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Ward EP, Vincent-Sheldon S, Tolat P, Kulkarni N, Aldakkak M, Budithi R, Clarke CN, Tsai S, Evans DB, Christians KK. Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy. Surgery 2024; 175:1386-1393. [PMID: 38413302 DOI: 10.1016/j.surg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut. METHODS All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]). RESULTS Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction. CONCLUSION Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.
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Affiliation(s)
- Erin P Ward
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT.
| | | | | | | | | | | | | | - Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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2
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Turner KM, Wilson GC, Patel SH, Ahmad SA. ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer. Ann Surg Oncol 2024; 31:1884-1897. [PMID: 37980709 DOI: 10.1245/s10434-023-14585-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/29/2023] [Indexed: 11/21/2023]
Abstract
Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well-selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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3
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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4
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Nicolais LM, Mohamed A, Macgillivray D, Verdini N, Inhorn R, Dugan M, Hayward CM, Fitzgerald TL. Improved Overall Survival of Patients with Pancreatic Cancer through Multiagent Chemotherapy and Increased Rates of Surgical Resection. Am Surg 2023; 89:5964-5971. [PMID: 37295019 DOI: 10.1177/00031348221148350] [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: 06/11/2023]
Abstract
BACKGROUND Seminal trials have demonstrated improved survival in pancreatic adenocarcinoma with novel multiagent chemotherapy regimens. To understand the clinical ramifications of this paradigm shift, we reviewed our institutional experience. METHODS This retrospective cohort study utilized a prospective database at a single institution to study all patients diagnosed with and treated for pancreatic adenocarcinoma between 2000 and 2020. RESULTS 1,572 patients were included of which 36% were diagnosed before (Era 1) and 64% after (Era 2) 2011. Survival improved in Era 2 (Median survival 10 vs 8 months, HR .79; P < .001). The survival advantage for Era 2 was primarily seen in patients with high-risk disease (12 vs10 months, HR .71; P < .001). A similar trend was noted for patients undergoing surgical resection (26 vs 21 months, HR .80; P = .081) and with imminently resectable tumors (19 vs 15 months, HR .88; P = .4); however, this was not statistically significant. There was no survival advantage for patients with stage IV disease (4 vs 4 months). Patients in Era 2 were more likely to undergo surgery (OR 2.78; CI 2.00-3.92, P < .001). This increase was driven primarily by increased surgical resection for those with high-risk disease (42 vs 20%, OR 3.74; P < .001). DISCUSSION/CONCLUSIONS This single institutional study showed improved survival after the shift to novel chemotherapy regimens. This was driven by improved survival for patients with high-risk disease and may be due to more effective eradication of microscopic metastatic disease with adjuvant chemotherapy and increased resection rates.
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Affiliation(s)
- Laura M Nicolais
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
- Graduate School of Biomedical Sciences, Tufts University Clinical and Translational Science Graduate Program, Boston, MA, USA
| | | | - Dougald Macgillivray
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
| | - Nicholas Verdini
- Tufts University School of Medicine, Washington St, Boston, MA, USA
- Boston Medical Center, Boston, MA, USA
| | - Roger Inhorn
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
| | - Matthew Dugan
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
| | - Cynthia M Hayward
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine Maine Medical Center, Portland, ME, USA
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Ahuja M, Pandé R, Chugtai S, Brown RM, Cain O, Bartlett DC, Dasari BVM, Marudanayagam R, Roberts KJ, Isaac J, Sutcliffe RP, Chatzizacharias N. Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma. Diagnostics (Basel) 2023; 13:3465. [PMID: 37998601 PMCID: PMC10670022 DOI: 10.3390/diagnostics13223465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Pancreaticoduodenectomy (PD) with vein resection is the only potentially curative option for patients with pancreatic ductal adenocarcinoma (PDAC) with venous involvement. The aim of our study was to assess the oncological prognostic significance of the different variables of venous involvement in patients undergoing PD for resectable and borderline-resectable with venous-only involvement (BR-V) PDAC. We performed a retrospective analysis of prospectively acquired data over a 10-year period. Of the 372 patients included, 105 (28%) required vein resection and vein wall involvement was identified in 37% of those. A multivariable analysis failed to identify the vein-related resection margins as independent predictors for OS, DFS or LR. Vein wall tumour involvement was an independent predictor of OS (risk x1.7-2) and DFS (risk x1.9-2.2) in all models, while it replaced overall surgical margin positivity as the only parameter independently predicting LR during an analysis of separate resection margins (risk x2.4). Vein wall tumour invasion may be a more reliable predictor of oncological outcomes compared to traditionally reported parameters. Future studies should focus on possible pre-operative investigations that could identify these cases and management pathways that could yield a survival benefit, such as the use of neoadjuvant treatments.
