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Jethwa KR, Kim E, Berlin J, Anker CJ, Tchelebi L, Abood G, Hallemeier CL, Jabbour S, Kennedy T, Kumar R, Lee P, Sharma N, Small W, Williams V, Russo S. Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma: Systematic Review and Guidelines. Am J Clin Oncol 2024; 47:185-199. [PMID: 38131628 DOI: 10.1097/coc.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and "Preferred Reporting Items for Systematic Reviews and Meta-analyses" 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ed Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jordan Berlin
- Department of Medicine, Division of Hematology-Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Christopher J Anker
- Department of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, VT
| | - Leila Tchelebi
- Department of Radiation Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
| | | | | | | | - Timothy Kennedy
- Department of Surgery, Rutgers Cancer Institute, New Brunswick, NJ
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Sibley Memorial Hospital, Washington DC
| | - Percy Lee
- Department of Radiation Oncology, City of Hope National Medical Center, Los Angeles, CA
| | - Navesh Sharma
- Department of Radiation Oncology, WellSpan Cancer Center, York, PA
| | - William Small
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, IL
| | - Vonetta Williams
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, NY
| | - Suzanne Russo
- Department of Radiation Oncology, University Hospitals Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH
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Gu J, Guo Y, Du J, Kong L, Deng J, Tao B, Li H, Jin C, Fu D, Li J. CDCA8/SNAI2 Complex Activates CD44 to Promote Proliferation and Invasion of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14215434. [PMID: 36358852 PMCID: PMC9657053 DOI: 10.3390/cancers14215434] [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: 09/25/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Simple Summary There is an urgent need to find an effective therapeutic target for pancreatic cancer owing to late diagnosis, tumor metastasis, and current ineffective targeted drugs. We aimed to identified potential targets for the treatment of pancreatic cancer. In this study, the specific mechanism by which the CDCA8 contributes to pancreatic cancer progression via the activation of CD44 was clarified, and CDCA8 knockdown inhibited the proliferation and metastasis of pancreatic cancer. This finding may provide a promising target for future targeted therapies of pancreatic cancer. Abstract (1) Background: Recently, cell division cycle associated 8 (CDCA8) was found to be overexpressed in pancreatic ductal adenocarcinoma (PDAC). Here, we aimed to explore the specific mechanism of action of CDCA8 in PDAC progression. (2) Methods: All human PDAC samples and clinical data were collected from Huashan Hospital, Fudan University. All experimental studies were carried out using many in vitro and in vivo assays, including lentiviral transfection, real-time quantitative polymerase chain reaction (qPCR), western blotting, co-immunoprecipitation (Co-IP), chromatin IP (ChIP)-qPCR, dual-luciferase reporter, and in vivo imaging assays. (3) Results: Clinical data analysis of human PDAC samples revealed that CDCA8 overexpression were positively and negatively associated with tumor grade (p = 0.007) and overall survival (p = 0.045), respectively. CDCA8 knockdown inhibited PDAC proliferation and invasion in in vitro and in vivo assays. CD44 was also up-regulated by CDCA8 during PDAC progression. CDCA8 could be combined with SNAI2 to form a CDCA8/SNAI2 complex to integrate with the CD44 promoter as indicated through ChIP-qPCR and dual-luciferase reporter assays. (4) Conclusion: We showed that CDCA8-CD44 axis plays a key role in the proliferation and invasion of PDAC, which provides a potential target for treatment.
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Affiliation(s)
- Jichun Gu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yujie Guo
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jiali Du
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Lei Kong
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Junyuan Deng
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Baian Tao
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Hengchao Li
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
- Pancreatic Disease Institute, Fudan University, Shanghai 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
- Correspondence: ; Tel.: +86-13816418978
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Puleo A, Malla M, Boone BA. Defining the Optimal Duration of Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Time for a Personalized Approach? Pancreas 2022; 51:1083-1091. [PMID: 37078929 PMCID: PMC10144367 DOI: 10.1097/mpa.0000000000002147] [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: 01/18/2022] [Accepted: 11/03/2022] [Indexed: 04/21/2023]
Abstract
ABSTRACT Despite recent advances, pancreatic ductal adenocarcinoma (PDAC) continues to be associated with dismal outcomes, with a cure evading most patients. While historic treatment for PDAC has been surgical resection followed by 6 months of adjuvant therapy, there has been a recent shift toward neoadjuvant treatment (NAT). Several considerations support this approach, including the characteristic early systemic spread of PDAC, and the morbidity often surrounding pancreatic resection, which can delay recovery and preclude patients from starting adjuvant treatment. The addition of NAT has been suggested to improve margin-negative resection rates, decrease lymph node positivity, and potentially translate to improved survival. Conversely, complications and disease progression can occur during preoperative treatment, potentially eliminating the chance of curative resection. As NAT utilization has increased, treatment durations have been found to vary widely between institutions with an optimal duration remaining undefined. In this review, we assess the existing literature on NAT for PDAC, reviewing treatment durations reported across retrospective case series and prospective clinical trials to establish currently used approaches and seek the optimal duration. We also analyze markers of treatment response and review the potential for personalized approaches that may help clarify this important treatment question and move NAT toward a more standardized approach.
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Affiliation(s)
- Amanda Puleo
- From the Division of Surgical Oncology, Department of Surgery
| | - Midhun Malla
- Section of Hematology/Oncology, Department of Medicine
| | - Brian A. Boone
- From the Division of Surgical Oncology, Department of Surgery
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
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4
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Turner KM, Delman AM, Kharofa JR, Smith MT, Choe KA, Olowokure O, Wilson GC, Patel SH, Sohal D, Ahmad SA. Radiation therapy in borderline resectable pancreatic cancer: A review. Surgery 2022; 172:284-290. [PMID: 35034793 DOI: 10.1016/j.surg.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/11/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, OH
| | - Milton T Smith
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, OH
| | - Olugbenga Olowokure
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Davendra Sohal
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH.
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5
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Nappo G, Donisi G, Zerbi A. Borderline resectable pancreatic cancer: Certainties and controversies. World J Gastrointest Surg 2021; 13:516-528. [PMID: 34194610 PMCID: PMC8223708 DOI: 10.4240/wjgs.v13.i6.516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Greta Donisi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano 20089, Italy
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6
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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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7
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Treatment Strategies for the Optimal Management of Locally Advanced Pancreatic Adenocarcinoma With Curative Intent: A Systematic Review. Pancreas 2020; 49:1264-1275. [PMID: 33122513 DOI: 10.1097/mpa.0000000000001694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Historically, locally advanced pancreatic adenocarcinoma (LAPDAC) was considered a palliative condition. Advances in treatment have resulted in studies reporting survival after neoadjuvant treatment and surgery similar to earlier disease stages. However, there is no consensus on optimal LAPDAC management. Our aim was a systematic review of published evidence on LAPDAC treatment strategies with curative intent. Twenty-eight studies defining LAPDAC as per established criteria and reporting outcomes after neoadjuvant treatment with a view to resection were included. Primary outcomes were resection rate and proportion of curative resections. Secondary outcomes were postoperative mortality, progression-free survival, and overall survival. Neoadjuvant treatment varied significantly, most common being the combination of folinic acid, fluorouracil, irontecan, and oxaliplatin. Median percentage of patients proceeding to surgery after completion of neoadjuvant pathway was 33.5%. Median resection rate was 25%. Median R0 resection was 80% of resected patients. These outcomes ranged 0% to 100% across studies. Ninety-day postoperative mortality ranged from 0% to 5%. Median progression-free and overall survival for resected patients were 12.9 and 30 months, respectively, versus 13.2 months overall survival for unresected patients. In conclusion, although there is wide variability in reported LAPDAC resection rates post-neoadjuvant chemotherapy, retrospective data suggest that neoadjuvant treatment followed by surgery results in improved survival.
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8
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Laura A, Anna C, Cinquepalmi M, Giovanni M, Sole MM, Nava AK, Niccolò P, Giuseppe N, Stefano V, Paolo A, Francesco D, Giovanni R. Is Complete Pathologic Response in Pancreatic Cancer Overestimated? A Systematic Review of Prospective Studies. J Gastrointest Surg 2020; 24:2336-2348. [PMID: 32583324 DOI: 10.1007/s11605-020-04697-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/11/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In literature, percentages of pathologic complete response (pCR) in patients presenting with resectable (RES), borderline resectable (BLR) or locally advanced (LA) pancreatic cancer (PaC) after neoadjuvant treatment (NADT) are variable, ranging 0-33%. Those data come mostly from retrospective reviews of single centres. The objective of this systematic review is to assess the incidence of pCR. METHODS Following the criteria of the PRISMA statement, a literature search was conducted looking for prospective papers focusing on neoadjuvant treatment in PaC. Retrospective papers, other than ductal carcinoma histologies and trials including metastatic patients, were excluded from the present review. Data extraction was carried out by 3 independent investigators. Meta-analysis was performed with ProMeta3 Software (Internovi, 2015). PROSPERO registry: CRD42018095641. RESULTS The literature search of Embase, Cochrane and Medline with the terms "neoadjuvant OR preoperative", "pancreatic OR pancreas" and "cancer OR adenocarcinoma OR tumor" led to the identification of 3128 papers. We restricted the search to humans, last 10 years and English language articles resulting in 1158 eligible articles to review. Extended paper revision led to the inclusion of 27 papers. Complete pathologic response ranged 0-11.11%, at the meta-analysis 4% (95% CI 3-5%), in prospective studies 0-9.09% and in prospective databases 1.63-11.11%. CONCLUSIONS Pathologic complete response in pancreatic cancer is actually infrequent: high-quality studies provide a more reliable picture of neoadjuvant effects, high rates of pCR are reported in selected retrospective studies but it is overestimated.
