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Sugiura T, Toyama H, Fukutomi A, Asakura H, Takeda Y, Yamamoto K, Hirano S, Satoi S, Matsumoto I, Takahashi S, Morinaga S, Yoshida M, Sakuma Y, Iwamoto H, Shimizu Y, Uesaka K. Randomized phase II trial of chemoradiotherapy with S-1 versus combination chemotherapy with gemcitabine and S-1 as neoadjuvant treatment for resectable pancreatic cancer (JASPAC 04). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1249-1260. [PMID: 37746781 DOI: 10.1002/jhbp.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The aim of the present study was to investigate which treatment, neoadjuvant chemoradiotherapy (NAC-RT) with S-1 or combination neoadjuvant chemotherapy with gemcitabine and S-1 (NAC-GS), is more promising as neoadjuvant treatment (NAT) for resectable pancreatic cancer in terms of effectiveness and safety. METHODS In the NAC-RT with S-1 group, the patients received a total radiation dose of 50.4 Gy in 28 fractions with oral S-1. In the NAC-GS group, the patients received intravenous gemcitabine at a dose of 1000 mg/m2 with oral S-1 for two cycles. The primary endpoint was the 2-year progression-free survival (PFS) rate. The trial was registered with the UMIN Clinical Trial Registry as UMIN000014894. RESULTS From April 2014 to April 2017, a total of 103 patients were enrolled. After exclusion of one patient because of ineligibility, 51 patients were included in the NAC-RT with S-1 group, and 51 patients were included in the NAC-GS group in the intention-to-treat analysis. The 2-year PFS rate was 45.0% (90% confidence interval [CI]: 33.3%-56.0%) in the NAC-RT with S-1 group and 54.9% (42.8%-65.5%) in the NAC-GS group (p = .350). The 2-year overall survival rate was 66.7% in the NAC-RT with S-1 group and 72.4% in the NAC-GS group (p = .300). Although leukopenia and neutropenia rates were significantly higher in the NAC-GS group than in the NAC-RT with S-1 group (p = .023 and p < .001), other adverse events of NAT and postoperative complications were comparable between the two groups. CONCLUSION Both NAC-RT with S-1 and NAC-GS are considered promising treatments for resectable pancreatic cancer.
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Affiliation(s)
- Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akira Fukutomi
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hirofumi Asakura
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuriko Takeda
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan
- Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ippei Matsumoto
- Department of Surgery, Kindai University, Osaka-Sayama, Japan
| | | | - Soichiro Morinaga
- Department of Hepato-Biliary-Pancreatic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University, Sapporo, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Jichi Medical University, Tochigi-Shimotsuke, Japan
| | - Hidetaka Iwamoto
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Habib JR, Kinny-Köster B, Bou-Samra P, Alsaad R, Sereni E, Javed AA, Ding D, Cameron JL, Lafaro KJ, Burns WR, He J, Yu J, Wolfgang CL, Burkhart RA. Surgical Decision-Making in Pancreatic Ductal Adenocarcinoma: Modeling Prognosis Following Pancreatectomy in the Era of Induction and Neoadjuvant Chemotherapy. Ann Surg 2023; 277:151-158. [PMID: 33843794 DOI: 10.1097/sla.0000000000004915] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a predictive model of oncologic outcomes for patients with pancreatic ductal adenocarcinoma (PDAC) undergoing resection after neoadjuvant or induction chemotherapy use. BACKGROUND Early recurrence following surgical resection for PDAC is common. The use of neoadjuvant chemotherapy prior to resection may increase the likelihood of long-term systemic disease control. Accurately characterizing an individual's likely oncologic outcome in the perioperative setting remains challenging. METHODS Data from patients with PDAC who received chemotherapy prior to pancreatectomy at a single high-volume institution between 2007 and 2018 were captured in a prospectively collected database. Core clinicopathologic data were reviewed for accuracy and survival data were abstracted from the electronic medical record and national databases. Cox-proportional regressions were used to model outcomes and develop an interactive prognostic tool for clinical decision-making. RESULTS A total of 581 patients were included with a median overall survival (OS) and recurrence-free survival (RFS) of 29.5 (26.5-32.5) and 16.6 (15.8-17.5) months, respectively. Multivariable analysis demonstrates OS and RFS were associated with type of chemotherapeutic used andthe number of chemotherapy cycles received preoperatively. Additional factors contributing to survival models included: tumor grade, histopathologic response to therapy, nodal status, and administration of adjuvant chemotherapy. The models were validated using an iterative bootstrap method and with randomized cohort splitting. The models were well calibrated with concordance indices of 0.68 and 0.65 for the final OS and RFS models, respectively. CONCLUSION We developed an intuitive and dynamic decision-making tool that can be useful in estimating OS, RFS, and location-specific disease recurrence rates. This prognostic tool may add value to patient care in discussing the benefits associated with surgical resection for PDAC.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Patrick Bou-Samra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ranim Alsaad
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elisabetta Sereni
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jun Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Department of Surgery, New York University School of Medicine and NYU-Langone Medical Center, New York, NY
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Gleeson EM, Leigh N, Golas BJ, Magge D, Sarpel U, Hiotis SP, Labow DM, Pintova S, Cohen NA. Adjuvant Chemotherapy Is Not Guided by Pathologic Treatment Effect After Neoadjuvant Chemotherapy in Pancreatic Cancer. Pancreas 2021; 50:1163-1168. [PMID: 34714279 DOI: 10.1097/mpa.0000000000001881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Currently, there is no guidance for optimal adjuvant chemotherapy selection after pancreatectomy with a partial or poor response to neoadjuvant therapy. This study seeks to describe an institution's practice patterns of adjuvant chemotherapy selection after neoadjuvant therapy. METHODS Patients at a single institution receiving neoadjuvant chemotherapy followed by pancreatectomy for pancreatic cancer were reviewed. Patients enrolled in trials or without follow-up were excluded. Types of chemotherapy, the College of American Pathologists pathologic tumor response, and medical oncology plans were recorded. RESULTS Forty-one patients met inclusion criteria. Pathologic review of treatment effect demonstrated that 3 patients (7.3%) had complete pathologic response, 3 (7.3%) had near complete pathologic response, 16 (39%) had partial response, and 14 (34.1%) had poor/no response to neoadjuvant chemotherapy. Fourteen of the 30 patients with partial or poor response (46.7%) received an alternate adjuvant regimen. Pathologic response to neoadjuvant chemotherapy specifically guided therapy in 11 (30.5%) patients. CONCLUSIONS Despite 73.1% of patients with partial or poor response to neoadjuvant chemotherapy, only 46.7% received a different adjuvant regimen. Medical oncologists infrequently considered treatment effect when choosing adjuvant therapy. Pathologic response to neoadjuvant chemotherapy should be considered when selecting adjuvant chemotherapy.