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Affiliation(s)
- Manish Ahuja
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rupaly Pandé
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Shafiq Chugtai
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rachel M. Brown
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - Owen Cain
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - David C. Bartlett
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Bobby V. M. Dasari
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Keith J. Roberts
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2SQ, UK
| | - John Isaac
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Robert P. Sutcliffe
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Nikolaos Chatzizacharias
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
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6
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Nicolais L, Brown AW, Mohamed A, Clark DE, Fitzgerald TL. Preoperative downstaging of pancreatic cancer is associated with improved survival after multi-agent chemotherapy, but not after radiation. Surg Oncol 2023; 48:101939. [PMID: 37116276 DOI: 10.1016/j.suronc.2023.101939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/06/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Downstaging has been associated with improved survival for many cancers. However, the implications of downstaging are unclear for pancreatic cancer in an era of effective neoadjuvant systemic chemotherapy. METHODS NCDB retrospective cohort study of resected pancreatic carcinoma treated with neoadjuvant therapy. RESULTS The study included 73,985 patients: 66,589 with no neoadjuvant therapy, 2,102 neoadjuvant radiation therapy (N-RT), 3,195 neoadjuvant multiagent chemotherapy (N-MAC) and 2.099 with both neoadjuvant radiation and multiagent chemotherapy. There was increased use of N-MAC over the period of this study. Patients selected for treatment with N-MAC had longer survival from surgery on univariate (23.1 vs. 18.7 months, p = < 0.01) and multivariate analyses HR 0.81 (0.76-0.87, p < 0.001) compared to those selected with N-RT. Downstaging was similar in N-RT and N-MAC groups (25.1 vs. 24.1%, p = 0.43). Downstaging following N-MAC was associated with a survival benefit, HR 0.85 (0.74-0.98). However, downstaging following N-RT was not associated with a survival advantage, HR 1.12 (0.99-0.99). CONCLUSION Clinicians have rapidly adopted N-MAC for treatment of pancreatic cancer. Although the rates of downstaging are similar between treatment groups, response translates into increased survival only with N-MAC and not with N-RT.
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Affiliation(s)
- Laura Nicolais
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA; Tufts University Clinical and Translational Science Graduate Program, Graduate School of Biomedical Sciences, Boston, MA, USA
| | - Austin W Brown
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
| | - Abdimajid Mohamed
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
| | - David E Clark
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, ME, USA.
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7
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Davis JM, Salibi PN, Motz BM, Vrochides D, McKillop IH, Iannitti DA. Irreversible Electroporation-Assisted Resection for Locally Advanced Pancreas Cancer. Surg Innov 2023:15533506231157442. [PMID: 36792137 DOI: 10.1177/15533506231157442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND A significant number of patients with advanced pancreatic cancer are unable to undergo resection due to vascular involvement. Irreversible electroporation (IRE) has shown promise in improving survival. This study sought to assess a novel IRE application whereby IRE was performed pre-resection to alter tissue plasticity and assist tumor removal from underlying vasculature when surgical excision was otherwise precluded. METHODS After multidisciplinary evaluation appropriate patients were consented for IRE therapy. All IRE cases were tracked prospectively using an institutional review board-approved database that was retrospectively queried for patients undergoing IRE-assisted resection (IRE-AR) for pancreatic adenocarcinoma located in the head/uncinate process. Patients who underwent other IRE therapy or had disease location elsewhere were excluded. RESULTS 5 patients met the study inclusion criteria with a mean tumor size of 3.2 cm (range 2.4-4.1 cm). Using IRE-AR median recurrence free survival was 10.6 months, with 21.6 month overall survival. The average comprehensive complication index score was 23.23. One patient had grade 3 [or higher] complications and there were no 90 day mortalities. DISCUSSION Employing a high-starting voltage for ablation along resection margins allows for resection when margins are anticipated to be positive. Patients with locally advanced pancreatic adenocarcinoma who underwent IRE-AR had promising outcomes. CONCLUSION This study reports IRE-AR as a novel approach for resecting locally advanced pancreatic adenocarcinoma. A prospective trial of IRE-AR for inoperable pancreatic adenocarcinoma will provide additional data for the long-term application of this approach.
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Affiliation(s)
- Joshua Mk Davis
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Patrick N Salibi
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Benjamin M Motz
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | | | - Iain H McKillop
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Hepato-Pancreato-Biliary Surgery, 2351Atrium Health, Charlotte, NC, USA
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8
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Thosani N, Cen P, Rowe J, Guha S, Bailey-Lundberg JM, Bhakta D, Patil P, Wray CJ. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for advanced pancreatic and periampullary adenocarcinoma. Sci Rep 2022; 12:16516. [PMID: 36192558 PMCID: PMC9530230 DOI: 10.1038/s41598-022-20316-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/12/2022] [Indexed: 11/15/2022] Open
Abstract
Long term prognosis and 5-year survival for pancreatic adenocarcinoma (PDAC) remains suboptimal. Endoscopic ultrasound (EUS) guided RFA (EUS-RFA) is an emerging technology and limited data exist regarding safety and long-term outcomes. The aim of this study is to report safety-profile, feasibility and outcomes of EUS-RFA for advanced PDAC. Prospective review of patients with diagnosis of locally-advanced or metastatic PDAC undergoing EUS-RFA between October 2016 to March 2018 with long-term follow up (> 30 months). Study patients underwent a total of 1–4 RFA sessions. All patients were enrolled in longitudinal cohort study and received standard of care chemotherapy. 10 patients underwent EUS-RFA. Location of the lesions was in the head(4), neck(2), body(2), and tail(2). 22 RFA sessions were performed with a range of 1–4 sessions per patient. There were no major adverse events (bleeding, perforation, infection, pancreatitis) in immediate (up to 72 h) and short-term follow up (4 weeks). Mild worsening of existing abdominal pain was noted during post-procedure observation in 12/22 (55%) of RFA treatments. Follow-up imaging demonstrated tumor progression in 2 patients, whereas tumor regression was noted in 6 patients (> 50% reduction in size in 3 patients). Median survival for the cohort was 20.5 months (95% CI, 9.93–42.2 months). Currently, 2 patients remain alive at 61 and 81 months follow-up since initial diagnosis. One patient had 3 cm PDAC with encasement of the portal confluence, abutment of the celiac axis, common hepatic and superior mesenteric artery. This patient had significant reduction in tumor size and underwent standard pancreaticoduodenectomy. In our experience, EUS-RFA was safe, well-tolerated and could be concurrently performed with standard chemotherapy. In this select cohort, median survival was improved when compared to published survival based upon SEER database and clinical trials. Future prospective trials are needed to understand the role of EUS-RFA in overall management of PDAC.