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Affiliation(s)
- Antolino Laura
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Crovetto Anna
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Matteo Cinquepalmi
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy.
| | - Moschetta Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Mattei Maria Sole
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Andrea Kazemi Nava
- Hepatopancreaticobiliary Group, Saint Vincent's University Hospital, Dublin, Ireland
| | - Petrucciani Niccolò
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Nigri Giuseppe
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Valabrega Stefano
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Aurello Paolo
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - D'Angelo Francesco
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Ramacciato Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
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9
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Oba A, Ho F, Bao QR, Al-Musawi MH, Schulick RD, Del Chiaro M. Neoadjuvant Treatment in Pancreatic Cancer. Front Oncol 2020; 10:245. [PMID: 32185128 PMCID: PMC7058791 DOI: 10.3389/fonc.2020.00245] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Thanks to the development of modern chemotherapeutic regimens, survival after surgery for pancreatic ductal adenocarcinoma (PDAC) has improved and pancreatologists worldwide agree that the treatment of PDAC demands a multidisciplinary approach. Neoadjuvant treatment (NAT) plays a major role in the treatment of PDAC since only about 20% of patients are considered resectable at the time of diagnosis. Moreover, increasing data demonstrating the benefits of NAT for borderline resectable/locally advanced PDAC are driving a shift from up-front surgery to NAT in the multidisciplinary treatment of even resectable PDAC. Our understanding of the role of NAT in PDAC has evolved from tumor shrinkage to controlling potential micrometastases and selecting patients who may benefit from radical resection. The present review gives an overview on the current literature of NAT concepts for BR/LA PDAC and resectable PDAC.
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Affiliation(s)
- Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Felix Ho
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Quoc Riccardo Bao
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Mohammed H Al-Musawi
- Clinical Trials Office, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, CO, United States
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10
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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11
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Comparison of Tumor Regression Grading of Residual Pancreatic Ductal Adenocarcinoma Following Neoadjuvant Chemotherapy Without Radiation: Would Fewer Tier-Stratification Be Favorable Toward Standardization? Am J Surg Pathol 2020; 43:334-340. [PMID: 30211728 DOI: 10.1097/pas.0000000000001152] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To assess whether the College of American Pathologists (CAP) and the Evans grading systems for neoadjuvant chemotherapy without radiation-treated pancreatectomy specimens are prognostic, and if a 3-tier stratification scheme preserves data granularity. Conducted retrospective review of 32 patients with ordinary pancreatic ductal adenocarcinoma treated with neoadjuvant therapy without radiation followed by surgical resection. Final pathologic tumor category (AJCC eighth edition) was 46.9% ypT1, 34.4% ypT2, and 18.7% ypT3. Median follow-up time was 29.8 months, median disease-free survival (DFS) was 19.6 months, and median overall survival (OS) was 34.2 months. CAP score 1, 2, 3 were present in 5 (15.6%), 18 (56.3%), and 9 (28.1%) patients, respectively. Evans grade III, IIb, IIa, and I were present in 10 (31.2%), 8 (25.0%), 7 (21.9%), and 7 (21.9%) patients, respectively. OS (CAP: P=0.005; Evans: P=0.001) and DFS (CAP: P=0.003; Evans: P=0.04) were statistically significant for both CAP and Evans. Stratified CAP scores 1 and 2 versus CAP score 3 was statistically significant for both OS (P=0.002) and DFS (P=0.002). Stratified Evans grades I, IIa, and IIb versus Evans grade III was statistically significant for both OS (P=0.04) and DFS (P=0.02). CAP, Evans, and 3-tier stratification are prognostic of OS and DFS.
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Phase 2 Study of Neoadjuvant Treatment of Sequential S-1-Based Concurrent Chemoradiation Therapy Followed by Systemic Chemotherapy with Gemcitabine for Borderline Resectable Pancreatic Adenocarcinoma (HOPS-BR 01). Int J Radiat Oncol Biol Phys 2019; 105:606-617. [PMID: 31306735 DOI: 10.1016/j.ijrobp.2019.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE Preoperative treatment is recommended for borderline resectable pancreatic ductal adenocarcinoma. However, the standard treatment has not yet been determined. We conducted a multicenter phase 2 study to investigate the efficacy of neoadjuvant treatment of sequential chemoradiation followed by chemotherapy. METHODS AND MATERIALS All enrolled patients were treated by preoperative chemoradiation (a total dose of 50.4 Gy in 28 fractions and orally administered S-1 at 80 mg/m2 on the day of irradiation) followed by chemotherapy (administration of gemcitabine at 1000 mg/m2/dose on days 1, 8, and 15 in 3 cycles of 4 weeks) and attempted curative resection. The primary outcome was an R0 resection rate among patients who completed preoperative treatment and pancreatectomy. The threshold of the R0 resection rate was defined as 74% based on a previous study of up-front surgery. RESULTS Forty-five patients were included. Twenty-one patients could not undergo pancreatectomy because of progressive diseases (n = 14), adverse events (n = 5), or consent withdrawal (n = 2), and 4 patients underwent additional resection after dropping out. The resection rates were 53.3% and 62.2% in the per-protocol set (PPS) and full analysis set (FAS) populations, respectively. The R0 resection rates were 95.8% (95% confidence interval, 78.9%-99.9%) and 96.4% (81.7%-99.9%) in the PPS and FAS populations, respectively. The median overall survival and progression-free survival of all the included patients were 17.3 and 10.5 months, respectively. The median survival time of the patients with pancreatectomy was significantly longer than that of the patients without pancreatectomy in the PPS (27.9 vs 12.3 months; P = .001) and FAS populations (32.2 vs 11.8 months; P < .001). CONCLUSIONS This study revealed that a long duration of preoperative treatment of sequential chemoradiation followed by systemic chemotherapy provides a high rate of R0 resection and sufficient survival time in patients undergoing pancreatectomy.
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Tajima H, Ohta T, Okazaki M, Yamaguchi T, Ohbatake Y, Okamoto K, Nakanuma S, Kinoshita J, Makino I, Nakamura K, Miyashita T, Takamura H, Ninomiya I, Fushida S, Nakamura H. Neoadjuvant chemotherapy with gemcitabine-based regimens improves the prognosis of node positive resectable pancreatic head cancer. Mol Clin Oncol 2019; 11:157-166. [PMID: 31281650 DOI: 10.3892/mco.2019.1867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/16/2019] [Indexed: 01/02/2023] Open
Abstract
The effectiveness of preoperative (neoadjuvant) chemotherapy (NAC) for resectable pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study retrospectively evaluated the efficacy of NAC with gemcitabine (GEM)-based regimens or GEM monotherapy for resectable PDAC. Between 2006 and 2015, NAC with GEM was performed in 52 cases (head 31, and body and tail 21) and compared with 34 resection-only cases serving as controls (head 20, and body and tail 14). According to the Response Evaluation Criteria In Solid Tumors guidelines, the treatment effect was a partial response in 5 cases, stable disease in 45 cases, and progressive disease in 2 cases. Maximum standardized uptake values and carbohydrate antigen (CA19-9) values were significantly reduced after preoperative chemotherapy. Using the Evans grading system, the treatment effect was grade I in 31 patients, grade IIa in 8, and grade IIb in 3 cases. There were significant differences in the overall survival rate between the NAC and control groups, only in the patients with node-positive pancreatic head cancer. Significantly higher CA19-9 values in peripheral blood and higher lymph node metastasis and plexus invasion rates were observed in early-recurring cases within a year. The preoperative CA 19-9 cutoff value as an early recurrence risk factor was calculated as 30 U/ml in the NAC group and 88 U/ml in the control group. NAC with GEM prolonged survival in patients with node-positive pancreatic head cancer. High CA19-9 values before operation, lymph node metastases and plexus invasion were risk factors for early tumor recurrence after surgery. Preoperative chemotherapy would be necessary for resectable pancreatic head cancer as lymph node metastasis was observed in >60% with resectable PDAC. Moreover, if normalization of CA19-9 values is not achieved with NAC, extension of preoperative chemotherapy should be considered as for borderline resectable PDAC cases.
