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Nugent K, Mukherjee S, Teoh S, George B, Martin A, Gaya A, Aznar-Garcia L, Chu K, Robinson M, Maughan T, Good J. Stereotactic Magnetic Resonance-Guided Daily Adaptive SABR (SMART) for Localised Non-Metastatic Pancreatic Cancer: First Reported Clinical Outcomes From the UK. Clin Oncol (R Coll Radiol) 2024; 36:576-584. [PMID: 38902119 DOI: 10.1016/j.clon.2024.05.012] [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: 03/22/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024]
Abstract
AIMS Prognosis of locally advanced pancreatic cancer (LAPC) remains poor with limited therapeutic options. Radiation therapy in pancreatic cancer has been restricted by the disease's proximity to radiosensitive organs at risk (OAR). However, stereotactic magnetic resonance-guided adaptive radiation therapy (SMART) has demonstrated promise in delivering ablative doses safely. We sought to report clinical outcomes from a UK-based Compassionate Access Programme that provided access to SMART to patients with LAPC. MATERIALS AND METHODS This was a registry retrospective study conducted at a single centre with access to SMART. Patients with LAPC were treated with prescription dose of 40 Gy in 5 fractions. The planning objective was that 98% of PTV received ≥95% of the prescribed dose, prioritising duodenal, stomach and bowel UK SABR consortium constraints. Daily online adaptation was performed using magnetic resonance guidance and on-table re-optimisation. 0-3 months and > 3-month post-treatment-related toxicities, local progression-free survival, metastatic-free survival and overall survival were evaluated. RESULTS 55 patients were treated with SMART at our institution from 2020 to 2022. Median follow-up from date of diagnosis was 17 months (range 5-37 months). Median age was 69.87% of patients underwent induction chemotherapy. 71% of patients reported 0-1 grade acute toxicity only. No grade >3 acute toxicity was reported. 5 patients (9%) reported a grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal stricture). No grade >3 toxicity after 3 months was reported. 6 (10%) of patients had grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal haemorrhage). Median local PFS post diagnosis was 17 months (95% CI 15.3-18.7). Median OS post diagnosis was 19 months (95% CI 15.9-22.1). One-year local control post SMART was 65%. CONCLUSION This is the first UK-reported experience of MR-guided daily adaptive pancreatic SABR. SMART shows promise in delivering ablative doses with acceptable toxicity rates and good clinical outcomes.
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Affiliation(s)
- K Nugent
- Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK; GenesisCare UK, OX4 6LB, UK.
| | - S Mukherjee
- Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK; Department of Oncology, University of Oxford, OX3 7DQ, UK
| | - S Teoh
- Oxford University Hospitals NHS Foundation Trust, OX3 7LE, UK; Department of Oncology, University of Oxford, OX3 7DQ, UK
| | | | | | - A Gaya
- GenesisCare UK, OX4 6LB, UK
| | | | - K Chu
- Department of Oncology, University of Oxford, OX3 7DQ, UK
| | - M Robinson
- Department of Oncology, University of Oxford, OX3 7DQ, UK
| | - T Maughan
- Department of Oncology, University of Oxford, OX3 7DQ, UK
| | - J Good
- GenesisCare UK, OX4 6LB, UK
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Domagała-Haduch M, Gorzelak-Magiera A, Michalecki Ł, Gisterek-Grocholska I. Radiochemotherapy in Pancreatic Cancer. Curr Oncol 2024; 31:3291-3300. [PMID: 38920733 PMCID: PMC11202861 DOI: 10.3390/curroncol31060250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
Despite the advancements made in oncology in recent years, the treatment of pancreatic cancer remains a challenge. Five-year survival rates for this cancer do not exceed 10%. Among the reasons contributing to poor treatment outcomes are the oligosymptomatic course of the tumor, diagnostic difficulties due to the anatomical location of the organ, and the unique biological features of pancreatic cancer. The mainstay of treatment for resectable cancer is surgery and adjuvant chemotherapy. For unresectable and metastatic cancers, chemotherapy remains the primary method of treatment. At the same time, for about thirty years, there have been attempts to improve treatment outcomes by using radiotherapy combined with systemic treatment. Unlike chemotherapy, radiotherapy has no established place in the treatment of pancreatic cancer. This paper addresses the topic of radiotherapy in pancreatic cancer as a valuable method that can improve treatment outcomes alongside chemotherapy.
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Affiliation(s)
- Małgorzata Domagała-Haduch
- Department of Oncology and Radiotherapy, Medical University of Silesia, 40-514 Katowice, Poland; (A.G.-M.); (Ł.M.); (I.G.-G.)
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Omatsu R, Nakano Y, Esaka N, Moriyoshi K, Miyamoto S. Metastatic pancreatic cancer with multiple metastases confined to the large intestine: a case report and literature review. Clin J Gastroenterol 2024; 17:75-79. [PMID: 38038857 DOI: 10.1007/s12328-023-01878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/09/2023] [Indexed: 12/02/2023]
Abstract
The incidence and mortality rate of pancreatic cancer are increasing worldwide. Regional lymph nodes, liver, lung, and peritoneum are common sites of metastasis from pancreatic cancer, but the gastrointestinal tract is rare as a metastatic organ from pancreatic cancer. An 80-year-old man was referred to our department for a hypovascular pancreatic mass on contrast-enhanced computed tomography (CECT). Endoscopic ultrasound-guided fine needle aspiration revealed adenocarcinoma, and he was diagnosed with pancreatic cancer. No lymph nodes or distant metastases were detected by either CECT or gadolinium-enhanced magnetic resonance imaging, and we evaluated this case as borderline resectable. However, total colonoscopy for positive fecal occult blood tests revealed a reddish and hemorrhagic mucosal thickening in the ascending and sigmoid colon and rectum, which was inconsistent with primary colorectal cancer. Biopsy specimens from these sites revealed cytokeratin (CK)7-positive and CK20- and CDX2-negative adenocarcinoma, consistent with cancer of pancreatic origin. The patient underwent palliative chemotherapy with gemcitabine but died from COVID-19 infection eight months after diagnosis. Performing total colonoscopy as a preoperative screening is important for accurate cancer staging of patients with possible resectable pancreatic cancer.
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Affiliation(s)
- Risa Omatsu
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, Japan
| | - Yoshiko Nakano
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, Japan
| | - Naoki Esaka
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, Japan
| | - Koki Moriyoshi
- Department of Diagnostic Pathology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, Japan
| | - Shin'ichi Miyamoto
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, Japan.
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Pacella G, Brunese MC, D’Imperio E, Rotondo M, Scacchi A, Carbone M, Guerra G. Pancreatic Ductal Adenocarcinoma: Update of CT-Based Radiomics Applications in the Pre-Surgical Prediction of the Risk of Post-Operative Fistula, Resectability Status and Prognosis. J Clin Med 2023; 12:7380. [PMID: 38068432 PMCID: PMC10707069 DOI: 10.3390/jcm12237380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors. METHODS The PubMed database was searched for papers published in the English language no earlier than January 2018. RESULTS We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective. CONCLUSIONS It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.
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Affiliation(s)
- Giulia Pacella
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Maria Chiara Brunese
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | | | - Marco Rotondo
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Andrea Scacchi
- General Surgery Unit, University of Milano-Bicocca, 20126 Milan, Italy
| | - Mattia Carbone
- San Giovanni di Dio e Ruggi d’Aragona Hospital, 84131 Salerno, Italy;
| | - Germano Guerra
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
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Ishizaki A, Okuwaki K, Kida M, Imaizumi H, Iwai T, Yamauchi H, Kaneko T, Hasegawa R, Watanabe M, Kurosu T, Ishizaki J, Kusano C. Implication of Skeletal Muscle Loss in the Prognosis of Patients with Pancreatic Ductal Adenocarcinoma Receiving Chemotherapy. Intern Med 2023; 62:2783-2793. [PMID: 36792197 PMCID: PMC10602831 DOI: 10.2169/internalmedicine.0900-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/26/2022] [Indexed: 02/16/2023] Open
Abstract
Objective The effect of sarcopenia on the prognosis of patients undergoing chemotherapy for unresectable pancreatic ductal adenocarcinoma remains largely unexplored. In this retrospective study, we investigated the relationship between sarcopenia and the prognosis of patients receiving first-line nanoparticle albumin-bound paclitaxel plus gemcitabine for unresectable pancreatic ductal adenocarcinoma. Methods We enrolled 251 patients with unresectable metastatic or locally advanced pancreatic ductal adenocarcinoma who had received chemotherapy between January 2015 and December 2020 at Kitasato University Hospital. Univariate and multivariate analyses were performed using the stratified Cox proportional hazards model to determine variables significantly associated with the progression-free and overall survival. Propensity score matching was performed to mitigate selection bias effects. Results In the propensity score-matched cohort, the progression-free and overall survival were not significantly different between the sarcopenia and non-sarcopenia groups (p=0.335, and 0.679 respectively). The skeletal muscle index decreased by 4.4% and 6.5% in the sarcopenia and non-sarcopenia groups, respectively, during the early treatment phase (p=0.084). There were no significant differences between groups with regard to major adverse events or drug toxicity occurrences. Both the progression-free and overall survival were significantly shorter in the skeletal muscle index loss group than in the non-skeletal muscle index loss group (p=0.026 and 0.045, respectively). Conclusion Skeletal muscle index loss during the initial treatment phase may be an early marker for the long-term prognosis of patients receiving nanoparticle albumin-bound paclitaxel plus gemcitabine as first-line treatment for unresectable pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Ayana Ishizaki
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Toru Kaneko
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Rikiya Hasegawa
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Masafumi Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Takahiro Kurosu
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Junro Ishizaki
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
| | - Chika Kusano
- Department of Gastroenterology, Kitasato University School of Medicine, Japan
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Elkhamisy SA, Valentini C, Lattermann A, Radhakrishna G, Künzel LA, Löck S, Troost EGC. Normo- or Hypo-Fractionated Photon or Proton Radiotherapy in the Management of Locally Advanced Unresectable Pancreatic Cancer: A Systematic Review. Cancers (Basel) 2023; 15:3771. [PMID: 37568587 PMCID: PMC10416887 DOI: 10.3390/cancers15153771] [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: 06/08/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
LAPC is associated with a poor prognosis and requires a multimodal treatment approach. However, the role of radiation therapy in LAPC treatment remains controversial. This systematic review aimed to explore the role of proton and photon therapy, with varying radiation techniques and fractionation, in treatment outcomes and their respective toxicity profiles. METHODS Clinical studies published from 2012 to 2022 were systematically reviewed using PubMed, MEDLINE (via PubMed) and Cochrane databases. Different radiotherapy-related data were extracted and analyzed. RESULTS A total of 31 studies matched the inclusion criteria. Acute toxicity was less remarkable in stereotactic body radiotherapy (SBRT) compared to conventionally fractionated radiotherapy (CFRT), while in proton beam therapy (PBT) grade 3 or higher acute toxicity was observed more commonly with doses of 67.5 Gy (RBE) or higher. Late toxicity was not reported in most studies; therefore, comparison between groups was not possible. The range of median overall survival (OS) for the CFRT and SBRT groups was 9.3-22.9 months and 8.5-20 months, respectively. For the PBT group, the range of median OS was 18.4-22.3 months. CONCLUSION CFRT and SBRT showed comparable survival outcomes with a more favorable acute toxicity profile for SBRT. PBT is a promising new treatment modality; however, additional clinical studies are needed to support its efficacy and safety.