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Affiliation(s)
- Nirav Thosani
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Putao Cen
- Department of Medicine, Division of Oncology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julie Rowe
- Department of Medicine, Division of Oncology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sushovan Guha
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Dimpal Bhakta
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Prithvi Patil
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Curtis J Wray
- Department of Surgery, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.164a, Houston, TX, 77030, USA.
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9
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Cadili L, Vasilyeva E, Li J, Kim P, Chung S, Segedi M. Pancreas tail adenocarcinoma tumor size is highly predictive of positive margins after a nonradical resection. Am J Surg 2022; 224:728-732. [PMID: 35643634 DOI: 10.1016/j.amjsurg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radical resection (RAMPS) of left sided pancreatic ductal adenocarcinoma (PDAC) is effective in achieving R0 margins; however, not universally accepted due to lack of improved survival. We hypothesized that only larger tumors lead to R1 in non-RAMPS procedures. METHODS A retrospective review of charts between 2008 and 2020 was performed. The primary outcome was evaluating R0 resection based on left-sided tumors' size and location, and secondary outcomes were OS and DFS. RESULTS Sixty-eight percent had R0 resection. R1 groups' tumors were larger (5.5 cm vs. 3.8 cm, p = 0.004) and had higher LVI involvement (p = 0.003). OS and DFS did not differ on multivariate analysis. Tumor size above 4 cm in the tail was associated with R1 (p = 0.01). CONCLUSIONS Larger tumors in the tail, but not body were associated with R1, but not worse survival. Perhaps larger tumors in the tail are a surrogate marker of poor disease biology.
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Affiliation(s)
- Lina Cadili
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elizaveta Vasilyeva
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Li
- Division of Liver and Pancreas Transplantation, University of California Los Angeles, Los Angeles, CA, USA
| | - Peter Kim
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Chung
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Maja Segedi
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
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10
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Sugumar K, Hurtado A, Naik I, Hue JJ, Rothermel LD, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Multimodal therapy with or without irreversible electroporation for unresectable locally advanced pancreatic adenocarcinoma: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:586-595. [PMID: 35000842 DOI: 10.1016/j.hpb.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) is used as a locoregional treatment modality for patients with locally advanced pancreatic cancer (LAPC), but is non-curative and is associated with postoperative morbidity and mortality. We performed a systematic review and meta-analysis comparing survival outcomes of multimodal therapy with or without IRE. METHODS Separate searches were performed for multimodal therapy + IRE and multimodal therapy alone given the lack of comparative literature using PubMed, SCOPUS, and Cochrane Library in 3/2021. We determined overall survival (OS) and progression-free survival (PFS) from diagnosis and time of IRE. Treatment-related morbidity and mortality was determined. RESULTS Of 585 published articles, 48 met inclusion criteria for IRE (n = 27) and without IRE (n = 21) with data for 1420 (IRE) and 1348 (without IRE) patients. The 6/12/24 months OS with IRE was 99%/84%/28%. The 6/12/24 months OS without IRE was 99%/80%/12%. At 12 months from IRE, OS was 55% and PFS was 12%. The mean major complication and 90-day mortality rates for IRE were 17.95% and 2.65%. CONCLUSION Multimodal therapy alone is associated with similar OS to multimodal therapy + IRE in patients with LAPC. Most patients progress and nearly half die within 1 year of the IRE procedure. Given the lack of quality prospective data, IRE should remain experimental and be used with caution in LAPC.
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Affiliation(s)
- Kavin Sugumar
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Alex Hurtado
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Ilora Naik
- Case Western Reserve University School of Medicine and the Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Jonathan J Hue
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Luke D Rothermel
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - John B Ammori
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Jordan M Winter
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA
| | - Lee M Ocuin
- University Hospitals Seidman Cancer Center and the Department of Surgery, Cleveland, OH, USA.
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11
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McIntyre CA, Cohen NA, Goldman DA, Gonen M, Sadot E, O’Reilly EM, Varghese AM, Yu KH, Balachandran VP, Soares KC, D’Angelica MI, Drebin JA, Kingham TP, Allen PJ, Wei AC, Jarnagin WR. Induction FOLFIRINOX for patients with locally unresectable pancreatic ductal adenocarcinoma. J Surg Oncol 2022; 125:425-436. [PMID: 34719035 PMCID: PMC8933849 DOI: 10.1002/jso.26735] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Patients with locally advanced pancreatic adenocarcinoma (PDAC) receive induction chemotherapy with or without radiation, with the goal of R0 resection and improving survival. Herein, we evaluate the outcomes of patients who presented with Stage III PDAC and received induction FOLFIRINOX. METHODS An institutional database was queried for consecutive patients who received induction FOLFIRINOX for locally unresectable PDAC between 2010 and 2016. Clinical and radiographic parameters were assessed pre- and posttreatment, and clinical outcomes were evaluated. RESULTS There were 200 patients who met the inclusion criteria. The median number of cycles of FOLFIRINOX was 8, 70% (n = 140) received radiation, and 18% (n = 36) underwent resection. Median overall survival (OS) in resected patients was 36 months (95% confidence interval [CI]: 24-56), and this group had improved OS compared to patients that did not undergo resection (hazard ratio (95% CI): 0.41 (0.26-0.64), p < 0.001). Patients (n = 112) who did not progress on induction therapy but remained unresectable had a median OS of 23.9 months (95% CI: 21.1-25.4). CONCLUSION Nearly 20% of patients with locally advanced PDAC responded sufficiently to induction FOLFIRINOX to undergo resection, which was associated with improved OS compared to patients that did not undergo resection. Patients with stable disease who remain unresectable represent a group of patients with locally advanced PDAC who may benefit from optimization of additional nonoperative treatment.
