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Jan IS, Ch'ang HJ. Selection of patients with pancreatic adenocarcinoma who may benefit from radiotherapy. Radiat Oncol 2023; 18:137. [PMID: 37596627 PMCID: PMC10439654 DOI: 10.1186/s13014-023-02328-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/03/2023] [Indexed: 08/20/2023] Open
Abstract
Despite combination chemotherapy demonstrating a positive effect on survival, the clinical outcomes of pancreatic adenocarcinoma (PDAC) remain poor. Radiotherapy was previously a component of the curative treatment of PDAC. Advances in imaging and computer sciences have enabled the prescription of higher dosage of radiation focused on tumours with minimal toxicity to normal tissue. However, the role of radiotherapy has not been established in the curative treatment of localized PDAC because of the conflicting results from large prospective trials. Most studies have demonstrated improved locoregional control but no survival benefit from additional chemoradiotherapy (CRT) in addition to chemotherapy for resectable, borderline or locally advanced PDAC. The improved locoregional control enabled by CRT does not cause extended survival because of rapid distant progression in a significant proportion of patients with PDAC. Several single-institute studies of prescribing intensive chemotherapy with modern ablative radiotherapy for locally advanced PDAC have demonstrated extended survival with an acceptable safety profile. In an analysis after long-term follow-up, the PREOPANC study demonstrated a survival benefit from neoadjuvant gemcitabine-based CRT in resected PDAC relative to upfront surgery followed by adjuvant gemcitabine only. These observations indicated that the role of radiotherapy in PDAC should be evaluated in a subgroup of patients without rapid distant progression because systemic therapy for PDAC remains underdeveloped. We reviewed critical imaging, tissue, liquid and clinical biomarkers to differentiate the heterogeneous biologic spectra of patients with PDAC to identify those who may benefit the most from local radiotherapy. Exclusion of patients with localised PDAC who develop distant progression in a short time and undergo extended upfront chemotherapy for over 4 months may enable the identification of a survival benefit of local radiotherapy. Though promising, the effectiveness of biomarkers must be validated in a multi-institutional prospective study of patients with PDAC receiving CRT or not receiving CRT.
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Affiliation(s)
- I-Shiow Jan
- Department of Laboratory Medicine, College of Medicine, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hui Ju Ch'ang
- National Institute of Cancer Research, National Health Research Institutes, Miaoli, Taiwan.
- Program for Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
- Department of Radiation Oncology, Taipei Medical University, Taipei, Taiwan.
- Department of Oncology, School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Passardi A, Rapposelli IG, Scarpi E, Sullo FG, Bartolini G, Neri E, Ghigi G, Tontini L, Ercolani G, Monti M, Ruscelli S, Matteucci L, Valgiusti M, Frassineti GL, Romeo A. Multimodal Treatment with GEMOX Plus Helical Tomotherapy in Unresectable Locally Advanced Pancreatic Cancer: A Pooled Analysis of Two Phase 2 Studies. Biomolecules 2021; 11:biom11081200. [PMID: 34439866 PMCID: PMC8393939 DOI: 10.3390/biom11081200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/29/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
In locally advanced pancreatic cancer (LAPC), the combination of chemotherapy and radiotherapy is a widely used treatment option. We performed a pooled analysis, including an exploratory analysis for prognostic and predictive factors, of two phase 2 trials including 73 patients with LAPC, treated with gemcitabine and oxaliplatin (GEMOX) and hypofractionated tomotherapy. With a median follow-up of 36 months (range 1–65), median progression-free (PFS) and overall survival (OS) were 10.2 (95% confidence interval [CI] 7.8–13.2) and 14.3 (95% CI 12.0–18.1) months, respectively. The overall resectability rate was 23.3% (95% CI 13.6–33.0), and the R0 resection rate was 13.7% (95% CI 5.8–21.6). In the multivariate analysis, ECOG performance status (PS) 0 and low levels of CA 19–9 were associated with improved OS and PFS. Concerning OS, log(CA19–9) resulted in a hazard ratio (HR) of 1.20 (95% CI 1.02–1.42), p = 0.027. For ECOG PS 0, HR was 1.00; for PS 1, HR was 2.69 (95% CI 1.46–4.96); for PS 2, HR was 4.18 (95% CI 0.90–19.46); p = 0.003. Low CA19–9 levels were also predictive for resection, with an odds ratio of 0.71 (95% CI 0.52–0.97), p = 0.034. In conclusion, GEMOX and hypofractionated radiotherapy is a treatment option in LAPC. Further studies are needed to identify differences in tumor biology, which may help to predict resectability and prognosis.