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Affiliation(s)
- Sally A. Elkhamisy
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Chiara Valentini
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Annika Lattermann
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Luise A. Künzel
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
| | - Steffen Löck
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Esther G. C. Troost
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- The Christie Hospital NHS Foundation Trust, Manchester M20 4BX, UK;
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, 01328 Dresden, Germany
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Lee M, Kang JS, Kim H, Kwon W, Lee SH, Ryu JK, Kim YT, Oh DY, Chie EK, Jang JY. Impact of conversion surgery on survival in locally advanced pancreatic cancer patients treated with FOLFIRINOX chemotherapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:111-121. [PMID: 34581022 DOI: 10.1002/jhbp.1050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Locally advanced (unresectable) pancreatic cancer (LAPC) is surgically unresectable and often treated with chemotherapy. Most previous studies, that have evaluated conversion surgery after chemotherapy, included heterogeneous patients and chemotherapy regimens, making it challenging to determine the impact of FOLFIRINOX. The present study evaluated the survival benefit of conversion surgery in patients with LAPC who received FOLFIRINOX chemotherapy, and analyzed the prognostic factors. METHODS Patients with LAPC who received FOLFIRINOX as first-line therapy for at least four cycles were included. During chemotherapy, surgical eligibility was determined based on radiologic and metabolic response to the treatment. Clinicopathologic characteristics were compared between the curative-intent surgery and non-resection groups, and the prognostic factors were analyzed. RESULTS A total of 279 patients were included. The rates of partial response (PR) and stable disease (SD) were 34.1% and 51.4%, respectively, and 16.8% patients underwent curative-intent surgery. The median survival was significantly longer in the resection group than in the non-resection group (56 vs 21 months, P < .001). In a multivariate analysis, curative-intent surgery (HR 0.260; P < .001) was the most important factor. CONCLUSIONS Conversion surgery after FOLFIRINOX chemotherapy effectively rescues patients with LAPC. Patients without progression after FOLFIRINOX could be considered as potential candidates for conversion surgery.
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Affiliation(s)
- Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Pacheco F, Luciano E, Hebert D, Marar O. Metastatic pancreatic adenocarcinoma presenting as large bowel obstruction: A case report. Int J Surg Case Rep 2022; 102:107801. [PMID: 36502659 PMCID: PMC9763373 DOI: 10.1016/j.ijscr.2022.107801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE The incidence of pancreatic cancer has gradually increased over the past decades. Metastatic pancreatic cancer to the colon is rare with only seven cases reported. Symptomatic metastasis to the colon as the initial presentation of pancreatic adenocarcinoma has only been reported in two occasions prior to this report. CASE PRESENTATION In this report, the diagnosis and operative management of a 78-year-old male who presented with three days of obstipation and computed tomography evidence of an annular obstructing mass in the sigmoid colon in addition to a pancreatic body and lesser sac mass involving the gastric antral region. The patient underwent a laparoscopic sigmoidectomy with end colostomy. Pathology revealed metastatic adenocarcinoma of pancreatic origin. The postoperative period was unremarkable, and the patient was referred to medical oncology to pursue further treatment. CLINICAL DISCUSSION Symptomatic metastasis to the colon as the initial presentation of pancreatic adenocarcinoma is exceedingly rare. To our knowledge, this is the 3rd case to be reported and the second that was located in the sigmoid colon. CONCLUSION The presentation of metastatic pancreatic cancer to the colon causing a colonic obstruction is rare but should be considered in cases of atypical synchronic masses in cross-sectional imaging. When metastatic disease is suspected in the sigmoid colon, it is advisable to perform a colostomy instead of an anastomosis to avoid the potential risk of anastomotic leak that could delay the immediate need for systemic therapy.
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Zhou S, Zhang XH, Zhang Y, Gong G, Yang X, Wan WH. The Age-Adjusted Charlson Comorbidity Index Predicts Prognosis in Elderly Cancer Patients. Cancer Manag Res 2022; 14:1683-1691. [PMID: 35573259 PMCID: PMC9091471 DOI: 10.2147/cmar.s361495] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/21/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose The age-adjusted Charlson comorbidity index (ACCI) is a useful measure of comorbidity to standardize the evaluation of elderly patients and has been reported to predict mortality in various cancers. To our best knowledge, no studies have examined the relationship between the ACCI and survival of elderly patients with cancer. Therefore, the primary objective of this study was to investigate the relationship between the ACCI and survival of elderly patients with cancer. Patients and Methods A total of 64 elderly patients (>80 years) with cancer between 2011 and 2021 were enrolled in this study. According to the ACCI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; patients with ACCI<11 were considered the low-ACCI group, whereas those with ACCI≥11 were considered the high-ACCI group. The correlations between the ACCI score and survival outcomes were statistically analyzed. Results There was a significant difference in overall survival (OS) and progression-free survival (PFS) between the high-ACCI group and the low-ACCI group (P<0.001). The median OS time of the high-ACCI group and the low-ACCI group were 13.9 (10.5–22.0) months and 51.9 (34.1–84.0) months, respectively. The 2-, 3-, and 5-year survival rates of the high-ACCI group were 28.1%, 18.8%, and 4.2%, respectively, whereas the 2-, 3-, and 5-year survival rates of the low-ACCI group were 77.3%, 66.4%, and 39.1%, respectively. Multivariate analysis showed that ACCI was independently associated with OS (HR=1.402, 95% CI: 1.226–1.604, P < 0.05) and PFS (HR=1.353, 95% CI: 1.085–1.688, P = 0.0073). Conclusion The ACCI score is a significant independent predictor of prognosis in elderly patients with cancer.
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Affiliation(s)
- Shi Zhou
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Xing-Hu Zhang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Yuan Zhang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Ge Gong
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Xiang Yang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Wen-Hui Wan
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
- Correspondence: Wen-Hui Wan, Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China, Tel/Fax +86 25 80862433, Email
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10
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Michalet M, Bordeau K, Cantaloube M, Valdenaire S, Debuire P, Simeon S, Portales F, Draghici R, Ychou M, Assenat E, Dupuy M, Gourgou S, Colombo PE, Carrere S, Souche FR, Aillères N, Fenoglietto P, Azria D, Riou O. Stereotactic MR-Guided Radiotherapy for Pancreatic Tumors: Dosimetric Benefit of Adaptation and First Clinical Results in a Prospective Registry Study. Front Oncol 2022; 12:842402. [PMID: 35356227 PMCID: PMC8959839 DOI: 10.3389/fonc.2022.842402] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/31/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Stereotactic MR-guided adaptive radiotherapy (SMART) is an attractive modality of radiotherapy for pancreatic tumors. The objectives of this prospective registry study were to report the dosimetric benefits of daily adaptation of SMART and the first clinical results in pancreatic tumors. Materials and Methods All patients treated in our center with SMART for a pancreatic tumor were included. Patients were planned for five daily-adapted fractions on consecutive days. Endpoints were acute toxicities, late toxicities, impact of adaptive treatment on target volume coverage and organs at risk (OAR) sparing, local control (LC) rate, distant metastasis-free survival (DMFS), and overall survival (OS). Results Thirty consecutive patients were included between October 2019 and April 2021. The median dose prescription was 50 Gy. No patient presented grade > 2 acute toxicities. The most frequent grade 1–2 toxicities were asthenia (40%), abdominal pain (40%), and nausea (43%). Daily adaptation significantly improved planning target volume (PTV) and gross tumor volume (GTV) coverage and OAR sparing. With a median follow-up of 9.7 months, the median OS, 6-month OS, and 1-year OS were 14.1 months, 89% (95% CI: 70%–96%), and 75% (95% CI: 51%–88%), respectively, from SMART completion. LC at 6 months and 1 year was respectively 97% (95% CI: 79–99.5%) and 86% (95% CI: 61%–95%). There were no grade > 2 late toxicities. With a median follow-up of 10.64 months, locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC) patients (22 patients) had a median OS, 6-month OS, and 1-year OS from SMART completion of 14.1 months, 76% (95% CI: 51%–89%), and 70% (95% CI: 45%–85%), respectively. Nine patients underwent surgical resection (42.1% of patients with initial LAPC and 33.3% of patients with BRPC), with negative margins (R0). Resected patients had a significantly better OS as compared to unresected patients (p = 0.0219, hazard ratio (HR) = 5.78 (95% CI: 1.29–25.9)). Conclusion SMART for pancreatic tumors is feasible without limiting toxicities. Daily adaptation demonstrated a benefit for tumor coverage and OAR sparing. The severity of observed acute and late toxicities was low. OS and LC rates were promising. SMART achieved a high secondary resection rate in LAPC patients. Surgery after SMART seemed to be feasible and might increase OS in these patients.
