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Thomas AS, Tehranifar P, Kwon W, Shridhar N, Sugahara KN, Schrope BA, Chabot JA, Manji GA, Genkinger JM, Kluger MD. Trends in the Care of Locally Advanced Pancreatic Cancer in the Modern Era of Chemotherapy. J Surg Oncol 2024. [PMID: 39348434 DOI: 10.1002/jso.27851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 08/04/2024] [Accepted: 08/18/2024] [Indexed: 10/02/2024]
Abstract
INTRODUCTION Current guidelines for treatment for locally advanced pancreatic cancer recommend chemotherapy ± radiation, or radiation alone when multimodal therapy is contraindicated. In a subset of patients, guideline-recommended treatment (GRT) achieves sufficient response to qualify for potentially curative resection. This study evaluated trends in treatment utilization and aimed to identify barriers to GRT. METHODS Patients with clinical T4M0 disease in the National Cancer Database from 2010 to 2017 were included. Potential predictors were assessed by relative risk regression with Poisson distribution and compared by log-link function. RESULTS In total, 28 056 patients met the criteria. Among 17 059 (67.67%) patients treated primarily with chemotherapy, 41.19% also had radiation and 8.89% went onto resection. Many received no cancer-directed treatment or failed to receive GRT. Another 710 patients had radiation (±surgery) without chemotherapy despite few contraindications to chemotherapy. Over time, patients were more likely to undergo resection after chemotherapy (aRR = 1.58; p < 0.0001) and less likely to have chemoradiation (aRR = 0.78; p < 0.0001) or go untreated (aRR = 0.90; p < 0.0001). Socioeconomic factors (race, education, income, and insurance status) affected the likelihood of receiving chemotherapy and surgery. Median overall survival (OS) was significantly improved for patients treated with chemotherapy and particularly in those patients who went on to receive RT or undergo surgical resection. OS was also longer for patients treated at high-volume academic centers. Patients insured by Medicaid, Medicare, or those without insurance had worse OS. CONCLUSIONS Despite improvement over time, many patients go untreated. Clinical factors were influential, but the impact of vulnerable social standing suggests persistent inequity in access to care.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Parisa Tehranifar
- Herbert Irving Comprehensive Cancer Center Cancer Population Science Program, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Wooil Kwon
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Nupur Shridhar
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Kazuki N Sugahara
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Gulam A Manji
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Jeanine M Genkinger
- Herbert Irving Comprehensive Cancer Center Cancer Population Science Program, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Yuan Z, Peng J, Shu Z, Qin X, Zhong J. Interpretable multitemporal liver function indicator model for prediction and risk factor analysis of drug induced liver injury. Sci Rep 2024; 14:21285. [PMID: 39261535 PMCID: PMC11390907 DOI: 10.1038/s41598-024-66952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 07/05/2024] [Indexed: 09/13/2024] Open
Abstract
The occurrence of liver injury during cancer treatment is extremely harmful. The risk factors for drug.induced liver injury (DILI) in the pancreatic cancer population have not been investigated. This study aims to develop and validate an interpretable decision tree (DT) model for the early prediction of DILI in pancreatic cancer patients using multitemporal clinical data and screening for related risk factors. A retrospective collection of data was conducted on 307 patients, the training set (n = 215) was used to develop the model, and the test set (n = 92) was used to evaluate the model. The classification and regression trees algorithm was employed to establish the DT model. The Shapley Additive explanations (SHAP) method was used to facilitate clinical interpretation. Model performance was assessed using AUC and the Hosmer‒Lemeshow test. The DT model exhibited superior diagnostic efficacy, the AUC values were 0.995 and 0.994 in the training and test sets, respectively. Four risk factors associated with DILI occurrence were identified: delta.albumin, delta.ALT, and post (AST: ALT), and post.GGT. The multiperiod liver function indicator.based interpretable DT model predicted DILI occurrence in the pancreatic cancer population and contributes to personalized clinical management of pancreatic cancer patients.
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Affiliation(s)
- Zhongyu Yuan
- Department of Radiology, the Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China, 322000, Yiwu, Zhejiang, China
| | - Jiaxuan Peng
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zhenyu Shu
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xue Qin
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jianguo Zhong
- Cancer Center, Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Yang SQ, Zou RQ, Dai YS, Li FY, Hu HJ. Comparison of the upfront surgery and neoadjuvant therapy in resectable and borderline resectable pancreatic cancer: an updated systematic review and meta-analysis. Updates Surg 2024; 76:1-15. [PMID: 37639177 DOI: 10.1007/s13304-023-01626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023]
Abstract
Pancreatic cancer is a malignant disease with a dismal prognosis. While neoadjuvant therapy has shown promise in the treatment of pancreatic cancer, its role remains a subject of controversy among physicians. We aimed to evaluate the benefits of neoadjuvant therapy in patients with resectable and borderline resectable pancreatic cancer. Eligible studies were identified from MEDLINE, Embase, Cochrane Library, and Web of Science. Studies comparing neoadjuvant therapy with upfront surgery (with or without adjuvant therapy) in resectable and borderline resectable pancreatic cancer were included. The primary endpoint assessed was overall survival. A total of 10,022 studies were identified, and the meta-analysis finally enrolled 50 revealed studies. The meta-analysis suggested that neoadjuvant therapy significantly improved the overall survival (HR 0.74, p < 0.001) and recurrence-free survival (HR 0.75, p = 0.006) compared to the upfront surgery approach. Furthermore, neoadjuvant therapy leads to favorable postoperative outcomes, with an enhanced R0 resection rate (OR 1.90, p < 0.001) and reduced lymph node metastasis (OR 0.36, p < 0.001) and perineural invasion (OR 0.42, p < 0.001), although it is associated with a reduced resection rate (OR 0.42, p < 0.001). In addition, patients treated with neoadjuvant therapy experience superior survival benefits compared to those undergoing adjuvant therapy (HR 0.87, p = 0.019). These results are further corroborated by the subgroup analysis of randomized controlled trials. Neoadjuvant therapy has the potential to provide survival benefits and improve postoperative long-term outcomes for patients with resectable and borderline resectable pancreatic cancer. However, to validate and reinforce these findings, further well-designed and large trials are required.
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Affiliation(s)
- Si-Qi Yang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Rui-Qi Zou
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu-Shi Dai
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Fu-Yu Li
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Hai-Jie Hu
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Mohamed A, Nicolais L, Fitzgerald TL. Pancreatic Cancer with Vascular Involvement: Adherence to Current Standard-of-Care Associated with Improved Survival. Am Surg 2023; 89:5535-5544. [PMID: 36854081 DOI: 10.1177/00031348231156756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
METHODS This study is a retrospective cohort study of National Cancer Data Base (NCDB) data for pancreatic cancer with vascular involvement. RESULTS A total of 23 903 patients with vascular involvement were included and divided into 3 groups; no treatment (40.6%), medical treatment (36.6%), and resection (22.8%). Of the patients undergoing resection, 31.3% received neoadjuvant multiagent chemotherapy (N-MAC). The remainder were treated with postoperative adjuvant treatment (33.8%), surgery alone (24.9%), preoperative radiotherapy (8.3%), or single-agent preoperative chemotherapy (1.7%). Median survival for N-MAC was superior (28.42 months) when compared to neoadjuvant radiotherapy (20.73 months), neoadjuvant single-agent chemotherapy (20.8 months), postoperative adjuvant therapy (17.87 months), and surgery alone (10.12 months). N-MAC was associated with improved survival compared to postoperative multiagent chemotherapy (P-MAC) (28.4 vs 16.95, HR 1.82; CI 1.64-2.02, P < .0010) (Figure 1). The addition of radiation therapy to N-MAC did not improve survival (27.4 vs 29.8, HR .93; CI .83-1.05, P = .3). Clinical downstaging occurred in 40% of patients treated with N-MAC, and downstaging was associated with improved survival (HR .74; CI .64-.85, P < .001). N-MAC patients were more likely to undergo an R0 resection than P-MAC (74% v. 48, P < .001). CONCLUSIONS Most resected pancreatic cancer patients in this study with vascular involvement receive either postoperative or no adjuvant therapy. N-MAC increases downstaging, R0 resection rates, and survival.
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Affiliation(s)
- Abdimajid Mohamed
- Division of Surgical Oncology, Tufts University School of Medicine, Boston, MA, USA
| | | | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine, Boston, MA, USA
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Karbhari A, Mosessian S, Trivedi KH, Valla F, Jacobson M, Truty MJ, Patnam NG, Simeone DM, Zan E, Brennan T, Chen H, Kuo PH, Herrmann K, Goenka AH. Gallium-68-labeled fibroblast activation protein inhibitor-46 PET in patients with resectable or borderline resectable pancreatic ductal adenocarcinoma: A phase 2, multicenter, single arm, open label non-randomized study protocol. PLoS One 2023; 18:e0294564. [PMID: 38011131 PMCID: PMC10681241 DOI: 10.1371/journal.pone.0294564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease prone to widespread metastatic dissemination and characterized by a desmoplastic stroma that contributes to poor outcomes. Fibroblast activation protein (FAP)-expressing Cancer-Associated Fibroblasts (CAFs) are crucial components of the tumor stroma, influencing carcinogenesis, fibrosis, tumor growth, metastases, and treatment resistance. Non-invasive tools to profile CAF identity and function are essential for overcoming CAF-mediated therapy resistance, developing innovative targeted therapies, and improved patient outcomes. We present the design of a multicenter phase 2 study (clinicaltrials.gov identifier NCT05262855) of [68Ga]FAPI-46 PET to image FAP-expressing CAFs in resectable or borderline resectable PDAC. METHODS We will enroll up to 60 adult treatment-naïve patients with confirmed PDAC. These patients will be eligible for curative surgical resection, either without prior treatment (Cohort 1) or after neoadjuvant therapy (NAT) (Cohort 2). A baseline PET scan will be conducted from the vertex to mid-thighs approximately 15 minutes after administering 5 mCi (±2) of [68Ga]FAPI-46 intravenously. Cohort 2 patients will undergo an additional PET after completing NAT but before surgery. Histopathology and FAP immunohistochemistry (IHC) of initial diagnostic biopsy and resected tumor samples will serve as the truth standards. Primary objective is to assess the sensitivity, specificity, and accuracy of [68Ga]FAPI-46 PET for detecting FAP-expressing CAFs. Secondary objectives will assess predictive values and safety profile validation. Exploratory objectives are comparison of diagnostic performance of [68Ga]FAPI-46 PET to standard-of-care imaging, and comparison of pre- versus post-NAT [68Ga]FAPI-46 PET in Cohort 2. CONCLUSION To facilitate the clinical translation of [68Ga]FAPI-46 in PDAC, the current study seeks to implement a coherent strategy to mitigate risks and increase the probability of meeting FDA requirements and stakeholder expectations. The findings from this study could potentially serve as a foundation for a New Drug Application to the FDA. TRIAL REGISTRATION @ClinicalTrials.gov identifier NCT05262855.
