1
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He J, Lv N, Yang Z, Luo Y, Zhong W, Wu C. Comparing upfront surgery with neoadjuvant treatments in patients with resectable, borderline resectable or locally advanced pancreatic cancer: a systematic review and network meta-analysis of randomized clinical trials. Int J Surg 2024; 110:3900-3909. [PMID: 38935819 PMCID: PMC11175811 DOI: 10.1097/js9.0000000000001313] [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: 11/02/2023] [Accepted: 02/25/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The aim was to explore the optimal neoadjuvant therapy strategy for resectable, borderline resectable, and locally advanced pancreatic cancer, in order to provide a theoretical basis for the development of new neoadjuvant treatment protocols for clinical use. PATIENTS AND METHODS The authors reviewed literature titles and abstracts comparing three treatment strategies (neoadjuvant chemoradiotherapy, neoadjuvant chemotherapy, and upfront surgery) in PubMed, Embase, The Cochrane Library, Web of Science from 2009 to 2023 to estimate relative odds ratios for resection rate and hazard ratios (HRs) for overall survival (OS) in all include trials. RESULTS A total of nine studies involving 889 patients were included in the analysis. The treatment methods included upfront surgery, neoadjuvant chemotherapy, and neoadjuvant chemoradiotherapy followed by surgery. The network meta-analysis results demonstrated that neoadjuvant chemoradiotherapy followed by surgery was an effective approach in improving OS for resectable and borderline resectable pancreatic cancer (RPC) patients compared to upfront surgery (HR: 0.79, 95% CI: 0.64-0.98) and neoadjuvant chemotherapy (HR: 0.79, 95% CI: 0.64-0.98). Additionally, neoadjuvant chemoradiotherapy significantly increased the margin negative resection (R0) rate and pathological negative lymph node (pN0) rate in patients with resectable and borderline RPC. However, it is worth noting that neoadjuvant chemoradiotherapy increased the risk of grade 3 or higher treatment-related adverse events, including in patients with locally advanced pancreatic cancer. CONCLUSIONS The current evidence suggests that neoadjuvant chemoradiotherapy followed by surgery is the optimal choice for treating patients with resectable and borderline RPC. Future research should focus on optimizing neoadjuvant chemoradiotherapy regimens to effectively improve OS while reducing the occurrence of adverse events.
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Affiliation(s)
| | | | | | | | | | - Chunli Wu
- Department of Radiation Oncology, The Fourth Affiliated Hospital of China Medical University, Liaoning, China
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2
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Shannon AH, Sarna A, Bressler L, Monsour C, Palettas M, Huang E, D'Souza DM, Kneuertz PJ, Ejaz A, Pawlik TM, Santry H, Cloyd JM. Quality of Life and Real-time Patient Experience During Neoadjuvant Therapy: A Prospective Cohort Study. Ann Surg 2024; 279:850-856. [PMID: 37641957 DOI: 10.1097/sla.0000000000006090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To use a customized smartphone application to prospectively measure QOL and the real-time patient experience during neoadjuvant therapy (NT). BACKGROUND NT is increasingly used for patients with localized gastrointestinal (GI) cancers. There is little data assessing patient experience and quality of life (QOL) during NT for GI cancers. METHODS Patients with GI cancers receiving NT were instructed on using a customized smartphone application through which the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, a validated measure of health-related QOL, was administered at baseline, every 30 days, and at the completion of NT. Participants also tracked their moods and symptoms and used free-text journaling functionalities in the application. Mean overall and subsection health-related QOL scores were calculated during NT. RESULTS Among 104 enrolled patients, the mean age was 60.5 ± 11.5 years and 55% were males. Common cancer diagnoses were colorectal (40%), pancreatic (37%), and esophageal (15%). Mean overall FACT-G scores did not change during NT ( P = 0.987). While functional well-being scores were consistently the lowest and social well-being scores the highest, FACT subscores similarly did not change during NT (all P > 0.01). The most common symptoms reported during NT were fatigue, insomnia, and anxiety (39.3%, 34.5%, and 28.3% of patient entries, respectively). Qualitative analysis of free-text journaling entries identified anxiety, fear, and frustration as the most common themes, but also the importance of social support systems and confidence in health care providers. CONCLUSIONS While patient symptom burden remains high, results of this prospective cohort study suggest QOL is maintained during NT for localized GI cancers.
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Affiliation(s)
- Alexander H Shannon
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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3
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Mangieri CW, Valenzuela CD, Solsky IB, Erali RA, Pardee T, Lima CMSR, Howerton R, Clark CJ, Shen P. Comparison of survival for metastatic pancreatic cancer patients treated with CPI-613 versus resected borderline-resectable pancreatic cancer patients. J Surg Oncol 2023; 128:844-850. [PMID: 37341164 DOI: 10.1002/jso.27365] [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: 02/18/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Treatment of advanced pancreatic adenocarcinoma remains suboptimal. Therapeutic agents with a novel mechanism of action are desperately needed; one such novel agent is CPI-613 targets. We here analyze the outcomes of 20 metastatic pancreatic cancer patients treated with CPI-613 and FOLFIRINOX in our institution and evaluate their outcomes to borderline-resectable patients treated with curative surgery. METHODS A post hoc analysis was performed of the phase I CPI-613 trial data (NCT03504423) comparing survival outcomes to borderline-resectable cases treated with curative resection at the same institution. Survival was measured by overall survival (OS) for all study cases and disease-free survival (DFS) for resected cases with progression-free survival for CPI-613 cases. RESULTS There were 20 patients in the CPI-613 cohort and 60 patients in the surgical cohort. Median follow-up times were 441 and 517 days for CPI-613 and resected cases, respectively. There was no difference in survival times between CPI-613 and resected cases with a mean OS of 1.8 versus 1.9 year (p = 0.779) and mean PFS/DFS of 1.4 versus 1.7 years (p = 0.512). There was also no difference in 3-year survival rates for OS (hazard ratio [HR] = 1.063, 95% confidence interval [CI] 0.302-3.744, p = 0.925) or DFS/PFS (HR = 1.462, 95% CI 0.285-7.505, p = 0.648). CONCLUSION The first study to evaluate the survival between metastatic patients treated with CPI-613 versus borderline-resectable cases undergoing curative resection. Analysis revealed no significant differences in survival outcomes between the cohorts. Study results are suggestive that there may be potential utility with the addition of CPI-613 to potentially resectable pancreatic adenocarcinoma, although additional research with more comparable study groups are required.
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Affiliation(s)
- Christopher W Mangieri
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Cristian D Valenzuela
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Ian B Solsky
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Richard A Erali
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Timothy Pardee
- Atrium Wake Forest Baptist Medical Center, Division of Hematology and Oncology, Winston-Salem, North Carolina, USA
| | - Caio Max S Rocha Lima
- Atrium Wake Forest Baptist Medical Center, Division of Hematology and Oncology, Winston-Salem, North Carolina, USA
| | - Russell Howerton
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Clancy J Clark
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
| | - Perry Shen
- Atrium Wake Forest Baptist Medical Center, Division of Surgical Oncology, Winston-Salem, North Carolina, USA
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4
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Aploks K, Kim M, Stroever S, Ostapenko A, Sim YB, Sooriyakumar A, Rahimi-Ardabily A, Seshadri R, Dong XD. Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss. World J Gastrointest Surg 2023; 15:1663-1672. [PMID: 37701691 PMCID: PMC10494586 DOI: 10.4240/wjgs.v15.i8.1663] [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: 03/29/2023] [Revised: 05/12/2023] [Accepted: 06/12/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States. In patients with "borderline resectable" disease, current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy. Although neoadjuvant radiotherapy may improve negative margin resection rate, it is theorized that its administration increases operative times and complexity. AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma. METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set, who received a pancreaticoduodenectomy for pancreatic adenocarcinoma, were divided into two groups based off neoadjuvant radiotherapy status. Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy, perioperative blood transfusion status, total operative time, and other perioperative outcomes. RESULTS Of the 11458 patients included in the study, 1470 (12.8%) underwent neoadjuvant radiotherapy. Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion [adjusted odds ratio (aOR) = 1.58, 95% confidence interval (CI): 1.37-1.82; P < 0.001] and have longer surgeries (insulin receptor-related receptor = 1.14, 95%CI: 1.11-1.16; P < 0.001), while simultaneously having lower rates of organ space infections (aOR = 0.80, 95%CI: 0.66-0.97; P = 0.02) and pancreatic fistula formation (aOR = 0.50, 95%CI: 0.40-0.63; P < 0.001) compared to those who underwent surgery alone. CONCLUSION Neoadjuvant radiotherapy, while not associated with increased mortality, will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Krist Aploks
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Minha Kim
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Stephanie Stroever
- Department of Research and Innovation, Nuvance Health, Danbury, CT 06810, United States
| | - Alexander Ostapenko
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Young Bo Sim
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | | | | | - Ramanathan Seshadri
- Division of Surgical Oncology/Hepato-Pancreato-Biliary Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Xiang Da Dong
- Division of Surgical Oncology/Hepato-Pancreato-Biliary Surgery, Danbury Hospital, Danbury, CT 06810, United States
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5
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Amr B, MacCormick A, Miles G, Shahtahmassebi G, Roobottom C, Stell D. Estimation of the organ of origin of peri-ampullary malignancy by preoperative CT scan. Acta Radiol 2023; 64:891-897. [PMID: 35593447 DOI: 10.1177/02841851221096284] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tumors occurring within the pancreatic head commonly arise from the pancreas, duodenal ampulla, distal bile duct, or duodenum. However, they are difficult to distinguish on standard preoperative imaging. PURPOSE To assess the ability of specialist reporting of preoperative computed tomography (CT) scans to determine the organ of origin of pancreatic cancer (PC). MATERIAL AND METHODS Blinded re-reporting of preoperative imaging from five hospitals was undertaken of a consecutive cohort of 411 patients undergoing surgery for PC between January 2006 and May 2014. Radiological identification of tumor site was determined by the presence of the main tumor bulk within the pancreatic head parenchyma and estimation of the pathological organ of origin of the PC was based on all the reported features. RESULTS Each pathological tumor type was noted to have distinct radiological features. Localization of a visible tumor within the pancreatic parenchyma was seen most commonly in PC (92%) than other tumor types (P < 0.0001). Local invasion into the duodenum was a characteristic feature seen in 79% of patients with ampullary tumors and isolated dilation of the bile duct without dilation of the pancreatic duct was seen most commonly in patients with ampullary or bile duct cancer. In the assessment of tumor origin, good agreement (kappa = 0.6, 0.51-0.68) was noted between the consensus radiology opinion and the final histology result. Overall accuracy was greatest for ampullary cancer (88.1%) and lowest for PC (83.2%). CONCLUSION Radiological assessment of preoperative imaging provides a high degree of accuracy in predicting the organ of origin of peri-ampullary cancer.