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Affiliation(s)
- Morgan Michalet
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Karl Bordeau
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Marie Cantaloube
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Simon Valdenaire
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Pierre Debuire
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Sebastien Simeon
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Fabienne Portales
- Medical Oncology Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Roxana Draghici
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Marc Ychou
- Medical Oncology Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Eric Assenat
- Medical Oncology Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Marie Dupuy
- Medical Oncology Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Sophie Gourgou
- Biometrics Unit Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Pierre-Emmanuel Colombo
- Digestive Surgery Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Sebastien Carrere
- Digestive Surgery Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - François-Regis Souche
- Surgical Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Norbert Aillères
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Pascal Fenoglietto
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - David Azria
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Olivier Riou
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
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11
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Wang M, Zhu P, Chen Z, Yang L. Conversion therapy, palliative chemotherapy and surgery, which of these is the best treatment for locally advanced and advanced pancreatic cancer? Anticancer Drugs 2022; 33:e686-e691. [PMID: 34459461 PMCID: PMC8670342 DOI: 10.1097/cad.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/04/2021] [Indexed: 11/26/2022]
Abstract
A retrospective study was conducted to analyze which translational therapy, palliative chemotherapy and surgery is the best treatment for locally advanced and advanced pancreatic cancer, and to screen out the dominant population for the best treatment. A total of 83 patients with pancreatic cancer, including locally advanced and advanced pancreatic cancer, who had lost the opportunity for radical surgery and were admitted to Zhejiang Provincial People's Hospital between January 2015 and July 2021 were collected. A total of 39 patients received palliative chemotherapy, 25 patients received conversion therapy and 19 patients tried surgery at the first visit. We conducted survival follow-up and prognostic evaluation of 83 patients. The median overall survival (mOS) and median progression-free survival (mPFS) of 25 pancreatic cancer patients who received conversion therapy were longer than those of pancreatic cancer patients who received palliative chemotherapy (mOS: 16 months vs. 9 months, P = 0.001; mPFS: 11 months vs. 7.5 months, P = 0.038) and surgery (mOS: 16 months vs. 9 months, P = 0.018; mPFS: 11 months vs. 5.5 months, P < 0.001). Multivariate and Kaplan-Meier analysis showed that age, distant metastasis, and the degree of CA199 declined after chemotherapy were independent factors affecting overall survival (OS) of pancreatic cancer patients who received conversion therapy. Conversion therapy can improve OS and progression-free survival in patients with locally advanced or advanced pancreatic cancer to a certain extent. Some patients with advanced pancreatic cancer have surprising results after receiving conversion therapy.
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Affiliation(s)
- Mingxing Wang
- Graduate School of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui Province
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Pengfei Zhu
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Zheling Chen
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
| | - Liu Yang
- Graduate School of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui Province
- Oncology Center, Department of Medical Oncology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, P. R. China
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12
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O’Sullivan B, Burton T, Van Dalen R, Welsh F, Pandita A, Fischer J. Beware the pancreatic incidentaloma in colorectal tumours: pancreatic adenocarcinoma with metastases to the colon and rectum. J Surg Case Rep 2022; 2022:rjab629. [PMID: 35087655 PMCID: PMC8788230 DOI: 10.1093/jscr/rjab629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Colorectal cancer (CRC) is the third most diagnosed malignancy in the Western world. Routine staging of CRC often identifies incidental lesions on cross-sectional imaging. Appropriate treatment is dependent on a correct histological diagnosis. Pancreatic Ductal Adenocarcinoma (PDAC) is a rarer and often devastating diagnosis for which the treatment pathway differs significantly to CRC. We report two rare cases: the first recorded case of PDAC with synchronous rectal metastasis and a case of an acute presentation with large bowel obstruction from synchronous colonic metastasis. Both cases presented a significant diagnostic challenge. The management of both cases would have been altered had the histological diagnosis been known prior to surgery. Clinicians treating CRC should be wary of incidental lesions on staging investigations as they rarely represent an occult extra-intestinal primary malignancy. Immunohistochemistry plays an important role in ascertaining the origin of gastrointestinal malignancy.
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13
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Ishtiaq R, Aziz M, Wilhelm DM, Gaduputi VV, Hamdani SU. An Uncommon Cause of Hematochezia. J Gastrointest Cancer 2021; 52:359-364. [PMID: 32761320 DOI: 10.1007/s12029-020-00470-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rizwan Ishtiaq
- Internal Medicine Residency Program, Mercy Health St. Vincent Medical Center, 2213 Cherry Street, Toledo, OH, 43608, USA.
| | - Muhammad Aziz
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
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14
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Muyinda IJ, Park JG, Jang EJ, Yoo BC. KRAS, A Prime Mediator in Pancreatic Lipid Synthesis through Extra Mitochondrial Glutamine and Citrate Metabolism. Int J Mol Sci 2021; 22:5070. [PMID: 34064761 PMCID: PMC8150642 DOI: 10.3390/ijms22105070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
Kirsten rat sarcoma viral oncogene homolog (KRAS)-driven pancreatic cancer is very lethal, with a five-year survival rate of <9%, irrespective of therapeutic advances. Different treatment modalities including chemotherapy, radiotherapy, and immunotherapy demonstrated only marginal efficacies because of pancreatic tumor specificities. Surgery at the early stage of the disease remains the only curative option, although only in 20% of patients with early stage disease. Clinical trials targeting the main oncogenic driver, KRAS, have largely been unsuccessful. Recently, global metabolic reprogramming has been identified in patients with pancreatic cancer and oncogenic KRAS mouse models. The newly reprogrammed metabolic pathways and oncometabolites affect the tumorigenic environment. The development of methods modulating metabolic reprogramming in pancreatic cancer cells might constitute a new approach to its therapy. In this review, we describe the major metabolic pathways providing acetyl-CoA and NADPH essential to sustain lipid synthesis and cell proliferation in pancreatic cancer cells.
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Affiliation(s)
- Isaac James Muyinda
- Department of Translational Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, Korea; (I.J.M.); (E.-J.J.)
- Uganda Cancer Institute, Mulago-Kampala 3935, Uganda
| | - Jae-Gwang Park
- Department of Translational Science, Research Institute, National Cancer Center, Goyang-si 10408, Korea;
| | - Eun-Jung Jang
- Department of Translational Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, Korea; (I.J.M.); (E.-J.J.)
| | - Byong-Chul Yoo
- Department of Translational Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si 10408, Korea; (I.J.M.); (E.-J.J.)
- Department of Translational Science, Research Institute, National Cancer Center, Goyang-si 10408, Korea;
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15
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Radiosensitizing Pancreatic Cancer with PARP Inhibitor and Gemcitabine: An In Vivo and a Whole-Transcriptome Analysis after Proton or Photon Irradiation. Cancers (Basel) 2021; 13:cancers13030527. [PMID: 33573176 PMCID: PMC7866541 DOI: 10.3390/cancers13030527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Pancreatic ductal adenocarcinoma is a devastating disease. Using modern technique of radiotherapy, such as proton therapy, may simultaneously enhance dose to the tumor and decrease dose to surrounding organ, thus limiting toxicity. Moreover, associating drugs to radiotherapy also increases its effectiveness on tumor. The aim of our study was to show the benefit of proton therapy compared to standard radiotherapy with photon, and the benefit of associating different drugs with those particles in vivo. Thus, our results displayed a higher effectiveness of associating proton therapy, gemcitabine and olaparib. Finally, we pointed out that treatment induced significant transcriptomic alterations. Abstract Over the past few years, studies have focused on the development of targeted radiosensitizers such as poly(ADP-ribose) polymerase inhibitors. We performed an in vivo study and a whole-transcriptome analysis to determine whether PARP inhibition enhanced gemcitabine-based chemoradiosensitization of pancreatic cancer xenografts, combined with either proton or photon irradiation. NMRI mice bearing MIA PaCa-2 xenografts were treated with olaparib and/or gemcitabine and irradiated with 10 Gy photon or proton. First, a significant growth inhibition was obtained after 10 Gy proton irradiation compared to 10 Gy photon irradiation (p = 0.046). Moreover, the combination of olaparib, gemcitabine and proton therapy significantly sensitized tumor xenografts, compared to gemcitabine (p = 0.05), olaparib (p = 0.034) or proton therapy (p < 0.0001) alone or to the association of olaparib, gemcitabine and radiotherapy (p = 0.024). Simultaneously, whole RNA sequencing profiling showed differentially expressed genes implicated in categories such as DNA repair, type I interferon signaling and cell cycle. Moreover, a large amount of lncRNA was dysregulated after proton therapy, gemcitabine and olaparib. This is the first study showing that addition of olaparib to gemcitabine-based chemoradiotherapy improved significantly local control in vivo, especially after proton therapy. RNA sequencing profiling analysis presented dynamic alteration of transcriptome after chemoradiation and identified a classifier of gemcitabine response.
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16
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Liu Z, Ahn MHY, Kurokawa T, Ly A, Zhang G, Wang F, Yamada T, Sadagopan A, Cheng J, Ferrone CR, Liss AS, Honselmann KC, Wojtkiewicz GR, Ferrone S, Wang X. A fast, simple, and cost-effective method of expanding patient-derived xenograft mouse models of pancreatic ductal adenocarcinoma. J Transl Med 2020; 18:255. [PMID: 32580742 PMCID: PMC7315507 DOI: 10.1186/s12967-020-02414-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patient-derived xenograft (PDX) mouse models of cancer have been recognized as better mouse models that recapitulate the characteristics of original malignancies including preserved tumor heterogeneity, lineage hierarchy, and tumor microenvironment. However, common challenges of PDX models are the significant time required for tumor expansion, reduced tumor take rates, and higher costs. Here, we describe a fast, simple, and cost-effective method of expanding PDX of pancreatic ductal adenocarcinoma (PDAC) in mice. METHODS We used two established frozen PDAC PDX tissues (derived from two different patients) and implanted them subcutaneously into SCID mice. After tissues reached 10-20 mm in diameter, we performed survival surgery on each mouse to harvest 90-95% of subcutaneous PDX (incomplete resection), allowing the remaining 5-10% of PDX to continue growing in the same mouse. RESULTS We expanded three consecutive passages (P1, P2, and P3) of PDX in the same mouse. Comparing the times required for in vivo expansion, P2 and P3 (expanded through incomplete resection) grew 26-60% faster than P1. Moreover, such expanded PDX tissues were successfully implanted orthotopically into mouse pancreases. Within 20 weeks using only 14 mice, we generated sufficient PDX tissue for future implantation of 200 mice. Our histology study confirmed that the morphologies of cancer cells and stromal structures were similar across all three passages of subcutaneous PDX and the orthotopic PDX and were reflective of the original patient tumors. CONCLUSIONS Taking advantage of incomplete resection of tumors associated with high local recurrence, we established a fast method of PDAC PDX expansion in mice.