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Affiliation(s)
- Aashna Karbhari
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sherly Mosessian
- Clinical Development, Sofie Biosciences, Dulles, Virginia, United States of America
| | - Kamaxi H. Trivedi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Frank Valla
- Radiopharmaceutical and Contract Manufacturing, Sofie Biosciences, Dulles, Virginia, United States of America
| | - Mark Jacobson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Mark J. Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Nandakumar G. Patnam
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Diane M. Simeone
- Departments of Surgery and Pathology, NYU Langone Health, New York, New York, United States of America
| | - Elcin Zan
- Department of Radiology, Weill Cornell Medicine, New York, New York, United States of America
| | - Tracy Brennan
- Discovery Life Sciences, Newtown, Pennsylvania, United States of America
| | - Hongli Chen
- Discovery Life Sciences, Newtown, Pennsylvania, United States of America
| | - Phillip H. Kuo
- Departments of Medical Imaging, Medicine and Biomedical Engineering, University of Arizona, Tucson, Arizona, United States of America
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ajit H. Goenka
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
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Yohanathan L, Hallet J. Neoadjuvant Sequencing for Early-stage Pancreas Cancer: More Cycles, More Doses, More Chemo for More Patients? Ann Surg 2023; 278:e685-e687. [PMID: 37436870 DOI: 10.1097/sla.0000000000005987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Lavanya Yohanathan
- Department of Surgery, Corewell East William Beaumont University Hospital, Royal Oak, MI
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Surgical Oncology, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Donisi G, Nappo G, Pacilli M, Capretti GL, Spaggiari P, Sollai M, Bozzarelli S, Zerbi A. Pathologic tumor response to neoadjuvant therapy in resected pancreatic cancer: does it affect prognosis? Updates Surg 2023; 75:1497-1508. [PMID: 37578734 DOI: 10.1007/s13304-023-01628-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
Neoadjuvant therapy (NAT) + surgical resection for pancreatic cancer (PC) has gained consensus in recent years. Pathological response (PR) is generally assessed according to the College of American Pathologists grading system, ranging from 0 (complete response) to 3 (no response). The aim of our study is to evaluate the PR in a series of resections for PC after NAT and its prognostic implication. 112 patients undergone NAT and resection for PC between 2011 and 2020 were retrospectively evaluated. PR was 0/1, 2 and 3 in 18 (15%), 79 (61%) and 29 (24%) cases, respectively. Chemotherapy regimens different from FOLFIRINOX and gemcitabine + nab-paclitaxel (OR 11.61 (2.53-53.36), p = 0.002) and lymphovascular invasion (OR 11.28 (1.89-67.23), p = 0.008) were associated to PR-3. Median follow-up was 25.8 (3.6-130.5) months. For PR-0/1, PR-2 and PR-3, median DFS was 45.8, 11.5, 4.6 months (p < 0.0001), respectively, while median OS was not reached, 27.1 and 17.5 months (p = 0.0006), respectively. At univariate analysis, PR-0/1 was significantly associated to better DFS and OS (HR 0.33 (0.17-0.67), p = 0.002; HR 0.20 (0.07-0.54), p = 0.002, respectively). At multivariate analysis, pancreaticoduodenectomy (HR 0.50 (0.30-0.84), p = 0.009), LNR (HR 27.14 (1.21-608.9), p = 0.038) and lymphovascular invasion (HR 1.99 (1.06-3.76), p = 0.033) were independently associated to DFS; pre-treatment CA 19.9 value (HR 1.00 (1.00-1.00), p = 0.025), post-treatment resectability status (HR 0.51 (0.28-0.95), p = 0.035), pancreaticoduodenectomy (HR 0.56 (0.32-0.99), p = 0.050), severe morbidity (2.99 (1.22-7.55), p = 0.017), LNR (HR 56.8 (2.08-1548.3), p = 0.017), lymphovascular invasion (HR 2.18 (1.08-4.37), p = 0.029) were independently associated to OS. PR did not reach statistical significance at multivariate analysis. A favorable PR is observed only in a limited number of cases. The prognostic role of PR, despite being promising, remains unclear and further multicentric studies are needed.
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Affiliation(s)
- G Donisi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Pieve Emanuele, Italy
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - G Nappo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Pieve Emanuele, Italy.
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy.
| | - M Pacilli
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - G L Capretti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Pieve Emanuele, Italy
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - P Spaggiari
- Department of Pathology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - M Sollai
- Department of Pathology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - S Bozzarelli
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - A Zerbi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Milan, Pieve Emanuele, Italy
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Milan, Rozzano, Italy
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Tamburrino D, Belfiori G, Andreasi V, Provinciali L, Cerchione R, De Stefano F, Fermi F, Gasparini G, Pecorelli N, Partelli S, Crippa S, Falconi M. Pancreatectomy with venous vascular resection for pancreatic cancer: Impact of types of vein resection on timing and pattern of recurrence. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1457-1465. [PMID: 37088601 DOI: 10.1016/j.ejso.2023.03.229] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/13/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Few studies analysed the impact of different venous resection techniques on recurrence in patients with pancreatic ductal adenocarcinoma (PDAC). Primary aim was to compare local recurrence rate and disease-free survival (DFS) between patients who underwent pancreatectomy with tangential versus segmental resection of portal vein/superior mesenteric vein. MATERIALS AND METHODS All consecutive patients who underwent pancreatectomy with venous resection for PDAC between 2009 and 2019 were included. A propensity score matching (PSM) was used to reduce the effect of treatment selection bias. RESULTS Overall, 120 patients (68%) underwent pancreatectomy with tangential venous resection and 57 patients (32%) were submitted to pancreatectomy with segmental venous resection. After a median follow-up of 24 months, local recurrence was comparable between the two groups (tangential: n = 32/120, 26.7% versus segmental: n = 10/57, 17.5%; p = 0.58). The median DFS was 17 months (IQR 9-31) in patients who underwent tangential resection, as compared to 12 months (IQR 5-21) in those who underwent segmental resection (p = 0.049). After PSM (n = 106), the median DFS was 18 months (IQR 9-26) in the tangential resection group, and 12 months (IQR 5-21) in the segmental resection group (p = 0.17). In the PSM population, lymph node ratio (HR 4.83; p = 0.028) and tumor size >25 mm (HR 3.26; p = 0.007) were identified as determinants of local recurrence. CONCLUSION Tangential venous resections are not associated with a higher rate of local recurrence. Long-term outcomes are more related to tumors characteristics than to venous resection techniques. A step-up approach to vein resection, with tangential resection being performed whenever technically feasible, should be strongly encouraged.
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Affiliation(s)
- Domenico Tamburrino
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Andreasi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Provinciali
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaele Cerchione
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Federico De Stefano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Fermi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Zhang G, Bao C, Liu Y, Wang Z, Du L, Zhang Y, Wang F, Xu B, Zhou SK, Liu R. 18F-FDG-PET/CT-based deep learning model for fully automated prediction of pathological grading for pancreatic ductal adenocarcinoma before surgery. EJNMMI Res 2023; 13:49. [PMID: 37231321 DOI: 10.1186/s13550-023-00985-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND The determination of pathological grading has a guiding significance for the treatment of pancreatic ductal adenocarcinoma (PDAC) patients. However, there is a lack of an accurate and safe method to obtain pathological grading before surgery. The aim of this study is to develop a deep learning (DL) model based on 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) for a fully automatic prediction of preoperative pathological grading of pancreatic cancer. METHODS A total of 370 PDAC patients from January 2016 to September 2021 were collected retrospectively. All patients underwent 18F-FDG-PET/CT examination before surgery and obtained pathological results after surgery. A DL model for pancreatic cancer lesion segmentation was first developed using 100 of these cases and applied to the remaining cases to obtain lesion regions. After that, all patients were divided into training set, validation set, and test set according to the ratio of 5:1:1. A predictive model of pancreatic cancer pathological grade was developed using the features computed from the lesion regions obtained by the lesion segmentation model and key clinical characteristics of the patients. Finally, the stability of the model was verified by sevenfold cross-validation. RESULTS The Dice score of the developed PET/CT-based tumor segmentation model for PDAC was 0.89. The area under curve (AUC) of the PET/CT-based DL model developed on the basis of the segmentation model was 0.74, with an accuracy, sensitivity, and specificity of 0.72, 0.73, and 0.72, respectively. After integrating key clinical data, the AUC of the model improved to 0.77, with its accuracy, sensitivity, and specificity boosted to 0.75, 0.77, and 0.73, respectively. CONCLUSION To the best of our knowledge, this is the first deep learning model to end-to-end predict the pathological grading of PDAC in a fully automatic manner, which is expected to improve clinical decision-making.
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Affiliation(s)
- Gong Zhang
- Medical School of Chinese PLA, Beijing, China
- Faculty of Hepato-Biliary-Pancreatic Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Chengkai Bao
- School of Biomedical Engineering, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
- Suzhou Institute for Advanced Research, University of Science and Technology of China, Suzhou, Jiangsu, China
| | - Yanzhe Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zizheng Wang
- Senior Department of Hepatology, The Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lei Du
- Department of Nuclear Medicine, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yue Zhang
- School of Biomedical Engineering, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
- Suzhou Institute for Advanced Research, University of Science and Technology of China, Suzhou, Jiangsu, China
| | - Fei Wang
- Faculty of Hepato-Biliary-Pancreatic Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Baixuan Xu
- Department of Nuclear Medicine, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
| | - S Kevin Zhou
- School of Biomedical Engineering, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
- Suzhou Institute for Advanced Research, University of Science and Technology of China, Suzhou, Jiangsu, China.
| | - Rong Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China.
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10
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Kurosu T, Kida M, Okuwaki K, Iwai T, Watanabe M, Hasegawa R, Imaizumi H, Tamaki A, Yoshida T, Kusano C. Pancreatic Cancer Cells May Adhere to the External Surface of the Puncture Needle After Endoscopic Ultrasound-Guided Fine-Needle Aspiration. Pancreas 2023; 52:e298-e304. [PMID: 37816165 DOI: 10.1097/mpa.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE We prospectively investigated whether cells derived from pancreatic cancers adhered to the puncture needle's external surface after endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and whether wiping the needle with alcohol swabs removed residual cancer cells. METHODS The participants were 100 consecutive patients who underwent EUS-FNA for suspected pancreatic ductal adenocarcinoma. In the first pass of EUS-FNA, we prepared aspiration and lavage cytological diagnosis materials from the lumen and external surface of the puncture needle, respectively. This was repeated in the second pass, although the needle's external surface was wiped with an alcohol swab. RESULTS The positivity rates of aspiration cytological diagnosis for the first and second passes were 67% and 72%, respectively. The positivity rates of lavage cytological diagnosis of the needle's external surface on the first and second passes were 20% and 3%, respectively. Wiping the needle's external surface with alcohol swabs significantly reduced the proportion of cancer cells detected ( P < 0.001). The accuracy rate based on all the collected specimens was 90%. There were no EUS-FNA-related adverse events. CONCLUSION Pancreatic cancer cells may adhere to the puncture needle's external surface after EUS-FNA. Wiping the needle with alcohol swabs after each puncture effectively removes residual cancer cells.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tsutomu Yoshida
- Pathology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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11
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Ivey GD, Shoucair S, Delitto DJ, Habib JR, Kinny-Köster B, Shubert CR, Lafaro KJ, Cameron JL, Burns WR, Burkhart RA, Thompson EL, Narang A, Zheng L, Wolfgang CL, He J. Postoperative Chemotherapy is Associated with Improved Survival in Patients with Node-Positive Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy. World J Surg 2022; 46:2751-2759. [PMID: 35861852 PMCID: PMC9532378 DOI: 10.1007/s00268-022-06667-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Postoperative chemotherapy following pancreatic cancer resection is the standard of care. The utility of postoperative chemotherapy for patients who receive neoadjuvant therapy (NAT) is unclear. METHODS Patients who underwent pancreatectomy after NAT with FOLFIRINOX or gemcitabine-based chemotherapy for non-metastatic pancreatic adenocarcinoma (2015-2019) were identified. Patients who received less than 2 months of neoadjuvant chemotherapy or died within 90 days from surgery were excluded. RESULTS A total of 427 patients (resectable, 22.2%; borderline resectable, 37.9%; locally advanced, 39.8%) were identified with the majority (69.3%) receiving neoadjuvant FOLFIRINOX. Median duration of NAT was 4.1 months. Following resection, postoperative chemotherapy was associated with an improved median overall survival (OS) (28.7 vs. 20.4 months, P = 0.006). Risk-adjusted multivariable modeling showed negative nodal status (N0), favorable pathologic response (College of American Pathologists score 0 & 1), and receipt of postoperative chemotherapy to be independent predictors of improved OS. Regimen, duration, and number of cycles of NAT were not significant predictors. Thirty-four percent (60/176) of node-positive and 50.1% (126/251) of node-negative patients did not receive postoperative chemotherapy due to poor functional status, postoperative complications, and patient preference. Among patients with node-positive disease, postoperative chemotherapy was associated with improved median OS (27.2 vs. 10.5 months, P < 0.001). Among node-negative patients, postoperative chemotherapy was not associated with a survival benefit (median OS, 30.9 vs. 36.9 months; P = 0.406). CONCLUSION Although there is no standard NAT regimen for patients with pancreatic cancer, postoperative chemotherapy following NAT and resection appears to be associated with improved OS for patients with node-positive disease.