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Affiliation(s)
- Bassem Amr
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Andrew MacCormick
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Gemma Miles
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | | | - Carl Roobottom
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - David Stell
- 6634University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
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6
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Saha A, Wadsley J, Sirohi B, Goody R, Anthony A, Perumal K, Ulahanan D, Collinson F. Can Concurrent Chemoradiotherapy Add Meaningful Benefit in Addition to Induction Chemotherapy in the Management of Borderline Resectable and Locally Advanced Pancreatic Cancer?: A Systematic Review. Pancreas 2023; 52:e7-e20. [PMID: 37378896 DOI: 10.1097/mpa.0000000000002215] [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: 06/29/2023]
Abstract
OBJECTIVES The role of concomitant chemoradiotherapy or radiotherapy (RT) after induction chemotherapy (IC) in borderline resectable and locally advanced pancreatic ductal adenocarcinoma is debatable. This systematic review aimed to explore this. METHODS We searched PubMed, MEDLINE, EMBASE, and Cochrane database. Studies were selected reporting outcomes on resection rate, R0 resection, pathological response, radiological response, progression-free survival, overall survival, local control, morbidity, and mortality. RESULTS The search resulted in 6635 articles. After 2 rounds of screening, 34 publications were selected. We found 3 randomized controlled studies and 1 prospective cohort study, and the rest were retrospective studies. There is consistent evidence that addition of concomitant chemoradiotherapy or RT after IC improves pathological response and local control. There are conflicting results in terms of other outcomes. CONCLUSIONS Concomitant chemoradiotherapy or RT after IC improves local control and pathological response in borderline resectable and locally advanced pancreatic ductal adenocarcinoma. The role of modern RT in improving other outcome requires further research.
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Affiliation(s)
- Animesh Saha
- From the Department of Radiation Oncology, Apollo Multispecilty Hospitals, Kolkata, India
| | - Jonathan Wadsley
- Department of Clinical Oncology, Weston Park Cancer Centre, Sheffield, United Kingdom
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, India
| | | | - Alan Anthony
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | | | - Danny Ulahanan
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | - Fiona Collinson
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
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7
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Acuna-Villaorduna A, Shankar V, Wysota M, Jirgal A, Kabarriti R, Bellemare S, Goldman I, Kaubisch A, Aparo S, Goel S, Chuy J. Induction Chemotherapy With FOLFIRINOX Followed by Chemoradiation With Gemcitabine in Patients With Borderline-Resectable Pancreatic Ductal Adenocarcinoma. Cancer Control 2022; 29:10732748221134411. [PMID: 36221952 PMCID: PMC9558866 DOI: 10.1177/10732748221134411] [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] [Indexed: 11/25/2022] Open
Abstract
Introduction Perioperative therapy is standard for patients with borderline-resectable
pancreatic ductal adenocarcinoma (BR-PDAC); however, an optimal neoadjuvant
regimen is lacking. We assessed the efficacy of FOLFIRINOX chemotherapy
followed by gemcitabine-based chemoradiation as preoperative therapy. Methods Patients received 4 cycles of FOLFIRINOX, followed by 6-weekly gemcitabine
with concomitant intensity-modulated radiation. The primary endpoint was the
R0 resection rate. Secondary outcomes included resection rate,
overall-response, overall survival (OS), progression-free survival (PFS),
and tolerability. The trial was terminated early due to slow accrual. A
Simon’s optimal two-stage phase II trial single arm design was used. The
primary hypothesis of treatment efficacy was tested using a multistage group
sequential inference procedure. The secondary failure time analysis
endpoints were assessed using the Kaplan-Meier procedure and the Cox
regression model. Results A total of 22 patients enrolled in the study, 18 (81.8%) completed
neoadjuvant treatment. The bias corrected R0 rate was 55.6% (90% CI: 33.3,
68.3; P value = .16) among patients that received at least
1 cycle of FOLFIRINOX and was 80% among patients that underwent surgery. The
median OS was 35.1 months. The median PFS among patients that underwent
surgery was 34 months. Conclusion An R0 resection rate of 55.6% is favorable. Neoadjuvant FOLFIRINOX followed
by concomitant Gemcitabine with radiation was well-tolerated.
NCT01897454
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Affiliation(s)
- Ana Acuna-Villaorduna
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Viswanathan Shankar
- Department of Epidemiology &
Population Health, Albert Einstein College of
Medicine, Bronx, NY, USA
| | - Michael Wysota
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Amanda Jirgal
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA
| | - Rafi Kabarriti
- Department of Radiation Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiation Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sarah Bellemare
- Department of Surgery,
Montefiore
Medical Center, Bronx, NY, USA,Department of Surgery,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Inessa Goldman
- Department of Radiology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Radiology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Andreas Kaubisch
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Santiago Aparo
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA
| | - Sanjay Goel
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
| | - Jennifer Chuy
- Department of Medical Oncology,
Montefiore
Medical Center, Bronx, NY, USA,Department of Medical Oncology,
Albert
Einstein College of Medicine, Bronx,
NY, USA,Sanjay Goel, MD, MS, Professor of Medicine,
Department of Medical Oncology, Albert Einstein College of Medicine, Montefiore
Medical Center, 1695 Eastchester Road, Bronx NY 10461, USA.
; Jennifer Chuy, MD, Assistant
Professor of Medicine, Department of Medical Oncology, Albert Einstein College
of Medicine, Montefiore Medical Center, 1695 Eastchester Road, Bronx NY 10461,
USA.
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8
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Hyman DW, Almerey T, Mujkanovic A, Hammons I, Tice M, Stauffer JA. Comparing Post-Operative Outcomes of Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: Neoadjuvant Therapy Versus Surgery First Approach. Am Surg 2022; 88:1868-1874. [PMID: 35465681 DOI: 10.1177/00031348221087900] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Optimal use of surgery first (SF) vs neoadjuvant therapy (NAT) for localized pancreatic ductal adenocarcinoma (PDAC) is still unclear. There is concern that NAT may result in worsened post-operative outcomes. Our study objectives were to show the impact of NAT on post-operative morbidity and mortality. METHODS All patients undergoing resection for PDAC between 1/1/2010 and 12/31/2020 were reviewed and those who underwent pancreaticoduodenectomy (PD) were included. Demographics, perioperative details, and pathology details were gathered. Data pertaining to 90-day complications were obtained and graded according to international consensus guidelines. Those undergoing SF were compared to those who had NAT. Categorical variables were compared by Fisher's exact test and continuous variables by Student's t-test. RESULTS Two hundred and forty-one subjects who underwent PD for PDAC were included in this review. There was no significant difference in the rate of major morbidity between subjects who received NAT vs SF (19.4 vs 20.3%, P = 1.0). Similarly, there were no significant differences in the rates of mortality (3.1 vs 4.2%, P = .742), post-operative pancreatic fistula (8.2 vs 10.5%, P = .658), or post-pancreatectomy hemorrhage (7.1 vs 7.7%, P = 1.0), respectively. CONCLUSION Post-operative outcomes are not worsened by the use of the NAT approach prior to PD for PDAC. Further investigation is needed to reveal which patient subgroups may benefit from the use of NAT, especially regarding survival.
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Affiliation(s)
- David W Hyman
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Tariq Almerey
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Amer Mujkanovic
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Isaac Hammons
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - Mary Tice
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
| | - John A Stauffer
- Department of Surgery, 23389Mayo Clinic, Jacksonville, FL, USA
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9
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Landa K, Schmitz R, Farrow NE, Rushing C, Niedzwiecki D, Cerullo M, Herbert GS, Shah KN, Zani S, Blazer DG, Allen PJ, Lidsky ME. Surgical resection is associated with improved long-term survival of patients with resectable pancreatic head cancer compared to multiagent chemotherapy. HPB (Oxford) 2022; 24:1153-1161. [PMID: 34987008 DOI: 10.1016/j.hpb.2021.12.007] [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: 09/12/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard of care for resectable pancreatic cancer is a combination of surgical resection (SR) and multiagent chemotherapy (MCT). We aim to determine whether SR or MCT is associated with superior survival for patients receiving only single-modality therapy. METHODS Patients with stage I-IIb pancreatic head adenocarcinoma who received either MCT or SR were identified in the NCDB (2013-2015). Following a piecewise approach to estimating hazards over the course of follow-up, conditional overall survival (OS) at 30, 60, and 90 days after treatment initiation was estimated using landmark analyses. RESULTS 3103 patients received MCT alone (60.3%) and 2043 underwent SR alone (39.7%). SR had an OS disadvantage at 30 (HR 3.99, 95% CI 3.12-5.11) and 60 days (HR 1.85, 95% CI 1.4-2.45), but an OS advantage after 90 days (HR 0.59, 95% CI 0.55-0.64). In a landmark analysis conditioned on 90 days survival post treatment initiation, median OS was improved for SR (17.0 vs. 12.2 months, p < 0.0001); SR improved 3-year OS by 21.3% (p < 0.05), despite patients being older (median 72 vs. 67 years, p < 0.0001) with higher Charlson-Deyo comorbidity scores (≥2: 11.2 vs. 8.6%, p = 0.006). CONCLUSION For patients with resectable pancreatic cancer, SR is associated with superior long-term survival compared to MCT.
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Affiliation(s)
- Karenia Landa
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Robin Schmitz
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Christel Rushing
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Garth S Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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10
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Du J, Gao X, Zhang H, Wan Z, Yu H, Wang D. Stent Selection in Preoperative Biliary Drainage for Patients With Operable Pancreatic Cancer Receiving Neoadjuvant Therapy: A Meta-Analysis and Systematic Review. Front Surg 2022; 9:875504. [PMID: 35846957 PMCID: PMC9280034 DOI: 10.3389/fsurg.2022.875504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/31/2022] [Indexed: 12/29/2022] Open
Abstract
With the increasing use of neoadjuvant therapy (NAT) in patients with pancreatic cancer to reduce tumor burden on prognosis, preoperative biliary drainage (PBD) is becoming increasingly necessary. The aim of this study was to summarize the latest evidence and compare the clinical efficacy of metal stents (MS) and plastic stents (PS) in patients undergoing neoadjuvant therapy for operable pancreatic cancer. Eligible studies were searched in PubMed, Embase and Cochrane Library from their inception to September 2021. In this study, RevMan 5.4 was used to perform the analyses. Two randomized controlled trials (RCTs) and six retrospective studies with 316 patients were included. All patients had pancreatic cancer and received NAT before surgical resection. Meta-analysis showed that the rate of endoscopic reintervention in MS (26/143, 18%) group was lower than that of PS (122/153, 80%) group (P < 0.05). The rate of stent-related complications in MS group was lower (18/118, 15%) than that of PS (52/117, 44%) group (P = 0.02). But there were no significant differences in operative time, operative blood loss, overall postoperative complications, postoperative hospitalization days and total medical costs between the two groups. For operable pancreatic cancer patients undergoing NAT surgery, MS was preferred over PS in terms of the incidence of endoscopic reintervention and stent-related complications. More clinical trials are needed in the future to confirm these data with higher levels of evidence.