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Affiliation(s)
- Zhenyang Liu
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Gastroenterology and Urology and of Medical Oncology, Hunan Cancer Hospital, Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Michael Ho-Young Ahn
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tomohiro Kurokawa
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gong Zhang
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Fuyou Wang
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Teppei Yamada
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ananthan Sadagopan
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane Cheng
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew S Liss
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kim C Honselmann
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory R Wojtkiewicz
- Mouse Imaging Program, Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Soldano Ferrone
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xinhui Wang
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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17
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Stackhouse KA, Storino A, Watkins AA, Gooding W, Callery MP, Kent TS, Sawhney MS, Moser AJ. Biliary palliation for unresectable pancreatic adenocarcinoma: surgical bypass or self-expanding metal stent? HPB (Oxford) 2020; 22:563-569. [PMID: 31537457 DOI: 10.1016/j.hpb.2019.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard of care guidelines endorse self-expanding metal stents (SEMS) rather than open surgical biliary bypass (OSBB) for biliary palliation in the setting of unresectable pancreatic ductal adenocarcinoma (PDAC). This study used competing risk analysis to compare short- and long-term morbidity and overall survival among patients undergoing SEMS or OSBB after unresectable or metastatic disease is identified at the time of exploration. METHODS Single institution retrospective cohort study (n = 127) evaluating outcomes after OSBB and SEMS for biliary palliation in patients found to have unresectable PDAC at exploration. Short-term, long-term, and lifetime risk of biliary occlusion and survival were compared after adjustment for stage and comprehensive complication index (CCI). RESULTS Baseline demographics and tumor characteristics were equivalent between cohorts. Short-term complications were more frequent after OSBB, whereas late complications were greater after SEMS. The cumulative incidence of recurrent biliary obstruction was greater after SEMS, but lifetime complication burden and median survival were equivalent. CONCLUSION OSBB was associated with longer hospital stays and more short-term complications, and SEMS was associated with a higher risk of recurrent biliary obstruction among surgical patients with unresectable PDAC. Patient preference should be defined pre-operatively in the case the unresectable disease is encountered during attempted resection.
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Affiliation(s)
- Kathryn A Stackhouse
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alessandra Storino
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ammara A Watkins
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - William Gooding
- Biostatistics Facility, University of Pittsburgh Cancer Institute, USA
| | - Mark P Callery
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tara S Kent
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A James Moser
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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18
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Abstract
Metastases from pancreatic malignancy are commonly known to occur in the regional lymph nodes, liver, lung, and peritoneum. Synchronous or metachronous metastasis from the pancreas to the colon is rare, with only 6 cases reported in the literature. We report a man who was found to have adenocarcinoma on biopsies from synchronous lesions in the colon and the pancreas. The immunohistochemistry report revealed the diagnosis of a primary pancreatic malignancy with synchronous colonic metastases.
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Lafranceschina S, Brunetti O, Delvecchio A, Conticchio M, Ammendola M, Currò G, Piardi T, de'Angelis N, Silvestris N, Memeo R. Systematic Review of Irreversible Electroporation Role in Management of Locally Advanced Pancreatic Cancer. Cancers (Basel) 2019; 11:E1718. [PMID: 31684186 PMCID: PMC6896066 DOI: 10.3390/cancers11111718] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/25/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Ablative techniques provide in patients with locally advanced pancreatic cancer (LAPC) symptomatic relief, survival benefit and potential downsizing. Irreversible Electroporation (IRE) represents potentially an ideal solution as no thermal tissue damage occurs. The purpose of this review is to present an overview on safety, feasibility, oncological results, survival and quality of life improvement obtained by IRE. METHODS A systematic search was performed in PubMed, regarding the use of IRE on PC in humans for studies published in English up to March 2019. RESULTS 15 original studies embodying 691 patients with unresectable LAPC who underwent IRE were included. As emerged, IRE works better on tumour sizes between 3-4 cm. Oncological results are promising: median OS from diagnosis or treatment up to 27 months. Two groups investigated borderline resectable tumours treated with IRE before resection with margin attenuation, whereas IRE has proved to be effective in pain control. CONCLUSIONS Electroporation is bringing new hopes in LAPC management. The first aim of IRE is to offer a palliative treatment. Further efforts are needed for patient selection, as well as the use of IRE for 'margin accentuation' during surgical resection. Even if promising, IRE needs to be validated in large, randomized, prospective series.
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Affiliation(s)
- Stefano Lafranceschina
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Oronzo Brunetti
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II 2", 70124 Bari, Italy.
| | - Antonella Delvecchio
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Maria Conticchio
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
| | - Michele Ammendola
- Department of Health Science, General Surgery, Magna Graecia University, Medicine School of Germaneto, 88100 Catanzaro, Italy.
| | - Giuseppe Currò
- Department of Health Science, General Surgery, Magna Graecia University, Medicine School of Germaneto, 88100 Catanzaro, Italy.
| | - Tullio Piardi
- Department of Surgery, Hôpital Robert Debré, University of Champagne-Ardenne, 51100 Reims, France.
| | - Nicola de'Angelis
- Department of Digestive and Hepato-Pancreato-Biliary Surgery, Henri Mondor University Hospital, AP-HP, Université Paris-Est Créteil (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II 2", 70124 Bari, Italy.
- Department of Biomedical Sciences and Human Oncology, University of Bari 'Aldo Moro', 70124 Bari, Italy.
| | - Riccardo Memeo
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bary, 70124 Bary, Italy.
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20
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Incerti E, Vanoli EG, Broggi S, Gumina C, Passoni P, Slim N, Fiorino C, Reni M, Mapelli P, Cattaneo M, Zanon S, Calandrino R, Gianolli L, Di Muzio N, Picchio M. Early variation of 18-fluorine-labelled fluorodeoxyglucose PET-derived parameters after chemoradiotherapy as predictors of survival in locally advanced pancreatic carcinoma patients. Nucl Med Commun 2019; 40:1072-1080. [PMID: 31365502 DOI: 10.1097/mnm.0000000000001065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate if early variation of PET-derived parameters after concomitant chemoradiotherapy (CRT) predicts overall survival (OS), local relapse free survival (LRFS), distant relapse free survival (DRFS) and progression free survival (PFS) in locally advanced pancreatic cancer (LAPC) patients. METHODS Fifty-two LAPC patients (median age: 61 years; range: 35-85) with available FDG PET/CT before and after RT (2-6 months, median: 2) were enrolled from May 2005 to June 2015. The predictive value of the percentage variation of mean/maximum standard uptake value (ΔSUVmean/max), metabolic tumour volume (ΔMTV) and total lesion glycolysis (ΔTLG), estimated considering different uptake thresholds (40-50-60%), was investigated between pre- and post-RT PET. The percentage difference between gastrointestinal cancer-associated antigen (ΔGICA) levels measured at the time of PET was also considered. Log-rank test and Cox regression analysis were performed to assess the prognostic value of considered PET-derived parameters on survival outcomes. RESULTS The median follow-up was 13 months (range: 4-130). At univariate analysis, ΔTLG50 showed borderline significance in predicting OS (P = 0.05) and was the most significant parameter correlated to LRFS and PFS (P = 0.001). Median LRFS was 4 and 33 months if ΔTLG50 was below or above 35% respectively (P = 0.0003); similarly, median PFS was 3 vs 6 months (P = 0.0009). No significant correlation was found between PET-derived parameters and DRFS, while the ΔGICA was the only borderline significant prognostic value for this endpoint (P = 0.05). CONCLUSION PET-derived parameters predict survival in LAPC patients; in particular, ΔTLG50 is the strongest predictor. The combination of these biochemical and imaging biomarkers is promising in identifying patients at higher risk of earlier relapse.
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Affiliation(s)
| | | | | | | | | | | | | | - Michele Reni
- Department of Oncology, IRCCS San Raffaele Scientific Institute
| | - Paola Mapelli
- Unit of Nuclear Medicine
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Silvia Zanon
- Department of Oncology, IRCCS San Raffaele Scientific Institute
| | | | | | | | - Maria Picchio
- Unit of Nuclear Medicine
- Vita-Salute San Raffaele University, Milan, Italy
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21
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Pancreatic ductal adenocarcinoma: biological hallmarks, current status, and future perspectives of combined modality treatment approaches. Radiat Oncol 2019; 14:141. [PMID: 31395068 PMCID: PMC6688256 DOI: 10.1186/s13014-019-1345-6] [Citation(s) in RCA: 251] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/24/2019] [Indexed: 01/18/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly devastating disease with poor prognosis and rising incidence. Late detection and a particularly aggressive biology are the major challenges which determine therapeutic failure. In this review, we present the current status and the recent advances in PDAC treatment together with the biological and immunological hallmarks of this cancer entity. On this basis, we discuss new concepts combining distinct treatment modalities in order to improve therapeutic efficacy and clinical outcome - with a specific focus on protocols involving radio(chemo)therapeutic approaches.