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Affiliation(s)
| | - Natasha Leigh
- From the Division of Surgical Oncology, Department of Surgery
| | | | - Deepa Magge
- From the Division of Surgical Oncology, Department of Surgery
| | - Umut Sarpel
- From the Division of Surgical Oncology, Department of Surgery
| | - Spiros P Hiotis
- From the Division of Surgical Oncology, Department of Surgery
| | - Daniel M Labow
- From the Division of Surgical Oncology, Department of Surgery
| | - Sofya Pintova
- Division of Hematology and Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Noah A Cohen
- From the Division of Surgical Oncology, Department of Surgery
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4
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Vazzano J, Frankel WL, Wolfe AR, Williams TM, Chen W. Morphologic changes associated with neoadjuvant-treated pancreatic ductal adenocarcinoma and comparison of two tumor regression grading systems. Hum Pathol 2021; 109:1-11. [PMID: 33245985 DOI: 10.1016/j.humpath.2020.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 01/04/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is aggressive, with an overall five-year survival rate of 9%, and few patients are candidates for pancreatectomy at presentation. The role of neoadjuvant therapy (NAT) is evolving, especially for high-risk potentially resectable tumors. Owing to the increasing number of NAT resection specimens, we aim to characterize the histologic changes associated with NAT and to compare two tumor regression grading schemes. One hundred eighteen resections for PDAC were selected from the cases between 2011 and 2018, 59 not treated and 59 treated with NAT. All H&E stained tumor slides were reviewed for histologic changes and graded using the four-tier modified Ryan score (recommended by College of American Pathologists) and the three-tier MD Anderson (MDA) score. The histologic changes evaluated included blue/grey fibrosis, islet cell hyperplasia, dystrophic calcification, amyloid deposition, cholesterol clefts, nerve hypertrophy, elastotic stromal/vascular change, abscess formation, and eosinophilic tumor cell changes. There were statistically significant differences for dystrophic calcification, eosinophilic tumor cell changes, elastotic stromal/vascular change, islet cell hyperplasia, and nerve hypertrophy between the two groups, with these features seen more frequently in NAT cases. Blue/grey stromal fibrosis was present in all cases regardless of NAT, except few complete regression cases and one treated case with intraneural invasion only. Blue/grey fibrosis is a useful histologic visual clue to suggest the possibility of adjacent tumor in the majority of PDAC cases regardless of NAT. By Kaplan-Meier analysis, neither grading scheme correlated with overall survival in our cohort. However, the MDA score was significantly correlated with both time to primary tumor recurrence (p = 0.002) and time to distant recurrence (p = 0.04), whereas the modified Ryan score was not.
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Affiliation(s)
- Jennifer Vazzano
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Wendy L Frankel
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Adam R Wolfe
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Terence M Williams
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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5
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Hemmings C, Connor S. Pathological assessment of tumour regression following neoadjuvant therapy in pancreatic carcinoma. Pathology 2020; 52:621-626. [PMID: 32800331 DOI: 10.1016/j.pathol.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Pancreatic carcinoma is a relatively common malignancy with an overall poor prognosis which is somewhat improved in those patients for whom resection and adjuvant therapy is feasible. In recent years there has been a trend to administering neoadjuvant therapy (combination chemotherapy and/or chemoradiotherapy), followed by resection in patients who remain surgical candidates at the completion of this treatment. Advantages of a neoadjuvant approach may include greater likelihood of achieving complete resection with negative surgical margins, reduced treatment toxicity and greater cost effectiveness, as well as potentially sparing patients with rapidly progressive disease from major surgery. To gauge the tumour's response to preoperative therapy, and to compare the efficacy of different regimens, there is a need for a robust and reproducible system of assessing tumour regression in resection specimens. Several such systems have been proposed, but there is generally a lack of consensus as to which system is the 'best'. This review describes the evolution of a number of tumour regression grading systems which have been proposed, and discusses the relative merits and shortfalls of several of the most frequently applied schemata. Some problems common to many of these include poorly defined criteria, low interobserver reproducibility and a reliance on fibrosis as a surrogate for tumour kill, which may not be valid. Despite that, recent evidence suggests that the Dworak grading system (first developed for rectal cancer) may be useful in terms of both interobserver concordance and correlation with survival.
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Affiliation(s)
- Chris Hemmings
- Department of Anatomic Pathology, Canterbury Health Laboratories, Christchurch Central, New Zealand; Department of Pathology and Biomedical Science, University of Otago Medical School, Christchurch Central, New Zealand.
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Christchurch Central, New Zealand
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Müller PC, Frey MC, Ruzza CM, Nickel F, Jost C, Gwerder C, Hackert T, Z'graggen K, Kessler U. Neoadjuvant Chemotherapy in Pancreatic Cancer: An Appraisal of the Current High-Level Evidence. Pharmacology 2020; 106:143-153. [PMID: 32966993 DOI: 10.1159/000510343] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/20/2020] [Indexed: 01/11/2023]
Abstract
At the time of diagnosis, only about 20% of patients with pancreatic ductal adenocarcinoma (PDAC) have resectable disease. PDAC treatment necessitates a multidisciplinary approach, and adjuvant chemotherapy after upfront resection is an established means of preventing recurrence. Neoadjuvant chemotherapy (NAT), originally introduced to downstage tumor size, is nowadays more frequently used for selection of patients with favorable tumor biology and to control potential micrometastases. While NAT is routinely applied in locally advanced (LA) PDAC, there is increasing evidence demonstrating benefits of NAT in borderline resectable (BR) PDAC. The concept of NAT has recently been tested in resectable PDAC, but to date NAT has been restricted to clinical trials, as the data are limited and no clear benefits have yet been shown in this patient group. This review summarizes the current evidence for NAT in resectable, BR, and LA PDAC, with a focus on high-level evidence and randomized controlled trials.
