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Lucocq J, Haugk B, Parkinson D, Darne A, Joseph N, Hawkyard J, White S, Mownah O, Menon K, Furukawa T, Inoue Y, Hirose Y, Sasahira N, Mittal A, Samra J, Sheen A, Feretis M, Balakrishnan A, Ceresa C, Davidson B, Pande R, Dasari BVM, Tanno L, Karavias D, Helliwell J, Young A, Nunes Q, Urbonas T, Silva M, Gordon-Weeks A, Barrie J, Gomez D, van Laarhoven S, Nawara H, Doyle J, Bhogal R, Harrison E, Roalso M, Ciprani D, Aroori S, Ratnayake B, Koea J, Capurso G, Bellotti R, Stättner S, Alsaoudi T, Bhardwaj N, Jeffery F, Connor S, Cameron A, Jamieson N, Roberts K, Soreide K, Gill AJ, Pandanaboyana S. Precursor Epithelial Subtypes of Adenocarcinoma Arising from Intraductal Papillary Mucinous Neoplasms (A-IPMN): Clinicopathological Features, Recurrence and Response to Adjuvant Chemotherapy. Ann Surg Oncol 2024; 31:7023-7032. [PMID: 38961040 DOI: 10.1245/s10434-024-15677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/10/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND The clinico-oncological outcomes of precursor epithelial subtypes of adenocarcinoma arising from intraductal papillary mucinous neoplasms (A-IPMN) are limited to small cohort studies. Differences in recurrence patterns and response to adjuvant chemotherapy between A-IPMN subtypes are unknown. METHODS Clincopathological features, recurrence patterns and long-term outcomes of patients undergoing pancreatic resection (2010-2020) for A-IPMN were reported from 18 academic pancreatic centres worldwide. Precursor epithelial subtype groups were compared using uni- and multivariate analysis. RESULTS In total, 297 patients were included (median age, 70 years; male, 78.9%), including 54 (18.2%) gastric, 111 (37.3%) pancreatobiliary, 80 (26.9%) intestinal and 52 (17.5%) mixed subtypes. Gastric, pancreaticobiliary and mixed subtypes had comparable clinicopathological features, yet the outcomes were significantly less favourable than the intestinal subtype. The median time to recurrence in gastric, pancreatobiliary, intestinal and mixed subtypes were 32, 30, 61 and 33 months. Gastric and pancreatobiliary subtypes had worse overall recurrence (p = 0.048 and p = 0.049, respectively) compared with the intestinal subtype but gastric and pancreatobiliary subtypes had comparable outcomes. Adjuvant chemotherapy was associated with improved survival in the pancreatobiliary subtype (p = 0.049) but not gastric (p = 0.992), intestinal (p = 0.852) or mixed subtypes (p = 0.723). In multivariate survival analysis, adjuvant chemotherapy was associated with a lower likelihood of death in pancreatobiliary subtype, albeit with borderline significance [hazard ratio (HR) 0.56; 95% confidence interval (CI) 0.31-1.01; p = 0.058]. CONCLUSIONS Gastric, pancreatobiliary and mixed subtypes have comparable recurrence and survival outcomes, which are inferior to the more indolent intestinal subtype. Pancreatobiliary subtype may respond to adjuvant chemotherapy and further research is warranted to determine the most appropriate adjuvant chemotherapy regimens for each subtype.
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Beate Haugk
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Daniel Parkinson
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Antony Darne
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Nejo Joseph
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Jake Hawkyard
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Steve White
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Omar Mownah
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Krishna Menon
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Takaki Furukawa
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuki Hirose
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | - Jas Samra
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Amy Sheen
- Department of Anatomical Pathology, Royal North Shore Hospital, New South Wales Health Pathology, Sydney, NSW, Australia
| | - Michael Feretis
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anita Balakrishnan
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Carlo Ceresa
- Hepatobiliary and Pancreatic Surgery Unit, The Royal Free Hospital, London, UK
| | - Brian Davidson
- Hepatobiliary and Pancreatic Surgery Unit, The Royal Free Hospital, London, UK
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Bobby V M Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Lulu Tanno
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Dimitrios Karavias
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Jack Helliwell
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Quentin Nunes
- Department of Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Lancashire, UK
| | - Tomas Urbonas
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Lancashire, UK
| | - Michael Silva
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Lancashire, UK
| | - Alex Gordon-Weeks
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Lancashire, UK
| | - Jenifer Barrie
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Lancashire, UK
| | - Dhanny Gomez
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Lancashire, UK
| | - Stijn van Laarhoven
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Hossam Nawara
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Joseph Doyle
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ricky Bhogal
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ewen Harrison
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Marcus Roalso
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Deborah Ciprani
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Bathiya Ratnayake
- Hepato-Pancreatico-Biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- Hepato-Pancreatico-Biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Centre of Operative Medicine, Medical University of Innsbrusk, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Centre of Operative Medicine, Medical University of Innsbrusk, Innsbruck, Austria
| | - Tareq Alsaoudi
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neil Bhardwaj
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fraser Jeffery
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Saxon Connor
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew Cameron
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Jamieson
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Anthony J Gill
- Royal North Shore Hospital, Sydney, NSW, Australia
- Department of Anatomical Pathology, Royal North Shore Hospital, New South Wales Health Pathology, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK.