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22
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Brú A, Bosch R, Céspedes MV, Carmona-Güedes S, Pascual E, Brú I, Souto JC. Antitumoral effect of maintained neutrophilia induced by rhG-CSF in a murine model of pancreatic cancer. Sci Rep 2019; 9:2879. [PMID: 30814617 PMCID: PMC6393423 DOI: 10.1038/s41598-019-39805-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 01/24/2019] [Indexed: 11/09/2022] Open
Abstract
Although the protumoral functions of polymorphonuclear neutrophils are well known, some now-forgotten studies report antitumoral roles for these cells. The present work examines the antitumoral effect of maintained neutrophilia induced via the injection of recombinant human granulocyte colony stimulating factor (rhG-CSF, 100 μg/kg/day) in a Panc-1 subcutaneous xenograft murine model of pancreatic cancer. This treatment was compared with gemcitabine administration (120 mg/kg every two days) and a saline control (n = 6–7 mice per group). Compared to the controls, both the rhG-CSF- and gemcitabine-treated mice showed significantly suppressed tumor growth by day 4 (p < 0.001 and p = 0.013 respectively). From a mean starting volume of 106.9 ± 3.1 mm3 for all treatment groups, the final mean tumor volumes reached were 282.0 ± 30.7 mm3 for the rhG-CSF-treated mice, 202.6 ± 18.1 mm3 for the gemcitabine-treated mice and 519.4 ± 62.9 mm3 for the control mice (p < 0.004 and p < 0.01, respectively, vs. control). The rhG-CSF-treated tumors showed higher percentage necrosis than those treated with gemcitabine (37.4 ± 4.6 vs. 7.5 ± 3.0; p < 0.001). This is the first report of a clear anti-tumoral effect of rhG-CSF when used in monotherapy against pancreatic cancer. Since rhG-CSF administration is known to be associated with very few adverse events, it may offer an attractive alternative in the clinical treatment of pancreatic cancer.
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Affiliation(s)
- A Brú
- Faculty of Mathematics, Universidad Complutense de Madrid, Madrid, Spain.
| | - R Bosch
- Laboratory of Oncology/Hematology and Transplantation, Institute of Biomedical Research, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Sant Creu i Sant Pau, Institute of Biomedical Research, IIB-Sant Pau, Barcelona, Spain
| | - M V Céspedes
- Institut d'Investigacions Biomédiques Sant Pau, Hospital de Santa Creu I Sant Pau, Barcelona, Spain.,CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - S Carmona-Güedes
- Institut d'Investigacions Biomédiques Sant Pau, Hospital de Santa Creu I Sant Pau, Barcelona, Spain.,CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - E Pascual
- Department of Hematology, Hospital de la Sant Creu i Sant Pau, Institute of Biomedical Research, IIB-Sant Pau, Barcelona, Spain
| | - I Brú
- Centro de Salud La Estación, Talavera de la Reina, Spain
| | - J C Souto
- Department of Hematology, Hospital de la Sant Creu i Sant Pau, Institute of Biomedical Research, IIB-Sant Pau, Barcelona, Spain.,Josep Carreras Leukemia Research Institute, Barcelona, Spain
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23
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Buwenge M, Macchia G, Arcelli A, Frakulli R, Fuccio L, Guerri S, Grassi E, Cammelli S, Cellini F, Morganti AG. Stereotactic radiotherapy of pancreatic cancer: a systematic review on pain relief. J Pain Res 2018; 11:2169-2178. [PMID: 30323651 PMCID: PMC6174909 DOI: 10.2147/jpr.s167994] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been reported to reduce pain in LAPC. Stereotactic RT (SBRT) is considered as an emerging radiotherapy technique able to achieve high local control rates with acceptable toxicity. However, its role in pain palliation is not clear. To review the impact on pain relief with SBRT in LAPC patients, a literature search was performed on PubMed, Scopus, and Embase (January 2000-December 2017) for prospective and retrospective articles published in English. Fourteen studies (479 patients) reporting the effect of SBRT on pain relief were finally included in this analysis. SBRT was delivered with both standard and/or robotic linear accelerators. The median prescribed SBRT doses ranged from 16.5 to 45 Gy (median: 27.8 Gy), and the number of fractions ranged from 1 to 6 (median: 3.5). Twelve of the 14 studies reported the percentage of pain relief (in patients with pain at presentation) with a global overall response rate (complete and partial response) of 84.9% (95% CI, 75.8%-91.5%), with high heterogeneity (Q 2 test: P<0.001; I2=83.63%). All studies reported toxicity data. Acute and late toxicity (grade ≥3) rates were 3.3%-18.0% and 6.0%-8.2%, respectively. Reported gastrointestinal side effects were duodenal obstruction/ulcer, small bowel obstruction, duodenal bleeding, hemorrhage, and gastric perforation. SBRT achieves pain relief in most patients with pancreatic cancer with an acceptable gastrointestinal toxicity rate. Further prospective studies are needed to define optimal dose/fractionation and the best systemic therapies modality integration to reduce toxicity and improve the palliative outcome. Finally, the quality of life and, particularly, pain control should be considered as an endpoint in all future trials on this emerging treatment technique.
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Affiliation(s)
- Milly Buwenge
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
| | - Gabriella Macchia
- Radiation Oncology Unit, Research and Care Foundation "Giovanni Paolo II", Catholic University of Sacred Heart, Campobasso, Italy
| | - Alessandra Arcelli
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
| | | | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences - DIMEC, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Sara Guerri
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
| | - Elisa Grassi
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
| | - Silvia Cammelli
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
| | - Francesco Cellini
- Department of Radiotherapy, "A. Gemelli" Hospital, Catholic University, Rome, Italy
| | - Alessio G Morganti
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy,
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Sutera P, Bernard ME, Wang H, Bahary N, Burton S, Zeh H, Heron DE. Stereotactic Body Radiation Therapy for Locally Progressive and Recurrent Pancreatic Cancer after Prior Radiation. Front Oncol 2018; 8:52. [PMID: 29564223 PMCID: PMC5845878 DOI: 10.3389/fonc.2018.00052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/19/2018] [Indexed: 01/14/2023] Open
Abstract
Introduction Pancreatic adenocarcinoma is an aggressive malignancy that has consistently demonstrated poor outcomes despite aggressive treatments. Despite multimodal treatment, local disease progression and local recurrence are common. Management of recurrent or progressive pancreatic carcinomas proves a further challenge. In patients previously treated with radiation therapy, stereotactic body radiation therapy (SBRT) is a promising modality capable of delivering high dose to the tumor while limiting dose to critical structures. We aimed to determine the feasibility and tolerability of SBRT for recurrent or local pancreatic cancer in patients previously treated with external beam radiation therapy (EBRT). Materials and methods Patients treated with EBRT who developed recurrent or local pancreatic ductal adenocarcinoma treated with SBRT reirradiation at our institution, from 2004 to 2014 were reviewed. Our primary endpoints included overall survival (OS), local control, regional control, and late grade 3+ radiation toxicity. Endpoints were analyzed with the Kaplan-Meier method. The association of these survival endpoints with risk factors was studied with univariate Cox proportional hazards models. Results We identified 38 patients with recurrent/progressive pancreatic cancer treated with SBRT following prior radiation therapy. Prior radiation was delivered to a median dose of 50.4 Gy in 28 fractions. SBRT was delivered to a median dose of 24.5 Gy in 1-3 fractions. Surgical resection was performed on 55.3% of all patients. Within a median follow-up of 24.4 months (inter-quartile range, 14.9-32.7 months), the median OS from diagnosis for the entire cohort was 26.6 months (95% CI: 20.3-29.8) with 2-year OS of 53.0%. Median survival from SBRT was 9.7 months (95% CI, 5.5-13.8). The 2-year freedom from local progression and regional progression was 58 and 82%, respectively. For the entire cohort, 18.4 and 10.5% experienced late grade 2+ and grade 3+ toxicity, respectively. Conclusion This single institution retrospective review identified SBRT reirradiation to be a feasible and tolerable treatment strategy for patients with previous locally progressive or recurrent pancreatic adenocarcinoma.
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Affiliation(s)
- Philip Sutera
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mark E Bernard
- Department of Radiation Medicine, University of Kentucky, Lexington, KY, United States
| | - Hong Wang
- Department of Biostatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, United States
| | - Steven Burton
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Herbert Zeh
- Department of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dwight E Heron
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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25
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Nogueira ST, Pinto BL, Silva EF, Garcia HA, Carneiro F. Pancreatic cancer presenting as colonic disease. A rare case report. Int J Surg Case Rep 2018; 44:4-7. [PMID: 29454229 PMCID: PMC5852301 DOI: 10.1016/j.ijscr.2018.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is the fourth major cause of cancer-related deaths. About 50% of the patients are diagnosed with advanced disease. Metastatic disease to the colon is a very rare entity with only 5 cases described in english literature. CASE PRESENTATION Male, 60 years-old, presents to a surgical consult with the diagnosis of an adenocarcinoma of the sigmoid colon. The physical exam revealed a periumbilical nodule with suspicious features. The staging CT-scan showed a mass in the tail of the pancreas involving the spleen and left kidney, thickening of the sigmoid colon, multiple mesenteric masses and trabecular changes in the ischium, suggesting metastatic disease. The case was discussed by a multidisciplinary team and it was decided to do a biopsy of the umbilical nodule and review the specimen obtained in colonoscopy. Pathological analysis revealed a metastasis from pancreatic adenocarcinoma. The patient was proposed to start palliative chemotherapy for metastatic pancreatic cancer. After 2 cycles of FOLFOX the patient was admitted in the OR with a perforation of the sigmoid mass. He was submitted to a sigmoidectomy with end colostomy, with discharge at the 5th postoperative day. Pathological analysis of the specimen confirmed the pancreatic origin of the tumor. Patient proceeded with palliative treatment, with death 9 months after the diagnosis. DISCUSSION Pancreatic metastasis to the colon is a very rare entity. Care should be taken when addressing these patients. CONCLUSION Although rare, a sigmoid tumor in a patient with known pancreatic adenocarcinoma must raise the suspicion of metastasis.