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Affiliation(s)
- Caitlin A. McIntyre
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah A. Cohen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A. Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eran Sadot
- Department of Surgery, Rabin Medical Center, Tel Aviv, Israel
| | - Eileen M. O’Reilly
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna M. Varghese
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H. Yu
- Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vinod P. Balachandran
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kevin C. Soares
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael I. D’Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey A. Drebin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter J. Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice C. Wei
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William R. Jarnagin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY,Corresponding Author, Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Gemenetzis G, Blair AB, Nagai M, Groot VP, Ding D, Javed AA, Burkhart RA, Fishman EK, Hruban RH, Weiss MJ, Cameron JL, Narang A, Laheru D, Lafaro K, Herman JM, Zheng L, Burns WR, Wolfgang CL, He J. Anatomic Criteria Determine Resectability in Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2022; 29:401-414. [PMID: 34448965 PMCID: PMC8688211 DOI: 10.1245/s10434-021-10663-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/01/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. RESULTS Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p < 0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). CONCLUSIONS Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.
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Affiliation(s)
- Georgios Gemenetzis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Royal Infirmary Edinburgh, Edinburgh, Scotland, UK
| | - Alex B Blair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Minako Nagai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Vincent P Groot
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- 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
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, 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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13
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Hammel P, Carrier E, Carney M, Eisner M, Fleming T. A novel event-free survival endpoint in locally advanced pancreatic cancer. Ther Adv Med Oncol 2021; 13:17588359211059586. [PMID: 34868352 PMCID: PMC8640304 DOI: 10.1177/17588359211059586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
The treatment paradigm for locally advanced pancreatic cancer (LAPC) is evolving rapidly. The development of neoadjuvant therapies composed of combination therapies and the evaluation of their impact on conversion to borderline resectable (BR) status, resection, and ultimately overall survival (OS) are presently being pursued. These efforts justify re-visiting study endpoints in order to better predict therapeutic effects on OS, by capturing not only the achievement of R0 resection at the end of induction therapy but also the long-term reductions in the rate of local and distal recurrence. The proposed herein event-free survival (EFS) endpoint, with its novel definition specific to LAPC, is formulated to achieve these objectives. It is an analog to disease-free survival (DFS) endpoint in the adjuvant setting applied to the neoadjuvant setting and may be a valuable surrogate endpoint for this patient population.
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Affiliation(s)
- Pascal Hammel
- Digestive and Medical Oncology Department, Hospital Paul Brousse, University Paris-Saclay, 94800 Villejuif, France
| | - Ewa Carrier
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Mairead Carney
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Mark Eisner
- Department of Clinical Development, FibroGen, Inc., San Francisco, CA, USA
| | - Thomas Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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14
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Li M. Clinical practice guidelines for the interventional treatment of advanced pancreatic cancer (5th edition). J Interv Med 2021; 4:159-171. [PMID: 35586384 PMCID: PMC8947992 DOI: 10.1016/j.jimed.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer has become a major disease affecting people's health because of its insidiousness, rapid progression and poor prognosis. Based on the practical needs of clinical work, combined with domestic multi-center research and experience, this guideline provides constructive suggestions for the interventional treatment of pancreatic cancer.
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Affiliation(s)
- Maoquan Li
- China Alliance of Cellular and Interventional Therapy Techniques for Diabetic Foot, China
- Technical Committee on Interventional Medicine and Bioengineering of Chinese Intervention Physicians Branch, China
- National Centre for Clinical Medical Research on Radiation and Treatment, China
- Department of Interventional and Vascular Surgery, Affiliated Tenth People's Hospital of Tongji University, China
- Interventional Vascular Institute of Tongji University, Shanghai, 200072, China
- China Alliance of Cellular and Interventional Therapy Techniques for Diabetic Foot, China.
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15
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Hall WA, Erickson B, Crane CH. Evolving Concepts Regarding Radiation Therapy for Pancreatic Cancer. Surg Oncol Clin N Am 2021; 30:719-730. [PMID: 34511192 PMCID: PMC8462521 DOI: 10.1016/j.soc.2021.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In todays practice most institutions individualize the use of adjuvant, neoadjuvant, and definitive RT based on their interpretation of the available data. This review highlights novel concepts and approaches to the use of RT that should be considered by the surgical oncologist.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA; Graduate School of Biomedical Sciences, Medical College of Wisconsin; Department of Surgery, Froedtert and the Medical College of Wisconsin.
| | - Beth Erickson
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA; Department of Surgery, Froedtert and the Medical College of Wisconsin
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16
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Christians KK, Evans DB. Pancreaticoduodenectomy and Vascular Reconstruction: Indications and Techniques. Surg Oncol Clin N Am 2021; 30:731-746. [PMID: 34511193 DOI: 10.1016/j.soc.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pancreaticoduodenectomy with vascular resection/reconstruction can be safely completed following 6 standard steps plus basic principles of vascular surgery. Particular attention is paid to the location of the tumor relative to the 2 first-order vein branches, portal vein -splenic vein -superior mesenteric vein confluence, inferior mesenteric vein, and the presence of arterial perineural invasion. Successful resection following neoadjuvant therapy can result in median survival 3 times that of historical controls.
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Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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17
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Ward EP, Evans DB, Tsai S. Ten-year experience in optimizing neoadjuvant therapy for localized pancreatic cancer-Medical college of Wisconsin perspective. J Surg Oncol 2021; 123:1405-1413. [PMID: 33831252 DOI: 10.1002/jso.26395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Treatment of localized pancreatic cancer has also evolved to prioritize preoperative (neoadjuvant) multimodality therapy over a surgery-first approach. Given the complexities of pancreatic cancer staging and the challenge of delivering multiple treatment modalities (chemotherapy, radiation therapy, and surgery), an experienced and highly integrated multidisciplinary team is necessary to achieve the best outcomes. In this review, we will discuss our institutional experience with neoadjuvant therapy, guiding principles for treatment, and outline the landscape for future investigations.