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Affiliation(s)
- Hidehiro Tajima
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Mitsuyoshi Okazaki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Takahisa Yamaguchi
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Koichi Okamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Jun Kinoshita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Keishi Nakamura
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Itasu Ninomiya
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Nakamura
- Department of Environmental and Preventive Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
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Bradley A, Van Der Meer R. Neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer: A Markov decision analysis. PLoS One 2019; 14:e0212805. [PMID: 30817807 PMCID: PMC6394923 DOI: 10.1371/journal.pone.0212805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. In the absence of large randomized controlled trials offering a direct comparison, this study aims to use Markov decision analysis to compare efficacy of traditional surgery first (SF) and neoadjuvant treatment (NAT) pathways for potentially resectable pancreatic cancer. Methods An advanced Markov decision analysis model was constructed to compare SF and NAT pathways for potentially resectable pancreatic cancer. Transition probabilities were calculated from randomized control and Phase II/III trials after comprehensive literature search. Utility outcomes were measured in overall and quality-adjusted life months (QALMs) on an intention-to-treat basis as the primary outcome. Markov cohort analysis of treatment received was the secondary outcome. Model uncertainties were tested with one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Results SF gave 23.72 months (18.51 QALMs) versus 20.22 months (16.26 QALMs). Markov Cohort Analysis showed that where all treatment modalities were received NAT gave 35.05 months (29.87 QALMs) versus 30.96 months (24.86QALMs) for R0 resection and 34.08 months (29.87 QALMs) versus 25.85 months (20.72 QALMs) for R1 resection. One-way deterministic sensitivity analysis showed that NAT was superior if the resection rate was greater than 51.04% or below 75.68% in SF pathway. Two-way sensitivity analysis showed that pathway superiority depended on obtaining multimodal treatment in either pathway. Conclusion Whilst NAT is a viable alternative to traditional SF approach, superior pathway selection depends on the individual patient’s likelihood of receiving multimodal treatment in either pathway.
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Affiliation(s)
- Alison Bradley
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
- West of Scotland Pancreatic Cancer Unit, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Robert Van Der Meer
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
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Yoo C, Shin SH, Kim KP, Jeong JH, Chang HM, Kang JH, Lee SS, Park DH, Song TJ, Seo DW, Lee SK, Kim MH, Park JH, Hwang DW, Song KB, Lee JH, Ryoo BY, Kim SC. Clinical Outcomes of Conversion Surgery after Neoadjuvant Chemotherapy in Patients with Borderline Resectable and Locally Advanced Unresectable Pancreatic Cancer: A Single-Center, Retrospective Analysis. Cancers (Basel) 2019; 11:cancers11030278. [PMID: 30813624 PMCID: PMC6468804 DOI: 10.3390/cancers11030278] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/12/2019] [Accepted: 02/24/2019] [Indexed: 12/17/2022] Open
Abstract
The clinical benefit and potential risks of conversion surgery after neoadjuvant chemotherapy (NACT) have not been fully investigated in patients with borderline resectable pancreatic cancer (BRPC) and locally advanced unresectable pancreatic cancer (LAPC). Therefore, this has been evaluated in a retrospective, prospective cohort-based analysis. Between October 2005 and April 2017, 135 patients (65 with BRPC and 70 with LAPC) received conversion surgery after NACT. Exploratory analysis to assess clinical outcomes in comparison with patients who underwent upfront surgery in the same time period (n = 359) was also conducted. NACT with gemcitabine-based regimens (including gemcitabine monotherapy, gemcitabine-capecitabine combination, and gemcitabine-erlotinib combination) was used in 69 patients (51%) and FOLFIRINOX in 66 patients (49%). The median overall survival (OS) and disease-free survival (DFS) from the time of surgery was 25.4 months (95% CI, 18.6–32.2 months) and 9.0 months (95% CI, 6.8–11.2 months), respectively. The median OS and progression-free survival from the initiation of NACT was 29.7 months (95% CI, 22.5–36.8 months) and 13.4 months (95% CI, 12.5–14.4 months), respectively. In the exploratory analysis, conversion surgery after NACT was associated with a better median OS and DFS than upfront surgery (vs. 17.1 months; 95% CI, 15.5–18.7 months; p = 0.001 and vs. 7.1 months; 95% CI, 6.4–7.8 months; p = 0.005, respectively). There was no difference in length of hospital stay between the two groups, and conversion surgery after NACT showed a significantly lower incidence of postoperative complications than upfront surgery (38% vs. 27%, p = 0.03). Conversion surgery after NACT is a feasible and effective therapeutic strategy for the treatment of patients with BRPC and LAPC. Further clinical trials investigating optimal therapeutic strategies for BRPC and LAPC are warranted.
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Affiliation(s)
- Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Sang Hyun Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Heung-Moon Chang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jun Ho Kang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Do Hyun Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Sung Koo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Myung-Hwan Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Dae Wook Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Ki Byung Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jae Hoon Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
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Wolfe AR, Jain R, Pawlik TM, Walker J, Williams TM. Radiation-Induced Colitis in a Pancreatic Cancer Patient With a Germline BRCA2 Mutation: A Case Report. Adv Radiat Oncol 2019; 4:10-14. [PMID: 30706003 PMCID: PMC6349605 DOI: 10.1016/j.adro.2018.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 01/07/2023] Open
Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Rishi Jain
- Department of Medical Oncology, Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgical Oncology, Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Jon Walker
- Department of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Terence M Williams
- Department of Radiation Oncology, Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
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Einama T, Kamachi H, Tsuruga Y, Sakata T, Shibuya K, Sakamoto Y, Shimada S, Wakayama K, Orimo T, Yokoo H, Kamiyama T, Katoh N, Uchinami Y, Mitsuhashi T, Taketomi A. Optimal resection area for superior mesenteric artery nerve plexuses after neoadjuvant chemoradiotherapy for locally advanced pancreatic carcinoma. Medicine (Baltimore) 2018; 97:e11309. [PMID: 30075497 PMCID: PMC6081073 DOI: 10.1097/md.0000000000011309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/26/2018] [Indexed: 02/05/2023] Open
Abstract
Recently, several reports demonstrated the efficacy of neoadjuvant chemotherapy (NAC) or chemoradiotherapy (NACRT) for patients with borderline resectable (BRPC) and locally advanced unresectable pancreatic carcinoma (LAPC). The aim of this study was to evaluate the treatment response after NACRT, especially for nerve plexuses, and the optimal resection area for superior mesenteric artery nerve plexuses in BRPC and LAPC patients after NACRT.A total of 17 patients with BRPC and LAPC received preoperative gemcitabine-based NACRT. The numbers of BRPC and LAPC patients were 13 and 4, respectively. We evaluated nerve plexus invasion by CT before and after NACRT, decided on the resection area of plexus invasion in SMA before NACRT, and compared the preoperative evaluation and clinicopathological findings.In the plexus of the supra-mesenteric artery (pl-SMA), arterial nerve plexus invasion, in cases <90°, all patients showed the absence of residual cancer in the resected specimen after NACRT. In cases between 90° and 180°, 1 of 2 patients (50%) showed nerve plexus invasion. In cases over 180°, all patients showed nerve plexus invasion. We could perform R0 resection in all 10 cases, and pl-SMA invasion disappeared in 6 of 7 BRPC patients.We demonstrated the relationship between the angle of nerve plexus tumor invasion and treatment effect after NACRT. We could perform R0 resection in all pl-SMA invasion cases, deciding on the resection area of pl-SMA based on CT before NACRT.
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Affiliation(s)
- Takahiro Einama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - Hirofumi Kamachi
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yosuke Tsuruga
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Toshihiro Sakata
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kazuaki Shibuya
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yuzuru Sakamoto
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Shingo Shimada
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kenji Wakayama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Tatsuya Orimo
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Hideki Yokoo
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Toshiya Kamiyama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine, Sapporo
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital Sapporo, Hokkaido
| | - Akinobu Taketomi
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
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18
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Shin SH, Kim SC, Song KB, Hwang DW, Lee JH, Park KM, Lee YJ. Chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma since 2000: A single-center experience with 2,029 patients. Surgery 2018; 164:432-442. [PMID: 29884479 DOI: 10.1016/j.surg.2018.04.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/20/2018] [Accepted: 04/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND To identify chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma based on diagnosis and treatment strategy development since 2000. METHODS Among 2,029 patients enrolled in this study, 746 and 1,283 were treated between 2000 and 2009 (group 1) and between 2010 and 2016 (group 2), respectively. We used patient clinicopathologic, biologic, and molecular factors to assess the prognostic factors. RESULTS Group 2 had a better survival outcome than group 1 (median survival time: 24.9 versus 18.4 months; 5-year survival rate: 27.6% versus 22.3%). The tendency for early diagnosis (lower CA19-9 levels, smaller size, and earlier T stage), use of neoadjuvant chemotherapy, decreased morbidity, early recovery (lesser hospital stay and more minimally invasive surgery), and standardization of surgical techniques appeared to improve patient survival. Multivariable analysis for prognosis revealed that tumor biologic factors (increased preoperative serum CA19-9 level, tumor size, tumor differentiation, N stage, and presence of lymphovascular invasion), operational factors (status of the resection margin, type of operation, and year of operation), and genetic factors (K-ras mutations) correlated with patient survival. CONCLUSION Early diagnosis and combined efforts, such as neoadjuvant chemotherapy and an established system of patient care, have gradually enhanced patient survival after operative resection for pancreatic ductal adenocarcinoma. Hence, multiplex prognostic parameters could provide additional information for improved prognostic estimation of pancreatic cancer exhibiting heterogeneous results.