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Affiliation(s)
| | - Bruno Lima Pinto
- Hospital Professor Doutor Fernando Fonseca, IC19, 2720-276 Amadora, Portugal
| | - Eduardo Faria Silva
- Hospital Professor Doutor Fernando Fonseca, IC19, 2720-276 Amadora, Portugal
| | | | - Francisco Carneiro
- Hospital Professor Doutor Fernando Fonseca, IC19, 2720-276 Amadora, Portugal
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26
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O Kane GM, Knox JJ. Locally advanced pancreatic cancer: An emerging entity. Curr Probl Cancer 2017; 42:12-25. [PMID: 29153290 DOI: 10.1016/j.currproblcancer.2017.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 12/23/2022]
Abstract
Pancreatic adenocarcinoma (PDAC) remains a highly fatal disease that is increasing in incidence. PDAC can be classified according to resectability status with 3 nonmetastatic groups defined: resectable, borderline resectable, and locally advanced PDAC (LAPC). Delineating these subtypes is important with the optimal treatment approach dictated by high-quality CT imaging and multidisciplinary team discussion. Patients with LAPC are thought unresectable and are therefore rarely cured. In these patients, chemotherapy remains the mainstay of treatment. Aggressive approaches in this cohort are increasingly employed. Local therapies after induction chemotherapy including standard fractionation radiation, stereotactic body radiotherapy (SBRT), and irreversible electroporation (IRE) are being investigated in an attempt to improve long-term control. In some cases, responses to neoadjuvant therapy may facilitate surgical resection. Biomarkers that can select patients most likely to benefit from these options are urgently needed. This review aims to highlight the emerging treatment of patients with LAPC and to discuss current trials.
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27
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Dose-escalated radiotherapy for unresectable or locally recurrent pancreatic cancer: Dose volume analysis, toxicity and outcome of 28 consecutive patients. PLoS One 2017; 12:e0186341. [PMID: 29023527 PMCID: PMC5638513 DOI: 10.1371/journal.pone.0186341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/01/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The role of radiotherapy for unresectable pancreatic cancer is controversial. A benefit of additional radiotherapy is supported by some observations. A dose-effect relationship was recently found by dose escalation employing image guided and intensity modulated radiotherapy. METHODS We retrospectively evaluated 28 consecutive patients, all with history of extensive prior therapies for unresectable locally advanced/ recurrent pancreatic cancer (LAPC/LRPC). Treatment was delivered by helical tomotherapy after daily position verification with computed tomography. Dose to the planned target volume (PTV) was 51 Gy, while the dose to the macroscopic tumor was escalated by a simultaneous integrated boost to a median cumulative dose of 66 Gy (60-66 Gy). Concomitant chemotherapy consisted mainly of capecitabine (n = 23). RESULTS 10 of 28 patients presented acute toxicities > grade 2, one patient succumbed to gastrointestinal bleeding after treatment. No correlations of toxicities and dose volume histograms (DVH) of retrospectively delineated small bowel loops were observed, although average small bowel volume receiving ≥ 20 Gy was 374 ml. DVH analyses revealed a correlation of splenic parameters and acute toxicity: Vomiting, anorexia, dehydration, hematologic toxicity, fatigue, combined gastro-intestinal toxicity wit R-values between 0.392 and 0.561 (all p-values > 0.05). Only one patient developed late toxicities > grade 2. With an average follow-up time in surviving patients of 14 months median overall survival time was 19 months and median time to local recurrence 13 months. In 8 patients with available imaging of local recurrence: 5 in field recurrences, 2 marginal recurrences and one lymph node recurrence outside the high dose radiation field were observed. In univariate analysis only ΔCA-19-9 during radiotherapy was associated with local control (p = 0.029) and overall survival (p = 0.049). CONCLUSION Dose escalated normo-fractionated radiotherapy for LAPC/LRPC seems feasible and suitable to prolong local control and in consequence long-term survival. However, in-field local progression is still frequently observed and possibilities to increase the local effectiveness should be evaluated. Exposure of the spleen was predictive for acute toxicity and should be further investigated.
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28
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de Geus SWL, Eskander MF, Kasumova GG, Ng SC, Kent TS, Mancias JD, Callery MP, Mahadevan A, Tseng JF. Stereotactic body radiotherapy for unresected pancreatic cancer: A nationwide review. Cancer 2017; 123:4158-4167. [PMID: 28708929 DOI: 10.1002/cncr.30856] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/02/2017] [Accepted: 05/30/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The role of conventional radiotherapy in the management of pancreatic cancer has yet to be elucidated. Over the past decade, stereotactic body radiotherapy (SBRT) has emerged as a novel therapeutic option in pancreatic cancer care. This study evaluated the survival impact of SBRT on patients with unresected pancreatic cancer. METHODS The National Cancer Data Base was queried for unresected patients who received chemotherapy for nonmetastatic pancreatic adenocarcinoma between 2004 and 2012. Four treatment groups were identified: chemotherapy alone, chemotherapy combined with external-beam radiotherapy (EBRT), chemotherapy combined with intensity-modulated radiotherapy (IMRT), and chemotherapy combined with SBRT. Propensity score models predicting the odds of receiving SBRT were created to control for potential selection bias, and patients were matched by propensity scores. The survival analysis was performed with the Kaplan-Meier method. RESULTS A total of 14,331 patients met the inclusion criteria. Chemotherapy alone was delivered to 5464 patients (38.1%); 6418 (44.8%), 322 (2.3%), and 2127 (14.8%) received chemotherapy along with EBRT, IMRT, and SBRT, respectively. The unadjusted median survival before matching was 9.9, 10.9, 12.0, and 13.9 months for patients treated with chemotherapy, EBRT, IMRT, and SBRT, respectively. In separate matched analyses, SBRT remained superior to chemotherapy alone (log-rank P < .0001) and EBRT (log-rank P = .0180). After matching, survival did not differ between patients receiving IMRT and patients receiving SBRT (log-rank P = .0492). CONCLUSIONS SBRT is associated with a significantly better outcome than chemotherapy alone or in conjunction with traditional EBRT. These results support the idea that SBRT is a promising treatment approach for patients with unresected pancreatic cancer. Cancer 2017;123:4158-4167. © 2017 American Cancer Society.
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Affiliation(s)
- Susanna W L de Geus
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mariam F Eskander
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sing Chau Ng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph D Mancias
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Mark P Callery
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anand Mahadevan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer F Tseng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Chen G, Xu YP, Sun CH, Qiu YK. Clinical efficacy of gemcitabine combined with intensity modulated radiotherapy in treatment of pancreatic cancer. Shijie Huaren Xiaohua Zazhi 2017; 25:1511-1515. [DOI: 10.11569/wcjd.v25.i16.1511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy and safety of gemcitabine combined with intensity modulated radiotherapy (IMRT) in the treatment of pancreatic cancer.
METHODS Fifty-three patients with locally advanced pancreatic cancer who underwent liver surgery from January 2012 to January 2015 were randomly divided into two groups: an observation group (n = 27) and a control group (n = 26). The observation group was initially treated with gemcitabine (1000 mg/m2, intravenous infusion on days 1, 8, and 15, every 28 d) combined with IMRT, and then 2-4 cycles of gemcitabine alone 1 mo after the end of the combination therapy. The control group was treated with gemcitabine alone. Clinical efficacy and safety were than evaluated for the two groups.
RESULTS The clinical benefit index was significantly higher in the observation group than in the control group (70.37% vs 42.31%, χ2 = 4.251, P = 0.029). The total effective rate and the local control rate were also significantly better in the observation group than in the control group (P < 0.05). Four cases in the observation group and one case in the control group are still alive now. Although the 1-year survival rate was significantly higher in the observation group than in the control group (P < 0.05), there was no significant difference between the two groups in the 2-year survival rate (P > 0.05). No grade 4 adverse events occurred in either group.
CONCLUSION Gemcitabine combined with IMRT is safe and effective in the treatment of pancreatic cancer and can significantly improve the rate of pain relief and quality of life.
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30
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Wilson JM, Mukherjee S, Brunner TB, Partridge M, Hawkins MA. Correlation of 18F-Fluorodeoxyglucose Positron Emission Tomography Parameters with Patterns of Disease Progression in Locally Advanced Pancreatic Cancer after Definitive Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2017; 29:370-377. [PMID: 28190636 PMCID: PMC5429392 DOI: 10.1016/j.clon.2017.01.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 12/13/2022]
Abstract
AIMS A proportion of patients with pancreatic cancer never develop metastatic disease. We evaluated a role for 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in identifying a subset of patients with locally advanced pancreatic cancer (LAPC) who never develop metastatic disease and only experience local disease and may therefore benefit from local treatment intensification. MATERIAL AND METHODS Patients with histologically confirmed LAPC entered a single-centre phase II study of definitive upfront chemoradiotherapy (CRT). All patients underwent FDG-PET/CT before and 6 weeks after CRT. Tumour volume, standardised uptake values (SUVmax, SUVpeak, SUVmean, SUVmedian) and total lesion glycolysis (TLG) were measured on each scan and the response in each parameter was evaluated. The presence or absence of metastatic disease was noted on contrast-enhanced CT carried out every 3 months for 1 year and then at clinician discretion. RESULTS Twenty-three patients with LAPC were recruited; 17/23 completed treatment and had interpretable sequential imaging. Twenty-four per cent of patients only ever experienced local disease. Median pre-CRT FDG-PET parameters were significantly lower in patients with local disease only during follow-up compared with those who developed metastatic disease: SUVmax 3.8 versus 8.6 (P=0.006), SUVpeak 2.5 versus 7.5 (P=0.002), SUVmean 1.8 versus 3.3 (P=0.001), SUVmedian 1.7 versus 3.0 (P=0.002), TLG 26.9 versus 115.9 (P=0.006). Tumour volume, post-CRT FDG-PET values and their relative change were not statistically different between local disease and metastatic disease groups. Receiver operating characteristic curves for pre-CRT FDG-PET parameters to predict those who never develop metastatic disease all had areas under the curve (AUCs) ≥ 0.932. Pre-CRT FDG-PET SUVmax < 6.2 predicted patients with local disease only during follow-up with 100.0% sensitivity and 92.3% specificity, 80.0% positive predictive value and 100% negative predictive value. CONCLUSIONS Our findings suggest that patients with less FDG-avid tumours are less likely to metastasise and may therefore benefit from upfront local treatment intensification.
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Affiliation(s)
- J M Wilson
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK.
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
| | - T B Brunner
- Department of Radiation Oncology, University Hospitals Freiburg, Freiburg im Breisgau, Germany
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
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31
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Asano T, Yamada S, Fujii T, Yabusaki N, Nakayama G, Sugimoto H, Koike M, Fujiwara M, Kodera Y. The Charlson age comorbidity index predicts prognosis in patients with resected pancreatic cancer. Int J Surg 2017; 39:169-175. [PMID: 28161529 DOI: 10.1016/j.ijsu.2017.01.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. METHOD A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI<4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. RESULTS The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P < 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P < 0.0001). CONCLUSIONS The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.