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Affiliation(s)
- Philip C Müller
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Michael C Frey
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Pediatric Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Claudio M Ruzza
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Jost
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Gastroenterology, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Christoph Gwerder
- Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Oncology, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Kaspar Z'graggen
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland, .,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland,
| | - Ulf Kessler
- Department of Surgery, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Swiss Pancreas Center, Hirslanden Klinik Beau-Site, Bern, Switzerland.,Department of Pediatric Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
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7
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Cools KS, Sanoff HK, Kim HJ, Yeh JJ, Stitzenberg KB. Impact of neoadjuvant therapy on postoperative outcomes after pancreaticoduodenectomy. J Surg Oncol 2018; 118:455-462. [PMID: 30114330 DOI: 10.1002/jso.25183] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical resection provides the only potentially curative treatment of pancreatic cancer. Neoadjuvant chemotherapy and/or radiation (NAT) is used to downstage patients with borderline resectable tumors. The objective of this study was to examine the postoperative morbidity and mortality of NAT after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA). METHODS Using the American College of Surgeons-National Surgical Quality Improvement Project Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA from 2014 to 2015. Patients were grouped by receipt of NAT 90 days before PD. Bivariable and multivariable analyses was used to compare postoperative outcomes. RESULTS A total of 3748 patients with PDA underwent PD; 926 (24.7%) received NAT. Those in the NAT group had more major vein resections, and longer operating times (all P < 0.001). On pathologic staging, those in the NAT group had smaller tumors (T1, 10.9% vs 5.1%; P < 0.001) and fewer nodes positive (N0, 49% vs 28%; P < 0.001). There were no differences in 30-day postoperative mortality or overall complications. On multivariable analysis, patients who received NAT had a lower likelihood of pancreatic fistula (OR, 0.67; P < 0.001). CONCLUSION NAT does not increase the overall postoperative morbidity or mortality of PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.
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Affiliation(s)
- Katherine S Cools
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hanna K Sanoff
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jen Jen Yeh
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Karyn B Stitzenberg
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Lee SM, Katz MH, Liu L, Sundar M, Wang H, Varadhachary GR, Wolff RA, Lee JE, Maitra A, Fleming JB, Rashid A, Wang H. Validation of a Proposed Tumor Regression Grading Scheme for Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy as a Prognostic Indicator for Survival. Am J Surg Pathol 2016; 40:1653-1660. [PMID: 27631521 PMCID: PMC5178828 DOI: 10.1097/pas.0000000000000738] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neoadjuvant therapy has been increasingly used to treat patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC). Although the College of American Pathologists (CAP) grading scheme for tumor response in posttherapy specimens has been used, its clinical significance has not been validated. Previously, we proposed a 3-tier histologic tumor regression grading (HTRG) scheme (HTRG 0, no viable tumor; HTRG 1, <5% viable tumor cells; HTRG 2, ≥5% viable tumor cells) and showed that the 3-tier HTRG scheme correlated with prognosis. In this study, we sought to validate our proposed HTRG scheme in a new cohort of 167 consecutive PDAC patients who completed neoadjuvant therapy and pancreaticoduodenectomy. We found that patients with HTRG 0 or 1 were associated with a lower frequency of lymph node metastasis (P=0.004) and recurrence (P=0.01), lower ypT (P<0.001) and AJCC stage (P<0.001), longer disease-free survival (DFS, P=0.004) and overall survival (OS, P=0.02) than those with HTRG 2. However, there was no difference in either DFS or OS between the groups with CAP grade 2 and those with CAP grade 3 (P>0.05). In multivariate analysis, HTRG grade 0 or 1 was an independent prognostic factor for better DFS (P=0.03), but not OS. Therefore we validated the proposed HTRG scheme from our previous study. The proposed HTRG scheme is simple and easy to apply in practice by pathologists and might be used as a successful surrogate for longer DFS in patients with potentially resectable PDAC who completed neoadjuvant therapy and surgery.
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Affiliation(s)
- Sun Mi Lee
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Matthew H. Katz
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Li Liu
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Manonmani Sundar
- Department of Translational Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Hua Wang
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Gauri R. Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Robert A. Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Anirban Maitra
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
- Department of Translational Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Jason B. Fleming
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Asif Rashid
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
| | - Huamin Wang
- Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
- Department of Translational Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030
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9
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Balaj C, Ayav A, Oliver A, Jausset F, Sellal C, Claudon M, Laurent V. CT imaging of early local recurrence of pancreatic adenocarcinoma following pancreaticoduodenectomy. Abdom Radiol (NY) 2016; 41:273-82. [PMID: 26867909 DOI: 10.1007/s00261-015-0564-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The objectives of this retrospective study were to describe the characteristics and topography of pancreatic ductal adenocarcinoma and its early local recurrence after pancreaticoduodenectomy and identify predictive factors of local early recurrence by imaging computed tomography (CT). METHODS The institutional review board approved the study and did require additional informed consent for reviewing the patients' medical records and images. Patients who underwent pancreaticoduodenectomy for ductal adenocarcinoma, a preoperative CT scan, and adequate postoperative CT were included. After postoperative imaging, correlations among clinical and histological characteristics and preoperative imaging were evaluated. RESULTS Among the 123 patients who underwent pancreaticoduodenectomy, 48 patients had sufficient follow-up imaging and were included in this study. A total of 33 patients experienced local early recurrence (Group 1), and 15 exhibited no local recurrence (Group 2). Local recurrence consisted of two types of anomalies: tissue nodules on surgical clips (94%) and peri-arterial encasement (82%). On preoperative imaging, the tumor diameter (p = 0.02) and the presence of a venous borderline resectable tumor (p < 0.0001) were predictive of local recurrence. CONCLUSIONS Tissue nodules on surgical clips and arterial encasement characterize early local recurrence, and nodules and encasement should not be considered common post-operative infiltration. The role of the radiologist is essential to assess the predictive factors of recurrence and to identify early local recurrence.