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Affiliation(s)
- Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Ilario Giovanni Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
- Correspondence: ; Tel.: +39-0543-739100
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy;
| | - Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giulia Bartolini
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy;
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Manlio Monti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Silvia Ruscelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Laura Matteucci
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Martina Valgiusti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
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Shen ZT, Zhou H, Li AM, Ji XQ, Jiang CC, Yuan X, Li B, Zhu XX, Huang GC. Clinical outcomes and prognostic factors of stereotactic body radiation therapy combined with gemcitabine plus capecitabine for locally advanced unresectable pancreatic cancer. J Cancer Res Clin Oncol 2019; 146:417-428. [PMID: 31667573 DOI: 10.1007/s00432-019-03066-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to evaluate the clinical outcomes, toxicity, and prognostic factors of SBRT combined with gemcitabine plus capecitabine (GEM-CAP) in treating locally advanced pancreatic cancer (LAPC). METHODS A total of 56 patients with LAPC treated with SBRT combined with GEM-CAP were reviewed from October 2010 to October 2016. The median total prescription dose at five fractions was 40 Gy (30-50 Gy). The patients were subjected to two cycles of GEM-CAP before SBRT. GEM-CAP chemotherapy was then offered for four cycles or until disease tolerance or progression. The primary endpoints included overall survival (OS) and progression-free survival (PFS). RESULTS The median OS and PFS from the date of diagnosis was 19 (95% CI 14.6-23.4) and 12 months (95% CI 8.34-15.66), respectively. The 1-year and 2-year survival rates were 82.1% and 35.7%, whereas the 1-year and 2-year PFS rates were 48.2% and 14.3%, respectively. The median carbohydrate antigen 19-9-determined PFS time was 11 months (95% CI 5.77-16.24). Multivariate analysis demonstrated that tumor diameter, lymph node metastasis, pre-treatment CA19-9 level, and post-treatment CA19-9 decline were independent prognostic factors (p < 0.05). Acute toxicity was minimal, with two cases (3.6%) experiencing grade 3 duodenal obstruction. No adverse events greater than grade 3 occurred. In late toxicity, three patients (5.4%) developed grade 3 gastrointestinal toxicity and two (3.6%) suffered from perforation caused by grade 4 radiation enteritis and intestinal fistula. CONCLUSIONS The combination of Cyberknife SBRT and GEM-CAP achieved excellent efficacy with acceptable toxicity for LAPC.
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Affiliation(s)
- Ze-Tian Shen
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Han Zhou
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Ao-Mei Li
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xiao-Qin Ji
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chang-Chen Jiang
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xi Yuan
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Bing Li
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xi-Xu Zhu
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| | - Gui-Chun Huang
- Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, 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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Li X, Wu J, Palta M, Zhang Y, Sheng Y, Zhang J, Wang C. A Collimator Setting Optimization Algorithm for Dual-Arc Volumetric Modulated Arc Therapy in Pancreas Stereotactic Body Radiation Therapy. Technol Cancer Res Treat 2019; 18:1533033819870767. [PMID: 31426721 PMCID: PMC6702773 DOI: 10.1177/1533033819870767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: To optimize collimator setting to improve dosimetric quality of pancreas volumetric modulated arc therapy plan for stereotactic body radiation therapy. Materials and Methods: Fifty-five volumetric modulated arc therapy cases in stereotactic body radiation therapy of pancreas were retrospectively included in this study with internal review board approval. Different from the routine practice of initializing collimator settings with a template, the proposed algorithm simultaneously optimizes the collimator angles and jaw positions that are customized to the patient geometry. Specifically, this algorithm includes 2 key steps: (1) an iterative optimization algorithm via simulated annealing that generates a set of potential collimator settings from 39 cases with pancreas stereotactic body radiation therapy, and (2) a multi-leaf collimator modulation scoring system that makes the final decision of the optimal collimator settings (collimator angles and jaw positions) based on organs at risk sparing criteria. For validation, the other 16 cases with pancreas stereotactic body radiation therapy were analyzed. Two plans were generated for each validation case, with one plan optimized using the proposed algorithm (Planopt) and the other plan with the template setting (Planconv). Each plan was optimized with 2 full arcs and the same set of constraints for the same case. Dosimetric results were analyzed and compared, including target dose coverage, conformity, organs at risk maximum dose, and modulation complexity score. All results were tested by Wilcoxon signed rank tests, and the statistical significance level was set to .05. Results: Both plan groups had comparable target dose coverage and mean doses of all organs at risk. However, organs at risk (stomach, duodenum, large/small bowel) maximum dose sparing (D0.1 cc and D0.03 cc) was improved in Planopt compared to Planconv. Planopt also showed lower modulation complexity score, which suggests better capability of handling complex shape and sparing organs at risk . Conclusions: The proposed collimator settings optimization algorithm successfully improved dosimetric performance for dual-arc pancreas volumetric modulated arc therapy plans in stereotactic body radiation therapy of pancreas. This algorithm has the capability of immediate clinical application.
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Affiliation(s)
- Xinyi Li
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,2 Medical Physics Graduate Program, Duke University, Durham, NC, USA
| | - Jackie Wu
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,2 Medical Physics Graduate Program, Duke University, Durham, NC, USA
| | - Manisha Palta
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - You Zhang
- 3 Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yang Sheng
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jiahan Zhang
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Chunhao Wang
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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