Adjuvant and neoadjuvant therapy in curable pancreatic cancer. Surg Clin North Am. 2010;90:323-339. [PMID: 20362789 DOI: 10.1016/j.suc.2009.12.010]

Evolving knowledge in surgical oncology of pancreatic cancer: from theory to clinical practice-a fifteen-year journey at a tertiary referral centre

Pancreatic ductal adenocarcinoma (PDAC) is an increasing disease having a poor prognosis. The aim of the present study was to evaluate the effect of different models of care for pancreatic cancer in a tertiary referral centre in the period 2006-2020. Retrospective study of patients with PDAC observed from January 2006 to December 2020. The demographic and clinical data, and data regarding the imaging techniques used, preoperative staging, management, survival and multidisciplinary tumour board (MDTB) evaluation were collected and compared in three different periods characterised by different organisation of pancreatic cancer services: period A (2006-2010); period B (2011-2015) and period C (2016-2020). One thousand four hundred seven patients were analysed: 441(31.3%) in period A; 413 (29.4%) in B and 553 (39.3%) in C. The proportion of patients increased significantly, from 31.3% to 39.3% (P = 0.032). Body mass index (P = 0.033), comorbidity rate (P = 0.002) and Karnofsky performance status (P < 0.001) showed significant differences. Computed tomography scans (P < 0.001), endoscopic ultrasound (P < 0.001), fine needle aspiration, fine needle biopsy (P < 0.001), and fluorodeoxyglucose-positron emission tomography/computed tomography (P < 0.001) increased; contrast-enhanced ultrasound (P = 0.028) decreased. The cTNM was significantly different (P < 0.001). The MDTB evaluation increased significantly (P < 0.001). Up-front surgery and exploratory laparotomy decreased (P < 0.001), neoadjuvant treatment increased (P < 0.001). The present study showed the evolving knowledge in surgical oncology of pancreatic cancer at a tertiary referral centre over the time. The different models of care of pancreatic cancer, in particular the introduction of the MDTB and the institution of a pancreas unit to the decision-making process seemed to be influential.

Obesity and Pancreatic Cysts in African American Patients

Objective

Obesity is one of the risk factors for pancreatic cancer and a prognostic factor for acute-chronic pancreatitis.

Aim

To explore the relationship and association between obesity and pancreatic cysts over a 25-year period in African American patients.

Methods

We reviewed the medical records of 207 patients diagnosed with pancreatic cysts via radiology and pathology data from January 1988 to December 2012. A control group was selected from a separate group of healthy patients without a history of pancreatic disease. The patients were evaluated in five groups according to the last 20 years of diagnosis in five-year intervals.

Results

Most patients with pancreatic cyst (73%) were overweight (defined as a body mass index (BMI) ≥ 25), and 53% had a history of chronic pancreatitis compared to patients in the control group. There was a significant difference between the two groups; 79% of patients group were overweight (BMI ≥ 25) vs. 66% in control group (p = 0.02). The incidence of obese and overweight patients was significant (85%) during the 2008 to 2012 interval for the test group (p = 0.009).

Conclusion

Given the increasing proportion of obese pancreatic cyst patients in recent decades compared to the proportion noted in the 1990s, obesity plays a large role in the formation of pancreatic cysts.

Role of tumor associated macrophages in regulating pancreatic cancer progression

Pancreatic cancer has an overall 5-year survival rate of less than 5%. Unfortunately, patient survival has not substantially improved in the last couple of decades despite advances in treatment modalities that have been successful in other cancer types. The poor response of pancreatic cancer to therapy is a major obstacle faced by clinicians. Increasing attention is being paid to how tumor cells and non-tumor cells influence each other in the pancreatic tumor microenvironment. Tumor-associated macrophages (TAMs) are a highlight in this field because of their vast presence in the tumor microenvironment. TAMs promote angiogenesis, metastasis, and suppress the anti-tumor immune response. Here we review the current understanding of the role of TAMs in regulating the progression of pancreatic cancer.

2564 resected periampullary adenocarcinomas at a single institution: trends over three decades

OBJECTIVE

This study was carried out to determine relative survival rates and trends in outcomes in patients who underwent resection of periampullary adenocarcinomas (PACs) with curative intent at a single institution over the last three decades.

METHODS

From 1980 to 2011, 2564 pancreaticoduodenectomies (PDs) were performed for PACs. Pathological diagnosis, therapy and survival were retrospectively analysed.

RESULTS

The primary sites included the pancreas (66%), ampulla (16%), bile duct (12%) and duodenum (6%). Operation volume increased from 11 per year in the 1980s to 135 per year in the 2000s (P < 0.001). Patients in the 1980s were younger (median age: 64 years; range: 33-90 years) than those in the 1990s (median age: 68 years; range: 31-103 years) and 2000s (median age: 68 years; range: 24-93 years) (P < 0.001). Over time, the frequency of a diagnosis of pancreatic cancer arising from intraductal papillary mucinous neoplasm increased from 2% in the 1980s to 8% in the 2000s (P < 0.001). The rate of 30-day mortality after surgery in the 1980s was 2%, which was similar to rates in the 1990s (1%) and 2000s (1%). Survival in each type of PAC did not change over time. Pancreatic cancer was associated with the worst survival (median survival: 19 months) compared with adenocarcinomas of the ampulla (median survival: 47 months), bile duct (median survival: 23 months) and duodenum (median survival: 54 months) (P < 0.001).