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Affiliation(s)
- Jianbing Du
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiangyu Gao
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Hongtao Zhang
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Zhuo Wan
- Department of Hematology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Hengchao Yu
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Correspondence: Hengchao Yu Desheng Wang
| | - Desheng Wang
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Correspondence: Hengchao Yu Desheng Wang
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11
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van Dongen JC, Suker M, Versteijne E, Bonsing BA, Mieog JSD, de Vos-Geelen J, van der Harst E, Patijn GA, de Hingh IH, Festen S, Ten Tije AJ, Busch OR, Besselink MG, van Tienhoven G, Koerkamp BG, van Eijck CHJ. Surgical Complications in a Multicenter Randomized Trial Comparing Preoperative Chemoradiotherapy and Immediate Surgery in Patients With Resectable and Borderline Resectable Pancreatic Cancer (PREOPANC Trial). Ann Surg 2022; 275:979-984. [PMID: 33201120 DOI: 10.1097/sla.0000000000004313] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the effect of preoperative chemoradiotherapy on surgical complications in patients after pancreatic resection for (borderline-)resectable pancreatic cancer. SUMMARY OF BACKGROUND DATA Preoperative chemoradiotherapy is increasingly used in patients with (borderline-)resectable pancreatic cancer. concerns have been raised about the potential harmful effect of any preoperative therapy on the surgical complication rate after pancreatic resection. METHODS An observational analysis was performed within the multicenter randomized controlled PREOPANC trial (April 2013-July 2017). The trial randomly assigned (1:1) patients to preoperative chemoradiotherapy followed by surgery and the remaining adjuvant chemotherapy or to immediate surgery, followed by adjuvant chemotherapy. The main analysis consisted of a per-protocol approach. The endpoints of the present analyses were the rate of postoperative complications. RESULTS This study included 246 patients from 16 centers, of whom 66 patients underwent resection after preoperative therapy and 98 patients after immediate surgery. No differences were found regarding major complications (37.9% vs 30.6%, P=0.400), postpancreatectomy hemorrhage (9.1% vs 5.1%, P=0.352), delayed gastric emptying (21.2% vs 22.4%, P=0.930), bile leakage (4.5% vs 3.1%, P=0.686), intra-abdominal infections (12.1% vs 10.2%, P=0.800), and mortality (3.0% vs 4.1%, P=1.000). There was a significant lower incidence of postoperative pancreatic fistula in patients who received preoperative chemoradiotherapy (0% vs 9.2%, P=0.011). CONCLUSIONS Preoperative chemoradiotherapy did not increase the incidence of surgical complications or mortality and reduced the rate of postoperative pancreatic fistula after resection in patients with (borderline-)resectable pancreatic cancer.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Albert J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Breda, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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12
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Sugumar K, Hue JJ, Hardacre JM, Ammori JB, Rothermel LD, Dorth J, Saltzman J, Mohamed A, Selfridge JE, Bajor D, Winter JM, Ocuin LM. Combined multiagent chemotherapy and radiotherapy is associated with prolonged overall survival in patients with non-operatively managed stage II-III pancreatic adenocarcinoma. HPB (Oxford) 2022; 24:433-442. [PMID: 34465529 DOI: 10.1016/j.hpb.2021.08.938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/25/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most patients with pancreatic adenocarcinoma (PDAC) do not undergo surgical resection. The role of radiotherapy (RT) in non-operatively managed localized pancreatic adenocarcinoma is unclear. METHODS The National Cancer Database (2010-2016) was queried for patients with clinical stage II-III PDAC treated with multiagent systemic chemotherapy (CT) +/- RT but not surgery. Factors associated with the receipt of RT and overall survival were compared after adjusting for patient demographics and clinical characteristics. RESULTS A total of 14,921 patients were included, of whom 9279 received CT and 5382 received CT + RT. Patients treated with CT + RT were more likely to be younger (65vs66yrs), treated at non-academic facilities (48.8%vs46.7%), have private insurance (40.3%vs36.5%), and have clinical T4 tumors (53.6%vs48.7%). Most patients who were treated with RT received external beam radiotherapy (89.3%), and the median dose was 5,000 cGy. Median time to start of RT was 129 days. CT + RT was associated with longer overall survival (15.9vs11.8mos,p < 0.001), and remained associated with survival on multivariable analysis (HR 0.74, 95%CI 0.70-0.78). On a 4-month conditional survival analysis, combined CT + RT remained associated with improved survival compared to CT alone (16.0vs13.1mos,p < 0.001). CONCLUSIONS In patients with non-operatively managed localized pancreatic adenocarcinoma, combined radiotherapy and multiagent systemic chemotherapy is associated with improved overall survival compared to chemotherapy alone.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Dorth
- Department of Radiology, Division of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Joel Saltzman
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amr Mohamed
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Bajor
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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13
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Hasegawa S, Endo I, Kubota K. Plastic or self-expandable metal stent: Which is the most suitable for patients with pancreatic head cancer in the upcoming era of neoadjuvant chemotherapy? A review. Dig Endosc 2022; 34:297-306. [PMID: 34388286 DOI: 10.1111/den.14107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/11/2021] [Indexed: 01/15/2023]
Abstract
Obstructive jaundice is a major symptom of pancreatic head cancer, and although its amelioration is required before scheduling chemotherapy, the decision to perform biliary drainage for resectable pancreatic cancer has remained controversial. In recent years, the effectiveness of neoadjuvant therapy for pancreatic cancer has been reported. Preoperative biliary drainage has become increasingly necessary, making the choice of stent an important one; thus, the longer the waiting period extends through neoadjuvant chemotherapy, the more durable stents - such as self-expandable metallic stents, rather than plastic stents - would be desired as an option. Still, there is insufficient evidence regarding surgical outcomes and long-term prognosis, and further confirmatory studies are needed. Through this review, we aim to provide an update on the characteristics of biliary stents and preoperative biliary drainage for potentially resectable pancreatic cancer.
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Affiliation(s)
- Sho Hasegawa
- Division of, Gastroenterology and Hepatology, Yokohama City University School of Medicine Graduate School of Medicine, Kanagawa, Japan
| | - Itaru Endo
- Division of, Gastroenterological Surgery, Yokohama City University School of Medicine Graduate School of Medicine, Kanagawa, Japan
| | - Kensuke Kubota
- Division of, Gastroenterology and Hepatology, Yokohama City University School of Medicine Graduate School of Medicine, Kanagawa, Japan
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14
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Hue JJ, Dorth J, Sugumar K, Hardacre JM, Ammori JB, Rothermel LD, Saltzman J, Mohamed A, Selfridge JE, Bajor D, Winter JM, Ocuin LM. Neoadjuvant Radiotherapy is Associated With Improved Pathologic Outcomes and Survival in Resected Stage II-III Pancreatic Adenocarcinoma Treated With Multiagent Neoadjuvant Chemotherapy in the Modern Era. Am Surg 2021; 87:1386-1395. [PMID: 34382877 DOI: 10.1177/00031348211038581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (CT) is being utilized more frequently in patients diagnosed with localized pancreatic cancer. The role of additional neoadjuvant radiotherapy (RT) remains undefined. We explored outcomes associated with neoadjuvant RT in the modern era. METHODS The National Cancer Database (2010-2017) was queried for patients with clinical stage II-III pancreatic adenocarcinoma who received neoadjuvant multiagent systemic CT +/- RT. Demographics, pathologic outcomes, postoperative outcomes, and overall survival were compared. RESULTS A total of 5245 patients were included, of whom 3123 received CT and 1941 received CT + RT. Use of RT decreased over the 8-year study period. On multivariable analysis, treatment at academic facilities (odds ratio (OR) = 1.52, P < .001) and clinical T4 tumors (OR = 1.68, P < .001) were independently associated with receipt of RT. Patients treated with CT + RT had a higher frequency of ypT0-T2 tumors (35.8% vs. 22.7%) and a lower rate of ypT3-T4 tumors (57.3% vs. 72.8%; P < .001), lower rate of node-positive disease (36.6% vs. 59.8%, P < .001), and margin-positive resections (13.8% vs. 20.2%, P < .001), but slightly higher 90-day postoperative mortality (4.9% vs. 3.6%, P = .04). Neoadjuvant chemotherapy+ RT was associated with longer overall survival (32.7 vs. 29.8 months, P = .008), and remained independently associated with survival on multivariable analysis (HR = .85, P < .001). DISCUSSION In patients with stage II-III pancreatic adenocarcinoma, the addition of neoadjuvant RT to multiagent neoadjuvant CT may be associated with increased rates of node-negative and margin-negative resection, as well as improved overall survival.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Dorth
- Department of Radiology, Division of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Joel Saltzman
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amr Mohamed
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Bajor
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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15
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He J, Schmocker R. Neoadjuvant Treatment and Surgical Resection Are Associated with Survival in Pancreatic Cancer. J Am Coll Surg 2021; 232:1023-1024. [PMID: 33722461 DOI: 10.1016/j.jamcollsurg.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
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16
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Kwon W, Thomas A, Kluger MD. Irreversible electroporation of locally advanced pancreatic cancer. Semin Oncol 2021; 48:84-94. [PMID: 33648735 DOI: 10.1053/j.seminoncol.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
Locally advanced pancreatic cancer (LAPC) constitutes approximately one-third of all pancreatic cancer, with standard of care inconsistently defined and achieving modest outcomes at best. While resection after downstaging offers the chance for cure, only a fraction of patients with LAPC become candidates for resection. Chemotherapy remains the mainstay of treatment for the remainder. In these patients, ablative therapy may be given for local control of the tumor. Irreversible electroporation (IRE) is an attractive ablative technique. IRE changes the permeability of tumor cell membranes to induce apoptosis. Unlike other ablative therapies, IRE causes little thermal injury to the target area, making it ideal for LAPC involving major vessels. Compared to systemic chemotherapy alone, IRE seems to offer some survival benefit. Although early studies reported notable morbidity and mortality rates, IRE presents opportunities for those who cannot undergo resection and who otherwise have limited options. Another role of IRE is to extend the margins of resected tumors when there is a concern for R1 resection. Perhaps most exciting, IRE is thought to have effects beyond local ablation. IRE has immunomodulatory effects, which may induce in vivo vaccination and may potentially synergize with immunotherapy. Through electrochemotherapy, IRE may enhance drug delivery to residual tumor cells. Ultimately the role of IRE in the treatment of LAPC still needs to be validated through well designed randomized trials. Investigations of its future possibilities are in the early stages. IRE offers the potential to provide more options to LAPC patients.