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Affiliation(s)
- Gabriel D Ivey
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J Delitto
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Christopher R Shubert
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth L Thompson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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12
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Vivarelli M, Mocchegiani F, Nicolini D, Vecchi A, Conte G, Dalla Bona E, Rossi R, Benedetti Cacciaguerra A. Neoadjuvant Treatment in Resectable Pancreatic Cancer. Is It Time for Pushing on It? Front Oncol 2022; 12:914203. [PMID: 35712487 PMCID: PMC9195424 DOI: 10.3389/fonc.2022.914203] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Pancreatic resection still represents the only curative option for patients affected by pancreatic ductal adenocarcinoma (PDAC). However, the association with modern chemotherapy regimens is a key factor in improving the inauspicious oncological outcome. The benefit of neoadjuvant treatment (NAT) for borderline resectable/locally advanced PDAC has been demonstrated; this evidence raises the question of whether even resectable PDAC should undergo NAT rather than upfront surgery. NAT may avoid futile surgery because of undetected distant metastases or aggressive tumor biology, providing more effective systemic control of the disease, which is hampered when adjuvant chemotherapy is delayed or precluded. However, recent data show controversial results regarding the efficacy and safety of NAT in resectable PDAC compared to upfront surgery. Although several prospective studies and meta-analyses indicate better oncologic outcomes after NAT, there are some biases, such as the methodological approaches used to capture the events of interest, which could make these results hardly reproducible. For instance, per-protocol studies, considering only the postoperative outcomes, tend to overestimate the performance of NAT by excluding patients who will never be suitable for surgery due to the development of chemotoxicity or tumor progression. To draw reliable conclusions, the studies should capture the events of interest of both strategies (NAT/upfront surgery) from the time of allocation to a specific treatment in an intention-to-treat fashion. This critical review highlights the current literature data concerning the use of NAT in resectable PDAC, summarizing the results of high-quality studies and focusing on the methodological issues of the most recent pieces of evidence.
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13
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Sumiyoshi T, Uemura K, Aoki G, Kawano R, Kitagawa H, Kondo N, Okada K, Seo S, Otsuka H, Takahashi S. Increased clostridium difficile infection in the era of preoperative chemotherapy for pancreatic cancer. Pancreatology 2022; 22:258-263. [PMID: 34991969 DOI: 10.1016/j.pan.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/18/2021] [Accepted: 12/20/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND In recent trend of preoperative chemotherapy, postoperative clostridium difficile infection (CDI) might be increasing in pancreatic ductal adenocarcinoma (PDAC) patients. This study aimed to elucidate the inducement of postoperative CDI in the new era of preoperative chemotherapy. METHODS Eligible patients were those who received pancreaticoduodenectomy for PDAC. Patients were classified into two groups according to the presence or absence of postoperative CDI, and the independently associated factors for postoperative CDI were investigated. Additionally, eligible patients were classified using the identified associated factors, and the duration of preoperative antimicrobial administration and incidence of CDI were compared between the groups. RESULTS Two hundred PDAC patients were eligible for this study, and postoperative CDI was detected in 15 (7.5%) patients. Multivariate analysis revealed that preoperative biliary tract infection (BTI) and chemotherapy (Chemo) were independently associated with postoperative CDI (OR, 4.05; 95% CI, 1.25-13.1; p = 0.0200 and OR, 3.64; 95% CI, 1.14-11.6; p = 0.0209, respectively). The patients were classified into four groups according to the presence or absence of preoperative BTI and Chemo (BTI-/Chemo-, BTI-/Chemo+, BTI+/Chemo- and BTI+/Chemo + group). The median durations of preoperative antimicrobial administration were 0, 2, 8 and 15 days in each group, respectively. Postoperative CDI was detected in 3.7%, 10.0%, 10.5% and 31.3% in each group, respectively, and patients in BTI+/Chemo + group suffered CDI more frequently compared to those in BTI-/Chemo-group (p = 0.00778). CONCLUSIONS Preoperative BTI and chemotherapy might induce postoperative CDI for PDAC patients.
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Affiliation(s)
- Tatsuaki Sumiyoshi
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.
| | - Gaku Aoki
- Division of Biostatistics and Data Management, Clinical Research Center, Hiroshima, Japan
| | - Reo Kawano
- Division of Biostatistics and Data Management, Clinical Research Center, Hiroshima, Japan
| | - Hiroki Kitagawa
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan; Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Naru Kondo
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Shingo Seo
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Otsuka
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
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14
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.
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15
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Crippa S, Belfiori G, Bissolati M, Partelli S, Pagnanelli M, Tamburrino D, Gasparini G, Rubini C, Zamboni G, Falconi M. Recurrence after surgical resection of pancreatic cancer: the importance of postoperative complications beyond tumor biology. HPB (Oxford) 2021; 23:1666-1673. [PMID: 33934960 DOI: 10.1016/j.hpb.2021.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/07/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC) includes pancreatic resection followed by adjuvant therapy. Aim of this study is to identify factors that are related with overall and early recurrence after pancreatectomy for PDAC. METHODS Retrospective analysis of patients with histologically confirmed PDAC who underwent pancreatectomy between September 2009 and December 2014. Early relapse was defined as recurrence within 12 months after surgery. Univariate/multivariate analysis was performed to identify prognostic factors for recurrence. RESULTS 261 patients were included (54% males, mean age 67 years). Neoadjuvant and adjuvant treatments were performed in 55 (21%) and 243 (93%) patients. Overall morbidity was 56% with a rate of grade 3-4 Clavien-Dindo complications of 25%. Median disease-free survival was 18 months. Multivariate analysis identified nodal metastases (OR: 3.6) and perineural invasion (OR: 2.14) as independent predictors of disease recurrence in the entire cohort. 76 patients (29%) had an early recurrence. Poorly differentiated tumors (OR: 3.019) and grade 3-4 Clavien-Dindo complications (OR: 3.05) were independent risk factors for early recurrence. CONCLUSION Although overall recurrence is associated with tumor-related factors, severe postoperative complications represent an independent predictor of early recurrence. Patients at increased risk of severe postoperative complications may benefit from neoadjuvant therapy.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimiliano Bissolati
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Pagnanelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Rubini
- Department of Pathology, Università Politecnica Delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Giuseppe Zamboni
- Department of Pathology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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16
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Hue JJ, Dorth J, Sugumar K, Hardacre JM, Ammori JB, Rothermel LD, Saltzman J, Mohamed A, Selfridge JE, Bajor D, Winter JM, Ocuin LM. Neoadjuvant Radiotherapy is Associated With Improved Pathologic Outcomes and Survival in Resected Stage II-III Pancreatic Adenocarcinoma Treated With Multiagent Neoadjuvant Chemotherapy in the Modern Era. Am Surg 2021; 87:1386-1395. [PMID: 34382877 DOI: 10.1177/00031348211038581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (CT) is being utilized more frequently in patients diagnosed with localized pancreatic cancer. The role of additional neoadjuvant radiotherapy (RT) remains undefined. We explored outcomes associated with neoadjuvant RT in the modern era. METHODS The National Cancer Database (2010-2017) was queried for patients with clinical stage II-III pancreatic adenocarcinoma who received neoadjuvant multiagent systemic CT +/- RT. Demographics, pathologic outcomes, postoperative outcomes, and overall survival were compared. RESULTS A total of 5245 patients were included, of whom 3123 received CT and 1941 received CT + RT. Use of RT decreased over the 8-year study period. On multivariable analysis, treatment at academic facilities (odds ratio (OR) = 1.52, P < .001) and clinical T4 tumors (OR = 1.68, P < .001) were independently associated with receipt of RT. Patients treated with CT + RT had a higher frequency of ypT0-T2 tumors (35.8% vs. 22.7%) and a lower rate of ypT3-T4 tumors (57.3% vs. 72.8%; P < .001), lower rate of node-positive disease (36.6% vs. 59.8%, P < .001), and margin-positive resections (13.8% vs. 20.2%, P < .001), but slightly higher 90-day postoperative mortality (4.9% vs. 3.6%, P = .04). Neoadjuvant chemotherapy+ RT was associated with longer overall survival (32.7 vs. 29.8 months, P = .008), and remained independently associated with survival on multivariable analysis (HR = .85, P < .001). DISCUSSION In patients with stage II-III pancreatic adenocarcinoma, the addition of neoadjuvant RT to multiagent neoadjuvant CT may be associated with increased rates of node-negative and margin-negative resection, as well as improved overall survival.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Dorth
- Department of Radiology, Division of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Joel Saltzman
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amr Mohamed
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer E Selfridge
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Bajor
- Department of Medicine, Division of Hematology/Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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17
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Bergquist JR, Thiels CA, Shubert CR, Ivanics T, Habermann EB, Vege SS, Grotz TE, Cleary SP, Smoot RL, Kendrick ML, Nagorney DM, Truty MJ. Perception versus reality: A National Cohort Analysis of the surgery-first approach for resectable pancreatic cancer. Cancer Med 2021; 10:5925-5935. [PMID: 34289264 PMCID: PMC8419760 DOI: 10.1002/cam4.4144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Although surgical resection is necessary, it is not sufficient for long‐term survival in pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate survival after up‐front surgery (UFS) in anatomically resectable PDAC in the context of three critical factors: (A) margin status; (B) CA19‐9; and (C) receipt of adjuvant chemotherapy. Methods The National Cancer Data Base (2010–2015) was reviewed for clinically resectable (stage 0/I/II) PDAC patients. Surgical margins, pre‐operative CA19‐9, and receipt of adjuvant chemotherapy were evaluated. Patient overall survival was stratified based on these factors and their respective combinations. Outcomes after UFS were compared to equivalently staged patients after neoadjuvant chemotherapy on an intention‐to‐treat (ITT) basis. Results Twelve thousand and eighty‐nine patients were included (n = 9197 UFS, n = 2892 ITT neoadjuvant). In the UFS cohort, only 20.4% had all three factors (median OS = 31.2 months). Nearly 1/3rd (32.7%) of UFS patients had none or only one factor with concomitant worst survival (median OS = 14.7 months). Survival after UFS decreased with each failing factor (two factors: 23 months, one factor: 15.5 months, no factors: 7.9 months) and this persisted after adjustment. Overall survival was superior in the ITT‐neoadjuvant cohort (27.9 vs. 22 months) to UFS. Conclusion Despite the perceived benefit of UFS, only 1‐in‐5 UFS patients actually realize maximal survival when known factors highly associated with outcomes are assessed. Patients are proportionally more likely to do worst, rather than best after UFS treatment. Similarly staged patients undergoing ITT‐neoadjuvant therapy achieve survival superior to the majority of UFS patients. Patients and providers should be aware of the false perception of ‘optimal’ survival benefit with UFS in anatomically resectable PDAC.
