Adjuvant chemotherapy for resectable biliary tract cancer: current status and future direction

Feasibility of S-1 adjuvant chemotherapy after major hepatectomy for biliary tract cancers: An exploratory subset analysis of JCOG1202

INTRODUCTION

Major hepatectomy (MH) may produce the impaired liver function and affect the feasibility of adjuvant chemotherapy in terms of early period after the surgery, but there have not been detailed investigations. JCOG1202 (UMIN000011688) is a randomized phase III trial demonstrating the superiority of adjuvant S-1 chemotherapy for biliary tract cancer (BTC). The aim of this study is to examine the influence of MH for BTC on adjuvant S-1.

MATERIALS AND METHODS

Of the total 424 patients, 207 received S-1 (S-1 arm) while the remaining 217 were not. We compared MH with non-major hepatectomy (NMH) for BTC.

RESULTS

In the S-1 arm, 42 had undergone MH, and 165 had undergone NMH. MH had similar pretreatment features to NMH, including the proportion of biliary reconstruction, to NMH, except for a lower platelet count (17.7 vs. 23.4 × 104/mm3, p < 0.0001) and lower serum albumin level (3.5 vs. 3.8 g/dL, p < 0.0001). The treatment completion proportion tended to be lower for MH than for NMH (59.5 % vs. 75.8 %; risk ratio, 0.786 [95 % confidence interval, 0.603-1.023], p = 0.0733), and the median dose intensity was lower as well (88.7 % vs. 99.6 %, p = 0.0358). The major reasons for discontinuation were biliary tract infections and gastrointestinal disorders after MH. The frequency of grade 3-4 biliary tract infection was 19.0 % in MH vs. 4.2 % in NMH.

CONCLUSION

The treatment completion proportion and dose intensity were lower in MH than in NMH. Caution should be exercised against biliary tract infections and gastrointestinal disorders during adjuvant S-1 after MH for BTC.

Clinical Significance of Nectins in HCC and Other Solid Malignant Tumors: Implications for Prognosis and New Treatment Opportunities-A Systematic Review

The nectin family comprises four proteins, nectin-1 to -4, which act as cell adhesion molecules. Nectins have various regulatory functions in the immune system and can be upregulated or decreased in different tumors. The literature research was conducted manually by the authors using the PubMed database by searching articles published before 2023 with the combination of several nectin-related keywords. A total of 43 studies were included in the main section of the review. Nectins-1-3 have different expressions in tumors. Both the loss of expression and overexpression could be negative prognostic factors. Nectin-4 is the best characterized and the most consistently overexpressed in various tumors, which generally correlates with a worse prognosis. New treatments based on targeting nectin-4 are currently being developed. Enfortumab vedotin is a potent antibody-drug conjugate approved for use in therapy against urothelial carcinoma. Few reports focus on hepatocellular carcinoma, which leaves room for further studies comparing the utility of nectins with commonly used markers.

Clinical prognostic significance of regional and extended lymphadenectomy for biliary cancer with para-aortic lymph node metastasis: A systematic review and meta-analysis

BACKGROUND

The aim of our study was to evaluate clinical prognostic significance of regional and extended lymphadenectomy for biliary cancer with para-aortic lymph node metastasis.

METHODS

A thorough literature search was performed in PubMed/Medline, Cochrane Central Register, Embase, ISI Web of Science and Google Scholar between January 1965 and May 2014 with restricted articles for the English language. Data were processed for a meta-analysis by RevMan 5 software.

RESULTS

Altogether 10 retrospective studies were finally enrolled in our study. For positive para-aortic lymph node group irrespective of regional lymph node metastasis, the overall 1-, 3-, 5-yr pooled RR estimates of survival rates were 2.30, 1.70, and 1.42. There were significant differences between positive para-aortic lymph node group and negative group. For positive para-aortic lymph node group in the setting of regional lymph node metastasis, the overall 1-, 3-, 5-yr pooled RR estimates of survival rates were 1.57, 1.29, and 1.11, respectively. The long-term outcomes referred to 5-yr survival rate were similar between para-aortic lymph node metastasis and regional lymph node metastasis only.

DISCUSSION

Radical resection with extended lymphadenectomy should be caution in terms of the results of an intraoperative sampling biopsy of para-aortic lymph node, which requires a well-designed, prospective controlled study in the future.

Surgery for recurrent biliary carcinoma: results for 27 recurrent cases

Background

Various chemotherapies have been used as best practice to treat recurrent biliary malignancies. Conversely, relatively few surgeries have been described for recurrent extrahepatic biliary carcinoma (RExBC), so whether surgery for RExBC is feasible has remained unclear. This retrospective study was conducted to evaluate the feasibility of surgery for RExBC.