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Affiliation(s)
- Erin P Ward
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Douglas B Evans
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Susan Tsai
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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18
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Huang M, Yi C, Huang XZ, Yan J, Wei LJ, Tang WJ, Chen SC, Huang Y. Recombinant protein TRAIL-Mu3 enhances the antitumor effects in pancreatic cancer cells by strengthening the apoptotic signaling pathway. Oncol Lett 2021; 21:438. [PMID: 33868476 PMCID: PMC8045166 DOI: 10.3892/ol.2021.12699] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/08/2021] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer is a highly malignant type of cancer and its treatment remains a major challenge. The novel recombinant protein TNF-related apoptosis-inducing ligand (TRAIL)-Mu3 has been shown to exert stronger tumor inhibitory effects in colon cancer in vitro and in vivo compared with TRAIL. The present study investigated the antitumor effects of TRAIL-Mu3 on pancreatic cancer cells, and the possible mechanisms were further examined. Compared with TRAIL, TRAIL-Mu3 exhibited significantly higher cytotoxic effects on pancreatic cancer cell lines. The inhibitory effect of TRAIL-Mu3 on the viability of PANC-1 cells was shown to be a caspase-dependent process. The affinity of TRAIL-Mu3 to PANC-1 cell membranes was significantly enhanced compared with TRAIL. In addition, TRAIL-Mu3 upregulated death receptor (DR) expression in PANC-1 cells and promoted the redistribution of DR5 in lipid rafts. Western blotting results demonstrated that TRAIL-Mu3 activated the caspase cascade in a faster and more efficient manner compared with TRAIL in PANC-1 cells. Therefore, TRAIL-Mu3 enhanced the antitumor effects in pancreatic cancer cells by strengthening the apoptotic signaling pathway. The present study indicated the potential of TRAIL-Mu3 for the treatment of pancreatic cancer.
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Affiliation(s)
- Min Huang
- Department of Physiology, Chengdu Medical College, Chengdu, Sichuan 610000, P.R. China
| | - Cheng Yi
- Department of Medical Oncology, West China Hospital, Sichuan University, Chengdu, Sichuan 610000, P.R. China
| | - Xian-Zhou Huang
- Chengdu Huachuang Biotechnology Co., Ltd., Chengdu, Sichuan 610000, P.R. China
| | - Juan Yan
- Chengdu Huachuang Biotechnology Co., Ltd., Chengdu, Sichuan 610000, P.R. China
| | - Li-Jia Wei
- Chengdu Huachuang Biotechnology Co., Ltd., Chengdu, Sichuan 610000, P.R. China
| | - Wei-Ju Tang
- Department of Neurology, The First People's Hospital of Longquanyi District, Chengdu, Sichuan 610000, P.R. China
| | - Shou-Chun Chen
- Chengdu Huachuang Biotechnology Co., Ltd., Chengdu, Sichuan 610000, P.R. China
| | - Ying Huang
- Department of Pathophysiology, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, Sichuan 610000, P.R. China
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19
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Prognostic Factors of Survival After Neoadjuvant Treatment and Resection for Initially Unresectable Pancreatic Cancer. Ann Surg 2021; 273:154-162. [PMID: 30921051 DOI: 10.1097/sla.0000000000003270] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the impact of clinical and pathological parameters, including resection margin (R) status, on survival in patients undergoing pancreatic surgery after neoadjuvant treatment for initially unresectable pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Prognostic factors are well documented for patients with resectable PDAC, but have not been described in detail for patients with initially unresectable PDAC undergoing resection after neoadjuvant therapy. METHODS Prospectively collected data of consecutive patients with initially unresectable pancreatic cancer treated by neoadjuvant treatment and resection were analyzed. The R status was categorized as R0 (tumor-free margin >1 mm), R1 ≤1 mm (tumor-free margin ≤1 mm), and R1 direct (microscopic tumor infiltration at margin). Clinicopathological characteristics and outcomes were compared among these groups and tested for survival prediction. RESULTS Between January, 2006 and February, 2017, 280 patients with borderline resectable (n = 18), locally advanced (n = 190), or oligometastatic (n = 72) disease underwent tumor resection after neoadjuvant treatment. Median overall survival from the time of surgery was 25.1 months for R0 (n = 82), 15.3 months for R1 ≤1 mm (n = 99), and 16.1 months for R1 direct (n = 99), with 3-year overall survival rates of 35.0%, 20.7%, and 18.5%, respectively (P = 0.0076). The median duration of the neoadjuvant treatment period was 5.1 months. In multivariable analysis, preoperative CA 19-9 levels, lymph node status, metastasis category, and vascular involvement were all significant prognostic factors for overall survival. The R status was not an independent prognostic factor. CONCLUSIONS In patients undergoing resection after neoadjuvant therapy for initially unresectable PDAC, preoperative CA 19-9 levels, lymph node involvement, metastasis category, and vascular involvement, but not the R status, were independent prognostic factors of overall survival.