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Affiliation(s)
- John R Bergquist
- Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, Palo Alto, California, USA.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Christopher R Shubert
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Division of Hepatopancreatobiliary Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tommy Ivanics
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.,Department of Surgery, Henry Ford Medical Center, Detroit, Michigan, USA
| | - Elizabeth B Habermann
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Santhi S Vege
- Mayo Clinic Rochester, Department of Medicine, Division of Gastroenterology, Pancreatology Section, Rochester, Minnesota, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
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18
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Gaskill CE, Maxwell J, Ikoma N, Kim MP, Tzeng CW, Lee JE, Katz MHG. History of preoperative therapy for pancreatic cancer and the MD Anderson experience. J Surg Oncol 2021; 123:1414-1422. [PMID: 33831256 DOI: 10.1002/jso.26394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
Systemic chemotherapy improves the survival of patients who undergo pancreatectomy, but whether chemotherapy should be delivered before or after surgery remains debated. At The University of Texas MD Anderson Cancer Center, localized pancreatic ductal adenocarcinoma (PDAC) has been preferentially treated with preoperative therapy-a practice supported by a robust history of institutional and national trials. In the following review, we discuss the historical use of perioperative therapy, our experience with it at MD Anderson Cancer Center and internationally, and the future of treatment and trials for PDAC.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Diagnosis of Pancreatic Solid Lesions, Subepithelial Lesions, and Lymph Nodes Using Endoscopic Ultrasound. J Clin Med 2021; 10:jcm10051076. [PMID: 33807558 PMCID: PMC7961381 DOI: 10.3390/jcm10051076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Currently, endoscopic ultrasound (EUS) has become widely accepted and has considerable advantages over computed tomography (CT) and other imaging modalities, given that it enables echostructure assessment in lesions with <1 cm diameter and permits high resolution imaging. EUS-guided tissue acquisition (EUS-TA) provides consistent results under ultrasound guidance and has been considered more effective compared to CT- or ultrasound-guided lesion biopsy. Moreover, complication rates, including pancreatitis and bleeding, have been extremely low, with <1% morbidity and mortality rates, thereby suggesting the exceptional overall safety of EUS-TA. The aggressive use of EUS for various lesions has been key in facilitating early diagnosis and therapy. This review summarizes the diagnostic ability of EUS for pancreatic solid lesions, subepithelial lesions, and lymph nodes where it is mainly used. EUS has played an important role in diagnosing these lesions and planning treatment strategies. Future developments in EUS imaging technology, such as producing images close to histopathological findings, are expected to further improve its diagnostic ability. Moreover, tissue acquisition via EUS is expected to be used for precision medicine, which facilitates the selection of an appropriate therapeutic agent by increasing the amount of tissue collected and improving genetic analysis.
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20
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Vidri RJ, Olsen WT, Clark DE, Fitzgerald TL. Upfront resection versus neoadjuvant therapy for T1/T2 pancreatic cancer. HPB (Oxford) 2021; 23:279-289. [PMID: 32698950 DOI: 10.1016/j.hpb.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of neoadjuvant therapy remains controversial for resectable pancreatic neoplasms. We evaluated treatment outcomes for T1/T2 tumors. METHODS Retrospective study of patients with T1/T2 (Stage I-II) pancreatic cancer within the NCDB. Treatment-sequence variables were used for classification: "surgery + chemotherapy" (S+C), "chemotherapy + surgery" (C+S), "surgery only" (SO), and "chemotherapy only" (CO). RESULTS 13 412 patients were included; the majority had T2 tumors. 8 490 received upfront surgery; 4 922 preoperative chemotherapy. In the surgery branch, 5 684 received surgery and chemotherapy (S+C); 2 806 did not receive chemotherapy (SO). Of those intended to receive preoperative chemotherapy, 3 804 received only chemotherapy (CO); 1 118 proceeded to surgery (C+S). Median survival for S+C and C+S groups was similar (25.9 vs 26.2) [HR 0.92, p= 0.41]. Compared to the CO group, the SO group had improved median survival (13.5 vs. 10.8) [HR 0.63, p<0.001]. Branched analyses demonstrated improved median and 5-year (20.8% vs 12.7%) survival for patients receiving upfront resection [HR 0.77, p<0.001]. CONCLUSION Patients with T1/T2 pancreatic cancer have similar survival irrespective of the timing of chemotherapy and surgery, if they receive both. Upfront resection ensures surgery is delivered, increasing the possibility of long-term survival.
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Affiliation(s)
- Roberto J Vidri
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Department of Surgery, St. Mary's Regional Medical Center, 99 Campus Avenue, 4th Floor, Suite 401, Lewiston, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | - David E Clark
- Center for Outcomes Research and Evaluation, Maine Medical Center, 509 Forest Avenue, Ste. 200, Portland, ME, 04101, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Tufts University School of Medicine, Boston, MA, USA.
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Tajima H, Makino I, Gabata R, Okazaki M, Ohbatake Y, Shimbashi H, Nakanuma S, Saitoh H, Shimada M, Yamaguchi T, Okamoto K, Moriyama H, Kinoshita J, Nakamura K, Miyashita T, Ninomiya I, Fushida S, Ikeda H, Ohta T. A phase I study of preoperative (neoadjuvant) chemotherapy with gemcitabine plus nab-paclitaxel for resectable pancreatic cancer. Mol Clin Oncol 2021; 14:26. [PMID: 33414907 PMCID: PMC7783717 DOI: 10.3892/mco.2020.2188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022] Open
Abstract
Neoadjuvant chemotherapy (NAC) has become a standard treatment for borderline resectable pancreatic ductal adenocarcinoma (PDAC). The present study examined the maximum tolerated dose of NAC with gemcitabine plus nab-paclitaxel (GnP) in patients with resectable PDAC. Between 2015 and 2019, 39 patients with resectable PDAC were enrolled in the present study. GnP was administered for two 28-day cycles on days 1, 8 and 15. The planned doses for levels 1, 2 and 3 were 75, 100 and 125 mg/m2, respectively, for nab-paclitaxel and 600, 800 and 1,000 mg/m2, respectively, for gemcitabine. Dose-limiting toxicity (neutropenia, anemia, thrombocytopenia and/or liver injury) was observed in 44.4% of patients treated at dose level 1 (21 patients) and 60.0% of those treated at dose level 2 (18 patients). Therefore, the maximum tolerated dose was set as level 1. Six patients withdrew from protocol treatment because of non-hematologic adverse events (skin rash, pancreatitis and biliary tract infection). Among the 31 patients with pathologically confirmed PDAC, partial response, stable disease and disease progression were recorded in 4 (12.9%), 24 (77.4%) and 3 (9.7%) patients, respectively. NAC significantly reduced tumor size according to computed tomography, and CA19-9 levels and the 18F-fluorodeoxyglucose maximum standardized uptake value were decreased in positron emission tomography. No postoperative complications attributable to NAC were recognized. Among the 27 patients with PDAC who underwent resection, the pathological treatment effect was judged as grades Ia, Ib and II in 21 (77.8%), 4 (14.8%) and 2 (7.4%) patients, respectively. R0 resection was performed in 24 out of 27 patients (88.9%). Adjuvant chemotherapy with oral S-1 was administered to 21 out of 27 patients (77.8%). In conclusion, NAC with GnP was safe and feasible for resectable PDAC at dose level 1. In the future, verification of the long-term results of the present study will be necessary, and a phase II clinical trial is anticipated.
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Affiliation(s)
- Hidehiro Tajima
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Isamu Makino
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Ryosuke Gabata
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Mitsuyoshi Okazaki
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Yoshinao Ohbatake
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Shimbashi
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Shinich Nakanuma
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroto Saitoh
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Mari Shimada
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Takahisa Yamaguchi
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Koichi Okamoto
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hideki Moriyama
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Jun Kinoshita
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Keishi Nakamura
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tomoharu Miyashita
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Itasu Ninomiya
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroko Ikeda
- Division of Pathology, Kanazawa University Hospital, Kanazawa, Ishikawa 920-8641, Japan
| | - Tetsuo Ohta
- Department of Hepato-Biliary-Pancreatic Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
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22
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Fujita A, Ryozawa S, Tanisaka Y, Ogawa T, Suzuki M, Katsuda H, Tashima T, Araki R, Mizuide M. Evaluation of endoscopic ultrasound-guided fine-needle biopsy for preoperative pancreatic solid lesions. Scand J Gastroenterol 2021; 56:188-192. [PMID: 33295211 DOI: 10.1080/00365521.2020.1857828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Obtaining an accurate preoperative diagnosis is crucial. This study aimed to evaluate the diagnostic accuracy and utility of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) for preoperative pancreatic solid lesions. MATERIALS AND METHODS We retrospectively assessed all patients who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB to evaluate solid pancreatic lesions preoperatively at our center between July 2013 and June 2020. We enrolled 71 patients who underwent EUS-FNA using a 22 G conventional needle (FNA group) and 34 patients who underwent EUS-FNB using a 22 G Franseen needle (FNB group). Overall, 105 patients were analyzed. We employed propensity-matched analysis and adjusted the confounders. RESULTS No procedural adverse events were encountered. Both groups showed no significant differences in the procedure time, technical success rate, and rate of operator changes from trainee to expert. Regarding diagnostic accuracy, the FNB group (88.2%; 30/34) was higher but not significantly different from the FNA group (85.3%; 29/34) (p > .99). Furthermore, the FNB group (median 2, IQR;2-3) had a significantly lower number of punctures than the FNA group (median 3, IQR; 2-4) (p = .01). CONCLUSIONS The FNB needle provides higher diagnostic accuracy and requires significantly fewer punctures than conventional needles even at facilities with no available rapid on-site evaluation. Thus, using the FNB needle can be useful for preoperative pancreatic solid lesions.
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Affiliation(s)
- Akashi Fujita
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yuki Tanisaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tomoya Ogawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Masahiro Suzuki
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hiromune Katsuda
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tomoaki Tashima
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ryuichiro Araki
- Community Health Science Center, Saitama Medical University, Saitama, Japan
| | - Masafumi Mizuide
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama, Japan
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23
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Kamarajah SK, Naffouje SA, Salti GI, Dahdaleh FS. Neoadjuvant Chemotherapy for Pancreatic Ductal Adenocarcinoma is Associated with Lower Post-Pancreatectomy Readmission Rates: A Population-Based Cohort Study. Ann Surg Oncol 2021; 28:1896-1905. [PMID: 33398644 DOI: 10.1245/s10434-020-09470-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Despite neoadjuvant chemotherapy (NAC) being increasingly utilized and possibly associated with improved oncological outcomes, the impact of NAC on textbook outcomes following pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) remains debated. METHODS A retrospective review of the National Cancer Database of patients undergoing resection of non-metastatic PDAC from 2004 to 2016 was performed. Propensity score matching was used to account for treatment selection bias in patients with and without NAC (noNAC). A multivariable binary logistic regression model was used to analyze the association of NAC with length of stay (LOS), 30-day readmission, and 30- and 90-day mortality. RESULTS Of 7975 (11%) NAC patients and 65,338 (89%) noNAC patients, 2911 NAC and 2911 noNAC patients remained in the cohort after matching. Clinicopathologic and demographic variables were well-balanced after matching. After matching, NAC was associated with significantly lower rates of 30-day readmission (5.5% vs. 7.4%; p = 0.006), which remained after multivariable adjustment (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.60-0.92; p = 0.006). There were no significant differences in LOS and 30- and 90-day mortality in patients receiving NAC and noNAC. Stratified analyses by surgery type (i.e. pancreaticoduodenectomy [PD] and distal pancreatectomy [DP]) demonstrated consistent results. CONCLUSION Receipt of NAC in PDAC patients undergoing DP or PD is associated with lower readmission rates and does not otherwise compromise short-term outcomes. These data reaffirm the safety of strategies incorporating NAC and is important to consider when devising policies aimed at quality improvement in achieving textbook outcomes.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, Newcastle, UK
| | - Samer A Naffouje
- Department of Surgical Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - George I Salti
- Department of General Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.,Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Fadi S Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA.
