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Jia WY, Gui Y, Chen XQ, Tan L, Zhang J, Xiao MS, Chang XY, Dai MH, Guo JC, Cheng YJ, Wang X, Zhang JH, Zhang XQ, Lv K. Efficacy of color Doppler ultrasound and contrast-enhanced ultrasound in identifying vascular invasion in pancreatic ductal adenocarcinoma. Insights Imaging 2024; 15:181. [PMID: 39060856 DOI: 10.1186/s13244-024-01779-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
OBJECTIVES To compare color Doppler ultrasound and contrast-enhanced ultrasound (CEUS) in evaluating vascular invasion in pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS This retrospective study included 210 patients with PDAC who were evaluated by color Doppler ultrasound, CEUS, and contrast-enhanced computed tomography (CECT) at our institution between January 2017 and December 2020. Pathologic results were used as the gold standard in patients who underwent surgical and intraoperative exploration. For nonsurgical patients, CECT results were used as the reference standard. The vessels evaluated included those in the peripancreatic arterial system and venous system. The diagnostic performances of color Doppler ultrasound and CEUS for vascular invasion were compared. RESULTS In 51 patients who underwent surgery and intraoperative exploration, color Doppler ultrasound and CEUS differed only in assessing venous system invasion in patients with PDAC of the pancreatic body and tail, with the former being superior to the latter. In 159 nonsurgical patients, there was no difference between CEUS and color Doppler ultrasound in assessing superior mesenteric arteriovenous invasion. CEUS was superior to color Doppler ultrasound in evaluating the celiac artery and its branches, with an accuracy of up to 97.8% for some vessels. Color Doppler ultrasound was ideal for evaluating the splenic and portal veins. CONCLUSION CEUS is more suitable for the evaluation of peripancreatic arteries than color Doppler. CEUS combined with color Doppler ultrasound can be used as a potential supplement to CECT and is also expected to be used to evaluate vascular invasion of PDAC after chemotherapy. CRITICAL RELEVANCE STATEMENT Contrast-enhanced US and color Doppler in the assessment of vascular invasion in pancreatic ductal adenocarcinoma have their respective advantages, through standardized ultrasound processes are expected to improve the efficiency of inspection. KEY POINTS Contrast-enhanced US has unique advantages in assessing pancreatic ductal adenocarcinoma invasion of the celiac artery. Doppler imaging is of high value in assessing venous system invasion. Standardization of ultrasound imaging procedures for pancreatic ductal adenocarcinoma is expected to improve efficiency.
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Affiliation(s)
- Wan-Ying Jia
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Gui
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Qi Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Tan
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Zhang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng-Su Xiao
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Yan Chang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng-Hua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun-Chao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Juan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiang Wang
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia-Hui Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Qian Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Lv
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Lee W, Park HJ, Lee YN, Sung MK, Hong K, Park Y, Song KB, Lee JH, Hwang DW, Kim HJ, Hong SM, Kim SC. Computed tomography-based vascular burden index as a predictor of vascular resection and pathological vascular invasion in pancreatic cancer with neo-adjuvant chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108494. [PMID: 38968855 DOI: 10.1016/j.ejso.2024.108494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/20/2024] [Accepted: 06/17/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Determination of vessel resection in patients with pancreatectomy after neo-adjuvant chemotherapy remains controversial. The recently introduced computed tomography-based vascular burden index presents a potential solution to this challenge. This study aimed to evaluate the model performance for the prediction of vascular resection and pathological invasion. METHODS Patients who underwent surgery after neo-adjuvant chemotherapy were included. Two independent reviewers measured the vascular tumour burden index around the adjacent artery (AVBI), and vein (VVBI). The area under the curve was compared to assess the predictive capacity of vascular burden index values and their changes for vascular resection and pathological vascular invasion. RESULTS Among 252 patients, 179 and 73 had borderline resectable and locally advanced pancreatic cancer, respectively. Concurrent vessel resection and pathological vascular invasion were observed in 121 (48.0 %) and 42 (16.6 %) patients, respectively. In all patients, the VVBI (area under the curve: 0.872) and AVBI (0.911) after neo-adjuvant therapy significantly predicted vessel resection. In patients with vascular resection, the VVBI after neo-adjuvant chemotherapy (0.752) and delta value of the AVBI (0.706) demonstrated better performance for predicting pathological invasion of the resected vein. The regression of the AVBI and VVBI was an independent prognostic factor for survival (hazard ratio: 0.54, 95 % confidence interval: 0.34-0.85; P = 0.009) CONCLUSIONS: Regressed VVBI on serial computed tomography scans is useful for predicting vein resection and pathological venous invasion before surgery. The delta value of the AVBI may therefore be helpful for predicting pathological arterial invasion after neo-adjuvant chemotherapy.
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Affiliation(s)
- Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyo Jung Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yoo Na Lee
- Department of Surgery, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Min Kyu Sung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kwangpyo Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Brain Korea 21 Project, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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3
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Goetze TO, Reichart A, Bankstahl US, Pauligk C, Loose M, Kraus TW, Elshafei M, Bechstein WO, Trojan J, Behrend M, Homann N, Venerito M, Bohle W, Varvenne M, Bolling C, Behringer DM, Kratz-Albers K, Siegler GM, Hozaeel W, Al-Batran SE. Adjuvant Gemcitabine Versus Neoadjuvant/Adjuvant FOLFIRINOX in Resectable Pancreatic Cancer: The Randomized Multicenter Phase II NEPAFOX Trial. Ann Surg Oncol 2024; 31:4073-4083. [PMID: 38459418 PMCID: PMC11076394 DOI: 10.1245/s10434-024-15011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Although addition of adjuvant chemotherapy is the current standard, the prognosis of pancreatic cancers still remains poor. The NEPAFOX trial evaluated perioperative treatment with FOLFIRINOX in resectable pancreatic cancer. PATIENTS AND METHODS This multicenter phase II trial randomized patients with resectable or borderline resectable pancreatic cancer without metastases into arm (A,) upfront surgery plus adjuvant gemcitabine, or arm (B,) perioperative FOLFIRINOX. The primary endpoint was overall survival (OS). RESULTS Owing to poor accrual, recruitment was prematurely stopped after randomization of 40 of the planned 126 patients (A: 21, B: 19). Overall, approximately three-quarters were classified as primarily resectable (A: 16, B: 15), and the remaining patients were classified as borderline resectable (A: 5, B: 4). Of the 12 evaluable patients, 3 achieved partial response under neoadjuvant FOLFIRINOX. Of the 21 patients in arm A and 19 patients in arm B, 17 and 7 underwent curative surgery, and R0-resection was achieved in 77% and 71%, respectively. Perioperative morbidity occurred in 72% in arm A and 46% in arm B, whereas non-surgical toxicity was comparable in both arms. Median RFS/PFS was almost doubled in arm B (14.1 months) compared with arm A (8.4 months) in the population with surgical resection, whereas median OS was comparable between both arms. CONCLUSIONS Although the analysis was only descriptive owing to small patient numbers, no safety issues regarding surgical complications were observed in the perioperative FOLFIRINOX arm. Thus, considering the small number of patients, perioperative treatment approach appears feasible and potentially effective in well-selected cohorts of patients. In pancreatic cancer, patient selection before initiation of neoadjuvant therapy appears to be critical.
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Affiliation(s)
- Thorsten O Goetze
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany.
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany.
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany.
| | - Alexander Reichart
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Ulli S Bankstahl
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Claudia Pauligk
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Maria Loose
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
| | - Thomas W Kraus
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Moustafa Elshafei
- Krankenhaus Nordwest, Allgemein-, Viszeral- und Minimal Invasive Chirurgie, Frankfurt, Germany
| | - Wolf O Bechstein
- Klinik für Allgemein-, Viszeral-, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jörg Trojan
- Gastrointestinale Onkologie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Matthias Behrend
- Viszeral-, Thorax- und Gefäßchirurgie, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Nils Homann
- Medizinische Klinik II, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Wolfram Bohle
- Klinik für Gastroenterologie, Gastroenterologische Onkologie, Klinikum Stuttgart, Stuttgart, Germany
- Hepatologie, Infektiologie und Pneumologie, Stuttgart, Germany
| | | | - Claus Bolling
- Hämatologie/Onkologie, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Dirk M Behringer
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | | | - Gabriele M Siegler
- Klinikum Nürnberg Nord/Paracelsus Medizinische Privatuniversität, Medizinische Klinik, Hämatologie/Onkologie, Nürnberg, Germany
| | - Wael Hozaeel
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Salah-Eddin Al-Batran
- Krankenhaus Nordwest, Institut für Klinisch Onkologische Forschchung IKF, University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt, Goethe Universität, Frankfurt, Germany
- Frankfurter Institut für Klinische Krebsforschung IKF am Krankenhaus Nordwest, Frankfurt, Germany
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4
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Bilreiro C, Andrade L, Santiago I, Marques RM, Matos C. Imaging of pancreatic ductal adenocarcinoma - An update for all stages of patient management. Eur J Radiol Open 2024; 12:100553. [PMID: 38357385 PMCID: PMC10864763 DOI: 10.1016/j.ejro.2024.100553] [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: 10/15/2023] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/16/2024] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is a common and lethal cancer. From diagnosis to disease staging, response to neoadjuvant therapy assessment and patient surveillance after resection, imaging plays a central role, guiding the multidisciplinary team in decision-planning. Review aims and findings This review discusses the most up-to-date imaging recommendations, typical and atypical findings, and issues related to each step of patient management. Example cases for each relevant condition are presented, and a structured report for disease staging is suggested. Conclusion Despite current issues in PDAC imaging at different stages of patient management, the radiologist is essential in the multidisciplinary team, as the conveyor of relevant imaging findings crucial for patient care.
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Affiliation(s)
- Carlos Bilreiro
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Luísa Andrade
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Inês Santiago
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Rui Mateus Marques
- Nova Medical School, Lisbon, Portugal
- Radiology Department, Hospital de S. José, Lisbon, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
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5
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Bilreiro C, Andrade L, Marques RM, Matos C. Diffusion-weighted imaging for determining response to neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis. Eur Radiol 2024; 34:3238-3248. [PMID: 37907761 PMCID: PMC11126427 DOI: 10.1007/s00330-023-10381-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/15/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES To determine the role of diffusion-weighted imaging (DWI) for predicting response to neoadjuvant therapy (NAT) in pancreatic cancer. MATERIALS AND METHODS MEDLINE, EMBASE, and Cochrane Library databases were searched for studies evaluating the performance of apparent diffusion coefficient (ADC) to assess response to NAT. Data extracted included ADC pre- and post-NAT, for predicting response as defined by imaging, histopathology, or clinical reference standards. ADC values were compared with standardized mean differences. Risk of bias was assessed using the Quality Assessment of Diagnostic Studies (QUADAS-2). RESULTS Of 337 studies, 7 were included in the analysis (161 patients). ADC values reported for the pre- and post-NAT assessments overlapped between responders and non-responders. One study reported inability of ADC increase after NAT for distinguishing responders and non-responders. A correlation with histopathological response was reported for pre- and post-NAT ADC in 4 studies. DWI's diagnostic performance was reported to be high in three studies, with a 91.6-100% sensitivity and 62.5-94.7% specificity. Finally, heterogeneity and high risk of bias were identified across studies, affecting the domains of patient selection, index test, reference standard, and flow and timing. CONCLUSION DWI might be useful for determining response to NAT in pancreatic cancer. However, there are still too few studies on this matter, which are also heterogeneous and at high risk for bias. Further studies with standardized procedures for data acquisition and accurate reference standards are needed. CLINICAL RELEVANCE STATEMENT Diffusion-weighted MRI might be useful for assessing response to neoadjuvant therapy in pancreatic cancer. However, further studies with robust data are needed to provide specific recommendations for clinical practice. KEY POINTS •The role of DWI with ADC measurements for assessing response to neoadjuvant therapy in pancreatic cancer is still unclear. •Pre- and post-neoadjuvant therapy ADC values overlap between responders and non-responders. •DWI has a reported high diagnostic performance for determining response when using histopathological or clinical reference standards; however, studies are still few and at high risk for bias.
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Affiliation(s)
- Carlos Bilreiro
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal.
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal.
