows favorable antitumor activity with an acceptable safety profile in patients with LAPC.
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Affiliation(s)
- Takahiro Goji
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, University of Tokushima Graduate School, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
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21
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Qiu M, Peng XC, Bi F, Wang X, Li Q, Xu F, Li ZP, Shen YL, Liu JY, Zhao YQ, Cao D, Gou HF, Yang Y, Chen Y, Yi C. Phase I study of postoperative radiotherapy concurrent with S-1 in patients with gastric cancer. Med Oncol 2015; 32:191. [PMID: 26025485 DOI: 10.1007/s12032-015-0635-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 05/11/2015] [Indexed: 02/05/2023]
Abstract
Postoperative chemoradiotherapy (CRT) with concurrent 5-fluorouracil is the standard care for gastric cancer patients after curative surgery. The previous studies revealed that the subgroup of patients with high recurrence risk would benefit most from adjuvant CRT. S-1, a novel oral fluorouracil, has showed very effective in metastatic gastric cancer and became the standard option for gastric cancer with D2 dissection. The safety and dosage of S-1 combined with postoperative radiotherapy have not yet been evaluated. This study is to determine the maximum tolerate dose (MTD) and dose-limiting toxicity (DLT) of S-1 given concurrently with postoperative high-dose radiotherapy in gastric cancer. Patients with more advanced stage (pT4 and/or pN+) after R0 resection were recruited. Eligible patients received one cycle standard SOX (S-1 plus oxaliplatin) chemotherapy, then S-1 monotherapy with concurrent radiotherapy for 6 weeks, followed by additional three cycles of SOX. During the concurrent CRT, S-1 was administered on every radiotherapy treatment day according to a predefined dose-escalation schedule. Radiotherapy (3D-RT or IMRT) was given to a total dose of 50.4 Gy in 28 fractions. DLT was defined as grade 3 or 4 hematologic and non-hematologic toxicity. From March 2011 to October 2012, 21 patients were enrolled at five dose levels: 40 (n = 3), 50 (n = 3), 60 (n = 6), 70 (n = 6) and 80 mg/m(2)/day (n = 3). D2-dissection was performed in 18 patients (85.7 %) and 15 patients (71.4 %) had stage III disease. The most common dose-related toxicity was anorexia, nausea and vomiting, fatigue and leucopenia. DLT was occurred in one patient at 60 mg/m(2)/day (grade 3 fatigue), one patient at 70 mg/m(2)/day (grade 3 vomiting and anorexia), two patients at 80 mg/m(2)/day (one with grade 3 vomiting and anorexia; another with grade 3 febrile leucopenia). Four patients did not complete CRT as planned. Overall, this phase I study demonstrated that postoperative CRT with daily S-1 was feasible in gastric cancer and the MTD of S-1 concurrent with radiotherapy was 70 mg/m(2)/day. This S-1-based postoperative CRT will be investigated in a multicenter phase III study in West China.
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Affiliation(s)
- Meng Qiu
- Department of Medical Oncology, Cancer Center, State Key Laboratory of Biotherapy West China Hospital, West China Medical School, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China,
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22
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Pancreatectomy with major arterial resection after neoadjuvant chemoradiotherapy gemcitabine and S-1 and concurrent radiotherapy for locally advanced unresectable pancreatic cancer. Surgery 2015; 158:191-200. [PMID: 25900035 DOI: 10.1016/j.surg.2015.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/07/2015] [Accepted: 02/19/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) with arterial invasion is currently a contraindication to resection and has a miserable prognosis. METHODS Seventeen patients with locally advanced PC involving the celiac axis and/or common hepatic artery (CHA) who received chemoradiotherapy (CRT) composed of gemcitabine, S-1, and external beam irradiation over the last 2 years were investigated. Thirteen patients underwent pancreatectomy with major arterial resection: 6 distal pancreatectomies with resection of the celiac axis, 4 total pancreatectomies with resection of both the celiac axis and the CHA, and 3 pancreatoduodenectomies with resection of the CHA. Preoperative arterial embolization and/or arterial reconstruction to prevent ischemic gastropathy and hepatopathy was performed in 7 of the 13 patients. RESULTS Distant metastases were found in 3 patients after CRT. One patient did not consent to operation after CRT. The morbidity rate of the 13 patients who underwent surgery was 62% (8/13), but no deaths occurred. Although there were no responders on CT, >90% of tumor cells were necrotic on histopathology in 5 of 13 tumors after CRT. Invasion of the celiac axis remained in 5 tumors, and extrapancreatic plexus invasion remained in 8 tumors, but an R0 resection was achieved in 12 of 13 tumors. Lymph node metastases were found in 3 of 13 cases. The overall 1-year survival rate from commencement of CRT and resection was 12 of 13 patients. CONCLUSION Neoadjuvant CRT containing gemcitabine and S-1 and subsequent pancreatectomy with major arterial resection for patients with locally advanced PC with arterial invasion were carried out safely with an acceptable R0 resection acceptable morbidity and mortality, and encouraging survival (12 of 13) at 1 year postoperatively.