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Affiliation(s)
- Tomonari Asano
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norimitsu Yabusaki
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Sugimoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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Irreversible electroporation as treatment of locally advanced and as margin accentuation in borderline resectable pancreatic adenocarcinoma. Med Biol Eng Comput 2017; 55:1123-1127. [PMID: 28078482 DOI: 10.1007/s11517-016-1603-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/01/2016] [Indexed: 02/06/2023]
Abstract
In recent years, many local ablation technologies based on thermal damage have been used in the treatment of locally advanced pancreatic carcinoma (LAPC) and borderline resectable pancreatic carcinoma (BLRPC). However, they are associated with major complications because of possible vascular and ductal damage. Irreversible electroporation (IRE) is a nonthermal ablation technology that seems safe near vital vascular and ductal structures. IRE could be used as exclusive treatment of LAPC (en situ to IRE) after induction chemotherapy In BLRPC, surgery is not really radical in 6% of patients (microscopic residual) and local recurrences occur in 11-42% of apparent radical resections. IRE could be used as margin accentuation to increase posterior margin during radical surgery in BLRPC. Our outcomes are safety, time to progression. Secondary outcomes are overall survival, pain control and quality of life. We are performing a prospective evaluation of patients undergoing IRE for LAPC or BLRPC since July 2014. We have included patients with non-metastatic LAPC with maximum size ≤4 cm (en situ to IRE) and patients with BLRPC (complementary IRE). We have performed induction chemotherapy in both groups. After treatment, patients were evaluated on days 1, 2, 4, 7, 14, 21, 30, 60 and 90 with amylase and lipase serum and abdominal drainage test. Based on Ethics Committee's request, follow-up imaging was performed at the 10th day for safety evaluation, at 30, 60 and 90 days for response evaluation and then every 3 months. Seven patients (two women and five men) underwent IRE. Two patients had LAPC and received en situ to IRE. In five patients affected by BLRPC we performed IRE and pancreatic head resection. In all patients, intraoperative imaging confirmed that the treatment of the whole tumor volume was complete. All seven patients demonstrated nonclinically relevant elevation of their amylase and lipase, which returned normal at 5 days postprocedure. No patient showed evidence of clinical pancreatitis or fistula. No major complications were recorded. Patients with LAPC died of distant metastases 6 month after treatment. At 3- and 6-month follow-up, all patients with BLPRC were alive and disease free. Only one patient has already reached 9-month follow-up and is alive and disease free. Our results are only preliminary. However, IRE ablation of LAPC and BLRPC seems a safe and feasible treatment.
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Panje C, Andratschke N, Brunner TB, Niyazi M, Guckenberger M. Stereotactic body radiotherapy for renal cell cancer and pancreatic cancer : Literature review and practice recommendations of the DEGRO Working Group on Stereotactic Radiotherapy. Strahlenther Onkol 2016; 192:875-885. [PMID: 27778052 DOI: 10.1007/s00066-016-1053-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/19/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE This report of the Working Group on Stereotactic Radiotherapy of the German Society of Radiation Oncology (DEGRO) aims to provide a literature review and practice recommendations for stereotactic body radiotherapy (SBRT) of primary renal cell cancer and primary pancreatic cancer. METHODS A literature search on SBRT for both renal cancer and pancreatic cancer was performed with focus on prospective trials and technical aspects for clinical implementation. RESULTS Data on renal and pancreatic SBRT are limited, but show promising rates of local control for both treatment sites. For pancreatic cancer, fractionated SBRT should be preferred to single-dose treatment to reduce the risk of gastrointestinal toxicity. Motion-compensation strategies and image guidance are paramount for safe SBRT delivery in both tumor entities. CONCLUSION SBRT for renal cancer and pancreatic cancer have been successfully evaluated in phase I and phase II trials. Pancreatic SBRT should be practiced carefully and only within prospective protocols due to the risk of severe gastrointestinal toxicity. SBRT for primary renal cell cancer appears a viable option for medically inoperable patients but future research needs to better define patient selection criteria and the detailed practice of SBRT.
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Affiliation(s)
- Cédric Panje
- Department of Radiation Oncology, Zurich University Hospital, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Nikolaus Andratschke
- Department of Radiation Oncology, Zurich University Hospital, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Thomas B Brunner
- Department of Radiation Oncology, Freiburg University Hospital, Freiburg, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University of Munich, Munich, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, Zurich University Hospital, Rämistrasse 100, 8091, Zurich, Switzerland.
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Wilson JM, Fokas E, Dutton SJ, Patel N, Hawkins MA, Eccles C, Chu KY, Durrant L, Abraham AG, Partridge M, Woodward M, O'Neill E, Maughan T, McKenna WG, Mukherjee S, Brunner TB. ARCII: A phase II trial of the HIV protease inhibitor Nelfinavir in combination with chemoradiation for locally advanced inoperable pancreatic cancer. Radiother Oncol 2016; 119:306-11. [PMID: 27117177 PMCID: PMC4917892 DOI: 10.1016/j.radonc.2016.03.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 03/09/2016] [Accepted: 03/20/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Nelfinavir can enhance intrinsic radiosensitivity, reduce hypoxia and improve vascularity. We conducted a phase II trial combining nelfinavir with chemoradiotherapy (CRT) for locally advanced inoperable pancreatic cancer (LAPC). MATERIALS AND METHODS Radiotherapy (50.4Gy/28 fractions; boost to 59.4Gy/33 fractions) was administered with weekly gemcitabine and cisplatin. Nelfinavir started 3-10days before and was continued during CRT. The primary end-point was 1-year overall survival (OS). Secondary end-points included histological downstaging, radiological response, 1-year progression free survival (PFS), overall survival (OS) and treatment toxicity. An imaging sub-study (n=6) evaluated hypoxia ((18)F-Fluoromisonidazole-PET) and perfusion (perfusion CT) during induction nelfinavir. RESULTS The study closed after recruiting 23 patients, due to non-availability of Nelfinavir in Europe. The 1-year OS was 73.4% (90% CI: 54.5-85.5%) and median OS was 17.4months (90% CI: 12.8-18.8). The 1-year PFS was 21.8% (90% CI: 8.9-38.3%) and median PFS was 5.5months (90% CI: 4.1-8.3). All patients experienced Grade 3/4 toxicity, but many were asymptomatic laboratory abnormalities. Four of 6 patients on the imaging sub-study demonstrated reduced hypoxia and increased perfusion post-nelfinavir. CONCLUSIONS CRT combined with nelfinavir showed acceptable toxicity and promising survival in pancreatic cancer.
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Affiliation(s)
- James M Wilson
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Emmanouil Fokas
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - Neel Patel
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, UK
| | - Maria A Hawkins
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Cynthia Eccles
- Department of Radiotherapy, Oxford University Hospitals NHS Foundation Trust, UK
| | - Kwun-Ye Chu
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK; Department of Radiotherapy, Oxford University Hospitals NHS Foundation Trust, UK
| | - Lisa Durrant
- Department of Radiotherapy, Oxford University Hospitals NHS Foundation Trust, UK
| | - Aswin G Abraham
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Mike Partridge
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Martha Woodward
- Early Phase Research Hub, Department of Oncology, Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, UK
| | - Eric O'Neill
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Tim Maughan
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - W Gillies McKenna
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK
| | - Somnath Mukherjee
- Department of Oncology, CRUK/MRC Institute for Radiation Oncology, University of Oxford, UK.
| | - Thomas B Brunner
- Department of Radiation Oncology, University of Freiburg, Germany; German Cancer Consortium (DKTK), Heidelberg, Partner Site Freiburg, Germany
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GONG JUN, TULI RICHARD, SHINDE ARVIND, HENDIFAR ANDREWE. Meta-analyses of treatment standards for pancreatic cancer. Mol Clin Oncol 2016; 4:315-325. [PMID: 26998283 PMCID: PMC4774516 DOI: 10.3892/mco.2015.716] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 11/23/2015] [Indexed: 01/05/2023] Open
Abstract
Pancreatic cancer is the most lethal common cancer with an estimated 5-year survival rate of 6-7% (across all stages). The only potential curative therapy is surgical resection in those with localized disease. Adjuvant (postoperative) therapy confers a survival advantage over postoperative observation alone. Neoadjuvant (preoperative) therapy offers the potential to downstage initially unresectable tumors for resection, sterilize resection margins and decrease locoregional recurrence, and identify a subset of patients with aggressive disease for whom surgery will not be beneficial. Induction chemotherapy followed by consolidation chemoradiation is another recommended approach in those with locally advanced disease. For those who cannot be downstaged, cannot tolerate surgery, or were diagnosed with metastatic disease, treatment remains palliative with chemotherapy being a critical component of this approach. Recently, intensive combination chemotherapy has been shown to improve survival rates in comparison to gemcitabine alone in advanced disease. The past few decades have afforded an accumulation of high-level evidence regarding neoadjuvant, adjuvant and palliative therapies in pancreatic cancer. There are numerous reviews discussing recent retrospective studies, prospective studies and randomized controlled trials in each of these areas. However, reviews of optimal and recommended treatment strategies across all stages of pancreatic cancer that focus on the highest levels of hierarchical evidence, such as meta-analyses, are limited. The discussion of novel therapeutics is beyond the scope of this review. However, an extensive and the most current collection of meta-analyses of first-line systemic and locoregional treatment options for all stages of pancreatic cancer to date has been accumulated.
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Affiliation(s)
- JUN GONG
- Department of Internal Medicine, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - RICHARD TULI
- Department of Radiation Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ARVIND SHINDE
- Department of Hematology and Oncology, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - ANDREW E. HENDIFAR
- Gastrointestinal and Neuroendocrine Malignancies, Samuel Oschin Cancer Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Ji HB, Chen ZH. Clinical effects of stereotactic radiotherapy combined with gemcitabine in treatment of locally advanced pancreatic carcinoma. Shijie Huaren Xiaohua Zazhi 2015; 23:5882-5888. [DOI: 10.11569/wcjd.v23.i36.5882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical effects of stereotactic conformal radiotherapy combined with gemcitabine in patients with locally advanced pancreatic carcinoma.