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Lucocq J, Haugk B, Joseph N, Hawkyard J, White S, Mownah O, Menon K, Furukawa T, Inoue Y, Hirose Y, Sasahira N, Mittal A, Samra J, Sheen A, Feretis M, Balakrishnan A, Ceresa C, Davidson B, Pande R, Dasari BVM, Tanno L, Karavias D, Helliwell J, Young A, Nunes Q, Urbonas T, Silva M, Gordon-Weeks A, Barrie J, Gomez D, van Laarhoven S, Nawara H, Doyle J, Bhogal R, Harrison E, Roalso M, Zaharia C, Ciprani D, Aroori S, Ratnayake B, Koea J, Capurso G, Bellotti R, Stättner S, Alsaoudi T, Bhardwaj N, Jeffery F, Connor S, Cameron A, Jamieson N, Roberts K, Soreide K, Gill AJ, Pandanaboyana S. Invasive intraductal oncocytic papillary neoplasms (IOPN) and adenocarcimoma arising from intraductal papillary mucinous neoplasms (A-IPMN) of the pancreas: comparative analysis of clinicopathological features, patterns of recurrence and survival: a multicentre study. HPB (Oxford) 2024:S1365-182X(24)02222-6. [PMID: 39084948 DOI: 10.1016/j.hpb.2024.07.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/07/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Intraductal oncocytic papillary neoplasms (IOPNs) of the pancreas are now considered a separate entity to intraductal papillary mucinous neoplasms (IPMN). Invasive IOPNs are extremely rare, and their recurrence patterns, response to adjuvant chemotherapy and long-term survival outcomes are unknown. METHODS Consecutive patients undergoing pancreatic resection (2010-2020) for invasive IOPNs or adenocarcinoma arising from IPMN (A-IPMN) from 18 academic pancreatic centers worldwide were included. Outcomes of invasive IOPNs were compared with A-IPMN invasive subtypes (ductal and colloid A-IPMN). RESULTS 415 patients were included: 20 invasive IOPN, 331 ductal A-IPMN and 64 colloid A-IPMN. After a median follow-up of 6-years, 45% and 60% of invasive IOPNs had developed recurrence and died, respectively. There was no significant difference in recurrence or overall survival between invasive IOPN and ductal A-IPMN. Overall survival of invasive IOPNs was inferior to colloid A-IPMNs (median time of survival 24.4 months vs. 86.7, months, p = 0.013), but the difference in recurrence only showed borderline significance (median time to recurrence, 22.5 months vs. 78.5 months, p = 0.132). Adjuvant chemotherapy, after accounting for high-risk features, did not reduce rates of recurrence in invasive IOPN (p = 0.443), ductal carcinoma (p = 0.192) or colloid carcinoma (p = 0.574). CONCLUSIONS Invasive IOPNs should be considered an aggressive cancer with a recurrence rate and prognosis consistent with ductal type A-IPMN.
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Affiliation(s)
| | - Beate Haugk
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Nejo Joseph
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jake Hawkyard
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Steve White
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Omar Mownah
- Department of Hepatobiliary & Pancreatic Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Krishna Menon
- Department of Hepatobiliary & Pancreatic Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Takaki Furukawa
- Cancer Institute Hospital of Japanese Foundation for Cancer Research, Hepato-Biliary-Pancreatic Medicine Department, Tokyo, Japan
| | - Yosuke Inoue
- Cancer Institute Hospital of Japanese Foundation for Cancer Research, Hepato-Biliary-Pancreatic Medicine Department, Tokyo, Japan
| | - Yuki Hirose
- Cancer Institute Hospital of Japanese Foundation for Cancer Research, Hepato-Biliary-Pancreatic Medicine Department, Tokyo, Japan
| | - Naoki Sasahira
- Cancer Institute Hospital of Japanese Foundation for Cancer Research, Hepato-Biliary-Pancreatic Medicine Department, Tokyo, Japan
| | | | - Jas Samra
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Amy Sheen
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Michael Feretis
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anita Balakrishnan
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Carlo Ceresa
- Hepatobiliary and Pancreatic Surgery Unit, The Royal Free Hospital, London, UK
| | - Brian Davidson
- Hepatobiliary and Pancreatic Surgery Unit, The Royal Free Hospital, London, UK
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Bobby V M Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Lulu Tanno
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Dimitrios Karavias
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Jack Helliwell
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Quentin Nunes
- Department of Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, UK
| | - Tomas Urbonas
- Oxford Hepato-Pancreato-Biliary (HPB) Surgical Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Michael Silva
- Oxford Hepato-Pancreato-Biliary (HPB) Surgical Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Alex Gordon-Weeks
- Oxford Hepato-Pancreato-Biliary (HPB) Surgical Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Jenifer Barrie
- Nottingham Hepato-Pancreatico-Biliary (HPB) Service, Nottingham University Hospitals NHS Foundation Trust, UK
| | - Dhanny Gomez
- Nottingham Hepato-Pancreatico-Biliary (HPB) Service, Nottingham University Hospitals NHS Foundation Trust, UK
| | - Stijn van Laarhoven
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Bristol & Weston NHS Foundation Trust, UK
| | - Hossam Nawara
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Bristol & Weston NHS Foundation Trust, UK
| | - Joseph Doyle
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ricky Bhogal
- Gastrointestinal Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ewen Harrison
- Department of Clinical Surgery, University of Edinburgh, UK
| | - Marcus Roalso
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway
| | - Claudia Zaharia
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway
| | - Debora Ciprani
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Bathiya Ratnayake
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Centre of Operative Medicine, Medical University of Innsbrusk, 6020 Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Centre of Operative Medicine, Medical University of Innsbrusk, 6020 Innsbruck, Austria
| | - Tareq Alsaoudi
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, UK
| | - Neil Bhardwaj
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, UK
| | - Fraser Jeffery
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, New Zealand
| | - Saxon Connor
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, New Zealand
| | - Andrew Cameron
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, UK
| | - Nigel Jamieson
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, UK
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway
| | - Anthony J Gill
- Royal North Shore Hospital, Sydney, NSW, Australia; New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK.