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Affiliation(s)
- Sang Hyun Shin
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Ki-Byung Song
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang-Min Park
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Joo Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ambe CM, Nguyen P, Centeno BA, Choi J, Strosberg J, Kvols L, Hodul P, Hoffe S, Malafa MP. Multimodality Management of "Borderline Resectable" Pancreatic Neuroendocrine Tumors: Report of a Single-Institution Experience. Cancer Control 2018; 24:1073274817729076. [PMID: 28975822 PMCID: PMC5937248 DOI: 10.1177/1073274817729076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Pancreatic neuroendocrine tumors (PanNETs) constitute approximately 3% of pancreatic neoplasms. Like patients with pancreatic ductal adenocarcinoma (PDAC), some of these patients present with “borderline resectable disease.” For these patients, an optimal treatment approach is lacking. We report our institution’s experience with borderline resectable PanNETs using multimodality treatment. Methods: We identified patients with borderline resectable PanNETs who had received neoadjuvant therapy at our institution between 2000 and 2013. The definition of borderline resectability was based on National Comprehensive Cancer Network criteria for PDAC. Neoadjuvant regimen, radiographic response, pathologic response, surgical margins, nodal retrieval, number of positive nodes, and recurrence were documented. Statistics were descriptive. Results: Of 112 patients who underwent surgical resection for PanNETs during the study period, 23 received neoadjuvant therapy, 6 of whom met all inclusion criteria and had borderline resectable disease. These 6 patients received at least 1 cycle of temozolomide and capecitabine, with 3 also receiving radiation. All had radiographic evidence of treatment response. Four (67%) had negative-margin resections. Four patients had histologic evidence of a moderate response. Follow-up (3.0-4.3 years) indicated that all patients were alive, with 5/6 free of disease (1 patient with metastatic disease still on treatment without progression). Conclusions: A multimodality treatment strategy (neoadjuvant temozolomide and capecitabine ± radiation) can be successfully applied to patients with PanNETs who meet NCCN borderline resectable criteria for PDAC. To our knowledge, this is the first report of the use of a multimodality protocol in the treatment of patients with borderline resectable PanNETs.
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Affiliation(s)
- Chenwi M Ambe
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Phuong Nguyen
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Barbara A Centeno
- 2 Department of Anatomic Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Junsung Choi
- 3 Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jonathan Strosberg
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Larry Kvols
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Pamela Hodul
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Sarah Hoffe
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Mokenge P Malafa
- 1 Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Efficacy and safety of neoadjuvant FOLFIRINOX for borderline resectable pancreatic adenocarcinoma: improved efficacy compared with gemcitabine-based regimen. Oncotarget 2018; 8:46337-46347. [PMID: 28564637 PMCID: PMC5542271 DOI: 10.18632/oncotarget.17940] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/06/2017] [Indexed: 12/11/2022] Open
Abstract
Borderline resectable pancreatic cancer (BRPC) is a potentially resectable disease but is associated with poorer survival compared to primary resectable disease. There has been no prospective trial that compare the efficacy of FOLFIRNOX and gemcitabine-based regimen for BRPC. Between February 2013 and December 2014, 18 patients with BRPC receiving FOLFIRINOX were reviewed retrospectively. For comparative analysis, data for all BRPC patients (n=18) in our previous phase 2 study of neoadjuvant fixed-dose rate-gemcitabine plus capecitabine were pooled. Patients received a median 6 cycles (range, 3-13) of FOLFIRINOX. Surgical resection was performed in 12 patients (67%) and R0 resection in 9 patients. Median progression-free survival (PFS) and overall survival (OS) were 16.8 (95% confidence interval [CI], 9.4-24.2) and 21.2 (95% CI, 14.2-28.2) months, respectively. Patients who underwent surgical resection showed significantly better PFS (p=0.01) and OS (p=0.003) than those unresected. In the exploratory analysis, patients receiving FOLFIRINOX showed significantly longer PFS compared to those receiving fixed-dose rate-gemcitabine plus capecitabine (median 16.8 months [95% CI, 9.4-24.2] vs. 6.5 months [1.6-11.3]; p = 0.04). There was a trend toward improved OS in patients who received FOLFIRINOX (median 21.2 months [95% CI, 14.2-28.2]) compared to those who received fixed-dose rate-gemcitabine plus capecitabine (13.6 months [11.8–15.4]; p=0.12). FOLFIRINOX was feasible and effective as neoadjuvant chemotherapy for patients with BRPC and may have improved efficacy compared to a gemcitabine-based regimen.
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Toesca DAS, Koong AJ, Poultsides GA, Visser BC, Haraldsdottir S, Koong AC, Chang DT. Management of Borderline Resectable Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2018; 100:1155-1174. [PMID: 29722658 DOI: 10.1016/j.ijrobp.2017.12.287] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/07/2017] [Accepted: 12/27/2017] [Indexed: 12/13/2022]
Abstract
With the rapid development of imaging modalities and surgical techniques, the clinical entity representing tumors that are intermediate between resectable and unresectable pancreatic adenocarcinoma has been identified has been termed "borderline resectable" (BR). These tumors are generally amenable for resection but portend an increased risk for positive margins after surgery and commonly necessitate vascular resection and reconstruction. Although there is a lack of consensus regarding the appropriate definition of what constitutes a BR pancreatic tumor, it has been demonstrated that this intermediate category carries a particular prognosis that is in between resectable and unresectable disease. In order to downstage the tumor and increase the probability of clear surgical margins, neoadjuvant therapy is being increasingly utilized and studied. There is a lack of high-level evidence to establish the optimal treatment regimen for BR tumors. When resection with negative margins is achieved after neoadjuvant therapy, the prognosis for BR tumors approaches and even exceeds that for resectable disease. This review presents the current definitions, different treatment approaches, and the clinical outcomes of BR pancreatic cancer.
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Affiliation(s)
- Diego A S Toesca
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - Amanda J Koong
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | | | - Brendan C Visser
- Department of Surgery, Stanford Cancer Institute, Stanford, California
| | | | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California.
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Bonucci M, Pastore C, Ferrera V, Fiorentini C, Fabbri A. Integrated Cancer Treatment in the Course of Metastatic Pancreatic Cancer: Complete Resolution in 2 Cases. Integr Cancer Ther 2018; 17:994-999. [PMID: 29478350 PMCID: PMC6142071 DOI: 10.1177/1534735418755479] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pancreatic cancer (PC) has a very low average survival, but its prognosis is
further reduced in the case of metastatic spread. Medical therapy in these cases
is the only applicable methodology in the international guidelines. During
anticancer treatments, common side effects are nausea, vomiting, arthralgia,
neuropathy, and alopecia as well as a myelosuppressive effect. The toxicity of
various drugs not only affects the quality of life of the patient, but often its
severity requires a reduction in if not the termination of drug administration.
Scientific studies have shown that a combined use of chemotherapy and certain
natural substances, in the form of standardized extracts, can lead to an
enhancement of the action of the chemotherapy. Here, we describe 2 cases of
metastatic PC. The first case concerns the integrated treatment of a patient
with cancer of the pancreas tail with metastatic involvement ab initio of
peripancreatic lymph nodes and liver parenchyma, with numerous secondary lesions
greater than 9.5 cm. The second case concerns the integrated treatment of a
patient with cancer of the pancreatic body with metastatic involvement of the
liver parenchyma, with a small secondary lesion. In both cases, an integrated
cancer treatment approach, combining chemotherapy with natural remedies,
extracts, and hyperthermia, induced a notable remission of primary and
metastatic lesions.
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Abstract
The majority of PCs present as advanced disease, and treatment goals are for prolongation of life and palliation of the symptoms. Oncologists rely on our radiology colleagues to provide information on the extent of disease and the effectiveness of our treatment. The stakes rise in those patients where the disease has seemingly not spread and who might be treated with a goal of cure. For this subset of patients, medical oncologists and surgeons require as precise a radiologic description as possible in order to most accurately characterize the extent of the disease, in turn informing us as to the likelihood of a successful surgery and potential cure. In this paper, we review the fine points of imaging that distinguish resectable from borderline or unresectable patients, explain the principles of neoadjuvant and adjuvant therapy for pancreatic cancer, highlight some of the novel therapies now being pioneered in pancreatic cancer, and review radiologic features important for palliative care in patients with these tumors.