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20
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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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21
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Schmocker RK, Delitto D, Wright MJ, Ding D, Cameron JL, Lafaro KJ, Burns WR, Wolfgang CL, Burkhart RA, He J. Impact of Margin Status on Survival in Patients with Pancreatic Ductal Adenocarcinoma Receiving Neoadjuvant Chemotherapy. J Am Coll Surg 2020; 232:405-413. [PMID: 33338577 DOI: 10.1016/j.jamcollsurg.2020.11.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Historically, a positive margin after pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) was associated with decreased survival. In an era when neoadjuvant chemotherapy (NAC) is being used frequently, the prognostic significance of margin status is unclear. STUDY DESIGN Patients with localized PDAC who received NAC and underwent pancreatectomy from 2011 to 2018 were identified from a single-institution database. Patients with fewer than 2 months of NAC, R2 resection, or fewer than 90 days of follow-up were excluded. A positive margin included tumors within 1 mm of the surgical margin. RESULTS Four hundred and sixty-eight patients met inclusion criteria. Median age was 65 years and 53% were female. Preoperative clinical staging demonstrated that most had locally advanced (n = 222 [47%]) or borderline resectable (n = 172 [37%]) disease. Median follow-up was 18.5 months (interquartile range 10.6 to 30.0 months). Median duration of NAC was 119 days (interquartile range 87 to 168 days). FOLFIRINOX was first-line therapy for 67%, and 73% received neoadjuvant radiotherapy. Most underwent pancreaticoduodenectomy (69%). Forty percent were node-positive and 80% had an R0 resection. Fifty-six percent received at least 1 cycle of adjuvant therapy. Median overall survival and recurrence-free survival were 22.0 months (95% CI, 19.4 to 25.1 months) and 11.0 months (95% CI, 10.0 to 12.1 months). On multivariate analysis, margin status was not a significant predictor of overall survival or recurrence-free survival. Factors associated with overall survival included clinical stage, duration of NAC, nodal status, histopathologic treatment response score, and receipt of adjuvant chemotherapy. CONCLUSIONS Microscopic margin positivity is not associated with recurrence and survival in localized PDAC patients resected after treatment with NAC. Aggressive surgical extirpation in high-volume centers should be considered in selected patients after extensive NAC.
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Affiliation(s)
- Ryan K Schmocker
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Surgical Oncology, Department of Surgery, The University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Daniel Delitto
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J Wright
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A Burkhart
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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22
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Christians KK. Commentary: Venous resection and reconstruction at the time of pancreatectomy for cancer. Surgery 2020; 168:1058-1059. [DOI: 10.1016/j.surg.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 01/30/2023]
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Treatment Strategies for the Optimal Management of Locally Advanced Pancreatic Adenocarcinoma With Curative Intent: A Systematic Review. Pancreas 2020; 49:1264-1275. [PMID: 33122513 DOI: 10.1097/mpa.0000000000001694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Historically, locally advanced pancreatic adenocarcinoma (LAPDAC) was considered a palliative condition. Advances in treatment have resulted in studies reporting survival after neoadjuvant treatment and surgery similar to earlier disease stages. However, there is no consensus on optimal LAPDAC management. Our aim was a systematic review of published evidence on LAPDAC treatment strategies with curative intent. Twenty-eight studies defining LAPDAC as per established criteria and reporting outcomes after neoadjuvant treatment with a view to resection were included. Primary outcomes were resection rate and proportion of curative resections. Secondary outcomes were postoperative mortality, progression-free survival, and overall survival. Neoadjuvant treatment varied significantly, most common being the combination of folinic acid, fluorouracil, irontecan, and oxaliplatin. Median percentage of patients proceeding to surgery after completion of neoadjuvant pathway was 33.5%. Median resection rate was 25%. Median R0 resection was 80% of resected patients. These outcomes ranged 0% to 100% across studies. Ninety-day postoperative mortality ranged from 0% to 5%. Median progression-free and overall survival for resected patients were 12.9 and 30 months, respectively, versus 13.2 months overall survival for unresected patients. In conclusion, although there is wide variability in reported LAPDAC resection rates post-neoadjuvant chemotherapy, retrospective data suggest that neoadjuvant treatment followed by surgery results in improved survival.
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Factors predicting survival in patients with locally advanced pancreatic cancer undergoing pancreatectomy with arterial resection. Updates Surg 2020; 73:233-249. [PMID: 32978753 PMCID: PMC7889566 DOI: 10.1007/s13304-020-00883-7] [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] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Pancreatectomy with arterial resection is a treatment option in selected patients with locally advanced pancreatic cancer. This study aimed to identify factors predicting cancer-specific survival in this patient population. A single-Institution prospective database was used. Pre-operative prognostic factors were identified and used to develop a prognostic score. Matching with pathologic parameters was used for internal validation. In a patient population with a median Ca 19.9 level of 19.8 U/mL(IQR: 7.1–77), cancer-specific survival was predicted by: metabolic deterioration of diabetes (OR = 0.22, p = 0.0012), platelet count (OR = 1.00; p = 0.0013), serum level of Ca 15.3 (OR = 1.01, p = 0.0018) and Ca 125 (OR = 1.02, p = 0.00000137), neutrophils-to-lymphocytes ratio (OR = 1.16; p = 0.00015), lymphocytes-to-monocytes ratio (OR = 0.88; p = 0.00233), platelets-to-lymphocytes ratio (OR = 0.99; p = 0.00118), and FOLFIRINOX neoadjuvant chemotherapy (OR = 0.57; p = 0.00144). A prognostic score was developed and three risk groups were identified. Harrell’s C-Index was 0.74. Median cancer-specific survival was 16.0 months (IQR: 12.3–28.2) for the high-risk group, 24.7 months (IQR: 17.6–33.4) for the intermediate-risk group, and 39.0 months (IQR: 22.7–NA) for the low-risk group (p = 0.0003). Matching the three risk groups against pathology parameters, N2 rate was 61.9, 42.1, and 23.8% (p = 0.04), median value of lymph-node ratio was 0.07 (IQR: 0.05–0.14), 0.04 (IQR:0.02–0.07), and 0.03 (IQR: 0.01–0.04) (p = 0.008), and mean value of logarithm odds of positive nodes was − 1.07 ± 0.5, − 1.3 ± 0.4, and − 1.4 ± 0.4 (p = 0.03), in the high-risk, intermediate-risk, and low-risk groups, respectively. An online calculator is available at www.survivalcalculator-lapdac-arterialresection.org. The prognostic factors identified in this study predict cancer-specific survival in patients with locally advanced pancreatic cancer and low Ca 19.9 levels undergoing pancreatectomy with arterial resection.