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3
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Lucocq J, Hawkyard J, Haugk B, Mownah O, Menon K, Furukawa T, Inoue Y, Hirose Y, Sasahira N, Feretis M, Balakrishnan A, Ceresa C, Davidson B, Pande R, Dasari B, Tanno L, Karavias D, Helliwell J, Young A, Nunes Q, Urbonas T, Silva M, Gordon-Weeks A, Barrie J, Gomez D, Van Laarhoven S, Robertson F, Nawara H, Doyle J, Bhogal R, Harrison E, Roalso M, Ciprani D, Aroori S, Ratnayake B, Koea J, Capurso G, Bellotti R, Stättner S, Alsaoudi T, Bhardwaj N, Rajesh S, Jeffery F, Connor S, Cameron A, Jamieson N, Sheen A, Mittal A, Samra J, Gill A, Roberts K, Søreide K, Pandanaboyana S. Adjuvant chemotherapy for adenocarcinoma arising from intraductal papillary mucinous neoplasia: multicentre ADENO-IPMN study. Br J Surg 2024; 111:znae100. [PMID: 38659247 DOI: 10.1093/bjs/znae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The clinical impact of adjuvant chemotherapy after resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia is unclear. The aim of this study was to identify factors related to receipt of adjuvant chemotherapy and its impact on recurrence and survival. METHODS This was a multicentre retrospective study of patients undergoing pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia between January 2010 and December 2020 at 18 centres. Recurrence and survival outcomes for patients who did and did not receive adjuvant chemotherapy were compared using propensity score matching. RESULTS Of 459 patients who underwent pancreatic resection, 275 (59.9%) received adjuvant chemotherapy (gemcitabine 51.3%, gemcitabine-capecitabine 21.8%, FOLFIRINOX 8.0%, other 18.9%). Median follow-up was 78 months. The overall recurrence rate was 45.5% and the median time to recurrence was 33 months. In univariable analysis in the matched cohort, adjuvant chemotherapy was not associated with reduced overall (P = 0.713), locoregional (P = 0.283) or systemic (P = 0.592) recurrence, disease-free survival (P = 0.284) or overall survival (P = 0.455). Adjuvant chemotherapy was not associated with reduced site-specific recurrence. In multivariable analysis, there was no association between adjuvant chemotherapy and overall recurrence (HR 0.89, 95% c.i. 0.57 to 1.40), disease-free survival (HR 0.86, 0.59 to 1.30) or overall survival (HR 0.77, 0.50 to 1.20). Adjuvant chemotherapy was not associated with reduced recurrence in any high-risk subgroup (for example, lymph node-positive, higher AJCC stage, poor differentiation). No particular chemotherapy regimen resulted in superior outcomes. CONCLUSION Chemotherapy following resection of adenocarcinoma arising from intraductal papillary mucinous neoplasia does not appear to influence recurrence rates, recurrence patterns or survival.
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MESH Headings
- Humans
- Female
- Male
- Retrospective Studies
- Aged
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/drug therapy
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/therapy
- Pancreatic Neoplasms/surgery
- Chemotherapy, Adjuvant
- Middle Aged
- Neoplasm Recurrence, Local/epidemiology
- Pancreatectomy
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/drug therapy
- Adenocarcinoma, Mucinous/therapy
- Adenocarcinoma, Mucinous/mortality
- Gemcitabine
- Deoxycytidine/analogs & derivatives
- Deoxycytidine/therapeutic use
- Deoxycytidine/administration & dosage
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/drug therapy
- Carcinoma, Pancreatic Ductal/therapy
- Carcinoma, Pancreatic Ductal/surgery
- Capecitabine/administration & dosage
- Capecitabine/therapeutic use
- Pancreatic Intraductal Neoplasms/pathology
- Pancreatic Intraductal Neoplasms/therapy
- Pancreatic Intraductal Neoplasms/mortality
- Pancreatic Intraductal Neoplasms/surgery
- Adenocarcinoma/pathology
- Adenocarcinoma/drug therapy
- Adenocarcinoma/mortality
- Adenocarcinoma/therapy
- Propensity Score
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Jake Hawkyard
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Beate Haugk
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Omar Mownah
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Krishna Menon
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Takaki Furukawa
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuki Hirose
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Michael Feretis
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anita Balakrishnan
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Carlo Ceresa
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Brian Davidson
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Lulu Tanno
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Dimitrios Karavias
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Jack Helliwell
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Quentin Nunes
- Department of Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, UK
| | - Tomas Urbonas
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael Silva
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Gordon-Weeks
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jenifer Barrie
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Dhanny Gomez
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Stijn Van Laarhoven
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Francis Robertson
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Hossain Nawara
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Joseph Doyle
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ricky Bhogal
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ewen Harrison
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Marcus Roalso
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Debora Ciprani
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Bathiya Ratnayake
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Tareq Alsaoudi
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neil Bhardwaj
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Srujan Rajesh
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fraser Jeffery
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Saxon Connor
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew Cameron
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Jamieson
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Amy Sheen
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jas Samra
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony Gill
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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4
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Conroy T, Pfeiffer P, Vilgrain V, Lamarca A, Seufferlein T, O'Reilly EM, Hackert T, Golan T, Prager G, Haustermans K, Vogel A, Ducreux M. Pancreatic cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2023; 34:987-1002. [PMID: 37678671 DOI: 10.1016/j.annonc.2023.08.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023] Open
Affiliation(s)
- T Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy; APEMAC, équipe MICS, Université de Lorraine, Nancy, France
| | - P Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - V Vilgrain
- Centre de Recherche sur l'Inflammation U 1149, Université Paris Cité, Paris; Department of Radiology, Beaujon Hospital, APHP Nord, Clichy, France
| | - A Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - T Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - E M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - T Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - T Golan
- Gastrointestinal Unit, Oncology Institute, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - G Prager
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - K Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - M Ducreux
- Université Paris-Saclay, Gustave Roussy, Inserm Unité Dynamique des Cellules Tumorales, Villejuif, France
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5
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Biagi JJ, Cosby R, Bahl M, Elfiki T, Goodwin R, Hallet J, Hirmiz K, Mahmud A. Adjuvant Chemotherapy and Radiotherapy in Resected Pancreatic Ductal Adenocarcinoma: A Systematic Review and Clinical Practice Guideline. Curr Oncol 2023; 30:6575-6586. [PMID: 37504342 PMCID: PMC10378160 DOI: 10.3390/curroncol30070482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/26/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023] Open
Abstract
Pancreatic cancer is the seventh leading cause of cancer deaths worldwide, accounting for 4.7% of all cancer deaths, and is expected to climb significantly over the next decade. The purpose of this systematic review and guidance document was to synthesize the evidence surrounding the role of adjuvant treatment (chemotherapy and chemoradiation therapy [CRT], and stereotactic body radiation therapy [SBRT]) in resected pancreatic ductal adenocarcinoma (PDAC). Systematic literature searches of MEDLINE, EMBASE, and 11 guideline databases were conducted. Both direct and indirect comparisons indicate adjuvant chemotherapy offers a survival advantage over surgery alone. The optimal regimens recommended are mFOLFIRINOX with alternative options of gemcitabine plus capecitabine, gemcitabine alone, or S-1 (which is not available in North America). Trials comparing a CRT strategy to modern chemotherapy regimens are lacking. However, current evidence demonstrates that the addition of CRT to chemotherapy does not result in a survival advantage over chemotherapy alone and is therefore not recommended. Trials evaluating SBRT in PDAC are also lacking. SBRT should only be used within a clinical trial or multi-institutional registry.