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24
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Joliat GR, Labgaa I, Gilgien J, Demartines N. Prognostic Impact of Time to Surgery in Patients With Resectable Pancreatic Ductal Adenocarcinoma. Pancreas 2021; 50:104-110. [PMID: 33370031 DOI: 10.1097/mpa.0000000000001719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Some studies suggested the importance of performing pancreatoduodenectomy expeditiously in resectable pancreatic ductal adenocarcinoma (PDAC). This study aimed to assess the prognostic value of time to surgery in patients undergoing pancreatoduodenectomy for PDAC. METHODS All PDAC patients who underwent upfront pancreatoduodenectomy were collected (2000-2015). Diagnosis date was the computed tomography scan date where a suspicious pancreatic head lesion was observed. Survival analyses were performed using Kaplan-Meier method. Cox model was used to find predictive factors of survival. RESULTS A total of 192 patients underwent pancreatoduodenectomy. The median time to surgery was 27 days (interquartile range, 17-40 days). The best dichotomous threshold for 24-month overall survival (OS) was 30 days. The median OS was similar between groups with time to surgery of fewer than 30 days and time to surgery of 30 days or more (25 vs 21 months, P = 0.609). Similar results were found for median recurrence-free survivals (19 vs 15 months, P = 0.561). On Cox regressions, time to surgery was not associated with shorter OS. Only lymph node invasion and adjuvant chemotherapy were independent OS predictors (hazard ratio, 2.610, P = 0.006, and hazard ratio, 2.042, P = 0.001). CONCLUSIONS Delaying surgery 30 days or more after diagnostic computed tomography scan was not associated with poorer OS and recurrence-free survival. Moreover, time to surgery was not prognostic of OS.
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Affiliation(s)
- Gaëtan-Romain Joliat
- From the Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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25
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Greco SH, August DA, Shah MM, Chen C, Moore DF, Masanam M, Turner AL, Jabbour SK, Javidian P, Grandhi MS, Kennedy TJ, Alexander HR, Carpizo DR, Langan RC. Neoadjuvant therapy is associated with lower margin positivity rates after Pancreaticoduodenectomy in T1 and T2 pancreatic head cancers: An analysis of the National Cancer Database. Surg Open Sci 2021; 3:22-28. [PMID: 33490937 PMCID: PMC7807160 DOI: 10.1016/j.sopen.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for T1/T2 pancreatic adenocarcinoma (PDAC) prior to pancreaticoduodenectomy remains controversial. We compared positive margin rates in patients with clinical T1&T2 tumors who did and did not receive NAT. METHODS The National Cancer Database (NCDB) found clinical T1&T2 PDAC patients who underwent pancreaticoduodenectomy from 2004 to 2014. Univariate and multivariate regression determined factors associated with a positive margin and survival. RESULTS 9795 patients underwent surgery for clinical T1 or T2 pancreatic head adenocarcinoma. 8472 patients had data regarding use of neoadjuvant and adjuvant therapies; of which, 774 (9.1%) received NAT and 435 (5.1%) received both chemotherapy and radiation therapy. NAT was found to lower positive margin rates from 21.8 to 15.5% (p < 0.0001) and when radiation was added this rate dropped to 13.4%. Positive margins were associated with worse overall survival (14.9 vs. 23.9 months; HR 1.702, p < 0.0001). CONCLUSIONS NAT is associated with a reduced positive margin rate in patients with T1 and T2 tumors. These findings support ongoing and future clinical trials of NAT in T1 and T2, early stage PDAC to determine impacts on survival.
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Affiliation(s)
- Stephanie H. Greco
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
| | - David A. August
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Emory University
| | - Chunxia Chen
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Dirk F. Moore
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Monika Masanam
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
| | - Amber L. Turner
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Salma K. Jabbour
- Division of Radiation Oncology, Rutgers Cancer Institute of New, Jersey
| | - Parisa Javidian
- Department of Pathology, Rutgers Robert Wood Johnson University Hospital
| | - Miral S. Grandhi
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Timothy J. Kennedy
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - H. Richard Alexander
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Darren R. Carpizo
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Russell C. Langan
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
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26
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Takeda T, Sasaki T, Mie T, Furukawa T, Kanata R, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. Novel risk factors for recurrent biliary obstruction and pancreatitis after metallic stent placement in pancreatic cancer. Endosc Int Open 2020; 8:E1603-E1610. [PMID: 33140016 PMCID: PMC7581474 DOI: 10.1055/a-1244-1989] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Self-expandable metallic stents (SEMS) are now widely used even for patients with borderline resectable (BR) pancreatic cancer (PC), as neoadjuvant therapy has become common. Therefore, we conducted this study to evaluate safety of SEMS placement in the population including BR PC and to explore risk factors for recurrent biliary obstruction (RBO), pancreatitis, and cholecystitis. Patients and methods We retrospectively investigated consecutive patients with PC who received initial SEMS between January 2015 and March 2019. We compared time to RBO (TRBO), causes of RBO, and stent-related adverse events (AEs) according to resectability status. Univariate and multivariate analyses were performed to explore risk factors for TRBO, pancreatitis, and cholecystitis. Results A total of 135 patients were included (BR 31 and unresectable [UR] 104). Stent-related AEs occurred in 39 patients: pancreatitis 14 (mild/moderate/severe 1/6/7), cholecystitis 12, and non-occluding cholangitis 13. TRBO, causes of RBO, and stent-related AEs were not significantly different according to resectability status. Overall rate of RBO was higher in UR PC due to the longer follow-up period. Sharp common bile duct (CBD) angulation was an independent risk factor for short duration of TRBO. High pancreatic volume index and SEMS of high axial force were independent risk factors for pancreatitis, whereas tumor involvement to orifice of cystic duct was the only risk factor for cholecystitis. Conclusions We demonstrated that SEMS can be safely deployed even in patients with BR PC. Sharp CBD angulation and high pancreatic volume index were identified as novel risk factors for RBO and pancreatitis, respectively, after SEMS placement.
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Affiliation(s)
- Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Kanata
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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Benefits of the multiplanar and volumetric analyses of pancreatic cancer using computed tomography. PLoS One 2020; 15:e0240318. [PMID: 33027288 PMCID: PMC7540900 DOI: 10.1371/journal.pone.0240318] [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: 05/04/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023] Open
Abstract
Although pancreatic cancer tumors are irregularly shaped in terms of their three-dimensional (3D) structure, when T staging by imaging results, generally only the axial plane is used to measure the largest tumor diameter. We investigated the size of pancreatic cancer tumors using multi-plane and 3D reconstructed computed tomography (CT) images and investigated their clinical usefulness. Patients who underwent surgery for pancreatic adenocarcinoma were included. We measured the largest diameter of each pancreatic tumor in the axial, coronal, and sagittal planes of CT images. In addition, maximal diameter and cancer volume were measured from 3D images that were constructed using a semi-automated software system. Final data were compared with pathologic examination and the effect of each value on prognosis was analyzed. A total of 183 patients were analyzed. The maximal diameters measured on the axial, coronal, and sagittal planes were 2.9 ± 1.1, 3.2 ± 0.9, and 3.2 ± 1.0 cm, respectively, which were significantly smaller than pathologic results (3.4 ± 1.4 cm, all p<0.05 by paired t-test). The longest diameter among them (3.4 ± 1.1 cm) was nearly similar to the pathologic diameter. Cancer volume measured on 3D images demonstrated a higher area under the receptor operating characteristic curve [0.714, (95% confidence interval: 0.640–0.788)] for predicting early death compared to any unidimensional CT diameters measured. The longest pancreatic tumor diameter measured on multiplanar CT images was most accurate when compared to its corresponding pathologic diameter. Tumor volume had a stronger correlation with overall survival than tumor diameter.
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Commentary: Anatomic versus biologic resectability: The role of predictive biomarkers in guiding surgical management. Surgery 2020; 168:1017-1018. [PMID: 32900493 DOI: 10.1016/j.surg.2020.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022]
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29
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Takeda T, Sasaki T, Inoue Y, Mie T, Furukawa T, Kanata R, Kasuga A, Matsuyama M, Ozaka M, Takahashi Y, Saiura A, Sasahira N. Comprehensive comparison of clinicopathological characteristics, treatment, and prognosis of borderline resectable pancreatic cancer according to tumor location. Pancreatology 2020; 20:1123-1130. [PMID: 32753119 DOI: 10.1016/j.pan.2020.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/14/2020] [Accepted: 07/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prognosis of borderline resectable (BR) pancreatic cancer (PC) has improved by multidisciplinary therapy. However, the differences in clinical course between pancreatic head (Ph) and pancreatic body and tail (Pbt) cancer has not been fully elucidated. Therefore, we conducted this study to compare the clinical course of BR PC patients according to tumor location. METHODS We retrospectively investigated consecutive patients with BR PC who initiated neoadjuvant chemotherapy (NAC) between March 2015 and April 2019. We compared clinicopathological characteristics, treatment, recurrence pattern and post recurrence treatment between Ph and Pbt cancer patients. We also compared recurrence free survival (RFS) and overall survival (OS) according to tumor location. RESULTS A total of 108 patients with BR PC were included. Tumor location was Ph 74 and Pbt 34, respectively. Initial regimen of NAC was nab-paclitaxel/gemcitabine in 106 and gemcitabine in 2, respectively. Although Pbt location was associated with more advanced T stage, it showed similar N stage, pathological stage, RFS, OS, and details of adjuvant chemotherapy compared to Ph location. The most common site of postoperative recurrence was liver-only recurrence in Ph tumor (32% vs. 6%, p = 0.04) and peritoneal dissemination-only recurrence in Pbt tumor (35% vs. 11%, p = 0.06). Furthermore, Ph cancer patients received a higher rate of monotherapy compared to Pbt cancer patients (19% vs. 0%, p = 0.08). CONCLUSIONS In our experience tumor location was not a prognostic factor for OS in BR PC. Postoperative recurrence pattern and treatment after recurrence were different according to tumor location.
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Affiliation(s)
- Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yosuke Inoue
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Ryo Kanata
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yu Takahashi
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Akio Saiura
- Department of Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Hepato-Biliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
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Tempero MA, Malafa MP, Chiorean EG, Czito B, Scaife C, Narang AK, Fountzilas C, Wolpin BM, Al-Hawary M, Asbun H, Behrman SW, Benson AB, Binder E, Cardin DB, Cha C, Chung V, Dillhoff M, Dotan E, Ferrone CR, Fisher G, Hardacre J, Hawkins WG, Ko AH, LoConte N, Lowy AM, Moravek C, Nakakura EK, O'Reilly EM, Obando J, Reddy S, Thayer S, Wolff RA, Burns JL, Zuccarino-Catania G. Pancreatic Adenocarcinoma, Version 1.2019. J Natl Compr Canc Netw 2020; 17:202-210. [PMID: 30865919 DOI: 10.6004/jnccn.2019.0014] [Citation(s) in RCA: 249] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The NCCN Guidelines for Pancreatic Adenocarcinoma discuss the diagnosis and management of adenocarcinomas of the exocrine pancreas and are intended to assist with clinical decision-making. These NCCN Guidelines Insights discuss important updates to the 2019 version of the guidelines, focusing on postoperative adjuvant treatment of patients with pancreatic cancers.