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Contemporary Management of Localized Resectable Pancreatic Cancer. Cancers (Basel) 2018; 10:cancers10010024. [PMID: 29361690 PMCID: PMC5789374 DOI: 10.3390/cancers10010024] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the third most common cause of cancer deaths in the United States. Surgical resection with negative margins still constitutes the cornerstone of potentially curative therapy, but is possible only in 15–20% of patients at the time of initial diagnosis. Accumulating evidence suggests that the neoadjuvant approach may improve R0 resection rate in localized resectable and borderline resectable diseases, and potentially downstage locally advanced disease to achieve surgical resection, though the impact on survival is to be determined. Despite advancements in the last decade in developing effective combinational chemo-radio therapeutic options, preoperative treatment strategies, and better peri-operative care, pancreatic cancer continues to carry a dismal prognosis in the majority. Prodigious efforts are currently being made in optimizing the neoadjuvant therapy with a better toxicity profile, developing novel agents, imaging techniques, and identification of biomarkers for the disease. Advancement in our understanding of the tumor microenvironment and molecular pathology is urgently needed to facilitate the development of novel targeted and immunotherapies for this setting. In this review, we detail the current literature on contemporary management of resectable, borderline resectable and locally advanced pancreatic cancer with a focus on future directions in the field.
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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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Dhir M, Malhotra GK, Sohal DP, Hein NA, Smith LM, O’Reilly EM, Bahary N, Are C. Neoadjuvant treatment of pancreatic adenocarcinoma: a systematic review and meta-analysis of 5520 patients. World J Surg Oncol 2017; 15:183. [PMID: 29017581 PMCID: PMC5634869 DOI: 10.1186/s12957-017-1240-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent years have seen standardization of the anatomic definitions of pancreatic adenocarcinoma, and increasing utilization of neoadjuvant therapy (NAT). The aim of the current review was to summarize the evidence for NAT in pancreatic adenocarcinoma since 2009, when consensus criteria for resectable (R), borderline resectable (BR), and locally advanced (LA) disease were endorsed. METHODS PubMed search was undertaken along with extensive backward search of the references of published articles to identify studies utilizing NAT for pancreatic adenocarcinoma. Abstracts from ASCO-GI 2014 and 2015 were also searched. RESULTS A total of 96 studies including 5520 patients were included in the final quantitative synthesis. Pooled estimates revealed 36% grade ≥ 3 toxicities, 5% biliary complications, 21% hospitalization rate and low mortality (0%, range 0-16%) during NAT. The majority of patients (59%) had stable disease. On an intention-to-treat basis, R0-resection rates varied from 63% among R patients to 23% among LA patients. R0 rates were > 80% among all patients who were resected after NAT. Among R and BR patients who underwent resection after NAT, median OS was 30 and 27.4 months, respectively. CONCLUSIONS The current study summarizes the recent literature for NAT in pancreatic adenocarcinoma and demonstrates improving outcomes after NAT compared to those historically associated with a surgery-first approach for pancreatic adenocarcinoma.
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Affiliation(s)
- Mashaal Dhir
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210 USA
| | - Gautam K. Malhotra
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 98198 USA
| | - Davendra P.S. Sohal
- Division of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195 USA
| | - Nicholas A. Hein
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198 USA
| | - Eileen M. O’Reilly
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA
| | - Nathan Bahary
- Department of Medicine, Division of Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232 USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE 98198 USA
- Department of Surgery/Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE 68198 USA
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Kim HS, Jang JY, Han Y, Lee KB, Joo I, Lee DH, Kim JR, Kim H, Kwon W, Kim SW. Survival outcome and prognostic factors of neoadjuvant treatment followed by resection for borderline resectable pancreatic cancer. Ann Surg Treat Res 2017; 93:186-194. [PMID: 29094028 PMCID: PMC5658300 DOI: 10.4174/astr.2017.93.4.186] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/12/2017] [Accepted: 03/30/2017] [Indexed: 12/17/2022] Open
Abstract
Purpose Neoadjuvant treatment may provide improved survival outcomes for patients with borderline resectable pancreatic cancer (BRPC). The purpose of this study is to evaluate the clinical outcomes of neoadjuvant treatment and to identify prognostic factors. Methods Forty patients who met the National Comprehensive Cancer Network definition of BRPC and received neoadjuvant treatment followed by surgery between 2007 and 2015 were evaluated. Prospectively collected clinicopathological outcomes were analyzed retrospectively. Results The mean age was 61.7 years and the male-to-female ratio was 1.8:1. Twenty-six, 3, and 11 patients received gemcitabine-based chemotherapy, 5-fluorouracil, and FOLFIRINOX, respectively. The 2-year survival rate (2YSR) was 36.6% and the median overall survival (OS) was 20 months. Of the 40 patients, 34 patients underwent resection and the 2YSR was 41.2% while the 2YSR of patients who did not undergo resection was 16.7% (P = 0.011). The 2YSR was significantly higher in patients who had partial response compared to stable disease (60.6% vs. 24.3%, P = 0.038), in patients who did than did not show a CA 19-9 response after neoadjuvant treatment (40.5% vs. 0%, P = 0.039) and in patients who did than did not receive radiotherapy (50.8% vs. 25.3%, P = 0.036). Five patients had local recurrence and 17 patients had systemic recurrence with a median disease specific survival of 15 months. Conclusion Neoadjuvant treatment followed by resection is effective for BRPC. Pancreatectomy and neoadjuvant treatment response may affect survival. Effective systemic therapy is needed to improve long-term survival since systemic metastasis accounts for a high proportion of recurrence.
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Affiliation(s)
- Hyeong Seok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Doo-Ho Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Ri Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Miyake K, Mori R, Homma Y, Matsuyama R, Okayama A, Murakami T, Hirano H, Endo I. MZB1 in borderline resectable pancreatic cancer resected after neoadjuvant chemoradiotherapy. J Surg Res 2017; 220:391-401. [PMID: 29180208 DOI: 10.1016/j.jss.2017.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/08/2017] [Accepted: 07/03/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND A high accumulation of CD8+ tumor-infiltrating lymphocytes (TILs) induced by neoadjuvant chemoradiotherapy (NACRT) is associated with a favorable prognosis in patients with pancreatic ductal adenocarcinoma (PDAC). However, the correlation between a high accumulation of CD8+ TILs and a favorable prognosis has yet to be fully clarified. The aim of this study was to determine predictive markers of a high accumulation of CD8+ TILs, with a favorable prognosis, using proteomic analysis. MATERIALS AND METHODS We studied 72 resected borderline resectable PDAC patients treated with NACRT between April 2009 and March 2014. Three matched pairs of high CD8+ TIL patients with a favorable prognosis and low CD8+ TIL patients with a poor prognosis were selected. Shotgun proteomics of the stroma and cancerous lesion was performed using formalin-fixed, paraffin-embedded tissue. Validation of the identified proteins was performed using immunohistochemical staining. Relationships between the identified proteins and TILs and clinical outcomes were assessed. RESULTS Marginal zone B- and B1-cell-specific protein (MZB1) was detected in the tumor stroma. MZB1 expression was positively correlated with a high accumulation of CD8+ TILs. High stromal MZB1 expression also correlated with disease-free and overall survival. In a subgroup analysis of CD8+ expression, there was a significant association between stromal MZB1 expression and disease-free and overall survival in the high CD8+ TIL group. CONCLUSIONS MZB1 is a potential marker of a high accumulation of CD8+ TILs in borderline resectable PDACs resected after NACRT. Combination of CD8+ TILs with MZB1 may be a new biomarker of resected cases after NACRT.
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Affiliation(s)
- Kentaro Miyake
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryutaro Mori
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akiko Okayama
- Advanced Medical Research Center, Yokohama City University, Yokohama, Japan
| | - Takashi Murakami
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hisashi Hirano
- Advanced Medical Research Center, Yokohama City University, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
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Heinrich S, Lang H. Neoadjuvant Therapy of Pancreatic Cancer: Definitions and Benefits. Int J Mol Sci 2017; 18:ijms18081622. [PMID: 28933761 PMCID: PMC5578014 DOI: 10.3390/ijms18081622] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/08/2017] [Accepted: 07/16/2017] [Indexed: 12/19/2022] Open
Abstract
The standard treatment of resectable pancreatic cancer is surgery followed by adjuvant chemotherapy. Due to the complication rate of pancreatic surgery and the high rate of primary irresectability, neoadjuvant concepts are increasingly used for pancreatic cancer. Neoadjuvant therapy is better tolerated than adjuvant and might decrease the surgical complication rate from pancreatic surgery. In contrast to neoadjuvant chemoradiation, the nutritional status improves during neoadjuvant chemotherapy. Also, the survival of patients who develop postoperative complications after neoadjuvant therapy is comparable to those without complications whereas the survival of patients who underwent upfront surgery and then develop surgical complications is impaired. Moreover, large data base analyses suggest a down-sizing effect and improvement of overall survival by neoadjuvant therapy. Neoadjuvant chemotherapy appears to be equally efficient in converting irresectable in resectable disease and more efficient with regard to systemic tumor progression and overall survival compared to neoadjuvant chemoradiation therapy. Despite these convincing findings from mostly small phase II trials, neoadjuvant therapy has not yet proven superiority over upfront surgery in randomized trials.