- Nova Medical School, Lisbon, Portugal.
| | - Luísa Andrade
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Rui Mateus Marques
- Nova Medical School, Lisbon, Portugal
- Radiology Department, Hospital de S. José, Lisbon, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
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Noda Y, Pisuchpen N, Parakh A, Srinivas-Rao S, Kinowaki Y, Mino-Kenudson M, Kambadakone AR. Does CT overestimate extra-pancreatic perineural invasion in patients with pancreatic ductal adenocarcinoma following neoadjuvant chemoradiation therapy? Br J Radiol 2024; 97:607-613. [PMID: 38305574 PMCID: PMC11027284 DOI: 10.1093/bjr/tqae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 06/27/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES To evaluate the diagnostic performance of CT in the assessment of extra-pancreatic perineural invasion (EPNI) in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS This retrospective study included 123 patients (66 men; median age, 66 years) with PDAC who underwent radical surgery and pancreatic protocol CT for assessing surgical resectability between September 2011 and March 2019. Among the 123 patients, 97 patients had received neoadjuvant chemoradiation therapy (CRT). Two radiologists reviewed the CT images for evidence of EPNI using a 5-point scale (5 = definitely present, 4 = probably present, 3 = equivocally present, 2 = probably absent, and 1 = definitely absent). Diagnostic performance for assessing EPNI was evaluated with receiver operating characteristic (ROC) curve analysis. RESULTS The sensitivity, specificity, and area under the ROC curve for assessing EPNI were 98%, 30%, and 0.62 in all patients; 97%, 22%, and 0.59 in patients with neoadjuvant CRT; and 100%, 100%, and 1.00 in patients without neoadjuvant CRT, respectively. False-positive assessment of EPNI occurred in 23% of patients (n = 28/123), and 100% of these (n = 28/28) had received neoadjuvant CRT. There was moderate to substantial agreement between the readers (ĸ = 0.49-0.62). CONCLUSION Pancreatic protocol CT has better diagnostic performance for determination of EPNI in treatment naïve patients with PDAC and overestimation of EPNI is likely in patients who have received preoperative CRT. ADVANCES IN KNOWLEDGE Pancreatic protocol CT has better diagnostic performance for the detection of EPNI in treatment naïve patients compared to patients receiving neoadjuvant CRT.
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Affiliation(s)
- Yoshifumi Noda
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
- Department of Radiology, Gifu University, Gifu 501-1194, Japan
| | - Nisanard Pisuchpen
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
- Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Anushri Parakh
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Shravya Srinivas-Rao
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Yuko Kinowaki
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Avinash R Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
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7
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Yun WG, Han Y, Cho YJ, Jung HS, Lee M, Kwon W, Jang JY. In Neoadjuvant FOLFIRINOX Chemotherapy for Pancreatic Ductal Adenocarcinoma, Which Response is the More Reliable Indicator for Prognosis, Radiologic or Biochemical? Ann Surg Oncol 2024; 31:1336-1346. [PMID: 37991581 DOI: 10.1245/s10434-023-14532-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/18/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND In this era of increasing neoadjuvant chemotherapy, methods for evaluating responses to neoadjuvant chemotherapy are still diverse among institutions. Additionally, the efficacy of adjuvant chemotherapy for patients undergoing neoadjuvant chemotherapy remains unclear. Therefore, this retrospective study was performed to evaluate the effectiveness of methods for assessing response to neoadjuvant chemotherapy and the need for adjuvant chemotherapy in treating patients with non-metastatic pancreatic ductal adenocarcinoma. METHODS The study identified 150 patients who underwent neoadjuvant FOLFIRINOX chemotherapy followed by curative-intent pancreatectomy. The patients were stratified by biochemical response based on the normalization of carbohydrate antigen 19-9 and by radiologic response based on size change at imaging. RESULTS The patients were classified into the following three groups based on their response to neoadjuvant chemotherapy and prognosis: biochemical responders (BR+), radiology-only responders (BR-/RR+), and non-responders (BR-/RR-). The 3-year overall survival rate was higher for BR+ (71.0%) than for BR-/RR+ (53.6%) or BR-/RR- (33.1%) (P < 0.001). Response to neoadjuvant chemotherapy also was identified as a significant risk factor for recurrence in a comparison between BR-/RR+ and BR+ (hazard ratio [HR], 2.15; 95% confidence interval [CI] 1.19-3.88; P = 0.011) and BR-/RR- (HR, 3.82; 95% CI 2.41-6.08; P < 0.001). Additionally, regardless of the response to neoadjuvant chemotherapy, patients who completed adjuvant chemotherapy had a significantly higher 3-year overall survival rate than those who did not. CONCLUSIONS This response evaluation criterion for neoadjuvant chemotherapy is feasible and can significantly predict prognosis. Additionally, completion of adjuvant chemotherapy could be helpful to patients who undergo neoadjuvant chemotherapy regardless of their response to neoadjuvant chemotherapy.
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Affiliation(s)
- Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Jae Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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8
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Watanabe Y, Tatsuguchi T, Date K, Shinkawa T, Kuga H, Tamiya S, Nishihara K, Nakano T. Conversion surgery for initially unresectable locally advanced pancreatic ductal adenocarcinoma after chemotherapy followed by carbon-ion radiotherapy: a case report. J Med Case Rep 2024; 18:13. [PMID: 38200536 PMCID: PMC10782725 DOI: 10.1186/s13256-023-04311-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/07/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Recent advances in chemotherapy and chemoradiotherapy have enabled conversion surgery (CS) to be performed for selected patients with initially unresectable locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). Many studies indicate CS might extend the survival of patients with initially unresectable LA PDAC. However, several clinical questions concerning CS remain, such as the optimal preoperative treatment. Carbon-ion radiotherapy (CIRT) is a unique radiotherapy that offers higher biological effectiveness than conventional radiotherapy. Here, we report a long-term survival case with initially unresectable LA PDAC who underwent CS after chemotherapy followed by CIRT. CASE PRESENTATION The patient was a 72-year-old Japanese woman with unresectable LA pancreatic head cancer with tumor contact to the superior mesenteric artery (SMA). She underwent four courses of chemotherapy (gemcitabine plus nanoparticle albumin-bound paclitaxel). However, the lesion did not shrink and tumor contact with the SMA did not improve after chemotherapy. Because the probability of achieving curative resection was judged to be low, she underwent radical dose CIRT, and chemotherapy was continued. She complained of vomiting 2 months after CIRT. Although imaging studies showed no tumor growth or metastasis, a duodenal obstruction which was speculated to be an adverse effect of CIRT was observed. She could not eat solid food and a trans-nasal feeding tube was inserted. Therapeutic intervention was required to enable enteral nutrition. We proposed several treatment options. She chose resection with the expectation of an anti-tumor effect of chemotherapy and CIRT rather than course observation with tube feeding or bypass surgery. Therefore, subtotal-stomach-preserving pancreatoduodenectomy with portal vein resection was performed as CS. Pathological examination of the resected specimen revealed an R0 resection with a histological response of Evans grade IIA. Postoperatively, she recovered uneventfully. Adjuvant chemotherapy with tegafur/gimeracil/oteracil (S1) was administrated. At the time of this report, 5 years have passed since the initial consultation and she has experienced no tumor recurrence. CONCLUSIONS The present case suggests that multidisciplinary treatment consisting of a combination of recent chemotherapy and CIRT may be beneficial for unresectable LA PDAC. However, further studies are required to assess the true efficacy of this treatment strategy.
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Affiliation(s)
- Yusuke Watanabe
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan.
- Department of Surgery, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-Ku, Fukuoka, 810-8539, Japan.
| | - Takaaki Tatsuguchi
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Kenjiro Date
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Tomohiko Shinkawa
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Hirotaka Kuga
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Sadafumi Tamiya
- Department of Pathology, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Kazuyoshi Nishihara
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
| | - Toru Nakano
- Department of Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-Ku, Kitakyushu, 802-0077, Japan
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9
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Tamburrino D, De Stefano F, Belfiori G, Partelli S, Crippa S, Falconi M. Surgical Planning for "Borderline Resectable" and "Locally Advanced" Pancreatic Cancer During Open Pancreatic Resection. J Gastrointest Surg 2023; 27:3014-3023. [PMID: 37783912 DOI: 10.1007/s11605-023-05848-w] [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: 07/17/2023] [Accepted: 09/16/2023] [Indexed: 10/04/2023]
Abstract
Pancreatic resection for pancreatic ductal adenocarcinoma (PDAC) is one of the most complex procedures in abdominal surgery due to the technical and oncological challenges given by its local aggressive growth. The improvement of new multidrug chemotherapy regimens and surgical techniques has increased the caseload of "borderline resectable" (BR) or even "locally advanced" (LA) PDAC candidates for surgical resection. As a result, the increased heterogeneity of surgical scenarios has made it essential to utilize a tailored surgical strategy for each individual case. Notably, the strategy employed to approach and assess the peripancreatic vessels should be weighted according to tumor's location and the site of suspected vascular infiltration. The aim of this paper is to describe the open surgical approach for "BR" or "LA" PDAC used at our Institution and summarizes a "step-up approach" to manage vascular infiltration.
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Affiliation(s)
- Domenico Tamburrino
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Federico De Stefano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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10
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Khasawneh H, Ferreira Dalla Pria HR, Miranda J, Nevin R, Chhabra S, Hamdan D, Chakraborty J, Biachi de Castria T, Horvat N. CT Imaging Assessment of Pancreatic Adenocarcinoma Resectability after Neoadjuvant Therapy: Current Status and Perspective on the Use of Radiomics. J Clin Med 2023; 12:6821. [PMID: 37959287 PMCID: PMC10649102 DOI: 10.3390/jcm12216821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Pancreatic adenocarcinoma (PDAC) is the most common pancreatic cancer and is associated with poor prognosis, a high mortality rate, and a substantial number of healthy life years lost. Surgical resection is the primary treatment option for patients with resectable disease; however, only 10-20% of all patients with PDAC are eligible for resection at the time of diagnosis. In this context, neoadjuvant therapy has the potential to increase the number of patients who are eligible for resection, thereby improving the overall survival rate. For patients who undergo neoadjuvant therapy, computed tomography (CT) remains the primary imaging tool for assessing treatment response. Nevertheless, the interpretation of imaging findings in this context remains challenging, given the similarity between viable tumor and treatment-related changes following neoadjuvant therapy. In this review, following an overview of the various treatment options for PDAC according to its resectability status, we will describe the key challenges regarding CT-based evaluation of PDAC treatment response following neoadjuvant therapy, as well as summarize the literature on CT-based evaluation of PDAC treatment response, including the use of radiomics. Finally, we will outline key recommendations for the management of PDAC after neoadjuvant therapy, taking into consideration CT-based findings.
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Affiliation(s)
- Hala Khasawneh
- Department of Radiology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA;
| | | | - Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
- Department of Radiology, University of Sao Paulo, R. Dr. Ovidio Pires de Campos, 75-Cerqueira Cesar, Sao Paulo 05403-010, SP, Brazil
| | - Rachel Nevin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
| | - Shalini Chhabra
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
| | - Dina Hamdan
- Department of Radiology, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, USA;
| | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Tiago Biachi de Castria
- Department of Gastrointestinal Oncology, Moffit Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
- Morsani College of Medicine, University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
- Department of Radiology, University of Sao Paulo, R. Dr. Ovidio Pires de Campos, 75-Cerqueira Cesar, Sao Paulo 05403-010, SP, Brazil
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11
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Alberti P, Pando E, Abu-Suboh M, Masachs M, Merino X, Salcedo M, Macarulla T, Balsells J, Charco R. Assessment of the level III of Inoue by preoperative endoscopic ultrasound and elastography: a novel approach to predict a periarterial divestment technique in borderline resectable (BR) or locally advanced (LA) pancreatic adenocarcinoma-How I do it. Langenbecks Arch Surg 2023; 408:367. [PMID: 37731066 PMCID: PMC10511378 DOI: 10.1007/s00423-023-03105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Periarterial divestment is a surgical technique to approach borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) with arterial involvement. There are no reports in the literature regarding the role of endoscopic ultrasound and elastography (EUS-EG) in exploring the integrity of Inoue's level III and its correlation with the periarterial divestment technique feasibility. Our research is aimed at exploring the role of EUS-EG in this scenario. METHODS We describe our approach to Inoue's level II by EUS-EG in patients with BR and LA pancreatic cancer patients after neoadjuvant chemotherapy. RESULTS Between June 2019 and December 2020, four patients out of 25 were eligible to perform a preoperative EUS-EG. In all cases, Inoue's level III integrity was corroborated by EUS-EG and confirmed posteriorly in the surgical scenario where a periarterial divestment technique was feasible. Vein resections were necessary in all cases, with no need for arterial resection. An R0 (> 1 mm) margin was achieved in all patients, and the histopathological assessment showed the presence of neurovascular tissue at the peripheral arterial margin. CONCLUSION Preoperatively, EUS-EG is a novel approach to explore the integrity of Inoue's level III and could be helpful to preclude a periarterial divestment technique in borderline resectable or locally advanced pancreatic adenocarcinoma with arterial involvement.