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Affiliation(s)
| | | | | | | | | | - Amol K Narang
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Stephen W Behrman
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Ellen Binder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Mary Dillhoff
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | - Jeffrey Hardacre
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - William G Hawkins
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Andrew H Ko
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | - Sushanth Reddy
- University of Alabama at Birmingham Comprehensive Cancer Center
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31
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Yane K, Kuwatani M, Yoshida M, Goto T, Matsumoto R, Ihara H, Okuda T, Taya Y, Ehira N, Kudo T, Adachi T, Eto K, Onodera M, Sano I, Nojima M, Katanuma A. Non-negligible rate of needle tract seeding after endoscopic ultrasound-guided fine-needle aspiration for patients undergoing distal pancreatectomy for pancreatic cancer. Dig Endosc 2020; 32:801-811. [PMID: 31876309 DOI: 10.1111/den.13615] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/08/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Needle tract seeding after preoperative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic body and tail cancer has been reported. This study aimed to investigate the long-term outcomes, including the needle tract seeding ratio, of patients undergoing distal pancreatectomy for pancreatic body and tail cancer diagnosed preoperatively by EUS-FNA. METHODS This retrospective, observational cohort study assessed patients from three university hospitals and 11 tertiary referral centers. All patients who underwent distal pancreatectomy for invasive cancer of the pancreatic body and tail between January 2006 and December 2015 were identified and reviewed. Needle tract seeding rate, recurrence-free survival (RFS), and overall survival (OS) were evaluated. RESULTS Of the 301 total patients analyzed, 176 underwent preoperative EUS-FNA (EUS-FNA group) and 125 did not (non-EUS-FNA group). The median follow-up periods of the EUS-FNA group and non-EUS-FNA group were 32.8 and 30.1 months. Six patients (3.4%) in the EUS-FNA group were diagnosed as having needle tract seeding. The 5-year cumulative needle tract seeding rate estimated using Fine and Gray's method was 3.8% (95% CI 1.6-7.8%). The median RFS or OS was not significantly different between the EUS-FNA group and the non-EUS-FNA group (23.7 vs 16.9 months: P = 0.205; 48.0 vs 43.9 months: P = 0.392). CONCLUSION Although preoperative EUS-FNA for pancreatic body and tail cancer has no negative effect on RFS or OS, needle tract seeding after EUS-FNA was observed to have a non-negligible rate. (UMIN000030719).
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Affiliation(s)
- Kei Yane
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
| | - Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Hokkaido, Japan
| | - Makoto Yoshida
- Department of Medical Oncology, Sapporo Medical University, Hokkaido, Japan
| | - Takuma Goto
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Ryusuke Matsumoto
- Department of Gastroenterology, Obihiro Kosei Hospital, Hokkaido, Japan
| | - Hideyuki Ihara
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
| | - Toshinori Okuda
- Department of Gastroenterology, Oji General Hospital, Hokkaido, Japan
| | - Yoko Taya
- Department of Gastroenterology, National Hospital Organization Hokkaido Medical Center, Hokkaido, Japan
| | - Nobuyuki Ehira
- Department of Gastroenterology, Japanese Red Cross Kitami Hospital, Hokkaido, Japan
| | - Taiki Kudo
- Department of Gastroenterology, Hakodate Municipal Hospital, Hokkaido, Japan
| | - Takeya Adachi
- Department of Gastroenterology, Otaru City General Hospital, Hokkaido, Japan
| | - Kazunori Eto
- Department of Gastroenterology, Tomakomai City Hospital, Hokkaido, Japan
| | - Manabu Onodera
- Department of Gastroenterology, NTT Medical Center Sapporo, Hokkaido, Japan
| | - Itsuki Sano
- Department of Gastroenterology, Kushiro Rosai Hospital, Hokkaido, Japan
| | - Masanori Nojima
- Center for Translational Research, Institute of Medical Science Hospital, University of Tokyo, Tokyo, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Hokkaido, Japan
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Kamarajah SK, Bundred JR, Boyle C, Oo J, Pandanaboyana S, Loveday B. Impact of neoadjuvant therapy on post-operative pancreatic fistula: a systematic review and meta-analysis. ANZ J Surg 2020; 90:2201-2210. [PMID: 32418344 DOI: 10.1111/ans.15885] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing, although its impact on post-operative pancreatic fistula (POPF) is variably reported. This systematic review and meta-analysis aimed to assess the impact of NAT on POPF. METHODS A systematic literature search until October 2019 identified studies reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy) versus upfront resection. The primary outcome was overall POPF. Secondary outcomes included grade B/C POPF, delayed gastric emptying (DGE), post-operative pancreatic haemorrhage (PPH) and overall and major complications. RESULTS The search identified 24 studies: pancreatoduodenectomy (PD), 19 studies (n = 19 416) and distal pancreatectomy (DP), five studies (n = 477). Local staging was reported in 17 studies, with borderline resectable and locally advanced disease comprising 6% (0-100%) and 1% (0-33%) of the population, respectively. For PD, any NAT was significantly associated with lower rates of overall POPF (OR: 0.57, P < 0.001) and grade B/C POPF (OR: 0.55, P < 0.001). In DP, NAT was not associated with significantly lower rates of overall or grade B/C POPF. CONCLUSION NAT is associated with significantly lower rates of POPF after PD but not after DP. Further studies are required to determine whether NAT should be added to POPF risk calculators.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, Newcastle, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Charles Boyle
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - June Oo
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Benjamin Loveday
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand
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O'Neill L, Guinan E, Doyle S, Connolly D, O'Sullivan J, Bennett A, Sheill G, Segurado R, Knapp P, Fairman C, Normand C, Geoghegan J, Conlon K, Reynolds JV, Hussey J. Rehabilitation strategies following oesophagogastric and Hepatopancreaticobiliary cancer (ReStOre II): a protocol for a randomized controlled trial. BMC Cancer 2020; 20:415. [PMID: 32404096 PMCID: PMC7222585 DOI: 10.1186/s12885-020-06889-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Curative treatment for upper gastrointestinal (UGI) and hepatopancreaticobiliary (HPB) cancers, involves complex surgical resection often in combination with neoadjuvant/adjuvant chemo/chemoradiotherapy. With advancing survival rates, there is an emergent cohort of UGI and HPB cancer survivors with physical and nutritional deficits, resultant from both the cancer and its treatments. Therefore, rehabilitation to counteract these impairments is required to maximise health related quality of life (HRQOL) in survivorship. The initial feasibility of a multidisciplinary rehabilitation programme for UGI survivors was established in the Rehabilitation Strategies following Oesophago-gastric Cancer (ReStOre) feasibility study and pilot randomised controlled trial (RCT). ReStOre II will now further investigate the efficacy of that programme as it applies to a wider cohort of UGI and HPB cancer survivors, namely survivors of cancer of the oesophagus, stomach, pancreas, and liver. METHODS The ReStOre II RCT will compare a 12-week multidisciplinary rehabilitation programme of supervised and self-managed exercise, dietary counselling, and education to standard survivorship care in a cohort of UGI and HPB cancer survivors who are > 3-months post-oesophagectomy/ gastrectomy/ pancreaticoduodenectomy, or major liver resection. One hundred twenty participants (60 per study arm) will be recruited to establish a mean increase in the primary outcome (cardiorespiratory fitness) of 3.5 ml/min/kg with 90% power, 5% significance allowing for 20% drop out. Study outcomes of physical function, body composition, nutritional status, HRQOL, and fatigue will be measured at baseline (T0), post-intervention (T1), and 3-months follow-up (T2). At 1-year follow-up (T3), HRQOL alone will be measured. The impact of ReStOre II on well-being will be examined qualitatively with focus groups/interviews (T1, T2). Bio-samples will be collected from T0-T2 to establish a national UGI and HPB cancer survivorship biobank. The cost effectiveness of ReStOre II will also be analysed. DISCUSSION This RCT will investigate the efficacy of a 12-week multidisciplinary rehabilitation programme for survivors of UGI and HPB cancer compared to standard survivorship care. If effective, ReStOre II will provide an exemplar model of rehabilitation for UGI and HPB cancer survivors. TRIAL REGISTRATION The study is registered with ClinicalTrials.gov, registration number: NCT03958019, date registered: 21/05/2019.
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Affiliation(s)
- Linda O'Neill
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland.
| | - Emer Guinan
- School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Suzanne Doyle
- School of Biological and Health Sciences, Technological University Dublin, Dublin, Ireland
| | - Deirdre Connolly
- Discipline of Occupational Therapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Jacintha O'Sullivan
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College, the University of Dublin and St. James's Hospital, Dublin, Ireland
| | - Annemarie Bennett
- Department of Clinical Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Grainne Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
| | - Ricardo Segurado
- Centre for Support and Training in Analysis and Research, and School of Public Health, Physiotherapy and Sports Sciences, University College Dublin, Dublin, Ireland
| | - Peter Knapp
- Department of Health Sciences and the Hull York Medical School, University of York, York, UK
| | - Ciaran Fairman
- Exercise Medicine Research Institute, School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College, the University of Dublin, Dublin, Ireland
| | - Justin Geoghegan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - Kevin Conlon
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- Department of Surgery, Trinity College, the University of Dublin, Dublin, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College, the University of Dublin and St. James's Hospital, Dublin, Ireland
| | - Juliette Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College, the University of Dublin, Dublin, Ireland
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Clinical Utility of Histological and Radiological Evaluations of Tumor Necrosis for Predicting Prognosis in Pancreatic Cancer. Pancreas 2020; 49:634-641. [PMID: 32433400 DOI: 10.1097/mpa.0000000000001539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Tumor necrosis is often found in pancreatic ductal adenocarcinoma (PDAC). Objective histological assessment and adequate radiological detection of necrosis could be used as biomarkers for therapeutic decision. However, standardized clinical utility of necrosis remains unknown. Here, we aimed to determine the prognostic potential of histological and radiological evaluations of necrosis. METHODS We investigated histological necrosis in 221 patients, who underwent surgery for PDAC, and classified its size as small (≤5 mm) or large (>5 mm). We also evaluated poorly enhanced areas on preoperative computed tomography to assess their ability for predicting histological necrosis and postoperative prognosis. RESULTS Tumor necrosis was found in 115 patients (52%) and was related to tumor area, lymph node metastasis, and lymphovascular invasion. Size of necrosis was significantly associated with tumor area, perimeter of necrosis, circularity of necrosis, number of ruptured cancer glands, and presence of collagen bundle (P < 0.05 for all). Both presence of necrosis and their size were strongly correlated to postoperative prognosis. Patients with poorly enhanced areas showed worse prognosis (P < 0.01). CONCLUSIONS Our findings underline the capacity of histological and radiological assessment of tumor necrosis for prognosis prediction in PDAC.
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Giuliani T, López Rubio M, Montalvá Oron E, Maupoey Ibañez J, Boscá Robledo A, López Valdivia C, Pérez Rojas J, Lopez Andujar R. Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging? Ann Hepatobiliary Pancreat Surg 2020; 24:90-96. [PMID: 32181436 PMCID: PMC7061049 DOI: 10.14701/ahbps.2020.24.1.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/18/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.