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Affiliation(s)
- Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
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Lau SC, Cheung WY. Evolving treatment landscape for early and advanced pancreatic cancer. World J Gastrointest Oncol 2017; 9:281-292. [PMID: 28808501 PMCID: PMC5534396 DOI: 10.4251/wjgo.v9.i7.281] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/21/2017] [Accepted: 04/19/2017] [Indexed: 02/05/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is an infrequent cancer with a high disease related mortality rate, even in the context of early stage disease. Until recently, the rate of death from pancreatic cancer has remained largely similar whereby gemcitabine monotherapy was the mainstay of systemic treatment for most stages of disease. With the discovery of active multi-agent chemotherapy regimens, namely FOLFIRINOX and gemcitabine plus nab-paclitaxel, the treatment landscape of pancreatic cancer is slowly evolving. FOLFIRINOX and gemcitabine plus nab-paclitaxel are now considered standard first line treatment options in metastatic pancreatic cancer. Studies are ongoing to investigate the utility of these same regimens in the adjuvant setting. The potential of these treatments to downstage disease is also being actively examined in the locally advanced context since neoadjuvant approaches may improve resection rates and surgical outcomes. As more emerging data become available, the management of pancreatic cancer is anticipated to change significantly in the coming years.
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Adamska A, Domenichini A, Falasca M. Pancreatic Ductal Adenocarcinoma: Current and Evolving Therapies. Int J Mol Sci 2017; 18:E1338. [PMID: 28640192 PMCID: PMC5535831 DOI: 10.3390/ijms18071338] [Citation(s) in RCA: 389] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/01/2017] [Accepted: 06/13/2017] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC), which constitutes 90% of pancreatic cancers, is the fourth leading cause of cancer-related deaths in the world. Due to the broad heterogeneity of genetic mutations and dense stromal environment, PDAC belongs to one of the most chemoresistant cancers. Most of the available treatments are palliative, with the objective of relieving disease-related symptoms and prolonging survival. Currently, available therapeutic options are surgery, radiation, chemotherapy, immunotherapy, and use of targeted drugs. However, thus far, therapies targeting cancer-associated molecular pathways have not given satisfactory results; this is due in part to the rapid upregulation of compensatory alternative pathways as well as dense desmoplastic reaction. In this review, we summarize currently available therapies and clinical trials, directed towards a plethora of pathways and components dysregulated during PDAC carcinogenesis. Emerging trends towards targeted therapies as the most promising approach will also be discussed.
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Affiliation(s)
- Aleksandra Adamska
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
| | - Alice Domenichini
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
| | - Marco Falasca
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia.
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Okano K, Suto H, Oshima M, Maeda E, Yamamoto N, Kakinoki K, Kamada H, Masaki T, Takahashi S, Shibata T, Suzuki Y. A Prospective Phase II Trial of Neoadjuvant S-1 with Concurrent Hypofractionated Radiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2017; 24:2777-2784. [PMID: 28608121 DOI: 10.1245/s10434-017-5921-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The ideal neoadjuvant treatment protocol for patients with pancreatic cancer (PDAC) remains unclear. We evaluated the efficacy and safety of neoadjuvant hypofractionated chemoradiotherapy with S-1 for patients with resectable (R) and borderline resectable (BR) PDAC. METHODS Eligibility criteria included patients with R and BR PDAC, performance status 0-1, and age 20-85 years. Hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) was delivered 5 days/week for 2 weeks prior to pancreatectomy. RESULTS Fifty-seven patients were enrolled in this study, including 33 R and 24 BR [19 BR tumors with portal vein contact (BR-PV) and 5 BR tumors with arterial contact (BR-A)]. The total rates of protocol treatment completion and resection were 91% (50/57) and 96% (55/57), respectively. Seven patients failed to complete S-1 due to cholangitis (n = 5) or neutropenia (n = 2). The most common grade 3 toxicities [Common Terminology Criteria for Adverse Events (CTCAE) version 4.0] were anorexia (7%), nausea (5%), neutropenia (4%), and leukopenia (4%). No patient experienced grade 4 toxicity. Pathologically negative margins (R0) were achieved in 54 of 55 patients (98%) who underwent pancreatectomy. Pathological response was classified as Evans grade I in 8 patients (15%), IIa in 31 patients (56%), IIb in 14 patients (25%), III in 1 patient (2%), and IV in 1 patient (2%), and operative morbidity (Clavien-Dindo grade IIIb or less) was observed in 4 patients (8%). The 1- and 2-year overall survival (OS) rates were 91 and 83% in R patients, respectively, and 77 and 58% in BR patients, respectively (p = 0.03). CONCLUSION Neoadjuvant S-1 with concurrent hypofractionated radiotherapy is tolerable and appears promising for patients with R and BR PDAC.
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Affiliation(s)
- Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan.
| | - Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Eri Maeda
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Naoki Yamamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Keitaro Kakinoki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Shigeo Takahashi
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Toru Shibata
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
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34
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Chang JS, Chiu YF, Yu JC, Chen LT, Ch'ang HJ. The Role of Consolidation Chemoradiotherapy in Locally Advanced Pancreatic Cancer Receiving Chemotherapy: An Updated Systematic Review and Meta-Analysis. Cancer Res Treat 2017; 50:562-574. [PMID: 28602054 PMCID: PMC5912129 DOI: 10.4143/crt.2017.105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/31/2017] [Indexed: 12/13/2022] Open
Abstract
Purpose The role of consolidation chemoradiation (CCRT) after systemic chemotherapy in locally advanced pancreatic cancer (LAPC) is still controversial. We aim to evaluate the effectiveness of CCRT in LAPC using systematic review and meta-analysis of prospective studies. Materials and Methods Prospective clinical trials of LAPC receiving chemotherapy with or without subsequent CCRT were included in the analysis. We systematically searched in PubMed, MEDLINE, Embase, and Web of Science. The primary outcome of interest was 1-year survival. Secondary endpoints were median overall survival, progression-free survival, toxicity, and resection rate. Results Forty-one studies with 49 study arms were included with a total of 1,018 patients receiving CCRT after induction chemotherapy (ICT) and 954 patients receiving chemotherapy alone. CCRT after ICT did not improve 1-year survival significantly in LAPC patients compared with chemotherapy alone (58% vs. 52%). ICT lasted for at least 3 months revealed significantly improved survival of additional CCRT to LAPC patients compared to chemotherapy alone (65% vs. 52%). A marginal survival benefit of consolidation CCRT was noted in studies using maintenance chemotherapy (59% vs. 52%), and fluorouracil-based CCRT (64% vs. 52%), as well as in studies conducted after the 2010 (64% vs. 55%). Conclusion The survival benefit of ICT+CCRT over chemotherapy alone in treating LAPC was noted when ICT lasted for at least 3 months. Fluorouracil-based CCRT, and maintenance chemotherapy were associated with improved clinical outcomes.
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Affiliation(s)
- Jeffrey S Chang
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan
| | - Yen-Feng Chiu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Jih-Chang Yu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Ju Ch'ang
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan.,Program for Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Taipei Cancer Center, Taipei Medical University, Taipei, Taiwan
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35
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Zhan HX, Xu JW, Wu D, Wu ZY, Wang L, Hu SY, Zhang GY. Neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of prospective studies. Cancer Med 2017; 6:1201-1219. [PMID: 28544758 PMCID: PMC5463082 DOI: 10.1002/cam4.1071] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/12/2017] [Accepted: 03/13/2017] [Indexed: 12/13/2022] Open
Abstract
There is a strong rationale and many theoretical advantages for neoadjuvant therapy in pancreatic cancer (PC). However, study results have varied significantly. In this study, a systematic review and meta‐analysis of prospective studies were performed in order to evaluate safety and effectiveness of neoadjuvant therapy in PC. Thirty‐nine studies were selected (n = 1458 patients), with 14 studies focusing on patients with resectable disease (group 1), and 19 studies focusing on patients with borderline resectable and locally advanced disease (group 2). Neoadjuvant chemotherapy was administered in 97.4% of the studies, in which 76.9% was given radiotherapy and 74.4% administered with chemoradiation. The complete and partial response rate was 3.8% and 20.9%. The incidence of grade 3/4 toxicity was 11.3%. The overall resection rate after neoadjuvant therapy was 57.7% (group 1: 73.0%, group 2: 40.2%). The R0 resection rate was 84.2% (group 1: 88.2%, group 2: 79.4%). The overall survival for all patients was 16.79 months (resected 24.24, unresected 9.81; group 1: 17.76, group 2: 16.20). Our results demonstrate that neoadjuvant therapy has not been proven to be beneficial and should be considered with caution in patients with resectable PC. Patients with borderline resectable or locally advanced disease may benefit from neoadjuvant therapy, but further research is needed.