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23
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Tomimaru Y, Eguchi H, Satoh T, Tomokuni A, Asaoka T, Wada H, Marubashi S, Ogawa K, Takehara T, Mori M, Doki Y, Nagano H. Feasibility of pre-operative chemoradiotherapy with gemcitabine to treat pancreatic cancer in patients with impaired renal function. Jpn J Clin Oncol 2015; 45:343-8. [PMID: 25589454 DOI: 10.1093/jjco/hyu224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Although pre-operative chemoradiotherapy appears to be a promising treatment for patients with pancreatic ductal adenocarcinoma, there have been no reports of the feasibility of pre-operative chemoradiotherapy in pancreatic ductal adenocarcinoma patients with renal impairment. The aim of this study was to evaluate retrospectively the feasibility of pre-operative chemoradiotherapy in pancreatic ductal adenocarcinoma patients with renal impairment. METHODS Twelve patients with resectable pancreatic ductal adenocarcinoma and a creatinine clearance of <60 ml/min were enrolled in this study. Gemcitabine-based pre-operative chemoradiotherapy was performed, followed by surgery. The feasibility of the treatment was evaluated in terms of clinical outcome and adverse events in the patients. RESULTS All 12 patients completed gemcitabine-based pre-operative chemoradiotherapy without worsening of renal function. Restaging after the therapy revealed radiologically unresectable disease in two patients. Among the remaining 10 patients who underwent laparotomy, curative resection was performed in eight patients. After curative resection, five patients out of the eight completed post-operative adjuvant therapy. The 1- and 3-year survival rates after the start of chemoradiotherapy in the 12 patients were 80.8 and 36.9%, respectively. CONCLUSIONS Our findings suggest that gemcitabine-based pre-operative chemoradiotherapy may be a safe and effective treatment for pancreatic ductal adenocarcinoma in patients with renal impairment.
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Affiliation(s)
- Yoshito Tomimaru
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Hidetoshi Eguchi
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Taroh Satoh
- Department of Frontier Science for Cancer and Chemotherapy, Graduate School of Medicine, Osaka University, Suita
| | - Akira Tomokuni
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Tadafumi Asaoka
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Hiroshi Wada
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Shigeru Marubashi
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Graduate School of Medicine, Osaka University, Suita
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Masaki Mori
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Yuichiro Doki
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Hiroaki Nagano
- Department of Surgery, Graduate School of Medicine, Osaka University, Suita
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24
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Franke AJ, Rosati LM, Pawlik TM, Kumar R, Herman JM. The role of radiation therapy in pancreatic ductal adenocarcinoma in the neoadjuvant and adjuvant settings. Semin Oncol 2014; 42:144-62. [PMID: 25726059 DOI: 10.1053/j.seminoncol.2014.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic adenocarcinoma (PCA) is associated with high rates of cancer-related morbidity and mortality. Yet despite modern treatment advances, the only curative therapy remains surgical resection. The adjuvant therapeutic standard of care for PCA in the United States includes both chemotherapy and chemoradiation; however, an optimal regimen has not been established. For patients with resectable and borderline resectable PCA, recent investigation has focused efforts on evaluating the feasibility and efficacy of neoadjuvant therapy. Neoadjuvant therapy allows for early initiation of systemic therapy and identification of patients who harbor micrometastatic disease, thus sparing patients the potential morbidities associated with unnecessary radiation or surgery. This article critically reviews the data supporting or refuting the role of radiation therapy in the neoadjuvant and adjuvant settings of PCA management, with a particular focus on determining which patients may be more likely to benefit from radiation therapy.
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Affiliation(s)
- Aaron J Franke
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren M Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachit Kumar
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
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25
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Ke QH, Zhou SQ, Yang JY, Du W, Liang G, Lei Y, Luo F. S-1 plus gemcitabine chemotherapy followed by concurrent radiotherapy and maintenance therapy with S-1 for unresectable pancreatic cancer. World J Gastroenterol 2014; 20:13987-13992. [PMID: 25320537 PMCID: PMC4194583 DOI: 10.3748/wjg.v20.i38.13987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/16/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility and efficacy of the combination of S-1 with gemcitabine followed by oral S-1 with concurrent radiotherapy (intensity modulated radiotherapy, IMRT) and maintenance therapy with S-1 for locally advanced pancreatic cancer.
METHODS: Subjects selected in the study were patients who had unresectable and locally advanced pancreatic cancer without distant metastases, adequate organ and marrow functions, an Eastern Cooperative Oncology Group performance status of 0-1 and no prior anticancer therapy. Initially the subjects received two cycles of chemotherapy, oral administration of S-1 40 mg/m2 twice daily from day 1 to day 14 of a 21-d cycle, with 30-min intravenous infusions of gemcitabine 1000 mg/m2 on day 1 and day 8. Two weeks after the completion of chemotherapy, S-1 was administered orally with concurrent IMRT. Oral S-1 was administered at a dose of 80 mg/m2 per day twice daily from day 1 to day 14 and from day 22 to day 35. Radiation was concurrently delivered at a dose of 50.4 Gy (1.8 Gy/d, 5 times per week, 28 fractions). One month after the completion of chemotherapy and radiotherapy, S-1 was administered orally at a dose of 80 mg/m2 per day twice daily for 14 d, followed by a 14-d rest period. This cycle was repeated as maintenance therapy, until unacceptable toxicity occurred or the disease worsened. Thirty-two patients were involved in this study. The median follow-up was 15.6 mo (range: 8.6-32.3 mo).
RESULTS: Thirty-two patients completed the scheduled course of chemotherapy, while 30 patients (93.8%) received chemoradiotherapy with two patients ceasing to continue with radiotherapy. The major toxic effects were nausea and leukopenia. There was no grade 4 toxicity or treatment-related death. According to the Response Evaluation Criteria in Solid Tumors criteria, the objective tumor response was partial response in 17 (53.1%) patients, stable disease in 9 (28.1%), and progressive disease in 6 (18.8%). The median overall survival and median progression-free survival were 15.2 mo and 9.3 mo, respectively. The survival rates at 1 year and 2 years were 75% and 34.4%, respectively.
CONCLUSION: The combination of S-1 with gemcitabine followed by oral S-1 with IMRT and maintenance therapy with S-1 alone in patients with locally advanced pancreatic cancer may be considered a well-tolerated, promising treatment regimen.
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