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Affiliation(s)
- Tommaso Giuliani
- Department of General and Pancreatic Surgery, University of Verona, The Pancreas Institute, Verona Hospital Trust, Verona, Italy
| | - Maria López Rubio
- Department of HPB Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Eva Montalvá Oron
- Department of HPB Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Javier Maupoey Ibañez
- Department of HPB Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Andrea Boscá Robledo
- Department of HPB Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | | | | | - Rafael Lopez Andujar
- Department of HPB Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
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36
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Thompson SM, Fleming CJ, Yohanathan L, Truty MJ, Kendrick ML, Andrews JC. Portomesenteric Venous Complications after Pancreatic Surgery with Venous Reconstruction: Imaging and Intervention. Radiographics 2020; 40:531-544. [PMID: 31977263 DOI: 10.1148/rg.2020190100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pancreatic surgery with en bloc venous resection and reconstruction is becoming increasingly common in the current era of expanding neoadjuvant oncologic therapies and advanced surgical techniques for patients with more anatomically complex tumors. However, patients who have alterations in their venous outflow are at increased risk for postoperative portomesenteric venous stenosis and/or thrombosis. Cross-sectional imaging for postoperative surveillance, including multiphase CT or MRI, is critical for recognizing portomesenteric venous complications and thus implementing early intervention and preventing complications related to portomesenteric venous hypertension. Hypertension-related complications include ascites, variceal or gastrointestinal bleeding, postprandial abdominal pain, intestinal edema, protein-losing enteropathy, malabsorptive diarrhea, and splenomegaly. Percutaneous transhepatic, transsplenic, and transjugular portomesenteric interventions, including venoplasty, stent placement, and thrombectomy or thrombolysis, are safe and effective options for restoring patency to the portomesenteric venous system. Preintervention CT or MRI and diagnostic catheter venography are important for procedural planning, while postintervention CT or MRI surveillance is critical for detecting recurrent stenosis or thrombosis, or de novo portomesenteric venous disease. Online supplemental material is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Scott M Thompson
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Chad J Fleming
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Lavanya Yohanathan
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Mark J Truty
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - Michael L Kendrick
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
| | - James C Andrews
- From the Department of Radiology, Division of Vascular and Interventional Radiology (S.M.T., C.J.F., J.C.A.), and Department of Surgery, Division of Hepatobiliary and Pancreas Surgery (L.Y., M.J.T., M.L.K.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905
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Pan L, Fang J, Tong C, Chen M, Zhang B, Juengpanich S, Wang Y, Cai X. Survival benefits of neoadjuvant chemo(radio)therapy versus surgery first in patients with resectable or borderline resectable pancreatic cancer: a systematic review and meta-analysis. World J Surg Oncol 2019; 18:1. [PMID: 31892339 PMCID: PMC6937851 DOI: 10.1186/s12957-019-1767-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/02/2019] [Indexed: 12/28/2022] Open
Abstract
Background Pancreatic adenocarcinoma is a highly lethal malignancy. Neoadjuvant chemo(radio)therapy [NAC(R)T] is recommended to use for borderline resectable pancreatic cancer (BRPC) and high-risk resectable pancreatic cancer (RPC), but no high-level evidence exists. Methods We searched PubMed, EMBASE, Web of Science, and Cochrane library to identify trials comparing survival data of NAC(R)T with SF for RPC or BRPC. Overall survival (OS) was synthesized in analysis of all the patients (intention-to-treat [ITT] analysis) and resected patients respectively. Results The meta-analysis included 17 trials with 2286 participants. For BRPC, NAC(R)T improved OS both in ITT analysis (HR, 0.49; 95% CI, 0.37–0.65; P < 0.001) and in analysis of resected patients (HR, 0.66; 95% CI, 0.51–0.85; P = 0.001) in comparison to SF, accompanied with comparable overall resection rate [odds ratio (OR), 0.69; 95% Cl, 0.41–1.16; P = 0.159]. Disease-free survival, R0 rate, and recurrence were also in favor of NAC(R)T. For RPC, OS in analysis of resected patients was higher with NAC(R)T (HR, 0.75; 95% CI, 0.63–0.89; P = 0.001), but OS in ITT analysis was similar (HR, 1.02; 95% CI, 0.85–1.22; P = 0.818). The overall resection rate (OR, 0.50; 95% Cl, 0.25–0.99; P = 0.048) was lower, but R0 rate was higher with NAC(R)T. No differences in disease-free survival and recurrence between NAC(R)T and SF. Survival benefits of NAC(R)T basically persisted across sensitivity and subgroup analyses. Conclusions This meta-analysis demonstrates that NAC(R)T can provide survival benefits in BRPC patients and a subgroup of RPC patients compared with SF. Future research should focus on investigating the potential biomarkers to screen the subgroup of RPC patients who can benefit from neoadjuvant therapy. Trial registration CRD42018103086.
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Affiliation(s)
- Long Pan
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Jing Fang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China
| | - Chenhao Tong
- Department of General Surgery, Shaoxing People's Hospital, Zhejiang University School of Medicine, Shaoxing, 312000, China
| | - Mingyu Chen
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Bin Zhang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China.,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China
| | - Sarun Juengpanich
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Yifan Wang
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China. .,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China. .,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China.
| | - Xiujun Cai
- Key Laboratory of Laparoscopic Technique Research of Zhejiang Province, Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China. .,Zhejiang Province Medical Research Center of Minimally Invasive Diagnosis and Treatment of Abdominal Diseases, Hangzhou, 310016, China. .,Institute of Minimally Invasive Surgery of Zhejiang University, Hangzhou, 310016, China.
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38
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Sugimoto M, Takahashi N, Farnell MB, Smyrk TC, Truty MJ, Nagorney DM, Smoot RL, Chari ST, Carter RE, Kendrick ML. Survival benefit of neoadjuvant therapy in patients with non-metastatic pancreatic ductal adenocarcinoma: A propensity matching and intention-to-treat analysis. J Surg Oncol 2019; 120:976-984. [PMID: 31452208 DOI: 10.1002/jso.25681] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Conclusive evidence in favor of neoadjuvant therapy for those with non-metastatic pancreatic ductal adenocarcinoma (PDAC) is still lacking. The objective of this study was to evaluate the survival benefit of neoadjuvant therapy vs upfront surgery for patients with non-metastatic PDAC. METHODS The study involved 565 patients undergoing neoadjuvant therapy or upfront surgery as the primary treatment for PDAC. Propensity score matching was performed between the neoadjuvant therapy group (NAT group) and the upfront surgery group (UFS group) using 20 clinical variables at diagnosis. Overall survival and surgical pathology were compared between the two treatment groups on an intent-to-treat basis. RESULTS In the matched cohort, the NAT group (n = 91) had a longer median overall survival than the UFS group (n = 91) (23.1 months vs 18.5 months, P = .043). The rate of patients undergoing surgical resection was lower in the NAT group (58% vs 80%, P = .001). Regarding surgical pathology, the NAT group had smaller tumor size (2.8 cm vs 4.0 cm, P = .001), lower incidence of positive surgical margins (8% vs 30%, P < .002), and less lymph node metastasis (45% vs 78%, P < .001). CONCLUSIONS The strategy of neoadjuvant therapy before surgical resection appears to offer pathologic effect and survival benefit for the patients presenting with non-metastatic PDAC.
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Affiliation(s)
- Motokazu Sugimoto
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | | | - Michael B Farnell
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Smyrk
- Division of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rickey E Carter
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
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Al Faraï A, Garnier J, Ewald J, Marchese U, Gilabert M, Moureau-Zabotto L, Poizat F, Giovannini M, Delpero JR, Turrini O. International Study Group of Pancreatic Surgery type 3 and 4 venous resections in patients with pancreatic adenocarcinoma:the Paoli-Calmettes Institute experience. Eur J Surg Oncol 2019; 45:1912-1918. [DOI: 10.1016/j.ejso.2019.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/07/2019] [Accepted: 06/01/2019] [Indexed: 12/23/2022] Open
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Tsiotos GG, Ballian N, Michelakos T, Milas F, Ziogou P, Papaioannou D, Salla C, Athanasiadis I, Razis E, Stavridi F, Psomas M. Portal-Mesenteric Vein Resection in Borderline Pancreatic Cancer; 33 Month-Survival in Patients with Good Performance Status. J Pancreat Cancer 2019; 5:43-50. [PMID: 31559380 PMCID: PMC6761582 DOI: 10.1089/pancan.2019.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Patients with pancreatic cancer (PC), which is not upfront resectable, but borderline, involving major peripancreatic vessels, have not been generally considered for surgery, considering that resection in such a setting may be futile. Materials and Methods: Retrospective analysis of prospectively collected data on patients with borderline pancreatic adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2012 and February 2017. Follow-up was complete up to January 2018. Results: Twenty-four patients were included. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs. 17%, p = 0.035). It was associated with smaller tumor size (median: 2.5 vs. 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs. 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs. 40%, p = 0.01), but not with survival. Resection was extensive: a median of 26 LNs were retrieved, R0 resection rate (≥1 mm) was 79%, and median length of vein segments was 4 cm, requiring interposition grafts in 58% (mostly polytetrafluoroethylene). Median intensive care unit stay was 0 days and length of hospital stay was 9 days. Post-operative mortality was 12.5%. Median overall survival was 24 months. Eastern Cooperative Oncology Group (ECOG) status was significantly associated with survival (p < 0.001) with ECOG-0: 33 months, ECOG-1: 12 months, and ECOG-2: 6 months. Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered.
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Affiliation(s)
| | | | | | - Fotios Milas
- Department of Surgery, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Panoraia Ziogou
- Department of Surgery, Mitera-Hygeia Hospitals, Marousi, Greece
| | | | - Charitini Salla
- Department of Cytology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Ilias Athanasiadis
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Evangelia Razis
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Flora Stavridi
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Maria Psomas
- Department of Anesthesiology, Mitera-Hygeia Hospitals, Marousi, Greece
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Brunner M, Wu Z, Krautz C, Pilarsky C, Grützmann R, Weber GF. Current Clinical Strategies of Pancreatic Cancer Treatment and Open Molecular Questions. Int J Mol Sci 2019; 20:E4543. [PMID: 31540286 PMCID: PMC6770743 DOI: 10.3390/ijms20184543] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer is one of the most lethal malignancies and is associated with a poor prognosis. Surgery is considered the only potential curative treatment for pancreatic cancer, followed by adjuvant chemotherapy, but surgery is reserved for the minority of patients with non-metastatic resectable tumors. In the future, neoadjuvant treatment strategies based on molecular testing of tumor biopsies may increase the amount of patients becoming eligible for surgery. In the context of non-metastatic disease, patients with resectable or borderline resectable pancreatic carcinoma might benefit from neoadjuvant chemo- or chemoradiotherapy followed by surgeryPatients with locally advanced or (oligo-/poly-)metastatic tumors presenting significant response to (neoadjuvant) chemotherapy should undergo surgery if R0 resection seems to be achievable. New immunotherapeutic strategies to induce potent immune response to the tumors and investigation in molecular mechanisms driving tumorigenesis of pancreatic cancer may provide novel therapeutic opportunities in patients with pancreatic carcinoma and help patient selection for optimal treatment.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Zhiyuan Wu
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Christian Pilarsky
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
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Rangarajan K, Pucher PH, Armstrong T, Bateman A, Hamady ZZR. Systemic neoadjuvant chemotherapy in modern pancreatic cancer treatment: a systematic review and meta-analysis. Ann R Coll Surg Engl 2019; 101:453-462. [PMID: 31304767 PMCID: PMC6667953 DOI: 10.1308/rcsann.2019.0060] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma remains a disease with a poor prognosis despite advances in surgery and systemic therapies. Neoadjuvant therapy strategies are a promising alternative to adjuvant chemotherapy. However, their role remains controversial. This meta-analysis aims to clarify the benefits of neoadjuvant therapy in resectable pancreatic ductal adenocarcinoma. METHODS Eligible studies were identified from MEDLINE, Embase, Web of Science and the Cochrane Library. Studies comparing neoadjuvant therapy with a surgery first approach (with or without adjuvant therapy) in resectable pancreatic ductal adenocarcinoma were included. The primary outcome assessed was overall survival. A random-effects meta-analysis was performed, together with pooling of unadjusted Kaplan-Meier curve data. RESULTS A total of 533 studies were identified that analysed the effect of neoadjuvant therapy in pancreatic ductal adenocarcinoma. Twenty-seven studies were included in the final data synthesis. Meta-analysis suggested beneficial effects of neoadjuvant therapy with prolonged survival compared with a surgery-first approach, (hazard ratio 0.72, 95% confidence interval 0.69-0.76). In addition, R0 resection rates were significantly higher in patients receiving neoadjuvant therapy (relative risk 0.51, 95% confidence interval 0.47-0.55). Individual patient data analysis suggested that overall survival was better for patients receiving neoadjuvant therapy (P = 0.008). CONCLUSIONS Current evidence suggests that neoadjuvant chemotherapy has a beneficial effect on overall survival in resectable pancreatic ductal adenocarcinoma in comparison with upfront surgery and adjuvant therapy. Further trials are needed to address the need for practice change.