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Affiliation(s)
- Clémence Balaj
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France.
| | - Ahmet Ayav
- Department of HBP Surgery, Brabois Hospital, University of Nancy, Vandoeuvre les Nancy, France
| | - Alexandre Oliver
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France
| | - François Jausset
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France
| | - Caroline Sellal
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France
| | - Michel Claudon
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France
| | - Valérie Laurent
- Department of Radiology Adults, Brabois Hospital, University of Nancy, Rue du Morvan, 54 511, Vandoeuvre les Nancy, France
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10
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Eloubeidi MA, Decker GA, Chandrasekhara V, Chathadi KV, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley K, Hwang JH, Jue TL, Lightdale JR, Pasha SF, Saltzman JR, Sharaf R, Shergill AK, Cash BD, DeWitt JM. The role of endoscopy in the evaluation and management of patients with solid pancreatic neoplasia. Gastrointest Endosc 2016; 83:17-28. [PMID: 26706297 DOI: 10.1016/j.gie.2015.09.009] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023]
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11
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The effects of neoadjuvant chemoradiation on pancreaticoduodenectomy—the American College of Surgeon's National Surgical Quality Improvement Program analysis. J Surg Res 2015; 196:67-73. [DOI: 10.1016/j.jss.2015.01.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 01/20/2015] [Accepted: 01/23/2015] [Indexed: 02/06/2023]
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Verbeke C, Löhr M, Karlsson JS, Del Chiaro M. Pathology reporting of pancreatic cancer following neoadjuvant therapy: challenges and uncertainties. Cancer Treat Rev 2015; 41:17-26. [PMID: 25434282 DOI: 10.1016/j.ctrv.2014.11.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/07/2014] [Accepted: 11/08/2014] [Indexed: 12/22/2022]
Abstract
An increasing number of studies investigate the use of neoadjuvant treatment for ductal adenocarcinoma of the pancreas. While a strong rationale supports this approach, study results are difficult to interpret and compare due to marked variance in multiple aspects of study design and performance. Divergence in pathology examination and reporting as a cause for heterogeneity and incomparability of study results has not been brought into this discussion yet, despite the fact that several key outcome measures for neoadjuvant treatment are pathology-based. This article discusses areas of controversy and difficulty regarding the evaluation of the extent of residual tumour tissue, grading of tumour regression and assessment of the margins, and explains the important clinical implications of the present uncertainty and divergence in pathology practice.
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Affiliation(s)
- C Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden; Department of Pathology & Cytology, Karolinska University Hospital, Hälsovägen, 141 86 Stockholm, Sweden.
| | - M Löhr
- Gastrocentrum, Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden.
| | - J Severin Karlsson
- Department of Pathology & Cytology, Karolinska University Hospital, Hälsovägen, 141 86 Stockholm, Sweden.
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden.
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13
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Mian OY, Ram AN, Tuli R, Herman JM. Management options in locally advanced pancreatic cancer. Curr Oncol Rep 2014; 16:388. [PMID: 24740136 DOI: 10.1007/s11912-014-0388-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pancreatic ductal adenocarcinoma is a highly lethal cancer that is rarely curable at the time of presentation. Unfortunately, most patients are diagnosed with either metastatic or locally advanced disease, which is not amenable to surgery owing to the high likelihood of incomplete resection. Given the generally poor prognosis with propensity for metastatic failure greater than that for local failure, treatment options are variable, and include chemotherapy, radiotherapy, targeted therapies, and combinations thereof. This review summarizes the current evidence for definitive management of locally advanced pancreatic adenocarcinoma, as well as the role of palliative therapies. Future directions, including the development of predictive biomarkers and novel systemic agents, are also discussed.
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Affiliation(s)
- Omar Y Mian
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, 401 North Broadway, Weinberg Suite, 1440, Baltimore, MD, 21231, USA
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Kobayashi M, Mizuno S, Murata Y, Kishiwada M, Usui M, Sakurai H, Tabata M, Ii N, Yamakado K, Inoue H, Shiraishi T, Yamada T, Isaji S. Gemcitabine-based chemoradiotherapy followed by surgery for borderline resectable and locally unresectable pancreatic ductal adenocarcinoma: significance of the CA19-9 reduction rate and intratumoral human equilibrative nucleoside transporter 1 expression. Pancreas 2014; 43:350-60. [PMID: 24622063 PMCID: PMC4210173 DOI: 10.1097/mpa.0000000000000059] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 09/22/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the efficacy of gemcitabine-based chemoradiotherapy followed by surgery (gem-CRTS) for pancreatic ductal adenocarcinoma (PDAC) for borderline resectable (BR) and locally unresectable (UR) tumors. METHODS One hundred patients with PDAC who underwent the gem-CRTS protocol were classified into 3 groups, namely, resectable (R; 14), BR (44), and UR (42). After chemoradiotherapy, the patients were reassessed for curative-intent resection. RESULTS At reassessment, distant metastases became apparent in 27% of R patients, in 12% of BR patients, and in 18% of UR patients. The multivariate analysis of preoperative factors indicated that the CA19-9 reduction rate was an independent prognostic factor in the BR group. Among reassessed patients, the resection rate was 63.6% in R, 83.7% in BR, and 50.0% in UR patients. In 63 patients that underwent curative-intent resection, the 3-year survival rate was 83.3% in R, 33.0% in BR, and 7.8% in UR patients. Using multivariate analysis, the independent prognostic factor was found to be the surgical margin in BR patients and human equilibrative nucleoside transporter 1 expression in UR patients. CONCLUSIONS We consider that our gem-CRTS protocol, even for locally UR PDAC, allows for the identification of candidates for aggressive resection at the time of reassessment and improved prognosis in the patients with positive human equilibrative nucleoside transporter 1 expression.