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Affiliation(s)
- Han-Xiang Zhan
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Jian-Wei Xu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Dong Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Zhi-Yang Wu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Lei Wang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - San-Yuan Hu
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Guang-Yong Zhang
- Department of General Surgery, Qilu hospital, Shandong University, Jinan, Shandong Province, 250012, China
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Palmarocchi MC, Balzarotti Canger RC, Saletti P. Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report. Oncol Lett 2017; 13:4445-4452. [PMID: 28588713 DOI: 10.3892/ol.2017.6026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/11/2017] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer mortality and is associated with a poor overall survival even when diagnosed early and considered resectable. Complete surgical removal with negative histological margins is an independent predictor of survival and remains the only potential curative treatment. In borderline resectable pancreatic adenocarcinoma (BRPAC), preoperative systemic therapy may increase resectability and margin-negative resection rate. There is no current consensus on the optimal chemotherapy regimen for BRPAC. The present case describes a patient with BRPAC who achieved a pathological complete response to neoadjuvant FOLFIRINOX (folinic acid, fluorouracil, irinotecan and oxaliplatin), but early relapse following a pancreaticoduodenectomy without vascular resection, with an uneventful postoperative course, except for a pulmonary embolism.
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Affiliation(s)
| | | | - Piercarlo Saletti
- Medical Oncology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
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37
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Neoadjuvant treatment in pancreatic cancer: Evidence-based medicine? A systematic review and meta-analysis. Med Oncol 2017; 34:85. [PMID: 28391577 DOI: 10.1007/s12032-017-0951-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 04/04/2017] [Indexed: 12/21/2022]
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38
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Tajima H, Makino I, Ohbatake Y, Nakanuma S, Hayashi H, Nakagawara H, Miyashita T, Takamura H, Ohta T. Neoadjuvant chemotherapy for pancreatic cancer: Effects on cancer tissue and novel perspectives. Oncol Lett 2017; 13:3975-3981. [PMID: 28599404 DOI: 10.3892/ol.2017.6008] [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: 11/28/2015] [Accepted: 02/17/2017] [Indexed: 01/05/2023] Open
Abstract
Chemotherapy for pancreatic cancer has diversified following the addition of more treatment regimens; however, in spite of this, pancreatic cancer remains a fatal disease. Preoperative (neoadjuvant) chemotherapy (NAC) or neoadjuvant chemoradiation therapy (NACRT) has been developed and implemented. For patients with borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), a number of clinical trials have been conducted; NACRT was demonstrated to improve resectability, R0 resection rate, overall survival rate, disease-free survival rate and even an LAPC and BRPC survival advantage over NAC. However, from the knowledge obtained from resected specimens following preoperative treatment, residual pancreatic cancer tissues following NAC are rich in chemoresistant cancer stem-like cells and epithelial-mesenchymal transition (EMT) markers. Conversely, metformin, angiotensin receptor blocker, statins and low-dose paclitaxel are well-known as drugs that inhibit EMT, which is associated with cancer stem cell-like characteristics. Although clinical effectiveness is unlikely to be achieved using one of these as an anticancer agent, it is reasonable to use these drugs for patients with comorbidities in the treatment of pancreatic cancer. Furthermore, gemcitabine (GEM) affects antitumor immunity by stimulating the expression of major histocompatibility complex class I-related chain A on the surface of cancer cells to enhance the cytotoxicity of natural killer cells. Considering EMT and antitumor immunity, there is a possibility that GEM and nanoparticle albumin-bound paclitaxel therapy is the most suitable regimen for treating pancreatic cancer. However, even as preoperative treatment progresses, R0 resection is the most important factor for the long-term survival of pancreatic cancer patients.
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Affiliation(s)
- Hidehiro Tajima
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hironori Hayashi
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hisatoshi Nakagawara
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
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Complete Response after Treatment with Neoadjuvant Chemoradiation with Prolonged Chemotherapy for Locally Advanced, Unresectable Adenocarcinoma of the Pancreas. Case Rep Oncol Med 2017; 2017:7834702. [PMID: 28373919 PMCID: PMC5360961 DOI: 10.1155/2017/7834702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/26/2017] [Indexed: 01/05/2023] Open
Abstract
Surgery is the only chance for cure in pancreatic ductal adenocarcinoma. In unresectable, locally advanced pancreatic cancer (LAPC), the National Comprehensive Cancer Network (NCCN) suggests chemotherapy and consideration for radiation in cases of unresectable LAPC. Here we present a rare case of unresectable LAPC with a complete histopathological response after chemoradiation followed by surgical resection. A 54-year-old female presented to our clinic in December 2013 with complaints of abdominal pain and 30-pound weight loss. An MRI demonstrated a mass in the pancreatic body measuring 6.2 × 3.2 cm; biopsy revealed proven ductal adenocarcinoma. Due to splenic vein/artery and contiguous celiac artery encasement, she was deemed surgically unresectable. She was started on FOLFIRINOX therapy (three cycles), intensity modulated radiation to a dose of 54 Gy in 30 fractions concurrent with capecitabine, followed by FOLFIRI, and finally XELIRI. After 8 cycles of ongoing XELIRI completed in March 2015, restaging showed a remarkable decrease in tumor size, along with PET-CT revealing no FDG-avid uptake. She was reevaluated by surgery and taken for definitive resection. Histopathological evaluation demonstrated a complete R0 resection and no residual tumor. Based on this patient and literature review, this strategy demonstrates potential efficacy of neoadjuvant chemoradiation with prolonged chemotherapy, followed by surgery, which may improve outcomes in patients deemed previously unresectable.
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40
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Miura F, Sano K, Wada K, Shibuya M, Ikeda Y, Takahashi K, Kainuma M, Kawamura S, Hayano K, Takada T. Prognostic impact of type of preoperative biliary drainage in patients with distal cholangiocarcinoma. Am J Surg 2017; 214:256-261. [PMID: 28108067 DOI: 10.1016/j.amjsurg.2017.01.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD). METHODS Eighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63). RESULTS Overall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P = 0.034). CONCLUSIONS PTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.
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Affiliation(s)
- Fumihiko Miura
- Department of Surgery, Teikyo University School of Medicine, Japan.
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Makoto Shibuya
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Yutaka Ikeda
- Department of Surgery, Teikyo University School of Medicine, Japan
| | | | - Masahiko Kainuma
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Sachiyo Kawamura
- Department of Surgery, Teikyo University School of Medicine, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Japan
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41
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Abstract
OBJECTIVES We evaluated whether neoadjuvant therapy followed by surgical resection improves the clinical outcome for patients with borderline resectable pancreatic cancer with radiologic artery involvement (BRPC-A). METHODS We reviewed 143 BRPC-A patients from among 330 pancreatic cancer patients, including 111 potentially resectable pancreatic cancer patients and 76 borderline resectable pancreatic cancer with portal/superior mesenteric vein involvement patients, who underwent surgery at Wakayama Medical University Hospital. We compared the clinicopathological factors of 40 BRPC-A patients treated with neoadjuvant therapy followed by surgery and those of 103 BRPC-A patients treated with upfront surgery. RESULTS The R0 rate and progression-free survival of BRPC-A patients who received neoadjuvant therapy and subsequent surgical resection were significantly better compared to those who received upfront surgery (R0: P = 0.041; progression-free survival: P = 0.033), but overall survival was not significantly different. A multivariate analysis showed that intraoperative transfusion (P = 0.007), moderately or poorly differentiated pathological adenocarcinoma (P = 0.019), and failure to complete postoperative adjuvant therapy (P < 0.001) independently predicted a poor prognosis for BRPC-A patients who underwent surgical resection. CONCLUSIONS Neoadjuvant treatment followed by surgery might provide clinical benefits for BRPC-A patients; however, the establishment of the most appropriate neoadjuvant therapy is needed by further studies.
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42
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Kim SS, Nakakura EK, Wang ZJ, Kim GE, Corvera CU, Harris HW, Kirkwood KS, Hirose R, Tempero MA, Ko AH. Preoperative FOLFIRINOX for borderline resectable pancreatic cancer: Is radiation necessary in the modern era of chemotherapy? J Surg Oncol 2016; 114:587-596. [PMID: 27444658 DOI: 10.1002/jso.24375] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND No consensus exists regarding the optimal neoadjuvant treatment paradigm for patients with borderline resectable pancreatic cancer (BRPC), including the respective roles of chemotherapy and radiation. METHODS We performed a retrospective analysis, including detailed pathologic and radiologic review, of pancreatic cancer patients undergoing FOLFIRINOX, with or without radiation therapy (RT), prior to surgical resection at a high-volume academic center over a 4-year period. RESULTS Of 26 patients meeting inclusion criteria, 22 (84.6%) received FOLFIRINOX alone without RT (median number of treatment cycles = 9). The majority of patients met formal radiographic criteria for BRPC, with the superior mesenteric vein representing the most common vessel involved. R0 resection rate was 90.9%, with 12 patients (54.5%) requiring vascular reconstruction. Treatment response was classified as moderate or marked in 16 patients (72.7%) according to the College of American Pathologists grading system. Estimated median disease-free and overall survival rates are 22.6 months and not reached (NR), respectively. CONCLUSIONS This is one of the largest series to describe the use of neoadjuvant FOLFIRINOX, without radiation therapy, in patients with BRPC undergoing surgical resection. Given the high R0 resection rates and favorable clinical outcomes with chemotherapy alone, this strategy should be further assessed in prospective study design. J. Surg. Oncol. 2016;114:587-596. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Sunhee S Kim
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Eric K Nakakura
- Department of Surgery, University of California San Francisco, San Francisco, California.
| | - Zhen J Wang
- Department of Radiology, University of California San Francisco, San Francisco, California
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Carlos U Corvera
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Hobart W Harris
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Ryutaro Hirose
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Margaret A Tempero
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Andrew H Ko
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California.