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Affiliation(s)
- Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Alexander Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
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17
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Casolino R, Braconi C, Malleo G, Paiella S, Bassi C, Milella M, Dreyer SB, Froeling FEM, Chang DK, Biankin AV, Golan T. Reshaping preoperative treatment of pancreatic cancer in the era of precision medicine. Ann Oncol 2021; 32:183-196. [PMID: 33248227 PMCID: PMC7840891 DOI: 10.1016/j.annonc.2020.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
This review summarises the recent evidence on preoperative therapeutic strategies in pancreatic cancer and discusses the rationale for an imminent need for a personalised therapeutic approach in non-metastatic disease. The molecular diversity of pancreatic cancer and its influence on prognosis and treatment response, combined with the failure of 'all-comer' treatments to significantly impact on patient outcomes, requires a paradigm shift towards a genomic-driven approach. This is particularly important in the preoperative, potentially curable setting, where a personalised treatment allocation has the substantial potential to reduce pancreatic cancer mortality.
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Affiliation(s)
- R Casolino
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - C Braconi
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK
| | - G Malleo
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - S Paiella
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - C Bassi
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - M Milella
- Department of Medicine, Medical Oncology, University and Hospital Trust of Verona, Verona (VR), Italy
| | - S B Dreyer
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - F E M Froeling
- Edinburgh Cancer Centre, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - D K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Bearsden, Glasgow, Scotland, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK; South Western Sydney Clinical School, Faculty of Medicine, University of NSW, Liverpool, NSW, Australia.
| | - T Golan
- Oncology Institute, Sheba Medical Center, Tel Hashomer, Israel
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18
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Schmocker RK, Delitto D, Wright MJ, Ding D, Cameron JL, Lafaro KJ, Burns WR, Wolfgang CL, Burkhart RA, He J. Impact of Margin Status on Survival in Patients with Pancreatic Ductal Adenocarcinoma Receiving Neoadjuvant Chemotherapy. J Am Coll Surg 2020; 232:405-413. [PMID: 33338577 DOI: 10.1016/j.jamcollsurg.2020.11.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Historically, a positive margin after pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) was associated with decreased survival. In an era when neoadjuvant chemotherapy (NAC) is being used frequently, the prognostic significance of margin status is unclear. STUDY DESIGN Patients with localized PDAC who received NAC and underwent pancreatectomy from 2011 to 2018 were identified from a single-institution database. Patients with fewer than 2 months of NAC, R2 resection, or fewer than 90 days of follow-up were excluded. A positive margin included tumors within 1 mm of the surgical margin. RESULTS Four hundred and sixty-eight patients met inclusion criteria. Median age was 65 years and 53% were female. Preoperative clinical staging demonstrated that most had locally advanced (n = 222 [47%]) or borderline resectable (n = 172 [37%]) disease. Median follow-up was 18.5 months (interquartile range 10.6 to 30.0 months). Median duration of NAC was 119 days (interquartile range 87 to 168 days). FOLFIRINOX was first-line therapy for 67%, and 73% received neoadjuvant radiotherapy. Most underwent pancreaticoduodenectomy (69%). Forty percent were node-positive and 80% had an R0 resection. Fifty-six percent received at least 1 cycle of adjuvant therapy. Median overall survival and recurrence-free survival were 22.0 months (95% CI, 19.4 to 25.1 months) and 11.0 months (95% CI, 10.0 to 12.1 months). On multivariate analysis, margin status was not a significant predictor of overall survival or recurrence-free survival. Factors associated with overall survival included clinical stage, duration of NAC, nodal status, histopathologic treatment response score, and receipt of adjuvant chemotherapy. CONCLUSIONS Microscopic margin positivity is not associated with recurrence and survival in localized PDAC patients resected after treatment with NAC. Aggressive surgical extirpation in high-volume centers should be considered in selected patients after extensive NAC.
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Affiliation(s)
- Ryan K Schmocker
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Surgical Oncology, Department of Surgery, The University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Daniel Delitto
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J Wright
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A Burkhart
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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19
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Affiliation(s)
- Kristin N Kelly
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA.
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20
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Rhee H, Park MS. The Role of Imaging in Current Treatment Strategies for Pancreatic Adenocarcinoma. Korean J Radiol 2020; 22:23-40. [PMID: 32901458 PMCID: PMC7772381 DOI: 10.3348/kjr.2019.0862] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023] Open
Abstract
In pancreatic cancer, imaging plays an essential role in surveillance, diagnosis, resectability evaluation, and treatment response evaluation. Pancreatic cancer surveillance in high-risk individuals has been attempted using endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI). Imaging diagnosis and resectability evaluation are the most important factors influencing treatment decisions, where computed tomography (CT) is the preferred modality. EUS, MRI, and positron emission tomography play a complementary role to CT. Treatment response evaluation is of increasing clinical importance, especially in patients undergoing neoadjuvant therapy. This review aimed to comprehensively review the role of imaging in relation to the current treatment strategy for pancreatic cancer, including surveillance, diagnosis, evaluation of resectability and treatment response, and prediction of prognosis.
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Affiliation(s)
- Hyungjin Rhee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Suk Park
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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21
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Loch FN, Asbach P, Haas M, Seeliger H, Beyer K, Schineis C, Degro CE, Margonis GA, Kreis ME, Kamphues C. Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging. World J Surg Oncol 2020; 18:213. [PMID: 32811523 PMCID: PMC7436989 DOI: 10.1186/s12957-020-01951-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymph node staging of ductal adenocarcinoma of the pancreatic head (PDAC) by cross-sectional imaging is limited. The aim of this study was to determine the diagnostic accuracy of expanded criteria in nodal staging in PDAC patients. METHODS Sixty-six patients with histologically confirmed PDAC that underwent primary surgery were included in this retrospective IRB-approved study. Cross-sectional imaging studies (CT and/or MRI) were evaluated by a radiologist blinded to histopathology. Number and size of lymph nodes were measured (short-axis diameter) and characterized in terms of expanded morphological criteria of border contour (spiculated, lobulated, and indistinct) and texture (homogeneous or inhomogeneous). Sensitivities and specificities were calculated with histopathology as a reference standard. RESULTS Forty-eight of 66 patients (80%) had histologically confirmed lymph node metastases (pN+). Sensitivity, specificity, and Youden's Index for the criterion "size" were 44.2%, 82.4%, and 0.27; for "inhomogeneous signal intensity" 25.6%, 94.1%, and 0.20; and for "border contour" 62.7%, 52.9%, and 0.16, respectively. There was a significant association between the number of visible lymph nodes on preoperative CT and lymph node involvement (pN+, p = 0.031). CONCLUSION Lymph node staging in PDAC is mainly limited due to low sensitivity for detection of metastatic disease. Using expanded morphological criteria instead of size did not improve regional nodal staging due to sensitivity remaining low. Combining specific criteria yields improved sensitivity with specificity and PPV remaining high.
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Affiliation(s)
- Florian N Loch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Patrick Asbach
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Matthias Haas
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hendrik Seeliger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Katharina Beyer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Schineis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Claudius E Degro
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Georgios A Margonis
- The Johns Hopkins University School of Medicine, Department of Surgery, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
| | - Martin E Kreis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Carsten Kamphues
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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22
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Giovinazzo F, Soggiu F, Jang JY, Versteijne E, van Tienhoven G, van Eijck CH, Han Y, Choi SH, Kang CM, Zalupski M, Ahmad H, Yentz S, Helton S, Rose JB, Takishita C, Nagakawa Y, Abu Hilal M. Gemcitabine-Based Neoadjuvant Treatment in Borderline Resectable Pancreatic Ductal Adenocarcinoma: A Meta-Analysis of Individual Patient Data. Front Oncol 2020; 10:1112. [PMID: 32850319 PMCID: PMC7431761 DOI: 10.3389/fonc.2020.01112] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/03/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Non-randomized studies have investigated multi-agent gemcitabine-based neo-adjuvant therapies (GEM-NAT) in borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC). Treatment sequencing and specific elements of neoadjuvant treatment are still under investigation. The present meta-analysis aims to assess the effectiveness of GEM-NAT on overall survival (OS) in BR-PDAC. Patients and Methods: A meta-analysis of individual participant data (IPD) on GEM-NAT for BR-PDAC were performed. The primary outcome was OS after treatment with GEM-based chemotherapy. In the Individual Patient Data analysis data were reappraised and confirmed as BR-PDAC on provided radiological data. Results: Six studies investigating GEM-NAT were included in the IPD metanalysis. The IPD metanalysis was conducted on 271 patients who received GEM-NAT. Pooled median patient-level OS was 22.2 months (95%CI 19.1–25.2). R0 rates ranged between 81 and 95% (I2 = 0%, p = 0.64), respectively. Median OS was 27.8 months (95%CI 23.9–31.6) in the patients who received NAT-GEM followed by resection compared to 15.4 months (95%CI 12.3–18.4) for NAT-GEM without resection and 13.0 months (95%CI 7.4–18.5) in the group of patients who received upfront surgery (p < 0.0001). R0 rates ranged between 81 and 95% (I2 = 0%, p = 0.64), respectively. Overall survival in the R0 group was 29.3 months (95% CI 24.3–34.2) vs. 16.2 months (95% CI 7·9–24.5) in the R1 group (p = 0·001). Conclusions: The present study is the first meta-analysis combining IPD from a number of international centers with BR-PDAC in a cohort that underwent multi-agent gemcitabine neoadjuvant therapy (GEM-NAT) before surgery. GEM-NAT followed by surgical resection improve survival and R0 resection in BR-PDAC. Also, GEM-NAT may result in a good palliative option in non-resected patients because of progressive disease after neoadjuvant treatment. Results from randomized controlled trials (RCTs) are awaited to validate these findings.