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Affiliation(s)
- Piero Alberti
- Department of Surgery, Universitat Autonoma de Barcelona, Barcelona, Spain
- Department of Hepatopancreatobiliary and Trasplant Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - Elizabeth Pando
- Department of Surgery, Universitat Autonoma de Barcelona, Barcelona, Spain.
- Department of Hepatopancreatobiliary and Trasplant Surgery, Hospital Vall d'Hebron, Barcelona, Spain.
| | - Monder Abu-Suboh
- Digestive Endoscopy Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Miquel Masachs
- Digestive Endoscopy Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Xavier Merino
- Radiology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Maite Salcedo
- Anatomopathology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Teresa Macarulla
- Oncology Department, Hospital Vall d'Hebron, Vall d´Hebrón Institute of Oncology, Barcelona, Spain
| | - Joaquin Balsells
- Department of Hepatopancreatobiliary and Trasplant Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - Ramon Charco
- Department of Hepatopancreatobiliary and Trasplant Surgery, Hospital Vall d'Hebron, Barcelona, Spain
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12
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Ninomiya R, Abe S, Chiyoda T, Kogure R, Kimura A, Komagome M, Maki A, Beck Y. Predicting conversion surgery in patients with locally advanced pancreatic cancer after modified FOLFIRINOX treatment. Asian J Surg 2023; 46:3542-3548. [PMID: 37087347 DOI: 10.1016/j.asjsur.2023.03.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/14/2023] [Accepted: 03/30/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND /Objective: FOLFIRINOX therapy (FFX) for locally advanced pancreatic cancer (LAPC) is increasingly recognized as a potent neoadjuvant therapy that enables transition to conversion surgery (CS). However, predictors of CS achievement after chemotherapy are controversial. This study aimed to demonstrate the efficacy of CS after modified FFX (mFFX) in patients with LAPC and to identify and score predictors of CS. METHODS From January 2014 to December 2018, patients with LAPC who received mFFX as a first-line treatment were screened. Patients' overall survival was compared with and without CS. Moreover, the predictors for CS were analyzed to create scores for the CS factors. RESULTS Forty-three patients received mFFX, including 20 patients who underwent CS (CS group, 46.5%). R0 resection was achieved in 16 patients (80%). The median survival time was 39.2 months (95% confidence interval [CI] 17.3-53.8) for the CS group and 16 months (95% CI 10.5-22.6) for the non-CS group (P < 0.001; hazard ratio 0.25, 95% CI 0.12-0.54). Since an average relative dose intensity of ≥90%, tumor reduction of ≥35%, and carbohydrate antigen 19-9 reduction of ≥70% or normalization were associated with successful transition to CS in the multivariate analysis, these factors were scored (CS score, range 0-3). All of the patients in the CS group fell into the 2-3 category, compared with 2 of 23 patients in the non-CS group (P < 0.001). CONCLUSION CS after FFX contributes to the long-term survival of patients with LAPC. The CS score could be an indicator for transition to CS.
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Affiliation(s)
- Riki Ninomiya
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
| | - Satoru Abe
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takehiro Chiyoda
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Ryota Kogure
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Akifumi Kimura
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Masahiko Komagome
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Akira Maki
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshifumi Beck
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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13
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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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14
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Lee DH, Ha HI, Jang JY, Lee JW, Choi JY, Bang S, Lee CH, Kim WB, Lee SS, Kim SC, Kang BK, Lee JM. High-resolution pancreatic computed tomography for assessing pancreatic ductal adenocarcinoma resectability: a multicenter prospective study. Eur Radiol 2023; 33:5965-5975. [PMID: 36988715 DOI: 10.1007/s00330-023-09584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE This prospective multicenter study aimed to evaluate the diagnostic performance of 80-kVp thin-section pancreatic CT in determining pancreatic ductal adenocarcinoma (PDAC) resectability according to the recent National Comprehensive Cancer Network (NCCN) guidelines. METHODS We prospectively enrolled surgical resection candidates for PDAC from six tertiary referral hospitals (study identifier: NCT03895177). All participants underwent pancreatic CT using 80 kVp tube voltage with 1-mm reconstruction interval. The local resectability was prospectively evaluated using NCCN guidelines at each center and classified into three categories: resectable, borderline resectable, and unresectable. RESULTS A total of 138 patients were enrolled; among them, 60 patients underwent neoadjuvant therapy. R0 resection was achieved in 103 patients (74.6%). The R0 resection rates were 88.7% (47/53), 52.4% (11/21), and 0.0% (0/4) for resectable, borderline resectable, and unresectable disease, respectively, in 78 patients who underwent upfront surgery. Meanwhile, the rates were 90.9% (20/22), 76.7% (23/30), and 25.0% (2/8) for resectable, borderline resectable, and unresectable PDAC, respectively, in patients who received neoadjuvant therapy. The area under curve of high-resolution CT in predicting R0 resection was 0.784, with sensitivity, specificity, and accuracy of 87.4% (90/103), 48.6% (17/35), and 77.5% (107/138), respectively. Tumor response was significantly associated with the R0 resection after neoadjuvant therapy (odds ratio [OR] = 38.99, p = 0.016). CONCLUSION An 80-kVp thin-section pancreatic CT has excellent diagnostic performance in assessing PDAC resectability, enabling R0 resection rates of 88.7% and 90.9% for patients with resectable PDAC who underwent upfront surgery and patients with resectable PDAC after neoadjuvant therapy, respectively. KEY POINTS • The margin-negative (R0) resection rates were 88.7% (47/53), 52.4% (11/21), and 0.0% (0/4) for resectable, borderline resectable, and unresectable pancreatic ductal adenocarcinoma (PDAC), respectively, on 80-kVp thin-section pancreatic CT in the 78 patients who underwent upfront surgery. • Among the 60 patients who underwent neoadjuvant therapy, the R0 rates were 90.9% (20/22), 76.7% (23/30), and 25.0% (2/8) for resectable, borderline resectable, and unresectable PDAC, respectively. • Tumor response, along with the resectability status on pancreatic CT, was significantly associated with the R0 resection rate after neoadjuvant therapy.
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Affiliation(s)
- Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Hong Il Ha
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Woo Lee
- Department of Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jin-Young Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Wan Bae Kim
- Division of Hepato-Biliary-Pancreatic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo-Kyeong Kang
- Department of Radiology, Hanyang University College of Medicine, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
- Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea.
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15
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Cassese G, Han HS, Yoon YS, Lee JS, Lee B, Cubisino A, Panaro F, Troisi RI. Role of neoadjuvant therapy for nonmetastatic pancreatic cancer: Current evidence and future perspectives. World J Gastrointest Oncol 2023; 15:911-924. [PMID: 37389109 PMCID: PMC10302990 DOI: 10.4251/wjgo.v15.i6.911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/17/2023] [Accepted: 04/24/2023] [Indexed: 06/14/2023] Open
Abstract
Pancreatic adenocarcinoma (PDAC) is one of the most common and lethal human cancers worldwide. Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC, although only approximately 20% of the patients have resectable tumors when diagnosed. Neoadjuvant chemotherapy (NACT) is recommended for borderline resectable pancreatic cancer. Several studies have investigated the role of NACT in treating resectable tumors based on the recent advances in PDAC biology, as NACT provides the potential benefit of selecting patients with favorable tumor biology and controls potential micro-metastases in high-risk patients with resectable PDAC. In such challenging cases, new potential tools, such as ct-DNA and molecular targeted therapy, are emerging as novel therapeutic options that may improve old paradigms. This review aims to summarize the current evidence regarding the role of NACT in treating non-metastatic pancreatic cancer while focusing on future perspectives in light of recent evidence.
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Affiliation(s)
- Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive HPB Surgery and Transplantation Service, Federico II University Hospital, Naples 80131, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seongnam 13620, Gyeonggi-do, South Korea
| | - Antonio Cubisino
- Department of HPB Surgery and Transplantation, Beaujon Hospital, Clichy 92110, France
| | - Fabrizio Panaro
- Department of Digestive Surgery and Liver Transplantation, CHU Montpellier, Montpellier 34100, France
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive HPB Surgery and Transplantation Service, Federico II University Hospital, Naples 80131, Italy
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16
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Kung H, Yu J. Targeted therapy for pancreatic ductal adenocarcinoma: Mechanisms and clinical study. MedComm (Beijing) 2023; 4:e216. [PMID: 36814688 PMCID: PMC9939368 DOI: 10.1002/mco2.216] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 02/21/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive and lethal malignancy with a high rate of recurrence and a dismal 5-year survival rate. Contributing to the poor prognosis of PDAC is the lack of early detection, a complex network of signaling pathways and molecular mechanisms, a dense and desmoplastic stroma, and an immunosuppressive tumor microenvironment. A recent shift toward a neoadjuvant approach to treating PDAC has been sparked by the numerous benefits neoadjuvant therapy (NAT) has to offer compared with upfront surgery. However, certain aspects of NAT against PDAC, including the optimal regimen, the use of radiotherapy, and the selection of patients that would benefit from NAT, have yet to be fully elucidated. This review describes the major signaling pathways and molecular mechanisms involved in PDAC initiation and progression in addition to the immunosuppressive tumor microenvironment of PDAC. We then review current guidelines, ongoing research, and future research directions on the use of NAT based on randomized clinical trials and other studies. Finally, the current use of and research regarding targeted therapy for PDAC are examined. This review bridges the molecular understanding of PDAC with its clinical significance, development of novel therapies, and shifting directions in treatment paradigm.
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Affiliation(s)
- Heng‐Chung Kung
- Krieger School of Arts and SciencesJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Jun Yu
- Departments of Medicine and OncologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Clinical Implications of FDG-PET in Pancreatic Ductal Adenocarcinoma Patients Treated with Neoadjuvant Therapy. J Gastrointest Surg 2023; 27:337-346. [PMID: 36652179 DOI: 10.1007/s11605-023-05591-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the clinical significance of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy. METHODS Among 285 consecutive patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma between 2015 and 2021, 86 who underwent preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography after completion of neoadjuvant treatment were reviewed. Among preoperative factors, including post-treatment maximum standardized uptake value, predictors of early recurrence and poor prognosis were identified using multivariate analysis for decision making in surgery. RESULTS Nineteen (22%) patients with pancreatic ductal adenocarcinoma demonstrated high maximum standardized uptake (≥ 4.5). High post-treatment maximum standardized uptake (≥ 4.5) predicted early recurrence within 6 months after surgery and correlated with shorter recurrence-free survival. Elevated post-treatment CA19-9 level (> 37 U/ml) and maximum standardized uptake ≥ 4.5 were independent prognostic factors. Post-treatment, a high maximum standardized uptake value indicated a poorer prognosis than a low maximum standardized uptake value in both patients with elevated CA19-9 and normal CA19-9 levels. The median overall survival in patients with elevated post-treatment CA19-9 and high maximum standardized uptake was only 17 months; 67% experienced early recurrence. Dynamic changes in maximum standardized uptake during neoadjuvant therapy were correlated with pathological response to neoadjuvant therapy, but not with radiological response or change in CA19-9 level. CONCLUSIONS Post-treatment assessment using maximum standardized uptake value is useful for stratifying patients with pancreatic ductal adenocarcinoma who will benefit from surgery. Instead of subsequent curative resection, additional neoadjuvant therapy should be considered in patients with a persistently high maximum standardized uptake value.
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de Jong TL, Koopman D, van der Worp CAJ, Stevens H, Vuijk FA, Vahrmeijer AL, Mieog JSD, de Groot JWB, Meijssen MAC, Nieuwenhuijs VB, Lioe-Fee DGO, Jager PL, Patijn GA. Added value of digital FDG-PET/CT in disease staging and restaging in patients with resectable or borderline resectable pancreatic cancer. Surg Oncol 2023; 47:101909. [PMID: 36739788 DOI: 10.1016/j.suronc.2023.101909] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/09/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND We studied the added value of digital FDG-PET/CT in disease staging and restaging compared to the standard work-up with contrast enhanced CT (ceCT) and CA19-9 in patients with resectable or borderline resectable pancreatic cancer who received neo-adjuvant therapy. Primary endpoints were tumor response compared to ceCT and CA19.9 as well as the ability to detect distant metastatic disease. METHODS 35 patients were included in this dual-center prospective study. FDG-PET using digital photon counting technology combined with CT scans were acquired before (T1) and after neo-adjuvant therapy (T2). Patients were staged and restaged based on standard protocol with ceCT and CA 19.9, while all PET/CT scans were stored securely and not included in clinical decision making. After the pancreatic resection, an expert team retrospectively assessed the CT tumor diameter, CA19-9, tumor FDG-uptake, and appearance of metastatic disease of all patients for both time points. RESULTS CA19-9 levels, CT tumor diameter, and tumor FDG-uptake on PET significantly decreased from T1 to T2 (p = 0.017, p = 0.001, and p < 0.0001). The change in FDG-uptake values showed a strong positive correlation with the change in CT tumor diameter and change in CA19-9 (R = 0.75 and R = 0.73, respectively). In addition, small-volume liver lesions were detected on digital PET/CT in 5/35 patients (14%), 4 of which were pathology confirmed at laparotomy. Only one of these five cases was detected on baseline staging ceCT (3%). CONCLUSION We found that adding digital PET/CT strengthens restaging after neo-adjuvant therapy based on the observed strong correlation with ceCT tumor diameter and Ca19.9. Also, digital PET/CT was found to detect occult metastatic disease not visualized on ceCT, that would have resulted in altered disease staging and therapeutic strategy in a substantial proportion of patients.