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Russo S, Wasif Saif M. Neoadjuvant therapy for pancreatic cancer: an ongoing debate. Therap Adv Gastroenterol 2016; 9:429-36. [PMID: 27366211 PMCID: PMC4913343 DOI: 10.1177/1756283x16646524] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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44
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Poruk KE, Wolfgang CL. Palliative Management of Unresectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:327-37. [DOI: 10.1016/j.soc.2015.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Krška Z, Šváb J, Hoskovec D, Ulrych J. Pancreatic Cancer Diagnostics and Treatment--Current State. Prague Med Rep 2016; 116:253-67. [PMID: 26654799 DOI: 10.14712/23362936.2015.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) represents permanent and ever rising issue worldwide. Five-year survival does not exceed 3 to 6%, i.e. the worst result among solid tumours. The article evaluates the current state of PDAC diagnostics and treatment specifying also development and trends. Percentage of non-resectable tumours due to locally advanced or metastatic condition varies 60-80%, mostly over 80%. Survival with non-resectable PDAC is 4 to 8 months (median 3.5). In contrast R0 resection shows the survival 18-27 months. Laboratory and imaging screening methods are not indicated on large scale. Risk factors are smoking, alcohol abuse, chronic pancreatitis, diabetes mellitus. Genetic background in most PDAC has not been detected yet. Some genes connected with high risk of PDAC (e.g. BRCA2, PALB2) have been identified as significant and highly penetrative, but link between PDAC and these genes can be seen only in 10-20%. This article surveys perspective oncogenes, tumour suppressor genes, microRNA. Albeit CT is still favoured over other imaging methods, involvement of NMR rises. Surgery prefers the "vessel first" approach, which proves to be justified especially in R0 resection. According to EBM immunotherapy same as radiotherapy are not significant in PDAC treatment. Chemotherapy shows limited importance in conversion treatment of locally advanced or borderline tumours or in case of metastatic spread. Unified procedures cannot be defined due to inhomogenous arrays. Surgical resection is the only chance for curative treatment of PDAC and depends mainly on timely indication for surgery and quality of multidisciplinary team in a high-volume centre.
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Affiliation(s)
- Zdeněk Krška
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic.
| | - Jan Šváb
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - David Hoskovec
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Pancreatic neck cancer has specific and oncologic characteristics regarding portal vein invasion and lymph node metastasis. Surgery 2016; 159:426-40. [DOI: 10.1016/j.surg.2015.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/23/2015] [Accepted: 07/01/2015] [Indexed: 01/08/2023]
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Russo S, Ammori J, Eads J, Dorth J. The role of neoadjuvant therapy in pancreatic cancer: a review. Future Oncol 2016; 12:669-85. [PMID: 26880384 DOI: 10.2217/fon.15.335] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Controversy remains regarding neoadjuvant approaches in the treatment of pancreatic cancer. Neoadjuvant therapy has several potential advantages over adjuvant therapy including earlier delivery of systemic treatment, in vivo assessment of response, increased resectability rate in borderline resectable patients and increased margin-negative resection rate. At present, there are no randomized data favoring neoadjuvant over adjuvant therapy and multiple neoadjuvant approaches are under investigation. Combination chemotherapy regimens including 5-fluorouracil, irinotecan and oxaliplatin, gemcitabine with or without abraxane, or docetaxel and capecitabine have been used in the neoadjuvant setting. Radiation and chemoradiation have also been incorporated into neoadjuvant strategies, and delivery of alternative fractionation regimens is being explored. This review provides an overview of neoadjuvant therapies for pancreatic cancer.
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Affiliation(s)
- Suzanne Russo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - John Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jennifer Eads
- Department of Medicine, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jennifer Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
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Preoperative Biliary Drainage in Cases of Borderline Resectable Pancreatic Cancer Treated with Neoadjuvant Chemotherapy and Surgery. Gastroenterol Res Pract 2016; 2016:7968201. [PMID: 26880897 PMCID: PMC4736763 DOI: 10.1155/2016/7968201] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/07/2015] [Indexed: 01/02/2023] Open
Abstract
Objective. To elucidate the optimum preoperative biliary drainage method for patients with pancreatic cancer treated with neoadjuvant chemotherapy (NAC). Material and Methods. From January 2010 through December 2014, 20 patients with borderline resectable pancreatic cancer underwent preoperative biliary drainage and NAC with a plastic or metallic stent and received NAC at Hiroshima University Hospital. We retrospectively analyzed delayed NAC and complication rates due to biliary drainage, effect of stent type on perioperative factors, and hospitalization costs from diagnosis to surgery. Results. There were 11 cases of preoperative biliary drainage with plastic stents and nine metallic stents. The median age was 64.5 years; delayed NAC occurred in 9 cases with plastic stent and 1 case with metallic stent (p = 0.01). The complication rates due to biliary drainage were 0% (0/9) with metallic stents and 72.7% (8/11) with plastic stents (p = 0.01). Cumulative rates of complications determined with the Kaplan-Meier method on day 90 were 60% with plastic stents and 0% with metallic stents (log-rank test, p = 0.012). There were no significant differences between group in perioperative factors or hospitalization costs from diagnosis to surgery. Conclusions. Metallic stent implantation may be effective for preoperative biliary drainage for pancreatic cancer treated with NAC.
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Rashid OM, Pimiento JM, Gamenthaler AW, Nguyen P, Ha TT, Hutchinson T, Springett G, Hoffe S, Shridhar R, Hodul PJ, Johnson BL, Illig K, Armstrong PA, Centeno BA, Fulp WJ, Chen DT, Malafa MP. Outcomes of a Clinical Pathway for Borderline Resectable Pancreatic Cancer. Ann Surg Oncol 2015; 23:1371-9. [DOI: 10.1245/s10434-015-5006-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Indexed: 12/23/2022]
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Tang K, Lu W, Qin W, Wu Y. Neoadjuvant therapy for patients with borderline resectable pancreatic cancer: A systematic review and meta-analysis of response and resection percentages. Pancreatology 2015; 16:28-37. [PMID: 26687001 DOI: 10.1016/j.pan.2015.11.007] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND We systematically reviewed and performed a meta-analysis of the available data regarding neoadjuvant chemo- and/or radiotherapy with special emphasis on tumor response/progression rates, toxicities, and clinical benefit, i.e. resection probabilities and survival estimates. METHODS AND FINDINGS Trials were identified by searching PUBMED, MEDLINE, and the Cochrane Central Register of Controlled Trials from 1966 to Feb 2015. A total of 18 studies (n = 959) were analyzed. the estimated fraction of patients with complete response was 2.8% (CI 0.8-4.7%) and with partial response 28.7% (CI 18.9%-38.5%). Stable disease was averaged to 45.9% (CI 32.9%-58.9%) in all patients and tumor progression under therapy occurred by estimation in 16.9% (CI 10.2%-23.6%) of the patients. The weighted frequency of those who underwent resection was 65.3% (CI 54.2%-76.5%), and the proportion of R0 resection amounted to 57.4% (CI 48.2%-66.5%). The weighted mean of median survival amounted to 17.9 months (range: 14.7-21.2 months) for the overall cohort of patients, 25.9 months (range: 21.1-30.7 months) for those who were resected, and 11.9 months (range: 10.4-13.5 months) for unresected patients. CONCLUSIONS The resection and R0 resection rates in the group of borderline resectable tumor patients after neoadjuvant therapy are similar to the resectable tumor patients, much higher than those in unresectable tumor patients. The survival estimates of borderline resectable tumor patients after neoadjuvant therapy were similar to resectable tumor patients. Patients with borderline resectable pancreatic cancer should be included in neoadjuvant protocols and subsequently be reevaluated for resection. How to find chemo-responsiveness before neoadjuvant chemotherapy so as to give individualized treatment is still an important issue.
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Affiliation(s)
- Kezhong Tang
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Wenjie Lu
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Wenjie Qin
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Yulian Wu
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China.
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