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25
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Evans DB. Commentary: Surgery for locally advanced pancreatic cancer after neoadjuvant therapy. Surgery 2020; 169:1032-1033. [PMID: 32868112 DOI: 10.1016/j.surg.2020.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Douglas B Evans
- The LaBahn Pancreatic Cancer Program, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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26
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Kim RY, Evans DB, Christians KK. Locally advanced pancreatic cancer: staging, operability, and the importance of multimodality therapy. Hepatobiliary Surg Nutr 2020; 9:497-500. [PMID: 32832502 DOI: 10.21037/hbsn.2019.11.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rebecca Y Kim
- Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen K Christians
- Department of Surgery and the LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
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Resection of Replaced Common Hepatic Artery in Locally Advanced Pancreatic Cancer: A Case Report and Analysis of Technical and Oncological Implications. Pancreas 2020; 49:e31-e33. [PMID: 32282777 DOI: 10.1097/mpa.0000000000001533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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28
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Kulkarni NM, Soloff EV, Tolat PP, Sangster GP, Fleming JB, Brook OR, Wang ZJ, Hecht EM, Zins M, Bhosale PR, Arif-Tiwari H, Mannelli L, Kambadakone AR, Tamm EP. White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease. Abdom Radiol (NY) 2020; 45:716-728. [PMID: 31748823 DOI: 10.1007/s00261-019-02289-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.
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Affiliation(s)
- Naveen M Kulkarni
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Erik V Soloff
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Parag P Tolat
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Guillermo P Sangster
- Department of Radiology, LSU Health - Shreveport Ochsner-LSU Health - Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Jason B Fleming
- Gastrointestinal Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 4, Boston, MA, 02215-5400, USA
| | - Zhen Jane Wang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University Medical Center, 622 W 168th St, PH1-317, New York, NY, 10032, USA
| | - Marc Zins
- Department of Radiology, Groupe Hospitalier Paris Saint-Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - Priya R Bhosale
- Abdominal Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX, 77030-400, USA
| | - Hina Arif-Tiwari
- Department of Radiology, University of Arizona College of Medicine, 1501 N. Campbell Ave., P.O. Box 245067, Tucson, AZ, 85724, USA
| | | | - Avinash R Kambadakone
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Eric P Tamm
- Abdominal Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX, 77030-400, USA
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Nasief H, Hall W, Zheng C, Tsai S, Wang L, Erickson B, Li XA. Improving Treatment Response Prediction for Chemoradiation Therapy of Pancreatic Cancer Using a Combination of Delta-Radiomics and the Clinical Biomarker CA19-9. Front Oncol 2020; 9:1464. [PMID: 31970088 PMCID: PMC6960122 DOI: 10.3389/fonc.2019.01464] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 12/06/2019] [Indexed: 12/11/2022] Open
Abstract
Recently we showed that delta radiomics features (DRF) from daily CT-guided chemoradiation therapy (CRT) is associated with early prediction of treatment response for pancreatic cancer. CA19-9 is a widely used clinical biomarker for pancreatic cancer. The purpose of this work is to investigate if the predictive power of such biomarkers (DRF or CA19-9) can improve by combining both biomarkers. Daily non-contrast CTs acquired during routine CT-guided neoadjuvant CRT for 24 patients (672 datasets, in 28 daily fractions), along with their CA19-9, pathology reports and follow-up data were analyzed. The pancreatic head was segmented on each daily CT and radiomic features were extracted from the segmented regions. The time between the end of treatment and last follow-up was used to build a survival model. Patients were divided into two groups based on their pathological response. Spearman correlations were used to find the DRFs correlated to CA19-9. A regression model was built to examine the effect of combining CA19-9 and DRFs on response prediction. C-index was used to measure model effectiveness. The effect of a decrease in CA19-9 levels during treatment vs. failure of CA19-9 levels to normalize on survival was examined. Univariate- and multivariate Cox-regression analysis were performed to determine the effect of combining CA19-9 and DRFs on survival correlations. Spearman correlation showed that CA19-9 is correlated to DRFs (Entropy, cluster tendency and coarseness). An Increase in CA19-9 levels during treatment were correlated to a bad response, while a decline was correlated to a good response. Incorporating CA19-9 with DRFs increased the c-index from 0.57 to 0.87 indicating a stronger model. The univariate analysis showed that patients with decreasing CA19-9 had an improved median survival (68 months) compared to those with increasing levels (33 months). The 5-years survival was improved for the decreasing CA19-9 group (55%) compared to the increasing group (30%). The Cox-multivariate analysis showed that treatment related decrease in CA19-9 levels (p = 0.031) and DRFs (p = 0.001) were predictors of survival. The hazard-ratio was reduced from 0.73, p = 0.032 using CA19-9 only to 0.58, p = 0.028 combining DRFs with CA19-9. DRFs-CA19-9 combination has the potential to increasing the possibility for response-based treatment adaptation.