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Affiliation(s)
- Motoyuki Kobayashi
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Shugo Mizuno
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Yasuhiro Murata
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masashi Kishiwada
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masanobu Usui
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Hiroyuki Sakurai
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Masami Tabata
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Noriko Ii
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Koichiro Yamakado
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Hiroyuki Inoue
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Taizo Shiraishi
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Tomomi Yamada
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
| | - Shuji Isaji
- From the Departments of *Hepatobiliary Pancreatic and Transplant Surgery, †Radiology, ‡Gastroenterology and Hepatology, and §Pathology, and ∥Translational Medical Science, Mie University School of Medicine, Mie, Japan
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15
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Rose JB, Rocha FG, Alseidi A, Biehl T, Moonka R, Ryan JA, Lin B, Picozzi V, Helton S. Extended neoadjuvant chemotherapy for borderline resectable pancreatic cancer demonstrates promising postoperative outcomes and survival. Ann Surg Oncol 2014; 21:1530-7. [PMID: 24473642 DOI: 10.1245/s10434-014-3486-z] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimum approach to neoadjuvant therapy for patients with borderline resectable pancreatic cancer is undefined. Herein we report the outcomes of an extended neoadjuvant chemotherapy regimen in patients presenting with borderline resectable adenocarcinoma of the pancreatic head. METHODS Patients identified as having borderline resectable pancreatic head cancer by American Hepato-Pancreato-Biliary Association/Society of Surgical Oncology consensus criteria from 2008 to 2012 were tracked in a prospectively maintained registry. Included patients were initiated on a 24-week course of neoadjuvant chemotherapy. Medically fit patients who completed neoadjuvant treatment without radiographic progression were offered resection with curative intent. Clinicopathologic variables and surgical outcomes were collected retrospectively and analyzed. RESULTS Sixty-four patients with borderline resectable pancreatic cancer started neoadjuvant therapy. Thirty-nine (61 %) met resection criteria and underwent operative exploration with curative intent, and 31 (48 %) were resected. Of the resected patients, 18 (58 %) had positive lymph nodes, 15 (48 %) required en-bloc venous resection, 27 (87 %) had a R0 resection, and 3 (10 %) had a complete pathologic response. There were no postoperative deaths at 90 days, 16 % of patients had a severe complication, and the 30-day readmission rate was 10 %. The median overall survival of all 64 patients was 23.6 months, whereas that of unresectable patients was 15.4 months. Twenty-five of the resected patients (81 %) are still alive at a median follow-up of 21.6 months. CONCLUSIONS Extended neoadjuvant chemotherapy is well tolerated by patients with borderline resectable pancreatic head adenocarcinoma, selects a subset of patients for curative surgery with low perioperative morbidity, and is associated with favorable survival.
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Affiliation(s)
- J Bart Rose
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
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Bold RJ. Re: CA 19-9 in potentially resectable pancreatic cancer: perspective to adjust surgical and preoperative therapy. Ann Surg Oncol 2013; 20:2108-10. [PMID: 23563959 DOI: 10.1245/s10434-012-2820-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
OBJECTIVE Pancreatic cancer continues to have a poor prognosis despite impressive improvements in the outcomes of many other types of cancer, often because most pancreatic neoplasms are found to be unresectable at diagnosis. The purpose of this review is to provide an overview of pancreatic cancer and the role of modern imaging in its diagnosis and management with an emphasis on (18)F-FDG PET/CT fusion imaging. CONCLUSION Multimodality imaging is critical in the diagnosis and management of pancreatic cancer. PET/CT is increasingly viewed as a useful, accurate, and cost-effective modality in diagnosing and managing pancreatic cancer, but further studies are warranted. Early data suggest that contrast-enhanced PET/CT performed with modern PET/CT scanners yields high-resolution anatomic information for surgical and radiotherapeutic planning and functional information for whole-body staging in the care of patients with this disease.
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18
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Heinemann V. Treatment of locoregional disease: adjuvant versus neoadjuvant. Ann Oncol 2012; 23 Suppl 10:x141-7. [DOI: 10.1093/annonc/mds312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Crippa S, Partelli S, Zamboni G, Barugola G, Capelli P, Inama M, Bassi C, Pederzoli P, Falconi M. Poorly differentiated resectable pancreatic cancer: is upfront resection worthwhile? Surgery 2012; 152:S112-9. [PMID: 22766365 DOI: 10.1016/j.surg.2012.05.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Poorly differentiated, resectable pancreatic ductal adenocarcinoma is associated with early recurrence and may benefit from neoadjuvant treatment. The aim of this study was to evaluate clinicopathologic characteristics and survival of patients with resectable pancreatic ductal adenocarcinoma according to histologic grading. METHODS A total of 502 patients who underwent resection for pancreatic ductal adenocarcinoma between 1990 and 2008 were analyzed via the use of different histologic grading. RESULTS Well-differentiated (G1), moderately differentiated (G2), and poorly differentiated (G3) pancreatic ductal adenocarcinomas were found in 23 (4.5%), 310 (62%), and 169 (33.5%) patients. Adjuvant therapy, N status, grading, and R status were independent predictors of disease-specific survival for the entire cohort, with 1- and 5-year disease-specific survival rates of 81% and 21%, respectively. Only the presence of symptoms was a significant clinical predictor of G3 status (P = .035). G3 neoplasms were characterized by a greater rate of lymph node metastases, microvascular/perineural invasion, and R2 resections. Median disease-specific survival was 77, 26, and 20 months for G1, G2, and G3 neoplasms (P < .0001). Median disease-free survival was 63, 14, and 9 months for G1, G2, and G3 pancreatic ductal adenocarcinoma (P < .0001). Adjuvant therapy improved disease-specific survival in G2 (P < .04) and G3 (P < .0001) pancreatic ductal adenocarcinoma, with a greater survival benefit for G3 neoplasms (hazard ratio: 1.334 vs 2.116). CONCLUSION G3 pancreatic ductal adenocarcinoma is associated with a lesser rate of disease-free survival after resection and with the presence of other poor prognostic factors. The benefit of adjuvant therapy is greater in G3 than in G1 and G2 neoplasms. On the basis of these findings, patients with resectable G3 PDAC can be considered as possible targets for neoadjuvant treatment.
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Affiliation(s)
- Stefano Crippa
- Department of Surgery, University of Verona, Verona, Italy.
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20
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Hsu CC, Wolfgang CL, Laheru DA, Pawlik TM, Swartz MJ, Winter JM, Robinson R, Edil BH, Narang AK, Choti MA, Hruban RH, Cameron JL, Schulick RD, Herman JM. Early mortality risk score: identification of poor outcomes following upfront surgery for resectable pancreatic cancer. J Gastrointest Surg 2012; 16:753-61. [PMID: 22311282 PMCID: PMC3561732 DOI: 10.1007/s11605-011-1811-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 12/28/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying pancreatic cancer patients at high risk of early mortality following pancreaticoduodenectomy (PD) is important for treatment decisions in a multidisciplinary setting. This study examines the preoperative predictors of early mortality following PD and combines these variables into an early mortality risk score (EMRS). METHODS Medical records of patients who underwent PD for pancreatic adenocarcinoma at the Johns Hopkins Hospital between 30 August 1993 and 28 February 2005 were reviewed. Cox proportional hazards analysis was performed to identify predictors of early mortality, defined as death at 9 and 12 months. EMRS was constructed from univariate associated risk factors (age >75 years, tumor size ≥ 3 cm, poor differentiation, co-morbid diseases) with each factor assigned 1 point (range of 0-4). EMRS was evaluated as an independent predictor of death at 9 and 12 months. RESULTS On univariate analysis, risk factors for death at 9 months included age ≥ 75 years (RR, 1.6; p = .009), comorbid disease (RR, 1.5; p = 0.020), tumor ≥ 3 cm (RR, 1.4; P = 0.050), and poor differentiation (RR, 2.1; P < 0.001). EMRS was associated with early mortality among those who did (p = 0.038) and did not receive adjuvant treatment (p < 0.001). A modified EMRS without tumor differentiation was also associated with early mortality (p < 0.001). Results persisted when reanalyzed using death at 12 months. CONCLUSIONS EMRS may identify patients at risk of early mortality following PD who may be candidates for alternatively sequenced treatment protocols. Prospective validation of this EMRS is needed.