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Affiliation(s)
- Tonke L de Jong
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Daniëlle Koopman
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | | | - Henk Stevens
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Floris A Vuijk
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Maarten A C Meijssen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | | | - de Geus-Oei Lioe-Fee
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; Biomedical Photonic Imaging Group, University of Twente, Enschede, the Netherlands
| | - Pieter L Jager
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Hospital, Zwolle, the Netherlands.
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Ono Y, Inoue Y, Ito H, Sasaki T, Takeda T, Ozaka M, Sasahira N, Hiratsuka M, Matsueda K, Oba A, Sato T, Saiura A, Takahashi Y. Analysis of prognostic factors for borderline resectable pancreatic cancer after neoadjuvant chemotherapy: the importance of CA19-9 decrease in patients with elevated pre-chemotherapy CA19-9 levels. HPB (Oxford) 2023; 25:100-108. [PMID: 36280425 DOI: 10.1016/j.hpb.2022.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 07/09/2022] [Accepted: 09/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is widely used to treat borderline resectable pancreatic cancer. This study aimed to evaluate the serum carbohydrate antigen (CA)19-9 response, in association with survival, after four cycles of NAC-gemcitabine plus nab-paclitaxel. METHODS From 2015 to 2018, patients with borderline resectable pancreatic cancer were treated with NAC. Patients were stratified into two groups after excluding CA19-9 non-secretor: Group L (CA19-9 ≥2 and ≤500 U/mL) and Group H (CA19-9 >500 U/mL). The CA19-9 decrease during NAC was evaluated as a response of NAC and was assessed in association with survival concomitant with other prognosis factors. RESULTS Eighty-seven patients were evaluated (Group L: n = 43, Group H: n = 44). In intention-to-treat-based analysis, Group L exhibited significantly better progression-free survival (PFS) than Group H (median PFS: 24 vs 14months). In resection cohort, no correlation was detected between the CA19-9 decrease and survival in Group L. In Group H, the CA19-9 decrease ≤80% was associated with unfavorable survival in multivariate analysis [Hazard ratio: 4.738 (P = 0.007)]. CONCLUSION In patients with pre-treatment CA19-9 >500 U/mL, the CA19-9 decrease ≤80% was strongly associated with poor survival and new strategy should be reconsidered for these patients.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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20
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Habib JR, Kinny-Köster B, Bou-Samra P, Alsaad R, Sereni E, Javed AA, Ding D, Cameron JL, Lafaro KJ, Burns WR, He J, Yu J, Wolfgang CL, Burkhart RA. Surgical Decision-Making in Pancreatic Ductal Adenocarcinoma: Modeling Prognosis Following Pancreatectomy in the Era of Induction and Neoadjuvant Chemotherapy. Ann Surg 2023; 277:151-158. [PMID: 33843794 DOI: 10.1097/sla.0000000000004915] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a predictive model of oncologic outcomes for patients with pancreatic ductal adenocarcinoma (PDAC) undergoing resection after neoadjuvant or induction chemotherapy use. BACKGROUND Early recurrence following surgical resection for PDAC is common. The use of neoadjuvant chemotherapy prior to resection may increase the likelihood of long-term systemic disease control. Accurately characterizing an individual's likely oncologic outcome in the perioperative setting remains challenging. METHODS Data from patients with PDAC who received chemotherapy prior to pancreatectomy at a single high-volume institution between 2007 and 2018 were captured in a prospectively collected database. Core clinicopathologic data were reviewed for accuracy and survival data were abstracted from the electronic medical record and national databases. Cox-proportional regressions were used to model outcomes and develop an interactive prognostic tool for clinical decision-making. RESULTS A total of 581 patients were included with a median overall survival (OS) and recurrence-free survival (RFS) of 29.5 (26.5-32.5) and 16.6 (15.8-17.5) months, respectively. Multivariable analysis demonstrates OS and RFS were associated with type of chemotherapeutic used andthe number of chemotherapy cycles received preoperatively. Additional factors contributing to survival models included: tumor grade, histopathologic response to therapy, nodal status, and administration of adjuvant chemotherapy. The models were validated using an iterative bootstrap method and with randomized cohort splitting. The models were well calibrated with concordance indices of 0.68 and 0.65 for the final OS and RFS models, respectively. CONCLUSION We developed an intuitive and dynamic decision-making tool that can be useful in estimating OS, RFS, and location-specific disease recurrence rates. This prognostic tool may add value to patient care in discussing the benefits associated with surgical resection for PDAC.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Patrick Bou-Samra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ranim Alsaad
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elisabetta Sereni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Department of Surgery, New York University School of Medicine and NYU-Langone Medical Center, New York, NY
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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21
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Sternby H, Andersson B. Nationwide trends and outcomes of neoadjuvant chemotherapy in pancreatic cancer - an analysis of the Swedish national pancreatic cancer registry. Scand J Gastroenterol 2022; 57:1361-1366. [PMID: 35635264 DOI: 10.1080/00365521.2022.2078668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES During the last decade, neoadjuvant therapy (NAT) for pancreatic cancer has become more frequent. Pathological response and overall survival are promising; however, various post-operative complications have been reported. Our primary aim was to compare the complication scenario of patients receiving NAT in borderline resectable and locally advanced disease with those who had upfront pancreatic surgery (UFS) for primarily resectable cancer. METHODS From the Swedish National Pancreatic and Periampullary Cancer Registry, patients resected for pancreatic ductal adenocarcinoma (PDAC) between 2010 and 2018 were identified. Data on patient characteristics, neoadjuvant therapy, post-operative complications and survival were obtained. Comparisons between groups as well as survival analysis were performed. RESULTS Within the total cohort of 13,948 patients, 1894 (median age 69 years, 51% men) were resected for PDAC. Among these, 112 (5.9%) patients received NAT followed by surgery. The patients who received NAT were younger (67 vs 70 years, p < .001), had a lower level of CA19-9 (47 vs 108, p = .001) and had to a larger extent vascular resection (58.9 vs 26.9%, p < .001) and total pancreatectomy performed (23.2 vs 9.1%, p < .001). No difference was found for major post-operative complications and there was no significant change in survival rate between the NAT and UFS groups (median 28 vs 26 months, p = .122). CONCLUSIONS When analyzing data from a national registry, no difference in post-operative complications was found between resected patients receiving UFS and NAT for PDAC. Also, the survival was equal between groups. NAT is a feasible treatment option for patients with potentially curable pancreatic cancer.
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Affiliation(s)
- Hanna Sternby
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
| | - Bodil Andersson
- Department of Surgery, Institute of Clinical Sciences-Malmö, Lund University, Lund, Sweden
- Skåne University Hospital, Lund, Sweden
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22
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Fromer MW, Wilson KD, Philips P, Egger ME, Scoggins CR, McMasters KM, Martin RCG. Locally advanced pancreatic cancer: a reliable contraindication to resection in the modern era? HPB (Oxford) 2022; 24:1789-1795. [PMID: 35491339 DOI: 10.1016/j.hpb.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/19/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study is to present radiologically designated LAPC found to be resectable upon surgical exploration and evaluate the outcomes of such resections. METHODS Sequential LAPC patients between 2013 and 2019 were staged and underwent resection were included in the analysis of both perioperative and long-term outcomes. RESULTS Twenty-eight patients with radiologically-designated LAPC underwent surgical resection after chemotherapy with a median follow-up of 31.7 m,75% underwent pancreaticoduodenectomy. The margin positivity and local recurrence rates were 21.4% and 35.7%, respectively. When compared to the 30 BRPC controls, the LAPC group had a higher rates of an arterial resection (11vs.1; p = 0.002), but the groups were similar with regard to all other preoperative and intraoperative variables (p < 0.05). Perioperative morbidity rates were similar (25.9%vs21.4%; p = 0.53). The LAPC and BRPC groups were also equivalent with respect to median recurrence-free survival (9.0mo; 95%CI 6.3, 11.7vs.8.3mo; 95%CI 5.4, 11.2) and median overall survival (19.9mo; 95%CI 17.0, 22.7 vs. 19.9mo; 95%CI 14.8, 25.1), respectively. CONCLUSION Despite a radiologic designation of locally advanced pancreatic cancer, certain subtypes of LAPC warrant surgical exploration provided the operative surgeon is prepared for major arterial and/or venous resection. Pancreatectomy in these patients has acceptable morbidity and oncologic outcomes, similar to patients who are radiologically borderline resectable.
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Affiliation(s)
- Marc W Fromer
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Khaleel D Wilson
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Prejesh Philips
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Michael E Egger
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Charles R Scoggins
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Kelly M McMasters
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, School of Medicine, University of Louisville, Louisville, KY 40202, USA.
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23
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Caliez O, Pietrasz D, Ksontini F, Doat S, Simon JM, Vaillant JC, Taly V, Laurent-Puig P, Bachet JB. Circulating tumor DNA: a help to guide therapeutic strategy in patients with borderline and locally advanced pancreatic adenocarcinoma? Dig Liver Dis 2022; 54:1428-1436. [PMID: 35120842 DOI: 10.1016/j.dld.2022.01.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/16/2021] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND prognostic biomarkers could be useful to better select patients with borderline resectable (BR) or locally advanced (LA) pancreatic adenocarcinoma (PA) for chemoradiotherapy (CRT) and/or secondary resection. AIMS The main objective of this work was to study characteristics, received treatments and prognostic of patients with BR or LA PA according to their baseline circulating tumor DNA status and, for secondary objective, neutrophil-to-lymphocyte Ratio (NLR). METHODS ctDNA status at baseline was determined using Next Generation Sequencing in a consecutive monocentric cohort of patients with a BR or LA PA. RESULTS 69 patients were included, 31 with BR PA and 38 with LA PA. 14 (20.3%) patients had baseline positive ctDNA. Five (7.8%) patients had NLR> 5. Patients with positive ctDNA had 3.7 months shorter progression free survival (p = 0.006). Patients with positive ctDNA had earlier progression after the beginning of CRT (4.4 vs 7.1 months; p = 0.068) and shorter relapse free survival after secondary resection (9.2 vs 22.9 months; p = 0.016). CONCLUSIONS positive ctDNA at baseline was associated with a worse prognosis in patients with BR or LA PA. These data are exploratory and must be confirmed in further prospective trials.
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Affiliation(s)
- Olivier Caliez
- Department of Gastroenterology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Institute of Health and Medical Research (INSERM), Centre de Recherche des Cordeliers, Sorbonne Université, Sorbonne Paris Cité, Université Paris Descartes, Université de Paris, Paris, France; Sorbonne Université, UPMC, Paris 6, France
| | - Daniel Pietrasz
- French National Institute of Health and Medical Research (INSERM), Centre de Recherche des Cordeliers, Sorbonne Université, Sorbonne Paris Cité, Université Paris Descartes, Université de Paris, Paris, France; Department of Digestive Surgery, Hôpital Paul Brousse, Villejuif, France
| | - Feryel Ksontini
- Department of Oncology, Institute Salah-Azaïz, Tunis, Tunisia
| | - Solène Doat
- Department of Gastroenterology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean-Marc Simon
- Department of Radiation Oncology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean-Christophe Vaillant
- Department of Digestive Surgery, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Valerie Taly
- French National Institute of Health and Medical Research (INSERM), Centre de Recherche des Cordeliers, Sorbonne Université, Sorbonne Paris Cité, Université Paris Descartes, Université de Paris, Paris, France
| | - Pierre Laurent-Puig
- French National Institute of Health and Medical Research (INSERM), Centre de Recherche des Cordeliers, Sorbonne Université, Sorbonne Paris Cité, Université Paris Descartes, Université de Paris, Paris, France
| | - Jean-Baptiste Bachet
- Department of Gastroenterology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Institute of Health and Medical Research (INSERM), Centre de Recherche des Cordeliers, Sorbonne Université, Sorbonne Paris Cité, Université Paris Descartes, Université de Paris, Paris, France; Sorbonne Université, UPMC, Paris 6, France.