Methods

From February 2000 to January 2014, a total of 27 patients, comprising 18 patients with extrahepatic cholangiocarcinoma and 9 patients with gallbladder carcinoma, met our criteria for radical resection of RExBC (resection group). Sites of recurrence consisted of liver metastases (ten patients), local/percutaneous transhepatic cholangio drainage (PTCD) fistula recurrence (eight patients), bile duct recurrence (six patients), and lymph node recurrence (one patient). To evaluate the survival impact of resection, we compared 123 RExBC patients (resection group) with patients who received palliative care (palliative group).

Results

Morbidity and mortality rates in the resection group were 6.6% and 0%, respectively. Overall cumulative 5-year survival rates were 23.5% in the resection group and 0% in the palliative group. Median survival time was 21.6 months in the resection group and 9.5 months in the palliative group, showing a significant difference (p < 0.01). No significant differences in cumulative survival were seen between extrahepatic cholangiocarcinoma and gallbladder carcinoma in the resection group. In addition, no significant differences were seen between liver metastases, bile duct recurrence, and local/percutaneous transhepatic biliary drainage (PTBD) fistula recurrence in the resection group.

Conclusions

Surgery appears feasible for RExBC and offers longer survival for selected patients.

Effect of NF-κB inhibition on chemoresistance in biliary-pancreatic cancer

Biliary cancer and pancreatic cancer are considered to be difficult diseases to cure. Although complete resection provides the only means of curing these cancers, the rate of resectability is not high. Therefore, chemotherapy is often selected in patients with advanced unresectable biliary-pancreatic cancer. Many combination chemotherapy regimens have been applied in clinical trials. However, the survival time is not satisfactory. On the other hand, most chemotherapeutic agents induce anti-apoptotic transcriptional factor nuclear factor kappa b (NF-κB) activation, and agent-induced NF-κB activation is deeply involved in the onset of chemoresistance. Recently, novel approaches to potentiating chemosensitivity in cases of biliary-pancreatic cancer using NF-κB inhibitors with cytotoxic agents have been reported, most of which comprise translational research, although some clinical trials have also been conducted. Nevertheless, to date, there is no breakthrough chemotherapy regimen for these diseases. As some reports show promising data, combination chemotherapy consisting of a NF-κB inhibitor with chemotherapeutic agents seems to improve chemosensitivity and prolong the survival time of biliary-pancreatic cancer patients.

The Hepatobiliary and Pancreatic Oncology (HBPO) Group of the Japan Clinical Oncology Group (JCOG): history and future direction

The Hepatobiliary and Pancreatic Oncology Group of the Japan Clinical Oncology Group (JCOG) was constituted in April 2008 to develop new standard treatments for hepatobiliary and pancreatic cancer. In pancreatic cancer, the Hepatobiliary and Pancreatic Oncology Group focuses on establishing standard chemotherapy or chemoradiotherapy for unresectable locally advanced disease. The JCOG 0506 study was a Phase II study of gemcitabine alone to examine its efficacy and safety in patients with locally advanced disease. The results in survival significantly exceeded expectations, and gemcitabine monotherapy has come to be regarded as the provisional standard therapy by our group. Following JCOG 0506, the JCOG 1106 study, which is currently under investigation, is a randomized Phase II study to evaluate the efficacy of induction chemotherapy with gemcitabine in combination with S-1 chemoradiotherapy and select a candidate therapeutic agent in a Phase III study comparing with gemcitabine alone. The JCOG 0805 study was a randomized Phase II study comparing S-1 monotherapy with gemcitabine plus S-1 combination therapy for unresectable biliary tract cancer. As a result, gemcitabine plus S-1 combination therapy was considered the more promising candidate in comparison with the gemcitabine plus cisplatin combination therapy in a subsequent Phase III trial. The Hepatobiliary and Pancreatic Oncology Group is planning a Phase III study to compare gemcitabine plus S-1 combination therapy with gemcitabine plus cisplatin combination therapy (JCOG PC1113 study). No standard postoperative adjuvant treatment has been established. We plan to conduct a Phase III study to compare S-1 as adjuvant therapy after surgery with surgery alone in patients with biliary tract cancer (JCOG PC1202).

Adjuvant treatment in biliary tract cancer: To treat or not to treat?

Biliary tract cancer is a rare malignant tumor. There is limited knowledge about biology and natural history of this disease and considerable uncertainty remains regarding its optimal diagnostic and therapeutic management. The role of adjuvant therapy is object of debate and controversy. Although resection is identified as the most effective and the only potentially curative treatment, there is no consensus on the impact of adjuvant chemotherapy and/or radiotherapy on the high incidence of disease recurrence and on survival. This is mainly due to the rarity of this disease and the consequent difficulty in performing randomized trials. The only two prospectively controlled trials concluded that adjuvant chemotherapy did not improve survival. Most of the retrospective trials, which had limited sample size and included heterogeneous patients population and non-standardized therapies, suggested a marginal benefit of chemoradiotherapy in reducing locoregional recurrence and an uncertain impact on survival. Well-designed multi-institutional randomized trials are necessary to clarify the role of adjuvant therapy. Two ongoing phase III trials may provide relevant information.