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Affiliation(s)
- Charles C. Hsu
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA. The Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher L. Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel A. Laheru
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J. Swartz
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Jordan M. Winter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raymond Robinson
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Barish H. Edil
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K. Narang
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Michael A. Choti
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H. Hruban
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Schulick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M. Herman
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Coppola R. Pancreas cancer treatment: A surgeon's perspective today. Int J Surg 2012; 10:187-9. [DOI: 10.1016/j.ijsu.2012.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 03/12/2012] [Indexed: 12/21/2022]
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Andriulli A, Festa V, Botteri E, Valvano MR, Koch M, Bassi C, Maisonneuve P, Sebastiano PD. Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies. Ann Surg Oncol 2011; 19:1644-62. [PMID: 22012027 DOI: 10.1245/s10434-011-2110-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term prognosis for localized pancreatic cancer remains poor. We sought to assess the benefit of neoadjuvant/preoperative chemotherapy with or without radiotherapy. METHODS Prospective studies where gemcitabine with or without radiotherapy was provided before surgery in patients with initially resectable or unresectable disease were reviewed by meta-analysis. Primary outcome was survival, and secondary outcomes were tumor response after therapy, toxicity, surgical exploration, and resection rates. RESULTS Twenty independent studies with 707 participants were included, 366 with resectable lesions and 341 with unresectable lesions. Seven studies were phase I/II trials, 10 phase II, and 3 prospective cohort studies. Estimated 1- and 2-year survival probabilities after resection were 91.7% (95% confidence interval [CI] 75-100) and 67.2% (95% CI 38-87) for initially resectable patients, and 86.3% (95% CI 78-100) and 54.2% (95% CI 25-100) for initially unresectable patients. The complete/partial response rate was 12% (95% CI 4-23) and 27% (95% CI 18-38) in resectable and unresectable lesions, respectively. The rate of treatment-related grade 3-4 toxicity was 31% (95% CI 21-42). Of resectable patients evaluable after restaging, 91% (95% CI 83-97) underwent surgery, and 82% (95% CI 65-95) of explored patients underwent resection. R0 resections amounted to 89% (95% CI 83-94). Of unresectable patients evaluable after restaging, 39% (95% CI 28-50) underwent surgery, and 68% (95% CI 53-82) of explored patients were resected, with 60% (95% CI 50-71) R0 resections. CONCLUSIONS Current analysis provides marginal support to the assumed benefits of neoadjuvant therapies for patients with resectable cancer, and indicates a potential advantage only for a minority of those with unresectable lesions.
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Affiliation(s)
- Angelo Andriulli
- Division of Gastroenterology, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Italy
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Turrini O, Ychou M, Moureau-Zabotto L, Rouanet P, Giovannini M, Moutardier V, Azria D, Delpero JR, Viret F. Neoadjuvant docetaxel-based chemoradiation for resectable adenocarcinoma of the pancreas: New neoadjuvant regimen was safe and provided an interesting pathologic response. Eur J Surg Oncol 2010; 36:987-92. [DOI: 10.1016/j.ejso.2010.07.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 07/12/2010] [Accepted: 07/15/2010] [Indexed: 01/18/2023] Open
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Abstract
Borderline resectable pancreatic cancer is an emerging stage of disease defined by computed tomogrpahy criteria, patient (Katz type B), or disease characteristics (Katz type C). These patients are particularly well suited to a surgery-last strategy with induction therapy consisting of chemotherapy (gemcitabine alone or in combination) followed by chemoradiation. With appropriate selection and preoperative planning, many patients with borderline resectable disease derive clinical benefit from multimodality therapy. The use of a standardized system for the staging of localized pancreatic cancer avoids indecision and allows for the optimal treatment of all patients guided by the extent of their disease. In this article, 2 case reports are presented, and the term borderline resectable pancreatic cancer is discussed. The advantages of neoadjuvant therapy and surgery are also discussed.
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Le Scodan R, Mornex F, Girard N, Mercier C, Valette PJ, Ychou M, Bibeau F, Roy P, Scoazec JY, Partensky C. Preoperative chemoradiation in potentially resectable pancreatic adenocarcinoma: feasibility, treatment effect evaluation and prognostic factors, analysis of the SFRO-FFCD 9704 trial and literature review. Ann Oncol 2009; 20:1387-96. [DOI: 10.1093/annonc/mdp015] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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The integration of chemoradiation in the care of patient with localized pancreatic cancer. Cancer Radiother 2009; 13:123-43. [PMID: 19167921 DOI: 10.1016/j.canrad.2008.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 10/23/2008] [Accepted: 11/18/2008] [Indexed: 02/03/2023]
Abstract
The use of chemoradiation for patients with localized pancreatic cancer is controversial. Although some randomized trials have indicated that chemoradiation improves the median survival of patients with locally advanced as well as resected pancreatic cancer, other more recent trials have called into question the role of chemoradiation and have supported the use of chemotherapy. In the adjuvant setting, the high local tumor recurrence/persistence rate in all trials probably reflects the inclusion of patients with incompletely resected tumors, whose prognosis is similar to the prognosis of patients with locally advanced who do not undergo resection, making these trials difficult to interpret. More precise clinical staging and selection of patients appropriate for surgical resection is an important goal. The keys to the successful integration of radiotherapy in the care of patients with localized pancreatic cancer are selection, sequencing and smaller treatment volumes. A strategy of initial chemotherapy followed by consolidation with a well-tolerated chemoradiation regimen both in the adjuvant and locally advanced settings maximizes benefits of both treatment options, which are in fact complementary. Herein, we discuss the rationale for this approach as well as the ongoing investigation of novel radiation approaches designed to enhance outcome through the molecular and physical targeting of disease as well as the investigation of neoadjuvant chemoradiation in radiographically resectable and borderline resectable pancreatic cancer.