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24
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Perik TH, van Genugten EAJ, Aarntzen EHJG, Smit EJ, Huisman HJ, Hermans JJ. Quantitative CT perfusion imaging in patients with pancreatic cancer: a systematic review. Abdom Radiol (NY) 2022; 47:3101-3117. [PMID: 34223961 PMCID: PMC9388409 DOI: 10.1007/s00261-021-03190-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 01/18/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related death with a 5-year survival rate of 10%. Quantitative CT perfusion (CTP) can provide additional diagnostic information compared to the limited accuracy of the current standard, contrast-enhanced CT (CECT). This systematic review evaluates CTP for diagnosis, grading, and treatment assessment of PDAC. The secondary goal is to provide an overview of scan protocols and perfusion models used for CTP in PDAC. The search strategy combined synonyms for 'CTP' and 'PDAC.' Pubmed, Embase, and Web of Science were systematically searched from January 2000 to December 2020 for studies using CTP to evaluate PDAC. The risk of bias was assessed using QUADAS-2. 607 abstracts were screened, of which 29 were selected for full-text eligibility. 21 studies were included in the final analysis with a total of 760 patients. All studies comparing PDAC with non-tumorous parenchyma found significant CTP-based differences in blood flow (BF) and blood volume (BV). Two studies found significant differences between pathological grades. Two other studies showed that BF could predict neoadjuvant treatment response. A wide variety in kinetic models and acquisition protocol was found among included studies. Quantitative CTP shows a potential benefit in PDAC diagnosis and can serve as a tool for pathological grading and treatment assessment; however, clinical evidence is still limited. To improve clinical use, standardized acquisition and reconstruction parameters are necessary for interchangeability of the perfusion parameters.
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Affiliation(s)
- T H Perik
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - E A J van Genugten
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - E H J G Aarntzen
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - E J Smit
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - H J Huisman
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J J Hermans
- Department of Medical Imaging, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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25
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Abdelrahman AM, Goenka AH, Alva-Ruiz R, Yonkus JA, Leiting JL, Graham RP, Merrell KW, Thiels CA, Hallemeier CL, Warner SG, Haddock MG, Grotz TE, Tran NH, Smoot RL, Ma WW, Cleary SP, McWilliams RR, Nagorney DM, Halfdanarson TR, Kendrick ML, Truty MJ. FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma. J Natl Compr Canc Netw 2022; 20:1023-1032.e3. [PMID: 36075389 DOI: 10.6004/jnccn.2022.7041] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. METHODS We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). RESULTS We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P<.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13-0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P<.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9-153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2-0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1-0.4). CONCLUSIONS Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.
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Affiliation(s)
| | - Ajit H Goenka
- Division of Nuclear Medicine Radiology, Department of Radiology
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Rondell P Graham
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology
| | | | | | | | - Susanne G Warner
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Nguyen H Tran
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Wen Wee Ma
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Robert R McWilliams
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | | | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
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Advances and Remaining Challenges in the Treatment for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma. J Clin Med 2022; 11:jcm11164866. [PMID: 36013111 PMCID: PMC9410260 DOI: 10.3390/jcm11164866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the deadliest malignancies in the United States. Improvements in imaging have permitted the categorization of patients according to radiologic involvement of surrounding vasculature, i.e., upfront resectable, borderline resectable, and locally advanced disease, and this, in turn, has influenced the sequence of chemotherapy, surgery, and radiation therapy. Though surgical resection remains the only curative treatment option, recent studies have shown improved overall survival with neoadjuvant chemotherapy, especially among patients with borderline resectable/locally advanced disease. The role of radiologic imaging after neoadjuvant therapy and the potential benefit of adjuvant therapy for borderline resectable and locally advanced disease remain areas of ongoing investigation. The advances made in the treatment of patients with borderline resectable/locally advanced disease are promising, yet disparities in access to cancer care persist. This review highlights the significant advances that have been made in the treatment of borderline resectable and locally advanced PDAC, while also calling attention to the remaining challenges.
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Hartlapp I, Valta-Seufzer D, Siveke JT, Algül H, Goekkurt E, Siegler G, Martens UM, Waldschmidt D, Pelzer U, Fuchs M, Kullmann F, Boeck S, Ettrich TJ, Held S, Keller R, Anger F, Germer CT, Stang A, Kimmel B, Heinemann V, Kunzmann V. Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113). ESMO Open 2022; 7:100552. [PMID: 35970013 PMCID: PMC9434418 DOI: 10.1016/j.esmoop.2022.100552] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The prognostic and predictive value of carbohydrate antigen 19-9 (CA 19-9) in locally advanced pancreatic cancer (LAPC) has not yet been defined from prospective randomized controlled trials (RCTs). PATIENTS AND METHODS A total of 165 LAPC patients were treated within the NEOLAP RCT for 16 weeks with multiagent induction chemotherapy [ICT; either nab-paclitaxel/gemcitabine alone or nab-paclitaxel/gemcitabine followed by FOLFIRINOX (combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin)] followed by surgical exploration of all patients without evidence of disease progression. CA 19-9 was determined at baseline and after ICT and correlated with overall survival (OS) and secondary R0 resection rate. RESULTS From the NEOLAP study population (N = 165) 133 patients (81%) were evaluable for CA 19-9 at baseline and 81/88 patients (92%) for post-ICT CA 19-9 response. Median OS (mOS) in the CA 19-9 cohort (n = 133) was 16.2 months [95% confidence interval (CI) 13.0-19.4] and R0 resection (n = 31; 23%) was associated with a significant survival benefit [40.8 months (95% CI 21.7-59.8)], while R1 resected patients (n = 14; 11%) had no survival benefit [14.0 (95% CI 11.7-16.3) months, hazard ratio (HR) 0.27; P = 0.001]. After ICT most patients showed a CA 19-9 response (median change from baseline: -82%; relative decrease ≥55%: 83%; absolute decrease to ≤50 U/ml: 43%). Robust CA 19-9 response (decrease to ≤50U/ml) was significantly associated with mOS [27.8 (95% CI 18.4-37.2) versus 16.5 (95% CI 11.7-21.2) months, HR 0.49; P = 0.013], whereas CA 19-9 baseline levels were not prognostic for OS. Multivariate analysis demonstrated that a robust CA 19-9 response was an independent predictive factor for R0 resection. Using a CA 19-9 decrease to ≤61 U/ml as optimal cut-off (by receiver operating characteristic analysis) yielded 72% sensitivity and 62% specificity for successful R0 resection, whereas CA 19-9 nonresponders (<20% decrease or increase) had no chance for successful R0 resection. CONCLUSIONS CA 19-9 response after multiagent ICT provides relevant prognostic and predictive information and is useful in selecting LAPC patients for explorative surgery. CLINICAL TRIAL NUMBER ClinicalTrials.govNCT02125136; https://clinicaltrials.gov/ct2/show/NCT02125136; EudraCT 2013-004796-12; https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-004796-12/results.
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Affiliation(s)
- I Hartlapp
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - D Valta-Seufzer
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - J T Siveke
- Department of Medical Oncology, Bridge Institute of Experimental Tumor Therapy, University Medicine Essen, Essen, Germany; Division of Solid Tumor Translational Oncology (DKTK Partner Site Essen, DKFZ Heidelberg), West German Cancer Center, University Medicine Essen, Essen, Germany
| | - H Algül
- Comprehensive Cancer Center Munich (CCCM(TUM)) at the Klinikum rechts der Isar, Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - E Goekkurt
- Hämatologisch-Onkologische Praxis Eppendorf (HOPE), Hamburg and University Cancer Center Hamburg (UCCH), Hamburg, Germany
| | - G Siegler
- Department of Internal Medicine 5, Hematology and Medical Oncology, Paracelsus Medical University, Nürnberg, Germany
| | - U M Martens
- Department of Internal Medicine III, SLK-Clinics Heilbronn GmbH, Heilbronn, Germany
| | - D Waldschmidt
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - U Pelzer
- Division of Oncology and Hematology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - M Fuchs
- Clinic for Gastroenterology, Hepatology and GI-Oncology, München Klinik Bogenhausen, Munich, Germany
| | - F Kullmann
- Department of Internal Medicine I, Kliniken Nordoberpfalz AG, Klinikum Weiden, Weiden, Germany
| | - S Boeck
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - T J Ettrich
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - S Held
- Department of Biometrics, ClinAssess GmbH, Leverkusen, Germany
| | - R Keller
- Clinical Research, AIO Studien gGmbH, Berlin, Germany
| | - F Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - A Stang
- Department of Haematology, Oncology and Palliative Care Medicine, Asklepios Hospital Barmbek, Hamburg, Germany
| | - B Kimmel
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - V Heinemann
- Department of Medical Oncology and Comprehensive Cancer Center, Ludwig Maximilians University-Grosshadern, Munich, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany.
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Addeo P, Charton J, de Marini P, Trog A, Noblet V, De Mathelin P, Avérous G, Bachellier P. Predicting pathologic venous invasion before pancreatectomy with venous resection: When does radiology tell the truth? Surgery 2022; 172:303-309. [PMID: 35074172 DOI: 10.1016/j.surg.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 12/06/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients factors in addition to radiological characteristics could predict the presence of pathologic venous invasion in patients undergoing pancreatectomy with venous resection. METHODS We tested the predictive value of 6 radiological classification methods for predicting pathologic venous invasion-the Nakao, Ishikawa, MD Anderson, Lu, Raptopoulos, and National Comprehensive Cancer Network methods-on a cohort of 198 pancreatectomies (160 pancreaticoduodenectomies and 38 total pancreatectomies) with venous resection for pancreatic adenocarcinomas. Radiological and clinical factors determining pathologic venous invasion were identified by multivariable logistic analysis. RESULTS Pathologic venous invasion was detected in 124 patients (63.2%). The multivariable logistic regression analysis identified Lu classification (odds ratio = 1.77, 95% confidence interval =1.34-2.35; P < .0001), elevated serum CA19-9 values (odds ratio = 1.97, 95% confidence interval = 1.00-3.90; P = .04), and preoperative neoadjuvant chemotherapy (odds ratio = 0.38, 95% confidence interval = 0.18-0.79; P = .009) as independent factors associated with pathologic venous invasion. Radiological tumor-vessel contact greater than 50% of the circumference or venous wall deformity was associated with a significantly higher rate of pathological venous invasion (80% vs 52%; P < .0001), deeper (media-intima) venous invasion (47% vs 25%; P < .0001), R1 resection (58% vs 41%; P = .03), higher transfusions (84% vs 66%; P = .005), and arterial resection rates (43% vs 27%; P < .0001). Tumor-vein circumference contact of >50% and/or venous wall deformity was still associated with significantly higher rates of pathologic venous invasion, regardless of whether neoadjuvant chemotherapy was used or not and CA19-9 normalized or not under preoperative treatment. CONCLUSION Preoperative radiological detection of tumor-vein circumference contact >50% and/or venous wall deformity is associated with up to 80% of cases of pathological venous invasion. The combination of radiologic features with biological (CA19-9) and clinical (presence of preoperative chemotherapy) factors could better refine preoperatively the need for venous resection.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France.
| | - Jeanne Charton
- Department of Radiology, Hôpital de Hautepierre University of Strasbourg, France
| | - Pierre de Marini
- Department of Radiology, Hôpital de Hautepierre University of Strasbourg, France
| | - Arnaud Trog
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Vincent Noblet
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Pierre De Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Gerlinde Avérous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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Oba A, Del Chiaro M, Satoi S, Kim SW, Takahashi H, Yu J, Hioki M, Tanaka M, Kato Y, Ariake K, Wu YHA, Inoue Y, Takahashi Y, Hackert T, Wolfgang CL, Besselink MG, Schulick RD, Nagakawa Y, Isaji S, Tsuchida A, Endo I. New criteria of resectability for pancreatic cancer: A position paper by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:725-731. [PMID: 34581016 DOI: 10.1002/jhbp.1049] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
The symposium "New criteria of resectability for pancreatic cancer" was held during the 33nd meeting of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) in 2021 to discuss the potential modifications that could be made in the current resectability classification. The meeting focused on setting the foundation for developing a new prognosis-based resectability classification that is based on the tumor biology and the response to neoadjuvant treatment (NAT). The symposium included selected experts from Western and Eastern high-volume centers who have discussed their concept of resectability status through published literature. During the symposium, presenters reported new resectability classifications from their respective institutions based on tumor biology, conditional status, pathology, and genetics, in addition to anatomical tumor involvement. Interestingly, experts from all the centers reached the agreement that anatomy alone is insufficient to define resectability in the current era of effective NAT. On behalf of the JSHBPS, we would like to summarize the content of the conference in this position paper. We also invite global experts as internal reviewers of this paper for intercontinental cooperation in creating an up-to-date, prognosis-based resectability classification that reflects the trends of contemporary clinical practice.