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Affiliation(s)
- K Rangarajan
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - PH Pucher
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, St Mary’s Hospital, Imperial College London, Southampton, UK
| | - T Armstrong
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A Bateman
- Department of Clinical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - ZZR Hamady
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Vidri RJ, Vogt AO, Macgillivray DC, Bristol IJ, Fitzgerald TL. Better Defining the Role of Total Neoadjuvant Radiation: Changing Paradigms in Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2019; 26:3701-3708. [DOI: 10.1245/s10434-019-07584-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Indexed: 02/06/2023]
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45
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Loveday BPT, Zilbert N, Serrano PE, Tomiyama K, Tremblay A, Fox AM, Segedi M, O'Malley M, Borgida A, Bianco T, Creighton S, Dodd A, Fraser A, Moore M, Kim J, Cleary S, Moulton CA, Greig P, Wei AC, Gallinger S, Dhani N, McGilvray ID. Neoadjuvant therapy and major arterial resection for potentially reconstructable arterial involvement by stage 3 adenocarcinoma of the pancreas. HPB (Oxford) 2019; 21:643-652. [PMID: 30471960 DOI: 10.1016/j.hpb.2018.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Stage 3 pancreatic ductal adenocarcinoma (PDAC) is defined by arterial involvement. This study objective was to evaluate outcomes for patients with stage 3 PDAC with potentially reconstructable arterial involvement, considered for neoadjuvant therapy (NAT) and pancreatic resection, and to compare outcomes following arterial (AR) and non-arterial resection (NAR). METHODS This study included patients from 2009 to 2016 with biopsy-proven stage 3 PDAC who were offered NAT before surgical exploration. AR was performed if required to achieve R0 resection. Time to event outcomes were analysed from diagnosis date. RESULTS 87/89 patients (97.8%) received NAT (chemotherapy 41.6%, chemotherapy/radiotherapy 56.2%). 46/89 (51.7%) underwent exploration; 31 underwent resection (AR n = 20, NAR n = 11). AR patients had longer operative time (681 vs. 563 min, p = 0.006) and more blood loss (1600 vs. 575 mL, p = 0.0004), with no difference for blood transfusion, pancreatic fistula, length of stay, reoperation, or mortality. R0 rate was 30/31. Post-resection 90-day mortality was 3.2%. Median overall survival was statistically comparable between the AR and NAR groups (19.7 vs. 28.4 months, p = 0.41). CONCLUSIONS AR had comparable clinical and oncologic outcomes to NAR. Following careful selection and non-progression after NAT, major AR may cautiously be considered if required to obtain a negative resection margin.
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Affiliation(s)
- Benjamin P T Loveday
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Nathan Zilbert
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Canada
| | - Koji Tomiyama
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Amélie Tremblay
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Adrian M Fox
- St-Vincent Hospital, University of Melbourne, Melbourne, Australia
| | - Maja Segedi
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Martin O'Malley
- Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Ayelet Borgida
- Ontario Pancreas Cancer Study, Mount Sinai Hospital, Toronto, Canada
| | - Teresa Bianco
- Ontario Pancreas Cancer Study, Mount Sinai Hospital, Toronto, Canada
| | - Sean Creighton
- McCain Center for Pancreas Cancer, Princess Margaret Cancer Centre, Toronto, Canada
| | - Anna Dodd
- McCain Center for Pancreas Cancer, Princess Margaret Cancer Centre, Toronto, Canada
| | - Adriana Fraser
- McCain Center for Pancreas Cancer, Princess Margaret Cancer Centre, Toronto, Canada
| | - Malcolm Moore
- University of Toronto, Toronto, Canada; BC Cancer Agency, Vancouver, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Sean Cleary
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada; Department of Surgery, Mayo Clinic, Rochester MN, USA
| | - Carol-Anne Moulton
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Paul Greig
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Alice C Wei
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Steven Gallinger
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Neesha Dhani
- University of Toronto, Toronto, Canada; Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Ian D McGilvray
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada.
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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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Long-term outcome following neoadjuvant therapy for resectable and borderline resectable pancreatic cancer compared to upfront surgery: a meta-analysis of comparative studies by intention-to-treat analysis. Surg Today 2019; 49:295-299. [PMID: 30877550 DOI: 10.1007/s00595-019-01786-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
The aim of the study was to evaluate the effect of neoadjuvant therapy on long-term survival in patients with resectable and borderline resectable pancreatic cancer. A meta-analysis was conducted using the reported randomized, controlled trials and retrospective studies using an intention-to-treat analysis to compare upfront surgery and neoadjuvant therapy in resectable or borderline resectable pancreatic cancer patients. Six comparative studies consisting of two randomized, controlled trials and four retrospective studies were included. The overall pooled hazard ratio was 0.66 (95% confidence interval: 0.50-0.87, P = 0.003), indicating that patients in the neoadjuvant group had better long-term survival than those in the upfront surgery group. However, considerable inter-study heterogeneity was observed (I2 = 62%). This meta-analysis focusing on comparative studies analyzed by intention-to-treat analysis showed that neoadjuvant therapy for resectable and borderline resectable pancreatic cancer tends to improve patients' long-term outcomes. However, the evidence level remains too low for a firm conclusion. The well-designed, randomized, controlled trials now ongoing will provide the definite evidence needed in the future.
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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: 9] [Impact Index Per Article: 1.8] [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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49
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Gulhati P, Prakash L, Katz MHG, Wang X, Javle M, Shroff R, Fogelman D, Lee JE, Tzeng CWD, Lee JH, Weston B, Tamm E, Bhosale P, Koay EJ, Maitra A, Wang H, Wolff RA, Varadhachary GR. First-Line Gemcitabine and Nab-Paclitaxel Chemotherapy for Localized Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2019; 26:619-627. [PMID: 30324485 DOI: 10.1245/s10434-018-6807-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preoperative chemotherapy provides early treatment of micro-metastases and guaranteed delivery of all components of multimodality therapy for localized pancreatic ductal adenocarcinoma (PDAC). For locally advanced (LA) PDAC, induction chemotherapy is the standard of care. This study evaluated the use of gemcitabine and nab-paclitaxel (Gem/nab-P) as first-line therapy for localized PDAC. METHODS Clinicopathologic features, treatment, and outcomes were evaluated for 99 patients with localized PDAC. The patients were staged using previously published criteria as follows: potentially resectable (PR), borderline type A (BR-A) (anatomy amenable to vascular resection), BR-B (biology suspicious for metastatic disease including high CA19-9), BR-C (comorbidities requiring medical optimization), and LA. RESULTS The 99 patients (PR/BR/LA: 45/14/40) were treated with Gem/nab-P. Clinical staging showed that 20 patients had PR or BR-A disease, whereas 39 patients had BR-B or BR-C disease. The BR-B+C cases included one or more of the following: age of 80 years or older (13%), Eastern Cooperative Oncology Group performance status (ECOG PS) of 2 or more (13%), moderate to severe comorbidities (55%), CA19-9 of 1000 or higher (28%), and suspicion for metastases (21%). The majority of the patients received biweekly Gem/nab-P dosing, which was well tolerated. Pancreatectomy was performed for 12 (60%) of 20 patients with PR+BR-A, 2 (5%) of 39 patients with BR-B+C, and 1 (3%) of 40 patients with LA disease. During a median follow-up period of 26 months, the median overall survival (OS) period was 18 months (95% confidence interval [CI], 15.6-20.5 months) for all the patients, 17 months (95% CI, 14.6-19.5 months) for the unresected patients, and not reached for the resected patients (p = 0.028 for resected vs unresected patients). CONCLUSIONS A significant number of patients with radiographically resectable PDAC albeit aggressive biology (BR-B), medically inoperable conditions (BR-C), or both received biweekly first-line Gem/nab-P. The resection rates were lower for the BR-B/BR-C patients than for the PR/BR-A patients (hazard ratio [HR], 0.43; 95% CI, 0.19-1.00; p = 0.05).
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Affiliation(s)
- Pat Gulhati
- Hematology/Oncology Fellowship Program, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura Prakash
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 426, Houston, TX, 77030, USA
| | - Rachna Shroff
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 426, Houston, TX, 77030, USA
| | - David Fogelman
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 426, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Division of Internal Medicine, Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian Weston
- Division of Internal Medicine, Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric Tamm
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priya Bhosale
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anirban Maitra
- Division of Pathology/Lab Medicine, Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huamin Wang
- Division of Pathology/Lab Medicine, Department of Anatomic Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 426, Houston, TX, 77030, USA
| | - Gauri R Varadhachary
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 426, Houston, TX, 77030, USA.
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Abstract
OBJECTIVES Epithelial-mesenchymal transition (EMT) plays an important role in the progression, metastasis, and chemoresistance of pancreatic duct adenocarcinoma (PDAC); however, the expression of EMT markers and their clinical significance in PDAC patients who received neoadjuvant therapy (NAT) are unclear. METHODS We examined the expression of EMT markers, including Zeb-1 (zinc finger E-box-binding homeobox 1), E-cadherin, and vimentin by immunohistochemistry in 120 PDAC patients who received NAT and pancreatectomy from 1999 to 2007. The results were correlated with clinicopathologic parameters and survival. RESULTS Among 120 cases, 45 (37.5%) and 14 (11.7%) were positive for Zeb-1 and vimentin, respectively, and 25 (20.8%) were E-cadherin-low. The median overall survival and disease-free survival were 35.3 (standard deviation [SD], 2.8) and 15.9 (SD, 3.6) months, respectively, in vimentin-negative group compared with 16.1 (SD, 1.1) (P = 0.03) and 7.0 (SD, 1.1) months (P = 0.02) in the vimentin-positive group. In multivariate analysis, vimentin expression was an independent predictor of shorter disease-free survival (hazard ratio, 2.50; 95% confidence interval, 1.31-4.78; P = 0.016) and overall survival (hazard ratio, 2.55; 95% confidence interval, 1.33-4.89; P = 0.01). CONCLUSIONS Epithelial-mesenchymal transition markers are frequently expressed in treated PDAC. Vimentin expression is a prognostic biomarker for survival in PDAC patients who received NAT.
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