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Abstract
OBJECTIVES The results of surgical therapy alone for pancreatic cancer are disappointing. We explored surgical results after neoadjuvant chemoradiation therapy (NACRT) for patients with pancreatic cancer that extended beyond the pancreas. METHODS Sixty-eight consecutive patients with pancreatic cancer who underwent pancreatic resection were included. Twenty-seven patients underwent surgical resection after NACRT (NACRT group). The other 41 patients were classified as surgery-alone group. Surgical results were compared in patients who underwent curative resection (R0/1) who were followed up for at least 25 months and underwent no adjuvant therapy. RESULTS A lower frequency of lymph node metastasis was observed in the NACRT group (P < 0.05). The frequency of residual tumor grading in the NACRT group was significantly different from that in surgery-alone (R0/1/2%, 52/15/33 vs 22/51/27; P = 0.0040). In R0/1 cases, overall survival and disease-free survival rates in the NACRT group (n = 18) were significantly longer than in surgery-alone (n = 30, P < 0.05). The rate of local recurrence in the NACRT group was significantly less than in surgery-alone (11% vs 47%, P = 0.0024). CONCLUSIONS This single-institution experience indicates that NACRT is able to increase the resectability rate with clear margins and to decrease the rate of metastatic lymph nodes, resulting in improved prognosis of curative cases with pancreatic cancer that extended beyond the pancreas.
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Kakoza RM, Vollmer CM, Stuart KE, Takoudes T, Hanto DW. Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review. J Gastrointest Surg 2009; 13:535-41. [PMID: 18815844 DOI: 10.1007/s11605-008-0697-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/08/2008] [Indexed: 01/31/2023]
Abstract
Pancreatic cancer is the fifth most common cause of cancer-related death in the USA. However, the antepartum diagnosis of pancreatic adenocarcinoma in the pregnant patient is exceedingly rare, with only six cases previously reported in the literature. Optimizing both maternal and fetal health outcomes is particularly challenging when surgical procedures are necessary for staging and/or therapeutic purposes--as these interventions often pose significant risks to both the mother and the developing fetus. In this article, we report a case of pancreatic adenocarcinoma diagnosed during pregnancy and review the literature on the management issues confronted in this unique clinical situation.
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Affiliation(s)
- Rose M Kakoza
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Evans DB, Varadhachary GR, Crane CH, Sun CC, Lee JE, Pisters PWT, Vauthey JN, Wang H, Cleary KR, Staerkel GA, Charnsangavej C, Lano EA, Ho L, Lenzi R, Abbruzzese JL, Wolff RA. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26:3496-502. [PMID: 18640930 DOI: 10.1200/jco.2007.15.8634] [Citation(s) in RCA: 533] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE We conducted a phase II trial to assess the outcomes of patients who received preoperative gemcitabine-based chemoradiation and pancreaticoduodenectomy (PD) for stage I/II pancreatic adenocarcinoma. PATIENTS AND METHODS Eligible patients with pancreatic head/uncinate process adenocarcinoma and radiographically defined potentially resectable disease received chemoradiation with 7 weekly intravenous (IV) infusions of gemcitabine (400 mg/m(2) IV over 30 minutes) plus radiation therapy (30 Gy in 10 fractions over 2 weeks). Patients underwent restaging 4 to 6 weeks after completion of chemoradiation and, in the absence of disease progression, were taken to surgery. RESULTS The study enrolled 86 patients. At the time of restaging, disease progression or a decline in performance status precluded 13 patients from surgery. Seventy-three (85%) of 86 patients were taken to surgery, extrapancreatic disease was found in nine, and 64 (74%) of 86 underwent a successful PD. Median overall survival (86 patients) was 22.7 months with a 27% 5-year survival. Median survival was 34 months for the 64 patients who underwent PD and 7 months for the 22 unresected patients (P < .001). The 5-year survival for those who did and did not undergo PD was 36% and 0%, respectively. CONCLUSION Preoperative gemcitabine-based chemoradiation followed by restaging and evaluation for surgery separated the study population into two different subsets: patients likely to benefit from PD (n = 64) and those in whom surgery would be unlikely to provide clinical benefit (n = 22). Furthermore, the encouraging overall survival observed in this large trial supports the continued investigation of gemcitabine-based preoperative therapy in resectable pancreatic cancer.
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Affiliation(s)
- Douglas B Evans
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM. Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Ann Surg Oncol 2008; 15:2081-8. [PMID: 18461404 DOI: 10.1245/s10434-008-9929-7] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 03/26/2008] [Accepted: 03/27/2008] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the impact of a multidisciplinary clinic on the clinical care recommendations of patients with pancreatic cancer compared with the recommendations the patients received prior to review by the multidisciplinary tumor board. METHODS The records of 203 consecutive patients referred to the Johns Hopkins pancreatic multidisciplinary clinic were prospectively collected from November 2006 to October 2007. Cross-sectional imaging, pathology, and medical history were evaluated by a panel of medical/radiation oncologists, surgical oncologists, pathologists, diagnostic radiologists, and geneticists. Alterations in treatment recommendations between the outside institution and the multidisciplinary clinic were recorded and compared. RESULTS On presentation, the outside computed tomography (CT) report described locally advanced/unresectable disease (34.9%), metastatic disease (17.7%), and locally advanced disease with metastasis (1.1%). On review of submitted imaging and imaging performed at Hopkins, 38 out of 203 (18.7%) patients had a change in the status of their clinical stage. Review of the histological slides by dedicated pancreatic pathologists resulted in changes in the interpretation for 7 of 203 patients (3.4%). Overall, 48 out of 203 (23.6%) patients had a change in their recommended management based on clinical review of their case by the multidisciplinary tumor board. Enrollment into the National Familial Pancreas Tumor Registry increased from 52 out of 106 (49.2%) patients in 2005 to 158 out of 203 (77.8%) with initiation of the multidisciplinary clinic. CONCLUSION The single-day pancreatic multidisciplinary clinic provided a comprehensive and coordinated evaluation of patients that led to changes in therapeutic recommendations in close to one-quarter of patients.