METHODS: A total of 118 patients with unresectable locally advanced pancreatic carcinoma were divided into two groups to receive either radiotherapy combined with gemcitabine (group A, 56 cases) or radiotherapy alone (group B, 62 cases). The standard dose of stereotactic conformal radiotherapy prescribed was 35-45 Gy to the 50%-65% isodose curve. The total dose was delivered over 10-13 d with a fraction dose of 2.8-3.5 Gy and 6 fractions per week. Concomitant chemotherapy started at the first day of radiotherapy: gemcitabine at a dose of 600 mg/m2 was given on days 1 and 8, and adjuvant chemotherapy was administered three weeks after radiotherapy at a dose of gemcitabine 1000 mg/m2 on days 1 and 8, 21 days per cycle, for 4-6 cycles continuously.
RESULTS: The patients underwent CT or MR examination 2 mo after 2 treatment. The tumor response rate of group A was 67.8% (38/56). Median survival time was 12.8 mo (range, 4-70 mo). The overall 1-year and 2-year survival rates were 58.9% (33/56) and 28.6% (16/56), respectively. Main side effects included leukopenia, thrombocytopenia, nausea and vomiting. The tumor response rate of group B was 30.6% (19/62). Median survival time was 8.5 mo (range, 5-56 mo). The overall 1-year and 2-year survival rates were 33.9% (21/66) and 12.9% (8/62), respectively. Main side effects were leukopenia and thrombocytopenia. Both the short-term and long-term therapeutic effects were better in the combination group than in the radiotherapy alone group.
CONCLUSION: Gemcitabine combined with stereotactic conformal radiotherapy is effective and safe in the treatment of patients with locally advanced pancreatic carcinoma.
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Wang Z, Lai ST, Ma NY, Deng Y, Liu Y, Wei DP, Zhao JD, Jiang GL. Radiosensitization of metformin in pancreatic cancer cells via abrogating the G2 checkpoint and inhibiting DNA damage repair. Cancer Lett 2015; 369:192-201. [PMID: 26304716 DOI: 10.1016/j.canlet.2015.08.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/14/2015] [Accepted: 08/18/2015] [Indexed: 12/20/2022]
Abstract
Recent evidences have demonstrated the potential of metformin as a novel agent for cancer prevention and treatment. Here, we investigated its ability of radiosensitization and the underlying mechanisms in human pancreatic cancer cells. In this study, we found that metformin at 5 mM concentration enhanced the radiosensitivity of MIA PaCa-2 and PANC-1 cells, with sensitization enhancement ratios of 1.39 and 1.27, respectively. Mechanistically, metformin caused abrogation of the G2 checkpoint and increase of mitotic catastrophe, associated with suppression of Wee1 kinase and in turn CDK1 Tyr15 phosphorylation. Furthermore, metformin inhibited both expression and irradiation-induced foci formation of Rad51, a key player in homologous recombination repair, ultimately leading to persistent DNA damage, as reflected by γ-H2AX and 53BP1 signaling. Finally, metformin-mediated AMPK/mTOR/p70S6K was identified as a possible upstream pathway controlling translational regulation of Wee1 and Rad51. Our data suggest that metformin radiosensitizes pancreatic cancer cells in vitro via abrogation of the G2 checkpoint and inhibition of DNA damage repair. However, the in vivo study is needed to further confirm the findings from the in vitro study.
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Affiliation(s)
- Zheng Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, Shanghai 200032, China
| | - Song-Tao Lai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, Shanghai 200032, China
| | - Ning-Yi Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, Shanghai 200032, China
| | - Yun Deng
- Cancer Research Institute, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China
| | - Yong Liu
- Cancer Research Institute, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China
| | - Dong-Ping Wei
- Cancer Research Institute, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China
| | - Jian-Dong Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, Shanghai 200032, China
| | - Guo-Liang Jiang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dongan Road, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, 270 Dongan Road, Shanghai 200032, China; Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, 4365 Kangxin Road, Shanghai 201321, China.
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Buwenge M, Cellini F, Silvestris N, Cilla S, Deodato F, Macchia G, Mattiucci GC, Valentini V, Morganti AG. Robotic radiosurgery in pancreatic cancer: A systematic review. World J Gastroenterol 2015; 21:9420-9429. [PMID: 26309369 PMCID: PMC4541395 DOI: 10.3748/wjg.v21.i31.9420] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/21/2014] [Accepted: 04/03/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To present a systematic review of techniques and clinical results.
METHODS: A systematic review of published literature was performed. Only studies reporting patient outcome after radiosurgery (single fraction) delivered with robotic devices [i.e., robotic radiosurgery (RRS)] have been analyzed.
RESULTS: A total of 96 patients from 5 studies were included. The studies are characterized by small series and different methods in terms of dose, target definition, combination with chemotherapy and/or standard fractionated radiotherapy and evaluation modalities. Preliminary results are positive in terms of tumor response (ORR = 56%) and local control of the tumor (crude rate of local progressions: 19.5%). Results for median overall survival (11.4 mo) seem comparable with the ones of prolonged chemoradiation (range: 8.6-13.0 mo). However, gastrointestinal toxicity seems to be the main limitation of RRS, especially at the duodenal level.
CONCLUSION: RRS allows for local treatment in a shortened time (1 fraction) compared to traditional treatments (about 1 mo), providing the possibility for an easy integration with systemic therapies. Preliminary results did not show any outcome differences compared to standard chemoradiation. Thus, further efforts to reduce gastrointestinal toxicity are strongly needed.
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Chen YG, Pan HH, Dai MS, Lin C, Lu CS, Su SL, Chang PY, Huang TC, Chen JH, Wu YY, Chen YC, Ho CL. Impact of Comorbidity and Age on Determinants Therapeutic Strategies in Advanced Pancreatic Head Cancer Patients With Obstructive Jaundices. Medicine (Baltimore) 2015; 94:e1298. [PMID: 26252308 PMCID: PMC4616572 DOI: 10.1097/md.0000000000001298] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The current retrospective study aimed to investigate the relationship between prognostic factors and overall survival (OS) in patients with advanced pancreatic head cancers who initially presented with obstructive jaundice. Furthermore, the impact of age and comorbidities on therapeutic strategies in such patients was evaluated.A total of 79 advanced pancreatic head cancer patients who were treated at our institution between January 2006 and November 2013 were reviewed. We analyzed OS risk factors including sex, age, laboratory characteristics, Eastern Cooperative Oncology Group performance status, Charlson Comorbidity Index Scores (CCIS), and therapeutic strategies using Cox proportional hazards regression models.There was no difference in the OS of patients according to the type biliary drainage procedure they underwent. Other related factors, such as better performance status, lower CCIS, and receiving chemotherapy significantly correlated with survival in multivariate analyses. There was a significant survival benefit in systemic chemotherapy compared to best supportive care (BSC) or local radiotherapy. However, no survival benefit was found in elderly patients (age >70 years) undergoing systemic therapy compared to younger patients, except in those elderly patients with CCIS ≤ 1.In advanced pancreatic head cancer patients with obstructive jaundice, systemic therapy and adequate biliary drainage were still the most effective procedures for improving OS in the general population. However, in elderly patients with relatively higher CCIS, BSC with adequate biliary drainage was palliative and no less effective than systemic/local therapies.
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Affiliation(s)
- Yu-Guang Chen
- From the Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC (Y-GC, M-SD, C-SL, P-YC, T-CH, J-HC, Y-YW, Y-CC, CLH); Department of Nursing, Tri-Service General Hospital; School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC (H-HP); Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, ROC (CL, SLS); School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC (S-LS); and Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC (C-SL)
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Fokas E, O'Neill E, Gordon-Weeks A, Mukherjee S, McKenna WG, Muschel RJ. Pancreatic ductal adenocarcinoma: From genetics to biology to radiobiology to oncoimmunology and all the way back to the clinic. BIOCHIMICA ET BIOPHYSICA ACTA 2015; 1855:61-82. [PMID: 25489989 DOI: 10.1016/j.bbcan.2014.12.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/01/2014] [Accepted: 12/03/2014] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer death. Despite improvements in the clinical management, the prognosis of PDAC remains dismal. In the present comprehensive review, we will examine the knowledge of PDAC genetics and the new insights into human genome sequencing and clonal evolution. Additionally, the biology and the role of the stroma in tumour progression and response to treatment will be presented. Furthermore, we will describe the evidence on tumour chemoresistance and radioresistance and will provide an overview on the recent advances in PDAC metabolism and circulating tumour cells. Next, we will explore the characteristics and merits of the different mouse models of PDAC. The inflammatory milieu and the immunosuppressive microenvironment mediate tumour initiation and treatment failure. Hence, we will also review the inflammatory and immune escaping mechanisms and the new immunotherapies tested in PDAC. A better understanding of the different mechanisms of tumour formation and progression will help us to identify the best targets for testing in future clinical studies of PDAC.
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MESH Headings
- Animals
- Cancer Vaccines/therapeutic use
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/immunology
- Carcinoma, Pancreatic Ductal/therapy
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/pathology
- Disease Models, Animal
- Drug Resistance, Neoplasm/genetics
- Drug Resistance, Neoplasm/immunology
- Humans
- Immunotherapy/methods
- Inflammation/pathology
- Mice
- Neoplastic Cells, Circulating/immunology
- Neoplastic Cells, Circulating/pathology
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/immunology
- Pancreatic Neoplasms/therapy
- Radiation Tolerance/genetics
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Affiliation(s)
- Emmanouil Fokas
- Department of Oncology, Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK.
| | - Eric O'Neill
- Department of Oncology, Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
| | - Alex Gordon-Weeks
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Somnath Mukherjee
- Department of Oncology, Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
| | - W Gillies McKenna
- Department of Oncology, Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
| | - Ruth J Muschel
- Department of Oncology, Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
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Mukherjee S, Symonds R. The Role of Radiotherapy in the Management of Upper Gastrointestinal and Hepato-biliary and Pancreatic Cancers: Current Status and Future Directions. Clin Oncol (R Coll Radiol) 2014; 26:519-21. [DOI: 10.1016/j.clon.2014.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/12/2014] [Indexed: 01/30/2023]
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