CONCLUSIONS

There are significant differences among PACs in longterm survival following PD. Although the numbers of patients undergoing safe resection have increased, overall longterm outcomes have not improved significantly.

Nationwide improvement of only short-term survival after resection for pancreatic cancer in the Netherlands

OBJECTIVES

Evaluation of incidence, treatment, and survival trends after resection of pancreatic cancer at a national level.

METHODS

Using data on patient and tumor characteristics from the nationwide Netherlands Cancer Registry trends were analyzed for the period 1989-2008.

RESULTS

A total of 30,025 patients diagnosed with pancreatic cancer were included. The incidence remained stable over the 20-year study period at approximately 9 per 100,000 inhabitants. Resection rates increased from 8% in 1989 to 12% in 2008, adjuvant chemotherapy rates increased from 7% to 29%, and palliative chemotherapy rates increased from 5% to 19% (P < 0.0001 each). Relative survival proportions did not change over time; besides a minimal, nonsignificant increase at 3 months from 53% to 55%, these remained 34% at 6 months and 4.5% at 3 years. Among the patients undergoing tumor resection, relative survival increased from 82% to 93% at 3 months and from 51% to 63% at 1 year after diagnosis. However, no improvement was seen after 3 years (23%).

CONCLUSIONS

The increased short-term survival among patients who underwent resection probably reflects decreased postoperative mortality driven by ongoing centralization efforts. However, longer-term survival remained poor irrespective of the changes in management in the past decades.

Adjuvant therapy for pancreas adenocarcinoma

Adjuvant therapy for pancreas adenocarcinoma in 2012 includes consideration of systemic therapy based on high level evidence and combined chemoradiotherapy based on less robust data. Current major adjuvant questions are examining the role of the addition of a second agent, either cytotoxic or targeted agent, to gemcitabine and whether or not the utilization of combined chemoradiotherapy improves overall survival. Progress to date has been modest and incremental in the adjuvant setting.

Adjuvant therapy for pancreas adenocarcinoma: where are we going?

Evaluation of: Neoptolemos JP, Stocken DD, Bassi C et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs. gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 304(10), 1073-1081 (2010). Over the last decade, adjuvant therapy in the treatment of resected pancreas adenocarcinoma has had its value established. Such treatment incrementally increases 5-year survivorship and delays time to tumor recurrence. The backbone of adjuvant therapy is the single-agent gemcitabine, based primarily on results from the Charité Onkologie Clinical (CONKO)-001 study. Based on the combined results of the European Study Group for Pancreas Cancer (ESPAC)-1 and ESPAC-3 trials, Neoptolemos and colleagues have established both bolus 5-fluorouracil and leucovorin and gemcitabine as standard options for resected pancreatic cancer. Gemcitabine remains the main standard therapy based on its ease of administration and a more favorable toxicity profile; however, there is now a clearly validated alternate option of 5-fluororuacil and leucovorin based on the results of ESPAC-3. Moving forward, the integration of novel cytotoxic and targeted agents into adjuvant therapy, along with refining the role of neoadjuvant therapy for patients with resectable pancreas cancer, will hopefully accrue a more substantial improvement in outcome for patients with resected pancreas adenocarcinoma.

Prognostic impact of postoperative serum CA 19-9 levels in patients with resectable pancreatic cancer

BACKGROUND

Perioperative serum carbohydrate antigen 19-9 (CA 19-9) level has been reported to be a useful prognostic marker in pancreatic cancer. The object of this study was to investigate the predictive factors for survival, including preoperative and postoperative serum CA 19-9 levels in patients with pancreatic cancer.

METHODS

Between 2003 and 2009, a total of 269 patients with pancreatic invasive ductal carcinoma underwent macroscopically curative resection, and pre- and postoperative (within 3 months after surgery) serum CA 19-9 levels were evaluated in all of them. The prognostic significance of clinicopathologic factors was evaluated by univariate and multivariate analyses.

RESULTS

Preoperative serum CA 19-9 levels were higher than normal (>37 U/ml, 38-4600 U/ml) in 218 of 269 patients. Of these, after surgery, serum CA 19-9 level returned to within a normal range in 136 patients (62%), whereas 82 patients (38%) remained in the higher-than-normal range. In univariate and multivariate analyses, node metastasis (P < 0.001) and postoperative CA 19-9 level (>37 U/ml) (P < 0.0001) were independent predictors for poor survival. Postoperative CA 19-9 level was higher in patients with microscopically positive surgical margin (P = 0.02). Hepatic recurrence and peritoneal dissemination were associated with postoperative higher CA 19-9 level.

CONCLUSIONS

Postoperative CA 19-9 level was associated with positive surgical margin and hepatic or peritoneal recurrence and may be a useful predictor for survival in patients with pancreatic cancer.