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Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Fiammetta Soggiu
- Hepato-Pancreato-Biliary and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Youngmin Han
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Seong Ho Choi
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chang Moo Kang
- Division of HBP Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Mark Zalupski
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Hasham Ahmad
- Department of Surgery, University Hospital of Leicester NHS Trust, Leicester, United Kingdom
| | - Sarah Yentz
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, United States
| | - J Bart Rose
- Section of Surgical Oncology, University of Alabama, Birmingham, AL, United States
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, United Kingdom.,Depatment of Surgery, Fondazione Poliambulanza Istituto Ospedaliero Multispecialistico, Brescia, Italy
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Aziz H, Zeeshan M, Jie T, Maegawa FB. Neoadjuvant Chemoradiation Therapy is Associated with Adverse Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Cancer. Am Surg 2020. [DOI: 10.1177/000313481908501136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of neoadjuvant chemoradiation therapy in patients with pancreatic adenocarcinoma is emerg-ing as an acceptable therapy option. The effects of neoadjuvant therapy on 30 days’ outcomes in patients with pancreatic cancer are not well defined in the literature. NSQIP (2009–2012) was used. Only patients with a diagnosis of pancreatic cancer and those who underwent a Whipple were included in the analysis. Patient who underwent neoadjuvant chemoradiation therapy were compared with those who did not receive therapy. Main outcome measures were as follows: complications, ≥2 units of blood transfusions, length of stay, readmission rates, return to the operating room, and 30-day mortality. A total of 1445 patients (395: neoadjuvant chemoradiation and 1050: no neoadjuvant therapy) were identified. The mean age was 67 ± 12 years, and 51 per cent of the patients were male. Neoadjuvant chemoradiation therapy was associated with increase in readmission rates (18% vs 12.2%, P 0.02), unanticipated return to the operating room (2.3% vs 1.1%, P 0.03) with no difference in mortality rates. Neoadjuvant chemoradiation therapy is associated with increase in inhospital complications. These differences in outcomes may be explained by the more advance stage of pancreatic cancer in these subsets of patients. Resource utilization and preoperative rehabilitation are of utmost significance to overcome this rise in complications associated with neoadjuvant chemoradiation therapy.
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Affiliation(s)
- Hassan Aziz
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplantation at Keck Hospital of USC, Los Angeles, California
| | - Muhammad Zeeshan
- Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Tun Jie
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona; and
| | - Felipe B. Maegawa
- Department of Surgery, Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona
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Survival Outcomes Associated With Clinical and Pathological Response Following Neoadjuvant FOLFIRINOX or Gemcitabine/Nab-Paclitaxel Chemotherapy in Resected Pancreatic Cancer. Ann Surg 2020; 270:400-413. [PMID: 31283563 DOI: 10.1097/sla.0000000000003468] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare the survival outcomes associated with clinical and pathological response in pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant chemotherapy (NAC) with FOLFIRINOX (FLX) or gemcitabine/nab-paclitaxel (GNP) followed by curative-intent pancreatectomy. BACKGROUND Newer multiagent NAC regimens have resulted in improved clinical and pathological responses in PDAC; however, the effects of these responses on survival outcomes remain unknown. METHODS Clinicopathological and survival data of PDAC patients treated at 7 academic medical centers were analyzed. Primary outcomes were overall survival (OS), local recurrence-free survival (L-RFS), and metastasis-free survival (MFS) associated with biochemical (CA 19-9 decrease ≥50% vs <50%) and pathological response (complete, pCR; partial, pPR or limited, pLR) following NAC. RESULTS Of 274 included patients, 46.4% were borderline resectable, 25.5% locally advanced, and 83.2% had pancreatic head/neck tumors. Vein resection was performed in 34.7% and 30-day mortality was 2.2%. R0 and pCR rates were 82.5% and 6%, respectively. Median, 3-year, and 5-year OS were 32 months, 46.3%, and 30.3%, respectively. OS, L-RFS, and MFS were superior in patients with marked biochemical response (CA 19-9 decrease ≥50% vs <50%; OS: 42.3 vs 24.3 months, P < 0.001; L-RFS-27.3 vs 14.1 months, P = 0.042; MFS-29.3 vs 13 months, P = 0.047) and pathological response [pCR vs pPR vs pLR: OS- not reached (NR) vs 40.3 vs 26.1 months, P < 0.001; L-RFS-NR vs 24.5 vs 21.4 months, P = 0.044; MFS-NR vs 23.7 vs 20.2 months, P = 0.017]. There was no difference in L-RFS, MFS, or OS between patients who received FLX or GNP. CONCLUSION This large, multicenter study shows that improved biochemical, pathological, and clinical responses associated with NAC FLX or GNP result in improved OS, L-RFS, and MFS in PDAC. NAC with FLX or GNP has similar survival outcomes.
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Lee YS, Lee JC, Yang SY, Kim J, Hwang JH. Neoadjuvant therapy versus upfront surgery in resectable pancreatic cancer according to intention-to-treat and per-protocol analysis: A systematic review and meta-analysis. Sci Rep 2019; 9:15662. [PMID: 31666626 PMCID: PMC6821820 DOI: 10.1038/s41598-019-52167-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/14/2019] [Indexed: 12/11/2022] Open
Abstract
The effectiveness of neoadjuvant therapy (NAT) remains unclear in resectable pancreatic cancer (PC) as compared with upfront surgery (US). The aim of this study was to investigate the survival gain of NAT over US in resectable PC. PubMed and EMBASE were searched for studies comparing survival outcomes between NAT and US for resectable PC until June 2018. Overall survival (OS) was analyzed according to treatment strategy (NAT versus US) and analytic methods (intention-to-treat analysis (ITT) and per-protocol analysis (PP)). In 14 studies, 2,699 and 6,992 patients were treated with NAT and US, respectively. Although PP analysis showed the survival gain of NAT (HR 0.72, 95% CI 0.68-0.76), ITT analysis did not show the statistical significance (HR 0.96, 95% CI 0.82-1.12). However, NAT completed with subsequent surgery showed better survival over US completed with adjuvant therapy (HR 0.82, 95% CI 0.71-0.93). In conclusion, the supporting evidence for NAT in resectable PC was insufficient because the benefit was not demonstrated in ITT analysis. However, among the patients who completed both surgery and chemotherapy, NAT showed survival benefit over adjuvant therapy. Therefore, NAT could have a role of triaging the patients for surgery even in resectable PC.
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Affiliation(s)
- Yoon Suk Lee
- Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Se Yeol Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Clinical impact of additional therapy for residual pancreatic cancer. Surg Today 2019; 50:440-448. [PMID: 31650262 DOI: 10.1007/s00595-019-01900-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to explore the prognostic significance of the resection margin (R) status of pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant therapy (NAT) or adjuvant chemotherapy (AC). METHODS We retrospectively reviewed 427 consecutive patients, and the overall survival (OS) and disease-free survival (DFS) were analyzed based on the R status by a propensity score analysis (PSA). RESULTS The R0 ratio of the NAT (+) group was significantly higher than that of the NAT (-) group (97.2% vs. 69.6%, P < 0.0001). Local recurrence was well controlled in the NAT (+) group compared to the NAT (-) group (15.3% vs. 34.1%, P = 0.0013). The PSA revealed no significant survival difference between R0 and R1 resection among those treated with AC (median survival time [MST]: 43.0 vs. 33.3 months, matching hazard ratio [HR]: 1.212, P = 0.5708). Furthermore, the DFS in R0 and R1 resection followed by AC was identical (MST: 20.6 vs. 17.7 months, matching HR: 1.020, P = 0.9482). CONCLUSIONS NAT was a significant predictor of R0 resection. When patients completed AC, there were no marked differences in the OS or DFS between R0 and R1 resection. Our results demonstrated that the clinical impact of the R1 status has waned in the current era of PDAC management.
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Jiang W, Haque W, Verma V, Butler EB, Teh BS. Neoadjuvant stereotactic body radiation therapy for nonmetastatic pancreatic adenocarcinoma. Acta Oncol 2019; 58:1259-1266. [PMID: 31237185 DOI: 10.1080/0284186x.2019.1631472] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/05/2019] [Indexed: 02/07/2023]
Abstract
Background: Neoadjuvant therapy is a strategy for resectable and borderline resectable pancreatic cancer, but a consensus approach regarding optimal management is undetermined. Neoadjuvant options include chemotherapy with/without radiotherapy. Stereotactic body radiation therapy (SBRT) is a novel radiation technique that may provide benefit over conventionally fractionated radiation therapy (CFRT) in the neoadjuvant setting. The purpose of the present study is to determine neoadjuvant treatment with SBRT to other neoadjuvant treatment options for patients with resectable pancreatic cancer. Material and methods: The National Cancer Database was queried (2004-2015) for patients with nonmetastatic pancreatic adenocarcinoma receiving neoadjuvant therapy followed by pancreatectomy. Patients were categorized based on the type of neoadjuvant treatment administered. Statistics included temporal trend assessment by annual percent change (APC), predictors for SBRT by multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling for univariable OS analysis. Results: Of 5828 patients, 332 (5.7%), 3234 (55.5%) and 2262 (38.8%) received neoadjuvant chemo-SBRT, chemotherapy, and chemo-CFRT, respectively. SBRT utilization increased from 0% in 2004 to 9.5% in 2015, with a greater APC after 2010 (p < .001). SBRT was more likely to be utilized in patients with T3-4 and node-positive disease (p < .05 for all). The chemo-SBRT cohort was associated with a higher OS rate before and after propensity matching (p < .05 for both). The rate of R0 resection was higher in radiotherapy groups than the chemotherapy cohort (p < .001). Conclusions: Utilization of neoadjuvant SBRT for pancreatic cancer is increasing. In the neoadjuvant setting, chemo-SBRT may improve R0 resection and OS over chemotherapy and chemo-CFRT, although confirmatory prospective studies are needed for confirmation.