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Affiliation(s)
- Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department Surgery, Kansai Medical University, Osaka, Japan
| | - Sun-Whe Kim
- Department Surgery, Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, Hiroshima, Japan
| | - Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyasu Kato
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyohei Ariake
- Department of Surgery, Tohoku University, Sendai, Japan
| | - Y H Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Shuji Isaji
- Director of Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School Medicine, Yokohama, Japan
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30
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Gray S, de Liguori Carino N, Radhakrishna G, Lamarca A, Hubner RA, Valle JW, McNamara MG. Clinical challenges associated with utility of neoadjuvant treatment in patients with pancreatic ductal adenocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1198-1208. [PMID: 35264307 DOI: 10.1016/j.ejso.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an increasingly common cancer with a persistently poor prognosis, and only approximately 20% of patients are clearly anatomically resectable at diagnosis. Historically, a paucity of effective therapy made it inappropriate to forego the traditional gold standard of upfront surgery in favour of neoadjuvant treatment; however, modern combination chemotherapy regimens have made neoadjuvant therapy increasingly viable. As its use has expanded, the rationale for neoadjuvant therapy has evolved from one of 'downstaging' to one of early treatment of micro-metastases and selection of patients with favourable tumour biology for resection. Defining resectability in PDAC is problematic; multiple differing definitions exist. Multidisciplinary input, both in initial assessment of resectability and in supervision of multimodality therapy, is therefore advised. European and North American guidelines recommend the use of neoadjuvant chemotherapy in borderline resectable (BR)-PDAC. Similar regimens may be applied in locally advanced (LA)-PDAC with the aim of improving potential access to curative-intent resection, but appropriate patient selection is key due to significant rates of recurrence after excision of LA disease. Upfront surgery and adjuvant chemotherapy remain standard-of-care in clearly resectable PDAC, but multiple trials evaluating the use of neoadjuvant therapy in this and other localised settings are ongoing.
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Affiliation(s)
- Simon Gray
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, United Kingdom
| | - Ganesh Radhakrishna
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom; Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, United Kingdom; Department of Medical Oncology, The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, United Kingdom.
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Kim SS, Lee S, Lee HS, Bang S, Han K, Park MS. Retrospective Evaluation of Treatment Response in Patients with Nonmetastatic Pancreatic Cancer Using CT and CA 19-9. Radiology 2022; 303:548-556. [PMID: 35258374 DOI: 10.1148/radiol.212236] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Imaging studies have limitations in evaluating pancreatic ductal adenocarcinoma (PDAC) treatment response. Purpose To investigate the effectiveness of combined CT and carbohydrate antigen 19-9 (CA 19-9) evaluation at 8 weeks after first-line treatment to predict overall survival (OS) of patients with nonmetastatic PDAC. Materials and Methods Patients with nonmetastatic PDAC who received first-line treatment with either chemotherapy or concurrent chemoradiation in a single-center PDAC cohort registry were retrospectively enrolled in the study between January 2013 and December 2016. Follow-up CT images obtained 8 weeks after treatment were evaluated according to Response Evaluation Criteria in Solid Tumors. Patients with partial response (PR) or stable disease (SD) were defined as CT responders, and those with progressive disease (PD) were defined as CT nonresponders. Patients with a normalized CA 19-9 level at 8-week follow-up were defined as CA 19-9 responders, and those with a nonnormalized or nonelevated CA 19-9 level were defined as CA 19-9 nonresponders. OS was compared using the Kaplan-Meier method with Breslow analysis. Results A total of 197 patients (mean age ± standard deviation, 65 years ± 10; 107 men) were evaluated. Patients with PD (n = 17) showed shorter OS than those with SD (n = 147; P < .001) or PR (n = 33; P = .003). OS did not differ between the patients with PR and those with SD (P = .60). When the CT and CA 19-9 responses were integrated, OS was longest in CT and CA 19-9 responders (group 1, n = 27; median OS, 26.6 months [95% CI: 9.0, 44.1]), followed by CT responders but CA 19-9 nonresponders (group 2, n = 153; median OS, 15.9 months [95% CI: 13.3, 18.5]; P = .007 vs group 1) and CT and CA 19-9 nonresponders (group 3, n = 17; median OS, 6.5 months [95% CI: 0.8, 12.2]; P < .001 vs group 2). Conclusion Integrated evaluation with CT and carbohydrate antigen 19-9 response allowed more accurate stratification of survival in patients with pancreatic ductal adenocarcinoma in the early treatment period than did evaluation according to Response Evaluation Criteria in Solid Tumors. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Seung-Seob Kim
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
| | - Sunyoung Lee
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
| | - Hee Seung Lee
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
| | - Seungmin Bang
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
| | - Kyunghwa Han
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
| | - Mi-Suk Park
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea (S.S.K., S.L., M.S.P.); Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (H.S.L., S.B.); and Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science (CCIDS), Yonsei University College of Medicine, Seoul, Republic of Korea (K.H.)
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Kim HY, Lee YJ, Chang W, Cho J, Park JH, Lee JC, Kim J, Hwang JH, Kim YH. Tumor resectability and response on CT following neoadjuvant therapy for pancreatic cancer: inter-observer agreement study. Eur Radiol 2022; 32:3799-3807. [PMID: 35032213 DOI: 10.1007/s00330-021-08494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/10/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES First, to measure inter-observer agreement regarding tumor resectability and response, and second, to measure diagnostic performance in predicting negative resection margin, on re-staging CTs of patients who received neoadjuvant therapy for pancreatic cancer. METHODS This retrospective study included patients who received neoadjuvant therapy for borderline resectable pancreatic cancer from 2017 to 2020. Six readers independently evaluated initial staging and re-staging CT images. They categorized the resectability on re-staging CT based on the NCCN guideline, and evaluated tumor response to neoadjuvant therapy according to our proposed criteria on a 5-grade scale. For inter-observer agreement, Gwet's agreement coefficients were used. A crossed random effect model was used to pool the sensitivity and specificity of six readers in predicting negative resection margin. RESULTS Seventy-seven patients with the median age of 66 (59-70) were included. The pooled agreement for tumor resectability was 0.64 (95% CI, 0.56-0.71) for differentiating the three categories, and 0.84 (0.77-0.91) for differentiating resectable or borderline resectable cancer vs. unresectable cancer. Agreement for tumor response grade was 0.89 (0.85-0.92). The pooled sensitivity and specificity for predicting negative resection margin were 48% (43-52%) and 61% (57-64%), respectively, when only "resectable" on re-staging CT was considered as index test positive. When either "resectable"' or "borderline resectable" was considered as positive, the pooled sensitivity and specificity were 91% (89-94%) and 5% (4-6%), respectively. CONCLUSION CT can be used reliably with a high inter-observer agreement in selecting candidates for surgery after neoadjuvant therapy of pancreatic cancer. KEY POINTS • On CT following neoadjuvant therapy of pancreatic cancer, six readers showed high agreement in differentiating resectable or borderline resectable vs. unresectable cancer (Gwet's coefficient, 0.84). • Inter-observer agreement was also high for our proposed tumor response grade (Gwet's coefficient, 0.89). • Specificity was very low (5%) while sensitivity was high (91%) when either resectable or borderline resectable cancer on re-staging CT was considered as predictive of negative resection margin status.
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Affiliation(s)
- Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea
| | - Won Chang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea
| | - Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Suwon, Republic of Korea
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, Seongnam-si, 13620, Republic of Korea.
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea.
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Pietrasz D, Sereni E, Lancelotti F, Pea A, Luchini C, Innamorati G, Salvia R, Bassi C. Circulating tumour DNA: a challenging innovation to develop "precision onco-surgery" in pancreatic adenocarcinoma. Br J Cancer 2022; 126:1676-1683. [PMID: 35197581 PMCID: PMC9174156 DOI: 10.1038/s41416-022-01745-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 12/20/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is predicted to become the third leading cause of cancer-related mortality within the next decade. Management of PDAC remains challenging with limited effective treatment options and a dismal long-term prognosis. Liquid biopsy and circulating biomarkers seem to be promising to improve the multidisciplinary approach in PDAC treatment. Circulating tumour DNA (ctDNA) is the most studied blood liquid biopsy analyte and can provide insight into the molecular profile and individual characteristics of the tumour in real-time and in advance of standard imaging modalities. This could pave the way for identifying new therapeutic targets and markers of tumour response to supplement diagnostic and provide enhanced stratified treatment. Although its specificity seems excellent, the current sensitivity of ctDNA remains a limitation for clinical use, especially in patients with a low tumour burden. Increasing evidence suggests that ctDNA is a pertinent candidate biomarker to assess minimal residual disease after surgery but also a strong independent prognostic biomarker. This review explores the current knowledge and recent developments in ctDNA as a screening, diagnostic, prognostic and predictive biomarker in the management of resectable PDAC but also technical and analytical challenges that must be overcome to move toward "precision onco-surgery."
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Affiliation(s)
- Daniel Pietrasz
- APHP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Université Paris-Saclay, 94800, Villejuif, France.
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
| | - Elisabetta Sereni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Francesco Lancelotti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Giulio Innamorati
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Soloff EV, Al-Hawary MM, Desser TS, Fishman EK, Minter RM, Zins M. Imaging Assessment of Pancreatic Cancer Resectability After Neoadjuvant Therapy: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:570-581. [PMID: 34851713 DOI: 10.2214/ajr.21.26931] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.
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Affiliation(s)
- Erik V Soloff
- Department of Radiology, University of Washington, Seattle, WA
| | - Mahmoud M Al-Hawary
- Department of Radiology and Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Terry S Desser
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Elliot K Fishman
- Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, MD
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Marc Zins
- Department of Radiology, Groupe Hospitalier Paris Saint Joseph, 185 Rue R Losserand, Paris 75014, France
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Rossi G, Altabella L, Simoni N, Benetti G, Rossi R, Venezia M, Paiella S, Malleo G, Salvia R, Guariglia S, Bassi C, Cavedon C, Mazzarotto R. Computed tomography-based radiomic to predict resectability in locally advanced pancreatic cancer treated with chemotherapy and radiotherapy. World J Gastrointest Oncol 2022; 14:703-715. [PMID: 35321278 PMCID: PMC8919018 DOI: 10.4251/wjgo.v14.i3.703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/06/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical resection after neoadjuvant treatment is the main driver for improved survival in locally advanced pancreatic cancer (LAPC). However, the diagnostic performance of computed tomography (CT) imaging to evaluate the residual tumour burden at restaging after neoadjuvant therapy is low due to the difficulty in distinguishing neoplastic tissue from fibrous scar or inflammation. In this context, radiomics has gained popularity over conventional imaging as a complementary clinical tool capable of providing additional, unprecedented information regarding the intratumor heterogeneity and the residual neoplastic tissue, potentially serving in the therapeutic decision-making process.
AIM To assess the capability of radiomic features to predict surgical resection in LAPC treated with neoadjuvant chemotherapy and radiotherapy.
METHODS Patients with LAPC treated with intensive chemotherapy followed by ablative radiation therapy were retrospectively reviewed. One thousand six hundred and fifty-five radiomic features were extracted from planning CT inside the gross tumour volume. Both extracted features and clinical data contribute to create and validate the predictive model of resectability status. Patients were repeatedly divided into training and validation sets. The discriminating performance of each model, obtained applying a LASSO regression analysis, was assessed with the area under the receiver operating characteristic curve (AUC). The validated model was applied to the entire dataset to obtain the most significant features.
RESULTS Seventy-one patients were included in the analysis. Median age was 65 years and 57.8% of patients were male. All patients underwent induction chemotherapy followed by ablative radiotherapy, and 19 (26.8%) ultimately received surgical resection. After the first step of variable selections, a predictive model of resectability was developed with a median AUC for training and validation sets of 0.862 (95%CI: 0.792-0.921) and 0.853 (95%CI: 0.706-0.960), respectively. The validated model was applied to the entire dataset and 4 features were selected to build the model with predictive performance as measured using AUC of 0.944 (95%CI: 0.892-0.996).