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Affiliation(s)
- James J Biagi
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
| | - Roxanne Cosby
- Program in Evidence-Based Care, Department of Oncology, Juravinski Campus, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada
| | - Mala Bahl
- Trillium Health Partners, 2200 Ellington Avenue West, Mississauga, ON L5M 2N1, Canada
| | - Tarek Elfiki
- Windsor Regional Cancer Centre, 2220 Kildare Road, Windsor, ON N8W 2X3, Canada
| | - Rachel Goodwin
- The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Julie Hallet
- Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M4, Canada
| | - Khalid Hirmiz
- Windsor Regional Cancer Centre, 2220 Kildare Road, Windsor, ON N8W 2X3, Canada
| | - Aamer Mahmud
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
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6
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Heumann T, Judkins C, Li K, Lim SJ, Hoare J, Parkinson R, Cao H, Zhang T, Gai J, Celiker B, Zhu Q, McPhaul T, Durham J, Purtell K, Klein R, Laheru D, De Jesus-Acosta A, Le DT, Narang A, Anders R, Burkhart R, Burns W, Soares K, Wolfgang C, Thompson E, Jaffee E, Wang H, He J, Zheng L. A platform trial of neoadjuvant and adjuvant antitumor vaccination alone or in combination with PD-1 antagonist and CD137 agonist antibodies in patients with resectable pancreatic adenocarcinoma. Nat Commun 2023; 14:3650. [PMID: 37339979 PMCID: PMC10281953 DOI: 10.1038/s41467-023-39196-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/01/2023] [Indexed: 06/22/2023] Open
Abstract
A neoadjuvant immunotherapy platform clinical trial allows for rapid evaluation of treatment-related changes in tumors and identifying targets to optimize treatment responses. We enrolled patients with resectable pancreatic adenocarcinoma into such a platform trial (NCT02451982) to receive pancreatic cancer GVAX vaccine with low-dose cyclophosphamide alone (Arm A; n = 16), with anti-PD-1 antibody nivolumab (Arm B; n = 14), and with both nivolumab and anti-CD137 agonist antibody urelumab (Arm C; n = 10), respectively. The primary endpoint for Arms A/B - treatment-related change in IL17A expression in vaccine-induced lymphoid aggregates - was previously published. Here, we report the primary endpoint for Arms B/C: treatment-related change in intratumoral CD8+ CD137+ cells and the secondary outcomes including safety, disease-free and overall survivals for all Arms. Treatment with GVAX+nivolumab+urelumab meets the primary endpoint by significantly increasing intratumoral CD8+ CD137+ cells (p = 0.003) compared to GVAX+Nivolumab. All treatments are well-tolerated. Median disease-free and overall survivals, respectively, are 13.90/14.98/33.51 and 23.59/27.01/35.55 months for Arms A/B/C. GVAX+nivolumab+urelumab demonstrates numerically-improved disease-free survival (HR = 0.55, p = 0.242; HR = 0.51, p = 0.173) and overall survival (HR = 0.59, p = 0.377; HR = 0.53, p = 0.279) compared to GVAX and GVAX+nivolumab, respectively, although not statistically significant due to small sample size. Therefore, neoadjuvant and adjuvant GVAX with PD-1 blockade and CD137 agonist antibody therapy is safe, increases intratumoral activated, cytotoxic T cells, and demonstrates a potentially promising efficacy signal in resectable pancreatic adenocarcinoma that warrants further study.
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Affiliation(s)
- Thatcher Heumann
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Vanderbilt University Medical Center, Department of Hematology-Oncology, Nashville, TN, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Carol Judkins
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Keyu Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Su Jin Lim
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Quantitative Sciences, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica Hoare
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Rose Parkinson
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Haihui Cao
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Tengyi Zhang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
| | - Jessica Gai
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
| | - Betul Celiker
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Qingfeng Zhu
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas McPhaul
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Durham
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Katrina Purtell
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
| | - Rachel Klein
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Laheru
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
| | - Ana De Jesus-Acosta
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
| | - Dung T Le
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
| | - Amol Narang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert Anders
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Burkhart
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William Burns
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kevin Soares
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher Wolfgang
- Department of Surgery, New York University School of Medicine and NYU-Langone Medical Center, New York, NY, USA
| | - Elizabeth Thompson
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Jaffee
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hao Wang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- Division of Quantitative Sciences, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Cancer Convergence Institute and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD, USA.
- The Pancreatic Cancer Precision Medicine Center of Excellence Program at Johns Hopkins, Baltimore, MD, USA.
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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7
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Springfeld C, Ferrone CR, Katz MHG, Philip PA, Hong TS, Hackert T, Büchler MW, Neoptolemos J. Neoadjuvant therapy for pancreatic cancer. Nat Rev Clin Oncol 2023; 20:318-337. [PMID: 36932224 DOI: 10.1038/s41571-023-00746-1] [Citation(s) in RCA: 102] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/19/2023]
Abstract
Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.
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Affiliation(s)
- Christoph Springfeld
- Department of Medical Oncology, National Center for Tumour Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Philip
- Wayne State University School of Medicine, Department of Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Theodore S Hong
- Research and Scientific Affairs, Gastrointestinal Service Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - John Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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8
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Conroy T, Castan F, Hammel P. Overall Survival With Adjuvant mFOLFIRINOX for Pancreatic Cancer-Reply. JAMA Oncol 2023; 9:436-437. [PMID: 36701135 DOI: 10.1001/jamaoncol.2022.7361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and APEMAC, équipe MICS, Université de Lorraine, Nancy, France
| | - Florence Castan
- Institut Régional du Cancer de Montpellier, Université de Montpellier, Montpellier, France
| | - Pascal Hammel
- Digestive and Medical Oncology department, Hôpital Paul Brousse and University Paris-Saclay, Villejuif, France
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9
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Chawla A, Ferrone CR. Surgeon-Led Clinical Trials in Pancreatic Cancer. Surg Oncol Clin N Am 2023; 32:143-151. [PMID: 36410914 DOI: 10.1016/j.soc.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The review also highlights key landmark adjuvant, neoadjuvant and perioperative trials with an emphasis on surgeon-run clinical trials that have helped to define the pancreatic cancer treatment paradigms.