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Affiliation(s)
- Wei Jiang
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Shenzhen , Guangdong , China
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital , Pittsburgh , PA , USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
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Hu Q, Wang D, Chen Y, Li X, Cao P, Cao D. Network meta-analysis comparing neoadjuvant chemoradiation, neoadjuvant chemotherapy and upfront surgery in patients with resectable, borderline resectable, and locally advanced pancreatic ductal adenocarcinoma. Radiat Oncol 2019; 14:120. [PMID: 31291998 PMCID: PMC6617703 DOI: 10.1186/s13014-019-1330-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023] Open
Abstract
Purpose Neoadjuvant chemoradiation or chemotherapy has improved the treatment efficacy of patients with resectable, borderline resectable, and locally advanced pancreatic ductal adenocarcinoma (PDAC). Due to the optimal regimen remains inconclusive, we aimed to compare these treatments in terms of margin negative (R0) resection rate and overall survival (OS) with Bayesian analysis. Patients and methods We reviewed literature titles and abstracts comparing three treatment strategies (neoadjuvant chemoradiation, neoadjuvant chemotherapy, and upfront surgery) in PubMed, Embase, Cochrane Library, the American Society of Clinical Oncology and ClinicalTrials.gov database from 2009 to 2018 to estimate relative odds ratios (ORs) for margin negative (R0) resection rate and hazard ratios (HRs) for overall survival (OS) in all include trials. Results A total of 14 literatures with 1056 patients were enrolled in this Bayesian analysis. In the pairwise meta-analysis from limited head-to-head studies, compared with neoadjuvant chemotherapy, neoadjuvant chemoradiation showed superior OS significantly (HR 0.8, 95% CI 0.60–0.99, p < 0.001) and there was no significant difference in R0 resection rate (OR 1.02, 95%CI 0.45–2.33, I2 = 34.6%). However, in the network meta-analysis from all enrolled clinical trials, neoadjuvant chemoradiation showed significantly higher R0 resection rate over upfront surgery (HR 0.15, 95% CrI 0.02–0.56), whereas neoadjuvant chemotherapy did not provide better efficacy in R0 resection over upfront surgery (HR 0.42, 95% CrI 0.02–4.41). For R0 resection rate, neoadjuvant chemoradiation has the highest probability of ranking one compared with neoadjuvant chemotherapy or upfront surgery (79% vs 21% vs 0%). For OS, neoadjuvant chemotherapy has the highest probability of ranking one compared with neoadjuvant chemoradiation or upfront surgery (98% vs 0% vs 2%). Neoadjuvant chemotherapy was associated with higher rates of postoperative complications (rank worst: 84%), followed by neoadjuvant chemoradiotherapy (13%) and upfront surgery (3%). Conclusions Different neoadjuvant treatment was selected based on various purposes, whether increasing R0 resection rate or not. Future clinical trials comparing neoadjuvant chemoradiation with neoadjuvant chemotherapy are warranted to confirm our results.
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Affiliation(s)
- Qiancheng Hu
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Dan Wang
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ye Chen
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Xiaofen Li
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Peng Cao
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Dan Cao
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
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Sonohara F, Yamada S, Takami H, Hayashi M, Kanda M, Tanaka C, Kobayashi D, Nakayama G, Koike M, Fujiwara M, Fujii T, Kodera Y. Novel implications of combined arterial resection for locally advanced pancreatic cancer in the era of newer chemo-regimens. Eur J Surg Oncol 2019; 45:1895-1900. [PMID: 31147087 DOI: 10.1016/j.ejso.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/08/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In this study, we assessed the prognostic efficacy and feasibility of combined arterial resection (AR) for locally advanced pancreatic cancer (LAPC), and aimed to identify significant prognostic factors for patients who underwent combined AR. METHODS Between 1981 and 2018, 733 consecutive patients who underwent pancreatic surgery for PC were identified. The 730 cases with detailed information were enrolled in the analysis. RESULTS Among 730 resected PC patients, 44 (6%) underwent AR including 21 hepatic (48%), 12 celiac (27%), five splenic (12%), four superior mesenteric (9%), and two other arteries (4%). The combined AR surgery showed significantly longer operative time (median, 608 vs 451 min, P < 0.0001), and the incidence of intraoperative blood transfusion was significantly higher in AR than surgery without AR (P = 0.0002), whereas there was no significant difference in the intraoperative blood loss (970 vs 1200 mL, P = 0.2) and occurrence of major complications (P = 0.5). In prognostic analysis of AR cases, multivariate Cox proportional hazard models revealed preoperative and postoperative therapy were the independent factors for both recurrence-free survival (RFS) and overall survival (OS) (preoperative therapy: RFS, HR = 0.21, P = 0.007; OS, HR = 0.18, P = 0.01; postoperative therapy: RFS, HR = 0.31, P = 0.003; OS, HR = 0.19, P = 0.002). CONCLUSION This study showed the feasibility of combined AR for LAPC and robust association of pre- and postoperative therapy and survival after AR surgery. Preoperative therapy following combined AR surgery is potentially powerful strategy for LAPC.
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Affiliation(s)
- Fuminori Sonohara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hideki Takami
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Kobayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Han S, Choi SH, Choi DW, Heo JS, Han IW, Park DJ, Ryu Y. Neoadjuvant therapy versus upfront surgery for borderline-resectable pancreatic cancer. MINERVA CHIR 2019; 75:15-24. [PMID: 31115240 DOI: 10.23736/s0026-4733.19.07958-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Neoadjuvant therapy is recommended for patients with borderline-resectable pancreatic cancer (BRPC). In this study, we compare survival outcomes of neoadjuvant therapy with upfront surgery. METHODS From January 2011 to June 2016, 1415 patients underwent treatments for pancreatic cancer in Samsung Medical Center. Among them, 112 (7.9%) patients were categorized as BRPC by the NCCN 2016 guideline. They were classified by type of initial treatments into neoadjuvant group (NA, N.=26) and upfront surgery group (US, N.=86). RESULTS The median survival duration of all patients was 18.3 months. Patients in the NA group had more T4 disease than those in the US group (38.5% in NA versus 15.1% in the US group; P=0.010). Arterial involvement was more frequent in the NA group (42.3% versus 15.1%; P=0.003). In the NA group, ten (38.5%) patients underwent surgery, and seven of them had complete R0 resection. In the US group, 83 (96.5%) patients received radical surgery, and 42 (48.8%) had R0 resection. In survival analysis according to intent to treat, the overall two-year survival rate was 51.1% in the US group and 36.7% in the NA group (P=0.001). However, among patients who underwent surgery (N.=96), the two-year overall survival rate was not significantly different between the two groups (P=0.089). According to involved vessels, the survival rate was not different between patients with arterial or both arterial and venous involvement and in patients with only venous involvement (P=0.649). CONCLUSIONS It is necessary to demonstrate the efficacy of neoadjuvant therapy and to standardize the regimens through large-scale, multicenter, randomized controlled studies.
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Affiliation(s)
- Sunjong Han
- Departments of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Sungnam, South Korea
| | - Seong H Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea -
| | - Dong W Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin S Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In W Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae-Joon Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Long-term outcome following neoadjuvant therapy for resectable and borderline resectable pancreatic cancer compared to upfront surgery: a meta-analysis of comparative studies by intention-to-treat analysis. Surg Today 2019; 49:295-299. [PMID: 30877550 DOI: 10.1007/s00595-019-01786-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
The aim of the study was to evaluate the effect of neoadjuvant therapy on long-term survival in patients with resectable and borderline resectable pancreatic cancer. A meta-analysis was conducted using the reported randomized, controlled trials and retrospective studies using an intention-to-treat analysis to compare upfront surgery and neoadjuvant therapy in resectable or borderline resectable pancreatic cancer patients. Six comparative studies consisting of two randomized, controlled trials and four retrospective studies were included. The overall pooled hazard ratio was 0.66 (95% confidence interval: 0.50-0.87, P = 0.003), indicating that patients in the neoadjuvant group had better long-term survival than those in the upfront surgery group. However, considerable inter-study heterogeneity was observed (I2 = 62%). This meta-analysis focusing on comparative studies analyzed by intention-to-treat analysis showed that neoadjuvant therapy for resectable and borderline resectable pancreatic cancer tends to improve patients' long-term outcomes. However, the evidence level remains too low for a firm conclusion. The well-designed, randomized, controlled trials now ongoing will provide the definite evidence needed in the future.
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Lombardi P, Silvestri S, Marino D, Santarelli M, Campra D, De Paolis P, Aglietta M, Leone F. “Shades of Gray” in pancreatic ductal adenocarcinoma: Reappraisals on resectability criteria. Crit Rev Oncol Hematol 2019; 133:17-24. [DOI: 10.1016/j.critrevonc.2018.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/26/2018] [Accepted: 10/28/2018] [Indexed: 12/29/2022] Open
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A Comparison Between Plastic and Metallic Biliary Stent Placement in Patients Receiving Preoperative Neoadjuvant Chemoradiotherapy for Resectable Pancreatic Cancer. World J Surg 2018; 43:642-648. [DOI: 10.1007/s00268-018-4820-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hashmi A, Kozick Z, Fluck M, Hunsinger MA, Wild J, Arora TK, Shabahang MM, Blansfield JA. Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis. Am Surg 2018. [DOI: 10.1177/000313481808400946] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099–1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547–3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.
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Affiliation(s)
- Ammar Hashmi
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Zachary Kozick
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Marcus Fluck
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Marie A. Hunsinger
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jeffrey Wild
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Tania K. Arora
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Mohsen M. Shabahang
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Joseph A. Blansfield
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Cools KS, Sanoff HK, Kim HJ, Yeh JJ, Stitzenberg KB. Impact of neoadjuvant therapy on postoperative outcomes after pancreaticoduodenectomy. J Surg Oncol 2018; 118:455-462. [PMID: 30114330 DOI: 10.1002/jso.25183] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical resection provides the only potentially curative treatment of pancreatic cancer. Neoadjuvant chemotherapy and/or radiation (NAT) is used to downstage patients with borderline resectable tumors. The objective of this study was to examine the postoperative morbidity and mortality of NAT after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA). METHODS Using the American College of Surgeons-National Surgical Quality Improvement Project Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA from 2014 to 2015. Patients were grouped by receipt of NAT 90 days before PD. Bivariable and multivariable analyses was used to compare postoperative outcomes. RESULTS A total of 3748 patients with PDA underwent PD; 926 (24.7%) received NAT. Those in the NAT group had more major vein resections, and longer operating times (all P < 0.001). On pathologic staging, those in the NAT group had smaller tumors (T1, 10.9% vs 5.1%; P < 0.001) and fewer nodes positive (N0, 49% vs 28%; P < 0.001). There were no differences in 30-day postoperative mortality or overall complications. On multivariable analysis, patients who received NAT had a lower likelihood of pancreatic fistula (OR, 0.67; P < 0.001). CONCLUSION NAT does not increase the overall postoperative morbidity or mortality of PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.