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Affiliation(s)
- Timothy M Pawlik
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
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Neoadjuvant and adjuvant strategies for pancreatic cancer. Eur J Surg Oncol 2008; 34:297-305. [DOI: 10.1016/j.ejso.2007.07.204] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 07/20/2007] [Indexed: 01/12/2023] Open
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Desai SP, Ben-Josef E, Normolle DP, Francis IR, Greenson JK, Simeone DM, Chang AE, Colletti LM, Lawrence TS, Zalupski MM. Phase I Study of Oxaliplatin, Full-Dose Gemcitabine, and Concurrent Radiation Therapy in Pancreatic Cancer. J Clin Oncol 2007; 25:4587-92. [DOI: 10.1200/jco.2007.12.0592] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PurposeTo determine a biweekly dose of oxaliplatin for combination with full-dose gemcitabine and concurrent radiation therapy (RT) in pancreatic cancer.Patients and MethodsPatients with previously untreated pancreatic cancer received gemcitabine days 1, 8, and 15, and oxaliplatin days 1 and 15, repeated at 28-day intervals. RT (27 Gy in 1.8-Gy fractions) was administered during cycle 1. Dose escalation was guided using the time-to-event continuous reassessment method. Dose levels 1 to 4 included gemcitabine 1 g/m2intravenously (IV) during 30 minutes and oxaliplatin 40, 55, 70, or 85 mg/m2IV during 90 minutes, respectively; for dose levels 5 and 6, oxaliplatin dose remained 85 mg/m2but infusion time for gemcitabine 1 g/m2was increased to 65 or 100 minutes, respectively. The trial objective was to determine the dose level associated with dose-limiting toxicity (DLT) through cycle 2 in ≤ 20% of patients.ResultsForty-four patients were enrolled (median age, 64 years; 27 men, 17 women) with resectable (n = 12), unresectable (n = 29), and metastatic (n = 3) pancreatic cancer. Ten DLTs occurred in nine patients, including grade 4 platelets (n = 4), decline in performance status (n = 2), GI bleeding (n = 2), and GI toxicity (n = 2). The estimated probability of DLT for dose level 3 was .21 (90% posterior probability interval [PI], .12 to .33); for dose level 4, the estimated probability was .24 (90% PI, .14 to .36).ConclusionThe addition of oxaliplatin 85 mg/m2days 1 and 15 to full-dose gemcitabine and radiation therapy was well tolerated. On the basis of these results, a multi-institutional neoadjuvant phase II study in resectable pancreatic cancer is planned.
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Affiliation(s)
- Sameer P. Desai
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Edgar Ben-Josef
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Daniel P. Normolle
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Isaac R. Francis
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Joel K. Greenson
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Diane M. Simeone
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Alfred E. Chang
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Lisa M. Colletti
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Theodore S. Lawrence
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Mark M. Zalupski
- From the Division of Hematology/Oncology, Department of Radiation Oncology, Department of Radiology, Department of Pathology, and Department of Surgery, University of Michigan, Ann Arbor, MI
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Reyes-Gibby CC, Chan W, Abbruzzese JL, Xiong HQ, Ho L, Evans DB, Varadhachary G, Bhat S, Wolff RA, Crane C. Patterns of self-reported symptoms in pancreatic cancer patients receiving chemoradiation. J Pain Symptom Manage 2007; 34:244-52. [PMID: 17513082 PMCID: PMC2084477 DOI: 10.1016/j.jpainsymman.2006.11.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 11/13/2006] [Accepted: 11/29/2006] [Indexed: 01/08/2023]
Abstract
Pancreatic cancer is a lethal disease characterized by multiple disease-related symptoms. Chemoradiation therapy is a standard of treatment for locally advanced pancreatic cancer. Although shown to prolong survival, there is little information about treatment-related symptoms or the palliative benefits of chemoradiation. We assessed symptoms of patients with locally advanced pancreatic cancer receiving chemoradiation to determine the prevalence, and co-occurrence, of symptoms and to identify the extent to which symptoms interfered with function. Forty-eight patients were treated with chemoradiation on a Phase I protocol. Patients received radiotherapy (50.4 Gy in 28 fractions), capecitabine (median dose 825 mg/m(2) twice daily), and bevacizumab (2.5-10 mg/kg). Symptom severity and its interference with function were prospectively assessed (at presentation, during, and after chemoradiation) in 43 consenting patients using the M.D. Anderson Symptom Inventory. Results showed that 95% of patients reported at least one of the 13 symptoms assessed at presentation. The most commonly reported symptoms of moderate to severe (>or=5 on a 0-10 scale) intensity at presentation were lack of appetite (24%), pain (19%), fatigue (19%), and sleep disturbance (10%). We observed an increase in patients reporting moderate to severe fatigue, nausea, and sleep disturbance during chemoradiation. McNemar tests for paired binary observations showed the proportion of patients reporting moderate to severe symptoms significantly (P<0.001) decreased after chemoradiation at 94 days follow-up (lack of appetite=7%, pain=7%, fatigue=13%, sleep disturbance=7%). This study demonstrates the feasibility and usefulness of symptom assessment in chemoradiation protocols. Future studies with larger cohorts are needed to further characterize multiple symptoms associated with chemoradiation.
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Affiliation(s)
- Cielito C Reyes-Gibby
- Department of Epidemiology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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Pappas S, Federle MP, Lokshin AE, Zeh HJ. Early detection and staging of adenocarcinoma of the pancreas. Gastroenterol Clin North Am 2007; 36:413-29, x. [PMID: 17533087 DOI: 10.1016/j.gtc.2007.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Early diagnosis is likely to improve the outcome and survival in patients who have pancreatic cancer. The sensitivity and specificity of current screening methods, however, limit their applicability to individuals at high risk for developing pancreatic cancer. Further development of serum markers may lead to improved diagnostic accuracy and allow screening to be implemented more broadly. Proteomic profiling and evaluation of panels of markers hold particular promise for the future. This article provides a review of current methods and results for the early detection and staging of pancreatic cancer, and discusses some potential areas for future development.
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Affiliation(s)
- Sam Pappas
- Division of Surgical Oncology, University of Pittsburgh, Suite 417 UPMC Cancer Pavilion 5150 Center Avenue, Pittsburgh, PA 15213, USA
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Abstract
No good evidence of benefit—trials needed
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Affiliation(s)
- J Kleeff
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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