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Affiliation(s)
- Akhil Chawla
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St., Suite 650Chicago, IL 60611, USA; Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
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10
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Abstract
The management of pancreatic ductal adenocarcinoma (PDAC) has evolved over the last two decades. Surgical resection remain the only potential cure for this cancer. Therefore, there is an emerging emphasis on neoadjuvant therapy to maximize the probability of resection, and identify failures early. The benefit of FOLFIRINOX in various clinical stages of PDAC have been practice changing. The addition of nab-paclitaxel to the traditional gemcitabine regimen added another option for treatment. In addition, immunotherapy and targeted therapies are applicable, based on molecular features and germline alterations; albeit, these are applicable to only a small minority of patients. In this review article, we discuss the key extant literature relevant to various stages of pancreatic cancer. We also summarize ongoing clinical trials which may guide future treatments.
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Affiliation(s)
- Yan Jiang
- University of Cincinnati, Cincinnati, OH
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11
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Sardar M, Recio-Boiles A, Mody K, Karime C, Chandana SR, Mahadevan D, Starr J, Jones J, Borad M, Babiker H. Pharmacotherapeutic options for pancreatic ductal adenocarcinoma. Expert Opin Pharmacother 2022; 23:2079-2089. [PMID: 36394449 DOI: 10.1080/14656566.2022.2149322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy projected to be the 2nd leading cause of cancer related death in the USA by 2030. This manuscript discusses current and evolving treatment approaches in patients with pancreatic cancer. AREAS COVERED PDAC is classified as: a) resectable, b) borderline resectable, c) unresectable (locally advanced and metastatic). The standard of care for patients who present with resectable pancreatic adenocarcinoma is six months of adjuvant modified (m) FOLFIRINOX, gemcitabine plus capecitabine, or single agent gemcitabine. For many reasons, there has been a paradigm shift to employing neoadjuvant chemotherapy. For resectable and borderline resectable patients, we generally start with systemic therapy and reevaluate resectability with subsequent scans specifically when the tumor is located in the head or body of the pancreas. Combined chemoradiation therapy can be employed in select patients. The standard of care for metastatic PDAC is FOLFIRINOX or gemcitabine and nab-paclitaxel. Germline and somatic genomic profiling should be obtained in all patients. Patients with a germline BRCA mutation can receive upfront gemcitabine and cisplatin. EXPERT OPINION Thorough understanding of molecular pathogenesis in PDAC has opened various therapeutic avenues. We remain optimistic that future treatment modalities such as targeted therapies, cellular therapies and immunotherapy will further improve survival in PDAC.
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Affiliation(s)
- Muhammad Sardar
- Division of Hematology-Oncology, Department of Medicine, University of Arizona Cancer Center, Tucson, Az, USA
| | - Alejandro Recio-Boiles
- Division of Hematology-Oncology, Department of Medicine, University of Arizona Cancer Center, Tucson, Az, USA
| | - Kabir Mody
- Division of Hematology-Oncology, Department of Medicine, Mayo Clinic Cancer Center, Jacksonville, FL, USA
| | | | | | - Daruka Mahadevan
- Division of Hematology and Oncology, Department of Medicine, University of Texas, San Antonio, Texas, USA
| | - Jason Starr
- Division of Hematology-Oncology, Department of Medicine, Mayo Clinic Cancer Center, Jacksonville, FL, USA
| | - Jeremy Jones
- Division of Hematology-Oncology, Department of Medicine, Mayo Clinic Cancer Center, Jacksonville, FL, USA
| | - Mitesh Borad
- Division of Hematology-Oncology, Department of Medicine, Mayo Clinic Cancer Center, Phoenix, AZ, USA
| | - Hani Babiker
- Division of Hematology-Oncology, Department of Medicine, Mayo Clinic Cancer Center, Jacksonville, FL, USA
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12
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Conroy T, Castan F, Lopez A, Turpin A, Ben Abdelghani M, Wei AC, Mitry E, Biagi JJ, Evesque L, Artru P, Lecomte T, Assenat E, Bauguion L, Ychou M, Bouché O, Monard L, Lambert A, Hammel P. Five-Year Outcomes of FOLFIRINOX vs Gemcitabine as Adjuvant Therapy for Pancreatic Cancer: A Randomized Clinical Trial. JAMA Oncol 2022; 8:1571-1578. [PMID: 36048453 PMCID: PMC9437831 DOI: 10.1001/jamaoncol.2022.3829] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/29/2022] [Indexed: 01/11/2023]
Abstract
Importance Early results at 3 years from the PRODIGE 24/Canadian Cancer Trials Group PA6 randomized clinical trial showed survival benefits with adjuvant treatment with modified FOLFIRINOX vs gemcitabine in patients with resected pancreatic ductal adenocarcinoma; mature data are now available. Objective To report 5-year outcomes and explore prognostic factors for overall survival. Design, Setting, and Participants This open-label, phase 3 randomized clinical trial was conducted at 77 hospitals in France and Canada and included patients aged 18 to 79 years with histologically confirmed pancreatic ductal adenocarcinoma who had undergone complete macroscopic (R0/R1) resection within 3 to 12 weeks before randomization. Patients were included from April 16, 2012, through October 3, 2016. The cutoff date for this analysis was June 28, 2021. Interventions A total of 493 patients were randomized (1:1) to receive treatment with modified FOLFIRINOX (oxaliplatin, 85 mg/m2 of body surface area; irinotecan, 150-180 mg/m2; leucovorin, 400 mg/m2; and fluorouracil, 2400 mg/m2, every 2 weeks) or gemcitabine (1000 mg/m2, days 1, 8, and 15, every 4 weeks) as adjuvant therapy for 24 weeks. Main Outcomes and Measures Primary end point was disease-free survival. Secondary end points included overall survival, metastasis-free survival, and cancer-specific survival. Prognostic factors for overall survival were determined. Results Of the 493 patients, 216 (43.8%) were women, and the mean (SD) age was 62.0 (8.9) years. At a median of 69.7 months' follow-up, 367 disease-free survival events were observed. In patients receiving chemotherapy with modified FOLFIRINOX vs gemcitabine, median disease-free survival was 21.4 months (95% CI, 17.5-26.7) vs 12.8 months (95% CI, 11.6-15.2) (hazard ratio [HR], 0.66; 95% CI, 0.54-0.82; P < .001) and 5-year disease-free survival was 26.1% vs 19.0%; median overall survival was 53.5 months (95% CI, 43.5-58.4) vs 35.5 months (95% CI, 30.1-40.3) (HR, 0.68; 95% CI, 0.54-0.85; P = .001), and 5-year overall survival was 43.2% vs 31.4%; median metastasis-free survival was 29.4 months (95% CI, 21.4-40.1) vs 17.7 months (95% CI, 14.0-21.2) (HR, 0.64; 95% CI, 0.52-0.80; P < .001); and median cancer-specific survival was 54.7 months (95% CI, 45.8-68.4) vs 36.3 months (95% CI, 30.5-43.9) (HR, 0.65; 95% CI, 0.51-0.82; P < .001). Multivariable analysis identified modified FOLFIRINOX, age, tumor grade, tumor staging, and larger-volume center as significant favorable prognostic factors for overall survival. Shorter relapse delay was an adverse prognostic factor. Conclusions and Relevance The final 5-year results from the PRODIGE 24/Canadian Cancer Trials Group PA6 randomized clinical trial indicate that adjuvant treatment with modified FOLFIRINOX yields significantly longer survival than gemcitabine in patients with resected pancreatic ductal adenocarcinoma. Trial Registration EudraCT: 2011-002026-52; ClinicalTrials.gov Identifier: NCT01526135.