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Affiliation(s)
- Katherine S Cools
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hanna K Sanoff
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jen Jen Yeh
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Tang R, Dong JH. A new three-step procedure for pancreatic head carcinoma with invasion of superior mesenteric artery. Hepatobiliary Pancreat Dis Int 2018; 17:286-289. [PMID: 29805086 DOI: 10.1016/j.hbpd.2018.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/15/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Rui Tang
- Department of Hepatopancreatobiliary Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.168 Litang Road, Changping District, Beijing 102218, China
| | - Jia-Hong Dong
- Department of Hepatopancreatobiliary Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No.168 Litang Road, Changping District, Beijing 102218, China.
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Neoadjuvant therapy affects margins and margins affect all: perioperative and survival outcomes in resected pancreatic adenocarcinoma. HPB (Oxford) 2018; 20:573-581. [PMID: 29426635 DOI: 10.1016/j.hpb.2017.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/20/2017] [Accepted: 12/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection margin status is an important prognostic factor in pancreatic cancer; however, the impact of positive resection margins in those who received neoadjuvant therapy remains unclear. The current study investigates the prognostic impact of resection margin status after neoadjuvant therapy and pancreaticoduodenectomy for patients with pancreatic adenocarcinoma. METHODS Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma between 2006 and 2013 were identified from the National Cancer Database. Multivariable logistic regression analysis was utilized to examine the predictive value of neoadjuvant therapy for resection margin status. Long-term outcomes were compared using a Cox proportional hazards model. RESULTS 7917 patients were identified in total: 1077 (13.6%) and 6840 (86.4%) patients received neoadjuvant therapy and upfront surgery, respectively. Upfront surgery was independently predictive of a positive margin (25.7% vs. 17.7%; OR, 1.54) compared to neoadjuvant therapy. After receipt of neoadjuvant therapy, positive margins (median overall survival, 18.5 vs. 25.9 months; HR, 1.58) remained significantly associated with poor survival on multivariable analysis. DISCUSSION While neoadjuvant therapy is associated with decreased R1/R2-resection rates after pancreaticoduodenectomy, the poor prognostic impact of positive margins is not abrogated by neoadjuvant therapy, stressing the need for complete tumor clearance and postoperative treatment even after neoadjuvant therapy.
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Versteijne E, Vogel JA, Besselink MG, Busch ORC, Wilmink JW, Daams JG, van Eijck CHJ, Groot Koerkamp B, Rasch CRN, van Tienhoven G. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg 2018; 105:946-958. [PMID: 29708592 PMCID: PMC6033157 DOI: 10.1002/bjs.10870] [Citation(s) in RCA: 339] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/14/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
Background Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer. Methods MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment. Results In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients. Conclusion Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374. Improved survival with neoadjuvant treatment
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Affiliation(s)
- E Versteijne
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Vogel
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J G Daams
- Medical Library, Academic Medical Centre, Amsterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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Clinical Significance of Histological Effect and Intratumor Stromal Expression of Tenascin-C in Resected Specimens After Chemoradiotherapy for Initially Locally Advanced Unresectable Pancreatic Ductal Adenocarcinoma. Pancreas 2018. [PMID: 29517632 DOI: 10.1097/mpa.0000000000001022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Tenascin-C (TN-C) is an extracellular matrix protein that is up-regulated in pancreatic ductal adenocarcinoma (PDAC) stroma and associated with tumor invasion. We examined intratumor stromal expression of TN-C in resected specimens and the histologic effect of chemoradiotherapy (CRT) as prognostic indicators in initially locally advanced unresectable (UR-LA) PDAC. METHODS Among 110 UR-LA PDAC patients enrolled in the CRT protocol from February 2005 to December 2015, 46 who underwent curative-intent resection were classified as high (tumor destruction >50%) and low (≤50%) responders according to the Evans grading system. Tenascin-C expression was immunohistologically evaluated in all patients except one with complete response. RESULTS The 12 high responders achieved a significantly higher R0 rate than did the 34 low responders (83.3 vs 47.1%), but disease-specific survival (DSS) time was not significantly different (median survival time, 29.8 vs 21.0 months). Tenascin-C expression was inversely correlated with histologic effect of CRT. The 22 patients with negative TN-C had significantly longer DSS time than did the 23 with positive TN-C (29.3 vs 17.1 months). In multivariate analysis, only TN-C expression was a significant prognostic factor for DSS. CONCLUSIONS Intratumor stromal expression of TN-C is a strong prognostic indicator in UR-LA PDAC patients with resection after CRT.
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Zhang Y, Zhu X, Liu D, Song J, Zhang H, Lu J. Pre-treatment DWI as a predictor of overall survival in locally advanced pancreatic cancer treated with Cyberknife radiotherapy and sequential S-1 therapy. Cancer Imaging 2018; 18:6. [PMID: 29471875 PMCID: PMC5824450 DOI: 10.1186/s40644-018-0139-7] [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: 09/12/2017] [Accepted: 02/05/2018] [Indexed: 11/30/2022] Open
Abstract
Background To identify the value of the pre-treatment apparent diffusion coefficient (ADC) derived from diffusion weighted imaging (DWI) in predicting the overall survival (OS) for locally advanced pancreatic cancer (LAPC) treated with Cyberknife followed by sequential S-1 chemotherapy. Methods Patients with UICC-T4 LAPC who underwent DWI scan (3.0 Tesla) using two b-values (0, 600 s/mm2) in our center between 2015 and 2017 were enrolled. Mean ADCs of the region of interest (ROI) drawn manually on DWI imaging were measured by two independent radiologists at an interval of 1 month. The association between prognostic factors and patient survival was determined using univariate and multivariate analyses. Cox proportional hazard model was used for identification of independent prognostic factors of OS. Results A total of 41 patients (28 males and 13 females) were included, with a median age of 64 years, with 5 patients (3 males and 2 females) lost. The median OS was 11.7 months (range 2.8–23.3) among all 41 patients. The 1-year OS was 46% (95% CI 30%–62%). Univariate and multivariate analyses indicated that pre-treatment ADC value (HR 10.652, P = 0.0093), age (HR 0.952, P = 0.015), CA19–9 (HR 1.001, P = 0.0022) and administration of S-1 (HR 0.128, P = 0.0002) were independent predicting factors of OS. Conclusion The mean ADC value of the primary tumor on pre-treatment DWI imaging was an independent predictor of OS in patients with LAPC receiving Cyberknife followed by sequential S-1.
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Affiliation(s)
- Yu Zhang
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu district, Shanghai, 200433, People's Republic of China
| | - Xiaofei Zhu
- Department of Oncology Radiation, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu district, Shanghai, 200433, People's Republic of China
| | - Denghui Liu
- Department of Orthopedics, No. 113 Hospital of People's Liberation Army, East Zhongshan Road 377, Jiangdong District, Ningbo, 315000, People's Republic of China
| | - Jiaqi Song
- Department of health statistics, Second Military Medical University, Xiangyin Road 800, Yangpu district, Shanghai, 200433, People's Republic of China
| | - Huojun Zhang
- Department of Oncology Radiation, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu district, Shanghai, 200433, People's Republic of China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu district, Shanghai, 200433, People's Republic of China.
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal (GI) malignancy with poor 5-year survival rate. Advances in surgical techniques and introduction of novel combination chemotherapy and radiation therapy regimens have necessitated the need for biomarkers for assessment of treatment response. Conventional imaging methods such as RECIST have been used for response evaluation in clinical trials particularly in patients with metastatic PDAC. However, the role of these approaches for assessing response to loco-regional and systemic therapies is limited due to complex morphological and histological nature of PDAC. Determination of tumor resectability after neoadjuvant therapy remains a challenge. This review article provides an overview of the challenges and limitations of response assessment in PDAC and reviews the current evidence for the utility of novel morphological and functional imaging tools in this disease.
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Long-Term Outcomes After Pancreatectomy for Pancreatic Ductal Adenocarcinoma in Elderly Patients: Special Reference to Postoperative Adjuvant Chemotherapy. World J Surg 2018; 42:2617-2626. [DOI: 10.1007/s00268-018-4496-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Berriochoa CA, Abdel-Wahab M, Leyrer CM, Khorana A, Matthew Walsh R, Kumar AMS. Neoadjuvant chemoradiation for non-metastatic pancreatic cancer increases margin-negative and node-negative rates at resection. J Dig Dis 2017; 18:642-649. [PMID: 29055078 DOI: 10.1111/1751-2980.12551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/01/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare neoadjuvant to adjuvant chemoradiation in non-metastatic pancreatic cancer patients. METHODS Single-institution data were obtained for patients with non-metastatic pancreatic cancer treated with concurrent chemoradiation from 2011 to 2014. Univariate analyses were performed to evaluate clinical and pathological outcomes. RESULTS Fifty-two well-matched patients were enrolled (21 underwent neoadjuvant chemoradiation, 11 with adjuvant chemoradiation and 20 in the definitive group). Median tumor size was 2.6 cm pretreatment and 2.5 cm after neoadjuvant chemoradiation but 3.2 cm on pathology, with a treatment effect in 95.2% of specimens. Clinical node positivity at diagnosis for neoadjuvant and adjuvant chemoradiation groups was similar (28.6% vs 27.3%, P = 0.12). Of the 36 neoadjuvant patients, 21 (58.3%) underwent complete resection. In the neoadjuvant vs adjuvant chemoradiation groups, positive margins were decreased (4.8% vs 63.6%, P < 0.001), as was pathological nodal positivity (23.8% vs 90.9%, P < 0.001). After a median follow-up of 13.3 months, locoregional control for neoadjuvant and adjuvant chemoradiation was 7.7 and 7.2 months, respectively (P = 0.12) and the definitive group was 1.2 months (P = 0.014 compared with the surgical cohort). One-year overall survival was better with neoadjuvant than with adjuvant chemoradiation but this was not significant (94% vs 82%, P = 0.20); 1-year survival for the definitive group was 59% (P = 0.03 compared with the surgical cohort). CONCLUSIONS Neoadjuvant chemoradiation remains a promising approach for non-metastatic pancreatic cancer for improving resectability and pathological and clinical findings. Computed tomography may not fully demonstrate the effectiveness of neoadjuvant treatment.