CONCLUSION The present radiomic model could help predict resectability in LAPC after neoadjuvant chemotherapy and radiotherapy, potentially integrating clinical and morphological parameters in predicting surgical resection.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Luisa Altabella
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giulio Benetti
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
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Halle-Smith JM, Hodson J, Coldham C, Dasari B, Chatzizacharias N, Marudanayagam R, Sutcliffe R, Isaac J, Mirza DF, Roberts KJ. Three decades of change in pancreatoduodenectomy and future prediction of pathological and operative complexity. Br J Surg 2022; 109:247-250. [PMID: 35026008 DOI: 10.1093/bjs/znab433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/05/2023]
Abstract
Despite increasing complexity of surgery and patient age, the duration of hospital stay and mortality rate after pancreatoduodenectomy are decreasing. Understanding changes over time permits an estimation of a future surgical cohort in which complexity will increase. It is important that surgeons continue to push boundaries.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - James Hodson
- Medical Statistics, Institute of Translational Medicine, Birmingham, UK
| | - Chris Coldham
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Makino I, Tajima H, Kitagawa H, Gabata R, Okazaki M, Shinbashi H, Ohbatake Y, Nakanuma S, Saito H, Yamaguchi T, Terai S, Okamoto K, Sakai S, Kinoshita J, Nakamura K, Ninomiya I, Fushida S, Ohta T. Verification of Resectability Status for Pancreatic Cancer: Radiological and Pathological Analysis of Patients Undergoing Pancreatoduodenectomy With Combined Resection of the Superior Mesenteric Artery. Pancreas 2022; 51:35-40. [PMID: 35195593 DOI: 10.1097/mpa.0000000000001964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Resectability status is considered an important indicator for progression of pancreatic cancer. We verified the superior mesenteric artery (SMA) factors of resectability status by radiological and pathological analysis in patients who underwent pancreatoduodenectomy with combined resection of the SMA. METHODS We enrolled 22 patients who underwent pancreatoduodenectomy with combined resection of the SMA. Patients were divided into 3 groups according to the contact angle between the tumor and the SMA in preoperative computed tomography images (no contact, R-sma; contact within 180 degrees, BR-sma; contact more than 180 degrees, UR-sma). We pathologically evaluated cancer progression toward the SMA. RESULTS There were 3 patients with R-sma, 12 with BR-sma, and 7 with UR-sma. The median distance (mm) between the cancer and the SMA was 7.0 with R-sma, 1.0 with BR-sma, and 0 with UR-sma (P = 0.0003). Invasion to the superior mesenteric nerve plexus was positive in none with R-sma, 11 with BR-sma, and 7 with UR-sma (P < 0.0001). Invasion to the SMA was positive in none with R-sma and BR-sma, and 7 with UR-sma (P < 0.0001). CONCLUSIONS Superior mesenteric artery factors of resectability status are reliable indicator for cancer progression toward the SMA.
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Affiliation(s)
- Isamu Makino
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Hidehiro Tajima
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | | | - Ryosuke Gabata
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Mitsuyoshi Okazaki
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Hiroyuki Shinbashi
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Yoshinao Ohbatake
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Shinichi Nakanuma
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Hiroto Saito
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Takahisa Yamaguchi
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Shiro Terai
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Koichi Okamoto
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Seisho Sakai
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Jun Kinoshita
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Keishi Nakamura
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Itasu Ninomiya
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Sachio Fushida
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
| | - Tetsuo Ohta
- From the Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa
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van Dam MA, Vuijk FA, Stibbe JA, Houvast RD, Luelmo SAC, Crobach S, Shahbazi Feshtali S, de Geus-Oei LF, Bonsing BA, Sier CFM, Kuppen PJK, Swijnenburg RJ, Windhorst AD, Burggraaf J, Vahrmeijer AL, Mieog JSD. Overview and Future Perspectives on Tumor-Targeted Positron Emission Tomography and Fluorescence Imaging of Pancreatic Cancer in the Era of Neoadjuvant Therapy. Cancers (Basel) 2021; 13:6088. [PMID: 34885196 PMCID: PMC8656821 DOI: 10.3390/cancers13236088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite recent advances in the multimodal treatment of pancreatic ductal adenocarcinoma (PDAC), overall survival remains poor with a 5-year cumulative survival of approximately 10%. Neoadjuvant (chemo- and/or radio-) therapy is increasingly incorporated in treatment strategies for patients with (borderline) resectable and locally advanced disease. Neoadjuvant therapy aims to improve radical resection rates by reducing tumor mass and (partial) encasement of important vascular structures, as well as eradicating occult micrometastases. Results from recent multicenter clinical trials evaluating this approach demonstrate prolonged survival and increased complete surgical resection rates (R0). Currently, tumor response to neoadjuvant therapy is monitored using computed tomography (CT) following the RECIST 1.1 criteria. Accurate assessment of neoadjuvant treatment response and tumor resectability is considered a major challenge, as current conventional imaging modalities provide limited accuracy and specificity for discrimination between necrosis, fibrosis, and remaining vital tumor tissue. As a consequence, resections with tumor-positive margins and subsequent early locoregional tumor recurrences are observed in a substantial number of patients following surgical resection with curative intent. Of these patients, up to 80% are diagnosed with recurrent disease after a median disease-free interval of merely 8 months. These numbers underline the urgent need to improve imaging modalities for more accurate assessment of therapy response and subsequent re-staging of disease, thereby aiming to optimize individual patient's treatment strategy. In cases of curative intent resection, additional intra-operative real-time guidance could aid surgeons during complex procedures and potentially reduce the rate of incomplete resections and early (locoregional) tumor recurrences. In recent years intraoperative imaging in cancer has made a shift towards tumor-specific molecular targeting. Several important molecular targets have been identified that show overexpression in PDAC, for example: CA19.9, CEA, EGFR, VEGFR/VEGF-A, uPA/uPAR, and various integrins. Tumor-targeted PET/CT combined with intraoperative fluorescence imaging, could provide valuable information for tumor detection and staging, therapy response evaluation with re-staging of disease and intraoperative guidance during surgical resection of PDAC. METHODS A literature search in the PubMed database and (inter)national trial registers was conducted, focusing on studies published over the last 15 years. Data and information of eligible articles regarding PET/CT as well as fluorescence imaging in PDAC were reviewed. Areas covered: This review covers the current strategies, obstacles, challenges, and developments in targeted tumor imaging, focusing on the feasibility and value of PET/CT and fluorescence imaging for integration in the work-up and treatment of PDAC. An overview is given of identified targets and their characteristics, as well as the available literature of conducted and ongoing clinical and preclinical trials evaluating PDAC-targeted nuclear and fluorescent tracers.
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Affiliation(s)
- Martijn A. van Dam
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Floris A. Vuijk
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Judith A. Stibbe
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Ruben D. Houvast
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Saskia A. C. Luelmo
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | | | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, University Medical Center Leiden, 2333 ZA Leiden, The Netherlands;
- Biomedical Photonic Imaging Group, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - Cornelis F. M. Sier
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Percuros B.V., 2333 CL Leiden, The Netherlands
| | - Peter J. K. Kuppen
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | | | - Albert D. Windhorst
- Department of Radiology, Section of Nuclear Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands;
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
- Centre for Human Drug Research, 2333 CL Leiden, The Netherlands
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (F.A.V.); (J.A.S.); (R.D.H.); (B.A.B.); (C.F.M.S.); (P.J.K.K.); (J.B.); (A.L.V.); (J.S.D.M.)
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40
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Can a simplified CT response criteria for vascular involvement in pancreatic adenocarcinoma after neoadjuvant therapy predict survival in patients who achieved subsequent R0 resection? Abdom Radiol (NY) 2021; 46:5609-5617. [PMID: 34557934 DOI: 10.1007/s00261-021-03284-5] [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: 07/31/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate if a simplified image based scoring system assessing treatment response after neoadjuvant therapy (NAT) can predict survival in patients with pancreatic ductal adenocarcinoma (PDAC) who achieved subsequent R0 resection. METHODS Retrospective analysis of 57 PDAC patients (male = 29, 51%) with mean age of 64 at diagnosis (range 42-79) who received NAT and R0 resection. Post-NAT overall, arterial and venous imaging response was characterized as improved, similar, or worse by 2 readers independently followed by consensus review. Kaplan-Meier Analysis was performed to compare overall survival (OS) with post-NAT overall imaging response. A Multivariable Cox proportional hazards analysis was performed to evaluate the association of the following variables with OS: overall, arterial and venous radiology response, clinical staging, postoperative CA19-9, and patient age. RESULTS At study conclusion, 30/57 patients were deceased (53%), 26/57 (46%) alive, and 1 patient unknown. Post-NAT, 39/57 (68.4%) had overall improved disease and 18/57 (31.6%) had similar disease. The median OS was 55.7 months (95% CI 33.4-not reached, NR) for those with improved disease vs. 53.9 months (95% CI 14.3-NR) with similar disease (p = 0.859) after NAT. Among all clinical parameters, only post-operative CA 19-9 level was associated with OS (p = 0.002) and PFS (p = 0.005), respectively. CONCLUSION Pancreatic cancer patients who underwent R0 resection showed no difference in survival when comparing those with similar vs improved disease on post-NAT imaging.
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Vernuccio F, Messina C, Merz V, Cannella R, Midiri M. Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: Role of the Radiologist and Oncologist in the Era of Precision Medicine. Diagnostics (Basel) 2021; 11:2166. [PMID: 34829513 PMCID: PMC8623921 DOI: 10.3390/diagnostics11112166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/22/2021] [Accepted: 11/19/2021] [Indexed: 12/24/2022] Open
Abstract
The incidence and mortality of pancreatic ductal adenocarcinoma are growing over time. The management of patients with pancreatic ductal adenocarcinoma involves a multidisciplinary team, ideally involving experts from surgery, diagnostic imaging, interventional endoscopy, medical oncology, radiation oncology, pathology, geriatric medicine, and palliative care. An adequate staging of pancreatic ductal adenocarcinoma and re-assessment of the tumor after neoadjuvant therapy allows the multidisciplinary team to choose the most appropriate treatment for the patient. This review article discusses advancement in the molecular basis of pancreatic ductal adenocarcinoma, diagnostic tools available for staging and tumor response assessment, and management of resectable or borderline resectable pancreatic cancer.
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Affiliation(s)
- Federica Vernuccio
- Radiology Unit, University Hospital "Paolo Giaccone", 90127 Palermo, Italy
| | - Carlo Messina
- Oncology Unit, A.R.N.A.S. Civico, 90127 Palermo, Italy
| | - Valeria Merz
- Department of Medical Oncology, Santa Chiara Hospital, 38122 Trento, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Via del Vespro 129, 90127 Palermo, Italy
| | - Massimo Midiri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University Hospital of Palermo, Via del Vespro 129, 90127 Palermo, Italy
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Systematic review and meta-analysis of diagnostic performance of CT imaging for assessing resectability of pancreatic ductal adenocarcinoma after neoadjuvant therapy: importance of CT criteria. Abdom Radiol (NY) 2021; 46:5201-5217. [PMID: 34331549 DOI: 10.1007/s00261-021-03198-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess the CT diagnostic performance for evaluating resectability of pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant therapy and identify the factor(s) that affect(s) diagnostic performance. METHODS Databases were searched to identify studies published from January 1, 2000, to November 5, 2019 that evaluated the CT diagnostic performance for assessing resectability of post-neoadjuvant PDAC. Two reviewers independently extracted data and assessed the study quality. A meta-analysis was performed to obtain summary sensitivity and specificity values using a bivariate random-effects model, and heterogeneity across studies was assessed. Univariable meta-regression analysis was performed with eight variables, including the different CT criteria for resectability, conventional National Comprehensive Cancer Network (NCCN) criteria for upfront surgery, and modified criteria for post-neoadjuvant surgery. RESULTS Ten studies were included and analyzed. The summary sensitivity and specificity for resectability were 78% (95% CI 68-86%) and 60% (95% CI 44-74%), respectively. No significant heterogeneity was identified (bivariate correlation coefficient ρ = - 1, p-value for hierarchical summary receiver operating characteristics model β = 0.667). The two different CT criteria showed different diagnostic performance (p < 0.01), with higher sensitivity (81% [95% CI 73-90%] vs. 28% [95% CI 15-42%], p < 0.01) and lower specificity (57% [95% CI 41-73%] vs. 90% [95% CI 80-100%], p < 0.01) for the modified criteria. No other variables affected the diagnostic performance. CONCLUSION CT criteria were the factors that affected the diagnostic performance. Modification of the conventional criteria improved sensitivity but lowered specificity. Further modifications are required to improve specificity and uniformity.