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Affiliation(s)
- Thierry Conroy
- Medical Oncology department, Institut de cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France and Université de Lorraine, APEMAC, équipe MICS, Nancy, France
| | - Florence Castan
- Biometry Department, ICM Regional Cancer Institute of Montpellier, Montpellier, France and Montpellier University, Montpellier, France
| | - Anthony Lopez
- Hepatogastroenterology department, University Hospital, Nancy, France
| | - Anthony Turpin
- Medical Oncology Department, University hospital, Lille, France and University of Lille, Lille, France
| | | | - Alice C. Wei
- Surgery department, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Emmanuel Mitry
- Medical Oncology department, Institut Paoli-Calmettes, Marseille, France
| | | | - Ludovic Evesque
- Medical oncology department, Centre Antoine-Lacassagne, Nice, France
| | - Pascal Artru
- Hepatogastroenterology department, Hôpital Jean-Mermoz, Lyon, France
| | - Thierry Lecomte
- Hepatogastroenterology department, Hôpital Trousseau, Tours, France and INSERM UMR 6239, Tours University, Tours, France
| | - Eric Assenat
- Medical oncology department, Centre Hospitalier Universitaire de Saint-Eloi, Montpellier, France
| | - Lucile Bauguion
- Hepatogastroenterology department, Centre Hospitalier Départemental Vendée, La Roche-sur-Yon, France
| | - Marc Ychou
- Oncology department, ICM Regional Cancer Institute of Montpellier, Montpellier, France and Montpellier University, Montpellier, France
| | - Olivier Bouché
- Digestive oncology department, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | | | - Aurélien Lambert
- Medical Oncology department, Institut de cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France and Université de Lorraine, APEMAC, équipe MICS, Nancy, France
| | - Pascal Hammel
- Digestive and Medical Oncology department, Hôpital Paul Brousse and University Paris-Saclay, Villejuif, France
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13
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Salamekh S, Gottumukkala S, Park C, Lin MH, Sanford NN. Radiotherapy for Pancreatic Adenocarcinoma: Recent Developments and Advances on the Horizon. Hematol Oncol Clin North Am 2022; 36:995-1009. [PMID: 36154787 DOI: 10.1016/j.hoc.2022.06.002] [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: 11/18/2022]
Abstract
Current indications for radiotherapy in pancreatic cancer vary by surgical resectability status of the tumor. Radiation is generally not used pre-operatively for resectable tumors, but may be given adjuvantly particularly in settings of a close or positive surgical margin. For borderline resectable tumors, pre-operative radiation has been shown to improve surgical parameters including lowering nodal positivity and positive margin rates. For locally advanced unresectable tumors, radiation can improve local control, give patients an interval off of chemotherapy and provide symptomatic relief. Multidisciplinary discussion is critical for choosing the best modality and sequencing of care for patients with pancreatic cancer. Prospective trials with appropriately chosen endpoints and meticulous radiotherapy quality assurance are needed to best define populations with pancreatic cancer most likely to benefit from radiotherapy.
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Affiliation(s)
- Samer Salamekh
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Sujana Gottumukkala
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Chunjoo Park
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA.
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14
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DuBois JS, Kambadakone A, Wo JY, Zhang ML. Case 19-2022: A 29-Year-Old Woman with Jaundice and Chronic Diarrhea. N Engl J Med 2022; 386:2413-2423. [PMID: 35731657 DOI: 10.1056/nejmcpc2201231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jon S DuBois
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Avinash Kambadakone
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Jennifer Y Wo
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - M Lisa Zhang
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
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15
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Ghanem I, Lora D, Herradón N, de Velasco G, Carretero-González A, Jiménez-Varas MÁ, Vázquez de Parga P, Feliu J. Neoadjuvant chemotherapy with or without radiotherapy versus upfront surgery for resectable pancreatic adenocarcinoma: a meta-analysis of randomized clinical trials. ESMO Open 2022; 7:100485. [PMID: 35580504 PMCID: PMC9117867 DOI: 10.1016/j.esmoop.2022.100485] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The role of neoadjuvant chemotherapy (NC) in resectable pancreatic cancer (RPC) has yet to be defined. This review aims to analyze the benefit of NC in RPC compared with upfront surgery (US) in terms of overall survival (OS) and disease-free survival (DFS). PATIENTS AND METHODS PubMed, CENTRAL (The Cochrane Library), and Embase were systematically reviewed until 3 November 2021. Abstract proceedings and virtual meeting presentations from the American Society of Clinical Oncology and the European Society of Medical Oncology conferences, reference articles of published clinical trials, and review articles were considered. Only randomized clinical trials (RCTs) comparing NC administration with or without radiotherapy previous with surgery (experimental arm) versus US followed by adjuvant chemotherapy with or without radiotherapy (control arm) for RPC were included. RESULTS A total of 1135 studies were screened. Of these, 1117 studies were primarily excluded. Of the remaining 18 studies, 5 were excluded because of no adequate trial design for this work and 7 others had no available results. Finally, 6 trials with 469 patients with pancreatic cancer randomized to NC (n = 212) or US (n = 257) were selected. Compared with US, NC significantly improved OS [hazard ratio (HR) 0.75; 95% confidence interval (CI) 0.58-0.98; P = 0.033] and DFS (HR 0.73; 95% CI 0.59-0.89; P = 0.002). While the NC approach was not significantly associated with lower resection rate [relative risk (RR) 0.92; 95% CI 0.84-1.01; P = 0.069], the R0 resection rate was significantly higher for NC than for US (RR 1.31; 95% CI 1.13-1.52; P = 0.0004). CONCLUSION This is the first meta-analysis of RCTs showing that NC improves OS for RPC compared with US followed by adjuvant therapy. Ongoing RCTs should confirm these findings with FOLFIRINOX to generalize the indication of NC.