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Affiliation(s)
- Camille A Berriochoa
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - May Abdel-Wahab
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Charles M Leyrer
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Alok Khorana
- Department of Medical Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Aryavarta M S Kumar
- Department of Radiation Oncology, Cleveland Medical Center, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
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Elmi A, Murphy J, Hedgire S, McDermott S, Abtahi SM, Halpern E, Fernandez-Del Castillo C, Harisinghani M. Post-Whipple imaging in patients with pancreatic ductal adenocarcinoma: association with overall survival: a multivariate analysis. Abdom Radiol (NY) 2017; 42:2101-2107. [PMID: 28293721 DOI: 10.1007/s00261-017-1099-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare the survival outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) who had regular imaging surveillance with those who had clinical follow-up after Whipple. METHOD We identified 229 patients, who underwent Whipple for resection of PDAC from 2005 to 2011, and had regular postoperative clinical follow-up at our hospital. Patients were retrospectively selected for two follow-up groups: imaging surveillance (IS) defined as routine imaging at scheduled intervals, vs. clinical (C) defined as imaging triggered by either change in clinical status or change in CA19-9. Follow-up was obtained through the hospital and Cancer Data Registry records. Survival was calculated from the date of surgery to death or last follow-up, with data censored as of March 13, 2013. Kaplan-Meier survival curves were compared using the log-rank test, and Cox regression models were used for multivariate analysis. RESULTS Patients were followed for a mean period of 24.35 ± 2.56 months. IS-group underwent significantly more imaging (4.41 vs. 2.08 scans/year). The most frequent imaging was CT of chest and abdomen at 3-4 month interval. Univariate associations with overall survival were detected with post-Whipple ECOG status, T-stage, N-stage, tumor grade, surgical margin, recurrence, and IS. In multivariate analysis, grade, ECOG status, and recurrence were independent predictors of survival. Also, our predictor of interest, IS, was highly associated with longer survival in multivariate modeling (median overall survival, 30.4±3.85 (IS-group) vs. 17.1 ± 2.42 (C-groups) month, log-rank p = 0.002). CONCLUSION Routine imaging surveillance was associated with prolonged overall survival post-Whipple in a multivariate model. This is a hypothesis-generating finding that should be studied prospectively and could ultimately impact surveillance guidelines.
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Affiliation(s)
- Azadeh Elmi
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA, 02114, USA
| | - Janet Murphy
- Division of Hematology and Oncology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Sandeep Hedgire
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA, 02114, USA.
| | - Shaunagh McDermott
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA, 02114, USA
| | - Seyed-Mahdi Abtahi
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA, 02114, USA
| | - Elkan Halpern
- Institute for Technology Assessment, Radiology - Data Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Carlos Fernandez-Del Castillo
- General and Gastrointestinal Surgery Department, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Mukesh Harisinghani
- Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA, 02114, USA
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Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
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Abstract
Pancreatic cancer is more common in older adults, who are underrepresented in clinical trials and frequently under treated. Chronological age alone should not deter clinicians from offering treatment to geriatric patients, as they are a heterogeneous population. Geriatric assessment, frailty assessment tools, and toxicity risk scores help clinicians select appropriate patients for therapy. For resectable disease, surgery can be safe but should be done at a high-volume center. Adjuvant therapy is important; though there remains controversy on the role of radiation, chemotherapy is well studied and efficacious. In locally advanced unresectable disease, chemoradiation or chemotherapy alone is an option. Neoadjuvant therapy improves the chances of resectability in borderline resectable disease. Chemotherapy extends survival in metastatic disease, but treatment goals and risk-benefit ratios have to be clarified. Adequate symptom management and supportive care are important. There are now many new treatment strategies and novel therapies for this disease.
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Preoperative Chemoradiation for Pancreatic Adenocarcinoma Does Not Increase 90-Day Postoperative Morbidity or Mortality. J Gastrointest Surg 2016; 20:1975-1985. [PMID: 27730398 DOI: 10.1007/s11605-016-3286-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of preoperative chemoradiation on postoperative morbidity and mortality of patients with pancreatic adenocarcinoma remains controversial. METHODS Consecutive pancreatectomies for adenocarcinoma performed between 2011 and 2015 were prospectively monitored for 90 days by using a previously reported surveillance system to determine the association between preoperative chemoradiation and adverse events, pancreatic fistulae, readmissions, and mortality. RESULTS Among 209 consecutive patients who underwent pancreatectomy, 159 (76 %) experienced at least one adverse event within 90 postoperative days. Patients who received preoperative chemoradiation (n = 137, 66 %) were more likely to have borderline resectable/locally advanced tumors, to have received induction chemotherapy, and to require vascular resection at pancreatectomy than those who did not receive chemoradiation (all P < 0.05). Nonetheless, there were no significant differences in the rates of severe complications, readmission, or mortality between these groups (all P > 0.05). Among patients who underwent pancreatoduodenectomy, the rate of pancreatic fistula was similar between those who received chemoradiation and those who did not (P = 0.96). In contrast, those who received chemoradiation prior to distal pancreatectomy had a lower rate of pancreatic fistula (P < 0.01). CONCLUSION Preoperative chemoradiation is not associated with an increase in 90-day morbidity or mortality, and it may reduce the rate of pancreatic fistula following distal pancreatectomy.
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Zhu X, Ju X, Cao F, Fang F, Qing S, Shen Y, Jia Z, Cao Y, Zhang H. Safety and efficacy of stereotactic body radiation therapy combined with S-1 simultaneously followed by sequential S-1 as an initial treatment for locally advanced pancreatic cancer (SILAPANC) trial: study design and rationale of a phase II clinical trial. BMJ Open 2016; 6:e013220. [PMID: 27909037 PMCID: PMC5168617 DOI: 10.1136/bmjopen-2016-013220] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Upfront surgeries are not beneficial to most patients with pancreatic cancer. Therefore, more emphasis has been placed chemoradiotherapy in locally advanced pancreatic cancer recently. Gemcitabine-based regimens or FOLFIRINOX (a chemotherapy regimen including leucovorin, 5-FU, irinotecan, oxaliplatin) has been proven as a standard chemotherapy in pancreatic cancer. However, severe toxicities may prevent the completion of chemotherapy. S-1 has showed better objective response rates, similar overall survival rates and progression-free survival rates compared with gemcitabine, revealing that S-1 may be a potential candidate in treating pancreatic cancer, especially for patients refractory to gemcitabine. Additionally, stereotactic body radiation therapy with Cyberknife could provide better efficacy than conventional radiotherapy in pancreatic cancer. Therefore, Cyberknife with S-1 simultaneously followed by sequential S-1 as an initial treatment may bring about favourable outcomes but needs further studies. METHODS AND ANALYSIS The S-1 as an initial treatment for locally advanced pancreatic cancer (SILAPANC) trial is a prospective, single-centre, one armed ongoing study. 190 eligible patients are required to initially receive Cyberknife with 1 cycle of S-1 simultaneously. After the concurrent chemoradiotherapy, 2 or 3 cycles of S-1 are sequentially given. Doses and fractions depend on the locations and volumes of tumours and the adjacent organs at risk. S-1 is taken orally, 2 times a day, at a dose of 80 mg/m2 for 28 days, followed by a 14-day interval. The primary objectives are overall survival and 1-year, 2-year, 3-year, 4-year and 5-year overall survival rates. The secondary objectives are cancer-specific survival, progression-free survival, time to progression, local control rates, clinical benefit rates, radiation-induced acute and late toxicities, adverse effects of chemotherapy and quality of life of patients. Besides, variables most predictive of prognosis would be identified via multivariate methods. ETHICS AND DISSEMINATION Approvals have been granted by the Changhai Hospital Ethics Committee (CHEC-2016-032-01). The results will be disseminated in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER NCT02704143; Pre-results.
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Affiliation(s)
- Xiaofei Zhu
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Xiaoping Ju
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Fei Cao
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Fang Fang
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Shuiwang Qing
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Yuxin Shen
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Zhen Jia
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Yangsen Cao
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
| | - Huojun Zhang
- Changhai Hospital Affiliated to Second Military Medical University, Shanghai, China
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Akasaka H, Mizushina Y, Yoshida K, Ejima Y, Mukumoto N, Wang T, Inubushi S, Nakayama M, Wakahara Y, Sasaki R. MGDG extracted from spinach enhances the cytotoxicity of radiation in pancreatic cancer cells. Radiat Oncol 2016; 11:153. [PMID: 27876069 PMCID: PMC5120455 DOI: 10.1186/s13014-016-0729-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/15/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In our previous study, monogalactosyl diacylglycerol (MGDG) purified from spinach was found to have cytotoxic effects in human cancer cell lines. This study further assessed whether MGDG can enhance the cytotoxic effects of radiation in human pancreatic cancer cells in vitro and in vivo. METHODS Glycoglycerolipids from spinach including MGDG were extracted from dried spinach. The cytotoxicity of MGDG were evaluated by the MTT assay using four human pancreatic cancer cell lines (MIAPaCa-2, AsPC-1, BxPC-3 and PANC-1) and normal human dermal fibroblasts (NHDFs). The effects of radiation and MGDG alone or in combination in MIAPaCa-2 cells was analyzed with the colony forming and apoptosis assays, western blotting and cell cycle and DNA damage analyses (γ-H2AX foci staining and comet assay). The inhibitory effects on tumor growth were assessed in a mouse xenograft tumor model. RESULTS MGDG showed dose- and time-dependent cytotoxicity, with half-maximal inhibitory concentrations (IC50) in PANC-1, BxPC-3, MIAPaCa-2 and AsPC-1 cells at 72 h of 25.6 ± 2.5, 26.9 ± 1.3, 18.5 ± 1.7, and 22.7 ± 1.9 μM, respectively. The colony forming assay revealed fewer MIAPaCa-2, BxPC-3 and AsPC-1 cell colonies upon treatment with both MGDG and radiation as compared to irradiation alone (P < 0.05). The combination of MGDG and radiation induced a higher proportion of apoptosis in MIAPaCa-2 cells; this effect was associated with increased mitochondrial release of cytochrome c and activation of cleaved poly (ADP-ribose) polymerase and caspase-3. DNA damage was detected and DNA repair mechanisms were more frequently impaired in cells receiving the combination treatment as compared to either one alone. Tumor growth was inhibited to a greater degree in mice treated by intratumoral injection of MGDG combined with irradiation as compared to either one alone (P < 0.05). CONCLUSIONS This is the first report demonstrating that MGDG enhances the cytotoxicity of radiation to induce apoptosis of cancer cells in vitro and in vivo. Our findings indicate that this therapeutic combination can be an effective strategy for the treatment of pancreatic cancer.
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Affiliation(s)
- Hiroaki Akasaka
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoshiyuki Mizushina
- Graduate School of Agriculture, Shinshu University, Minamiminowa-mura, Kamiina-gun, Nagano, 399-4598, Japan
| | - Kenji Yoshida
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yasuo Ejima
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Naritoshi Mukumoto
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tianyuan Wang
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Sachiko Inubushi
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Masao Nakayama
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuki Wakahara
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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