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Schizas D, Koumpoura A, Galari M, Economopoulou P, Vailas M, Sotiropoulou M, Dimitroulis D, Maroulis I, Felekouras E. A personalized approach to pancreatic ductal adenocarcinoma and its application in surgical practice. Per Med 2021; 18:613-627. [PMID: 34676789 DOI: 10.2217/pme-2021-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pancreatic duct adenocarcinoma is an aggressive tumor which constitutes the fourth leading cause of cancer-related mortality in the USA. Despite the fact that surgery is an integral part of treatment, 5-year survival rates remain unfavorable, partly because of the complex genetic background, delayed diagnosis and also the absence of effective therapeutic approaches. To optimize surgery's results in recent years, the use of patients' genetic profile has been implemented through classification into subtypes; subtypes based on mutations which could efficiently lead oncologists to the path of targeted novel neoadjuvant regimens. This approach aims to achieve the most effective selection of patients undergoing surgery, to increase the number of potentially resectable tumors and also control micro-metastases, aiming to extend overall survival.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Alkmini Koumpoura
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Meropi Galari
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Panagiota Economopoulou
- Oncology Unit, Second Propaideutic Department of Internal Medicine, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, 12462, Greece
| | - Michail Vailas
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Maria Sotiropoulou
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Dimitrios Dimitroulis
- Second Propaedeutic Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
| | - Ioannis Maroulis
- Department of Surgery, University of Patras, University Hospital of Patras, Rio, 26504, Greece
| | - Evangelos Felekouras
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 11527, Greece
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Arterial involvement and resectability scoring system to predict R0 resection in patients with pancreatic ductal adenocarcinoma treated with neoadjuvant chemoradiation therapy. Eur Radiol 2021; 32:2470-2480. [PMID: 34665317 DOI: 10.1007/s00330-021-08304-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/25/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To derive a CT-based scoring system incorporating arterial involvement and resectability status to predict R0 resection in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing neoadjuvant chemoradiation therapy (CRT). METHODS This retrospective study included 112 patients with PDAC who underwent dynamic contrast-enhanced CT before and after neoadjuvant CRT. A 5-point score was used to determine arterial involvement (A score; 1 = no involvement, 2 = haziness, 3 = abutment, 4 = encasement, 5 = deformity) and 4-point score evaluating resectability status (R score; 1 = resectable, 2 = borderline resectable [BR] with venous involvement, 3 = BR with arterial involvement, 4 = locally advanced [LA]). A score before and after CRT were summed with R score before and after CRT to compute the AR score (ARtotal). The associations between ARtotal, R0 resection, overall survival (OS), and disease-free survival (DFS) were assessed. RESULTS The ARtotal was associated with R0 resection (p < .001) and showed area under the ROC curve of 0.79 for differentiating R0 and R1 resections. Median OS was significantly lower for patients with ARtotal > 9 (median: 35.2 months) compared to patients with ARtotal ≤ 9 (median: not estimable) (p < .001). Similar results were observed for DFS (median, 16.8 months in > 9 vs median, not estimable in ≤ 9; p < .001). CONCLUSIONS A composite score which incorporates degree of arterial involvement and resectability status before and after neoadjuvant CRT is associated with R0 resection and discriminates between R0 and R1 resections in PDAC. KEY POINTS • A scoring system incorporating arterial involvement and resectability status was associated with R0 resection. • ARtotal > 9 could predict patients' overall and disease-free survival.
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45
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Park SJ, Kim JH, Joo I, Han JK. Predictors of conversion surgery in patients with pancreatic cancer who underwent neoadjuvant or palliative FOLFIRINOX treatment using baseline and follow-up CT. Abdom Radiol (NY) 2021; 46:4765-4778. [PMID: 34085090 DOI: 10.1007/s00261-021-03127-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/11/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE We aimed to evaluate the predictive factors of conversion surgery in pancreatic adenocarcinoma (PAC) after neoadjuvant or palliative FOLFIRINOX using baseline and follow-up CT. METHODS We retrospectively included 189 patients who had undergone more than 4 cycles of FOLFIRINOX. We reviewed baseline CT (B-CT), 1st follow-up CT (1st-CT), and the preoperative or last follow-up CT (L-CT) and determined tumor size changes according to the Response Evaluation Criteria in Solid Tumors (RECIST 1.1). Extra-pancreatic perineural invasion (EPNI) and resectability using NCCN 2019 guideline were evaluated. Subgroup analysis by baseline resectability was performed. RESULTS B-CT included resectable (n = 25, 23.2%), borderline (n = 55, 29.1%), locally advanced (n = 44, 23.3%), and metastatic (n = 65, 34.4%) PAC. Seventy-four patients had undergone surgery (39.2%) with an 83.8% (62/74) R0 resection. For operability, resectable status at L-CT (hazard ratio (HR) 65.5; 95% confidence interval (CI) 5.0-865; P = 0.002), RECIST (partial response) at 1st-CT (HR 3.6; 95% CI 1.1-11.7; P = 0.032), and baseline borderline resectability (HR 8.6; 95% CI 1.6-46.4; P = 0.013) were important predictors. Based on a size reduction cut-off of 22.2%, the area under the receiver operating characteristic (ROC) curve (Az) was 0.761 (sensitivity = 70.3%, specificity = 74.8%). In subgroup analysis, RECIST (partial response) at 1st-CT was a significant predictor of locally advanced PAC (HR 32; 95% CI 4.5-227, P 0.001), and the optimal cut-off was 22.2% (Az = 0.914; sensitivity = 100%, specificity = 75%). Baseline tumor size ([Formula: see text] 4 cm) (HR 5.6, 95% CI 1.3-24.3, P = 0.022) and unresectable status at 1st-CT (HR 4.8, 95% CI 1.1-20.6, P = 0.035) were significantly associated with margin-positive resection. CONCLUSION Both baseline and follow-up CT findings are useful to predict conversion surgery for PAC after FOLFIRINOX.
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Affiliation(s)
- Sae-Jin Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, SMG-SNU Boramae Medical Cencer, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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46
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McKinney M, Griffin MO, Tolat PP. Multimodality Imaging for the Staging of Pancreatic Cancer. Surg Oncol Clin N Am 2021; 30:621-637. [PMID: 34511186 DOI: 10.1016/j.soc.2021.06.006] [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] [Indexed: 12/12/2022]
Abstract
Imaging plays a key role in the diagnosis, staging, and follow-up of pancreatic ductal adenocarcinoma. The pancreatic protocol dual-phase multidetector computed tomography scan is the imaging modality of choice. A computed tomography scan is highly accurate for pancreatic tumor detection, assessment of resectability, and detection of metastatic disease. This article reviews key principles of the acquisition, interpretation, and reporting of pancreatic ductal adenocarcinoma imaging with computed tomography scanning and highlights potential roles for newer and supplemental imaging technologies. We discuss the importance of structured interpretation and reporting for providing the most complete and accurate assessment of tumor stage and resectability.
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Affiliation(s)
- Martin McKinney
- Department of Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Michael O Griffin
- Department of Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA; Department of and Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Parag P Tolat
- Department of Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA; Department of and Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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47
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Vascular resections in minimally invasive surgery for pancreatic cancer. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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48
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Lamarca A, Foster L, Valle JW, Satyadas T, Siriwardena A. FOLFIRINOX or FOLFOXIRI in locally advanced duodenal adenocarcinoma: are we missing out? ESMO Open 2021; 5:e000633. [PMID: 33122352 PMCID: PMC7597489 DOI: 10.1136/esmoopen-2019-000633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/20/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Lucy Foster
- Department of Pathology, Manchester Royal Infirmary, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.
| | - Thomas Satyadas
- Department ogf HPB Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Ajith Siriwardena
- Department ogf HPB Surgery, Manchester Royal Infirmary, Manchester, UK
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49
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Watanabe G, Ushida Y, Oba A, Ono Y, Sato T, Inoue Y, Takahashi Y, Saiura A, Ito H. Impact of Tumor Size on the Outcomes of Patients with Resectable Distal Pancreatic Cancer: Lessons Learned from a Series of 158 Radical Resections. Ann Surg Oncol 2021; 29:378-388. [PMID: 34403004 DOI: 10.1245/s10434-021-10560-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/19/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Neoadjuvant therapy is used for borderline resectable pancreatic ductal adenocarcinoma (PDAC) with high risk of incomplete resection and early recurrence. Because distal PDAC is rare, the optimal criteria for neoadjuvant therapy specific for distal PDAC remain unclear. We hypothesized large distal PDAC would recur earlier than small distal PDAC. OBJECTIVE The aim of this study was to identify the risk factors for failure of upfront resection for resectable distal PDAC. METHODS The study cohort comprised 158 patients with resectable distal PDAC who underwent radical resection. The long-term outcomes were recurrence-free survival (RFS), disease-specific survival (DSS), and post-recurrence survival (PRS). RESULTS R0 resection was achieved in 92% of patients, and median DSS for the entire cohort was 31 months. Among 103 patients who developed recurrence, 32 (31%) developed recurrence within 6 months. The median PRS and DSS for those with early recurrence was 6 and 10 months, respectively, compared with 11 and 30 months, respectively, for those with late recurrence (p = 0.017 and p < 0.001, respectively). Patients with tumors > 4 cm had higher rates of R1 resection (16%) and concomitant resection of another organ (19%) than those with smaller tumors (4% and 2%, p = 0.009 and p < 0.001, respectively). In multivariate analysis, tumor > 4 cm remained a significant predictor of early recurrence (p < 0.001, hazard ratio [HR] 6.51), shorter RFS (p = 0.018, HR 1.71), and shorter DSS (p = 0.002, HR 2.07). CONCLUSION Tumor size > 4 cm is a reliable predictor of early recurrence after resection of distal PDAC, and neoadjuvant therapy may help select patients who can benefit from radical resection.
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Affiliation(s)
- Genki Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuta Ushida
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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50
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Lee W, Oh M, Kim JS, Park Y, Kwon JW, Jun E, Song KB, Lee JH, Hwang DW, Yoo C, Kim KP, Jeong JH, Chang HM, Ryoo BY, Park SY, Kim SC. Metabolic activity by FDG-PET/CT after neoadjuvant chemotherapy in borderline resectable and locally advanced pancreatic cancer and association with survival. Br J Surg 2021; 109:61-70. [PMID: 34378010 DOI: 10.1093/bjs/znab229] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/11/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The optimal prognostic markers for neoadjuvant chemotherapy in patients with borderline resectable or locally advanced pancreatic cancer are not yet established. METHOD Patients who received neoadjuvant chemotherapy prior to surgery and underwent FDG-PET/CT between July 2012 and December 2017 were included. Metabolic parameters including standardised uptake value (SUV), metabolic tumour volume (MTV), and total lesion glycolysis (TLG) on PET/CT, and response evaluations using PERCIST criteria, were investigated for its impact on survival and recurrence. Cox proportional hazards model was performed. Differences in risk were expressed as hazard ratio [HR] with 95% confidence interval [c.i.]. RESULTS The patients with borderline resectable (N = 106) or locally advanced pancreatic cancer (N = 82) were identified. The median survival was 33.6 months. Decreased metabolic parameters of PET/CT after neoadjuvant chemotherapy were associated with positive impacts on survival and recurrence such as SUVmax (HR 1.16, 95% c.i. 1.01 to 1.32, P = 0.025), SUVpeak (HR 1.26, 95% c.i. 1.05 to 1.51, P = 0.011), and MTV (HR 1.15, 95% c.i. 1.04 to 1.26, P = 0.005). Large delta values were related to a positive impact on recurrence such as SUVmax (HR 1.21, 95% c.i. 1.06 to 1.38, P = 0.005). Post-neoadjuvant chemotherapy SUVmax ≥3 (HR 3.46, 95% c.i. 1.21 to 9.91; P = 0.036) was an independent prognostic factor for negative impact on survival. Patients with post-neoadjuvant chemotherapy SUVmax <3 showed more chemotherapy cycles (8.7 versus 6.2, P = 0.001), more frequent complete metabolic response (25 vs 2.2%, P = 0.002), smaller tumour size (2.1 vs 3.1 cm, P = 0.002), and less frequent lymphovascular invasion (23.7 vs 51.1%, P = 0.020) than patients with SUVmax ≥3. CONCLUSION Reduction in metabolic tumour parameters of FDG- PET/CT after neoadjuvant chemotherapy indicates improved overall survival and recurrence-free survival.
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Affiliation(s)
- Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Minyoung Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Woo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung-Moon Chang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.,Department of Statistics and Data Science, Korea National Open University, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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