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Affiliation(s)
- I Ghanem
- Department of Medical Oncology, Hospital Universitario La Paz (IdiPAZ), Madrid, Spain.
| | - D Lora
- Clinical Research Unit (imas12-CIBERESP), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - N Herradón
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - G de Velasco
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - A Carretero-González
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, USA
| | | | - P Vázquez de Parga
- Department of Gastroenterology and Hepatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - J Feliu
- Department of Medical Oncology, Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Cátedra UAM-AMGEN, CIBERONC, Madrid, Spain
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16
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Koessler T, Alsina M, Arnold D, Ben-Aharon I, Collienne M, Lutz MP, Neuzillet C, Obermannova R, Peeters M, Sclafani F, Smyth E, Valle JW, Wagner AD, Wyrwicz L, Fontana E, Moehler M. ESMO Congress 2021: highlights from the EORTC gastrointestinal tract cancer group's perspective. ESMO Open 2022; 7:100392. [PMID: 35180656 PMCID: PMC8857487 DOI: 10.1016/j.esmoop.2022.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022] Open
Abstract
There has been no major change of practice in gastrointestinal oncology at the European Society for Medical Oncology (ESMO) symposium 2021, but confirmation that immunotherapy in combination with chemotherapy has become standard of care in several indications. The European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Track Cancer Group has selected important phase II and III trials presented during the symposium across all gastrointestinal cancers as well as early reports on new drugs or new combinations that may change practice in the future.
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Affiliation(s)
- T Koessler
- Department of Oncology, Geneva University Hospital, Geneva, Switzerland; Swiss Cancer Center Leman (SCCL), University of Geneva, Lausanne, Switzerland.
| | - M Alsina
- Hospital Universitario de Navarra (HUN), Medical Oncology Department, Pamplona, Spain; Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - D Arnold
- Department of Oncology, Haematology and Palliative Care, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Hamburg, Germany
| | - I Ben-Aharon
- Division of Oncology, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - M Collienne
- Department of Oncology, Haematology and Palliative Care, Asklepios Klinik Altona, Asklepios Tumorzentrum Hamburg, Hamburg, Germany; European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - M P Lutz
- Caritasklinikum, Saarbrucken, Germany
| | - C Neuzillet
- GI Oncology, Medical Oncology Department, Institut Curie Saint-Cloud, Versailles Saint Quentin University, Saint-Cloud, France
| | - R Obermannova
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute and Faculty of Medicine, Masaryk University, Brno; Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - M Peeters
- Department of Oncology, Universitair Ziekenhuis Antwerpen, Antwerp, Belgium
| | - F Sclafani
- Department of Medical Oncology, Institut Jules Bordet-Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - E Smyth
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - J W Valle
- Division of Cancer Sciences, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - A D Wagner
- Department of Oncology, Division of Medical Oncology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - L Wyrwicz
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - E Fontana
- Sarah Cannon Research Institute, London, UK
| | - M Moehler
- Department of Internal Medicine, Johannes-Gutenberg University, Mainz, Germany
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17
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Pecorelli N, Licinio AW, Guarneri G, Aleotti F, Crippa S, Reni M, Falconi M, Balzano G. Prognosis of Upfront Surgery for Pancreatic Cancer: A Systematic Review and Meta-Analysis of Prospective Studies. Front Oncol 2022; 11:812102. [PMID: 35083158 PMCID: PMC8784375 DOI: 10.3389/fonc.2021.812102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The rate of patients with pancreatic ductal adenocarcinoma (PDAC) receiving neoadjuvant chemotherapy is increasing, but upfront resection is still offered to most patients with resectable or borderline resectable disease. Encouraging data reported in adjuvant chemotherapy trials prompts surgeons towards upfront surgery, but such trials are subject to a significant selection bias. This systematic review aims to summarize available high-quality evidence regarding survival of patients treated with upfront surgery for PDAC. METHODS Pubmed, Cochrane, and Web of Science Databases were interrogated for prospective studies published between 2000 and 2021 that included at least a cohort of patients treated with upfront surgery for resectable or borderline resectable PDAC. The Cochrane Collaboration's risk-of-bias tool for randomized trials (RoB-2) was used to assess risk of bias in all randomized studies. Patient weighted median overall survival (OS) and disease-free survival (DFS) were calculated. RESULTS Overall, 8,341 abstracts were screened, 17 reports were reviewed in full text, and finally 5 articles and 1 conference abstract underwent data extraction. Included studies were published between 2014 and 2021. All studies were RCTs comparing different neoadjuvant treatment strategies to upfront surgery. Three studies included only resectable PDAC patients, two studies recruited patients with resectable and borderline resectable disease, and one study selected only borderline resectable patients. A total of 439 patients were included in the upfront resection cohorts of the 6 studies, ranging between 20 to 180 patients per study. The weighted median OS after upfront surgery was 18.8 (95% CI 12.4 - 20.6) months. Median DFS was 9 (95% CI 1.6 - 12.5) months. Resection rate was 74.5% (range 65-90%). Adjuvant treatment was initiated in 68% (range 43-77%) of resected patients. CONCLUSIONS High-quality data for PDAC patients undergoing upfront surgery is scarce. Meta-analysis from the included studies showed a significantly shorter OS and DFS compared to recently published studies focusing on adjuvant combination chemotherapy, suggesting that the latter may overestimate survival due to the exclusion of most patients scheduled for upfront surgery.
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Affiliation(s)
- Nicolò Pecorelli
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Alice W Licinio
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Michele Reni
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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Nguyen M, Segelov E, Goldstein D, Pavlakis N, Shapiro J, Price TJ, Nagrial A, Chantrill L, Leong T, Chen J, Burge M, Karapetis CS, Chau I, Lordick F, Renouf D, Tebbutt N, Roy AC. Update on optimal management for pancreatic cancer: expert perspectives from members of the Australasian Gastrointestinal Trials Group (AGITG) with invited international faculty. Expert Rev Anticancer Ther 2022; 22:39-51. [PMID: 34739362 DOI: 10.1080/14737140.2022.2002689] [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: 09/02/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pancreatic cancer remains a challenging malignancy due to the high proportion of patients diagnosed at advanced stages and the limited treatment options. This article discusses recent evidence in the management of both localized and advanced pancreatic cancer and offers an expert opinion on current best practice. AREAS COVERED For patients with localized disease, the evidence for adjuvant chemotherapy is discussed as well as emerging neoadjuvant approaches for resectable, borderline resectable, and locally advanced disease. Advances in metastatic disease are discussed including cytotoxic chemotherapy, targeted therapies, and the role of genomic testing to identify patients with molecular alterations. Reviewed literature included journal publications, abstracts presented at major international oncology meetings, and ongoing clinical trials databases. EXPERT OPINION Pancreatic cancer is a devastating diagnosis and despite recent advances has a very poor prognosis. Only a minority of patients, 20%, are diagnosed with potentially curable disease. The shifting paradigm toward neoadjuvant therapy may improve resectability and survival rates; however, robust evidence is required. Thus far, there has only been limited progress in advanced stage disease. Genomic testing may potentially identify more treatment targets although limited to small subgroups.
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Affiliation(s)
- Mike Nguyen
- Department of Medical Oncology, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Australia
| | - Eva Segelov
- Department of Medical Oncology, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Australia
| | - David Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, University of NSW, Sydney, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | | | - Timothy J Price
- Department of Haematology and Oncology, The Queen Elizabeth Hospital/University of Adelaide, Adelaide, Australia
| | - Adnan Nagrial
- Department of Medical Oncology, Westmead & Blacktown Hospitals, University of Sydney, Sydney, Australia
| | - Lorraine Chantrill
- Department Medical Oncology, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Trevor Leong
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - John Chen
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | - Matt Burge
- Department of Cancer Care Services, Royal Brisbane Hospital, University of Queensland, Herston, Australia
| | - Christos S Karapetis
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | - Ian Chau
- Department of Medicine, Royal Marsden Hospital, Institute of Cancer Research, Surrey, London, UK
| | - Florian Lordick
- University Cancer Center Leipzig and Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Medical Center, Leipzig, Germany
| | - Daniel Renouf
- Department of Medical Oncology, BC Cancer. Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Wellness and Research Centre. Austin Health, Heidelberg, Australia
| | - Amitesh C Roy
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
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19
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Khakoo S, Petrillo A, Salati M, Muhith A, Evangelista J, Seghezzi S, Petrelli F, Tomasello G, Ghidini M. Neoadjuvant Treatment for Pancreatic Adenocarcinoma: A False Promise or an Opportunity to Improve Outcome? Cancers (Basel) 2021; 13:cancers13174396. [PMID: 34503206 PMCID: PMC8431597 DOI: 10.3390/cancers13174396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Pancreatic cancer usually presents late when it has spread to distant sites. In a small proportion of patients, the cancer can be removed by surgery. Surgery is usually followed by chemotherapy, as studies have shown that this improves survival. However, due to complications after surgery and a decline in fitness, some patients do not start their chemotherapy and many do not complete the planned course. The cancer returns in the majority of patients. Chemotherapy or a combination of chemotherapy and radiotherapy before surgery are being investigated to improve survival. The best treatment regime and patient selection for different treatment strategies remains to be defined and is discussed here. Abstract Pancreatic ductal adenocarcinoma (PDAC) has an aggressive tumor biology and is associated with poor survival outcomes. Most patients present with metastatic or locally advanced disease. In the 10–20% of patients with upfront resectable disease, surgery offers the only chance of cure, with the addition of adjuvant chemotherapy representing an established standard of care for improving outcomes. Despite resection followed by adjuvant chemotherapy, at best, 3-year survival reaches 63.4%. Post-operative complications and poor performance mean that around 50% of the patients do not commence adjuvant chemotherapy, and a significant proportion do not complete the intended treatment course. These factors, along with the advantages of early treatment of micrometastatic disease, the ability to downstage tumors, and the increase in R0 resection rates, have increased interest in neo-adjuvant treatment strategies. Here we review biomarkers for early diagnosis of PDAC and patient selection for a neo-adjuvant approach. We also review the current evidence for different chemotherapy regimens in this setting, as well as the role of chemoradiotherapy and immunotherapy, and we discuss ongoing trials.
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Affiliation(s)
- Shelize Khakoo
- Department of Medicine, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK;
- Correspondence: (S.K.); (M.G.); Tel.: +39-02-5503-2660 (M.G.); Fax: +39-02-5503-2659 (M.G.)
| | - Angelica Petrillo
- Division of Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania Luigi Vanvitelli, 80131 Naples, Italy;
- Oncology Unit, Ospedale del Mare, 80147 Naples, Italy
| | - Massimiliano Salati
- Department of Oncology, University Hospital of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Abdul Muhith
- Department of Medicine, Royal Marsden Hospital, Sutton, Surrey SM2 5PT, UK;
| | - Jessica Evangelista
- Department of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Silvia Seghezzi
- Nuclear Medicine Unit, ASST Bergamo Ovest, 24047 Treviglio, Italy;
| | - Fausto Petrelli
- Oncology Unit, Medical Sciences Department, ASST Bergamo Ovest, 24047 Treviglio, Italy;
| | - Gianluca Tomasello
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Correspondence: (S.K.); (M.G.); Tel.: +39-02-5503-2660 (M.G.); Fax: +39-02-5503-2659 (M.G.)
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