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Affiliation(s)
- Haidy Nasief
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Cheng Zheng
- Joseph J. Zilber School of Public Health, University of Wisconsin Milwaukee, Milwaukee, WI, United States
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Liang Wang
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
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30
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Maggino L, Malleo G, Marchegiani G, Viviani E, Nessi C, Ciprani D, Esposito A, Landoni L, Casetti L, Tuveri M, Paiella S, Casciani F, Sereni E, Binco A, Bonamini D, Secchettin E, Auriemma A, Merz V, Simionato F, Zecchetto C, D’Onofrio M, Melisi D, Bassi C, Salvia R. Outcomes of Primary Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma. JAMA Surg 2019; 154:932-942. [PMID: 31339530 PMCID: PMC6659151 DOI: 10.1001/jamasurg.2019.2277] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/17/2019] [Indexed: 12/21/2022]
Abstract
Importance Chemotherapy is the recommended induction strategy in borderline resectable and locally advanced pancreatic ductal adenocarcinoma. However, the associated results on an intention-to-treat basis are poorly understood. Objective To investigate pragmatically the treatment compliance, conversion to surgery, and survival outcomes of patients with borderline resectable and locally advanced pancreatic ductal adenocarcinoma undergoing primary chemotherapy. Design, Setting, and Participants This prospective study took place in a national referral center for pancreatic diseases in Italy. Consecutive patients with borderline resectable and locally advanced pancreatic ductal adenocarcinoma were enrolled at the time of diagnosis (January 2013 through December 2015) and followed up to June 2018. Exposures The chemotherapy regimen, assigned based on multidisciplinary evaluation, was delivered either at a hub center or at spoke centers. By convention, primary chemotherapy was considered completed after 6 months. After restaging, surgical candidates were selected based on radiologic and biochemical response. All surgeries were carried out at the hub center. Main Outcomes and Measures Rates of receipt and completion of chemotherapy, rates of conversion to surgery, and disease-specific survival. Results Of 680 patients, 267 (39.3%) had borderline resectable and 413 (60.7%) had locally advanced pancreatic ductal adenocarcinoma. Overall, 66 patients (9.7%) were lost to follow-up. The rate of chemotherapy receipt was 92.9% (n = 570). The chemotherapeutic regimens most commonly used included FOLFIRINOX (fluorouracil, leucovorin, oxaliplatin, and irinotecan) (260 [45.6%]) and gemcitabine plus nanoparticle albumin-bound-paclitaxel (123 [21.6%]). Nineteen patients (3.3%) receiving chemotherapy died within 6 months, mainly for disease progression. The treatment completion rate was 71.6% (408 of 570). The overall rate of resection was 15.1% (93 of 614) (borderline resectable, 60 of 249 [24.1%]; locally advanced, 33 of 365 [9%]; resection:exploration ratio, 63.3%). Independent predictors of resection were age, borderline resectable disease, chemotherapy completion, radiologic response, and biochemical response. The median survival for the whole cohort was 12.8 (95% CI, 11.7-13.9) months. Factors independently associated with survival were completion of chemotherapy, receipt of complementary radiation therapy, and resection. In patients who underwent resection, the median survival was 35.4 (95% CI, 27.0-43.7) months for initially borderline resectable and 41.8 (95% CI, 27.5-56.1) months for initially locally advanced disease. No pretreatment and posttreatment factors were associated with survival after pancreatectomy. Conclusions and Relevance This pragmatic observational cohort study with an intention-to-treat design provides real-world evidence of outcomes associated with the most current primary chemotherapy regimens used for borderline resectable and locally advanced pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Elena Viviani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Nessi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Debora Ciprani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Elisabetta Sereni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Binco
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Valeria Merz
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Francesca Simionato
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Camilla Zecchetto
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Mirko D’Onofrio
- Unit of Radiology, Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Davide Melisi
- Unit of Medical Oncology, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Evans DB, Kamgar M, Tsai S. Goals of Treatment Sequencing for Localized Pancreatic Cancer. Ann Surg Oncol 2019; 26:3815-3819. [DOI: 10.1245/s10434-019-07738-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Indexed: 12/29/2022]
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32
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Wei AC, Ou FS, Shi Q, Carrero X, O'Reilly EM, Meyerhardt J, Wolff RA, Kindler HL, Evans DB, Deshpande V, Misdraji J, Tamm E, Sahani D, Moore M, Newman E, Merchant N, Berlin J, Goff LW, Pisters P, Posner MC. Perioperative Gemcitabine + Erlotinib Plus Pancreaticoduodenectomy for Resectable Pancreatic Adenocarcinoma: ACOSOG Z5041 (Alliance) Phase II Trial. Ann Surg Oncol 2019; 26:4489-4497. [PMID: 31418130 DOI: 10.1245/s10434-019-07685-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is considerable interest in a neoadjuvant approach for resectable pancreatic ductal adenocarcinoma (PDAC). This study evaluated perioperative gemcitabine + erlotinib (G+E) for resectable PDAC. METHODS A multicenter, cooperative group, single-arm, phase II trial was conducted between April 2009 and November 2013 (ACOSOG Z5041). Patients with biopsy-confirmed PDAC in the pancreatic head without evidence of involvement of major mesenteric vessels (resectable) were eligible. Patients (n = 123) received an 8-week cycle of G+E before and after surgery. The primary endpoint was 2-year overall survival (OS), and secondary endpoints included toxicity, response, resection rate, and time to progression. Resectability was assessed retrospectively by central review. The study closed early due to slow accrual, and no formal hypothesis testing was performed. RESULTS Overall, 114 patients were eligible, consented, and initiated protocol treatment. By central radiologic review, 97 (85%) of the 114 patients met the protocol-defined resectability criteria. Grade 3+ toxicity was reported in 60% and 79% of patients during the neoadjuvant phase and overall, respectively. Twenty-two of 114 (19%) patients did not proceed to surgery; 83 patients (73%) were successfully resected. R0 and R1 margins were obtained in 67 (81%) and 16 (19%) resected patients, respectively, and 54 patients completed postoperative G+E (65%). The 2-year OS rate for the entire cohort (n = 114) was 40% (95% confidence interval [CI] 31-50), with a median OS of 21.3 months (95% CI 17.2-25.9). The 2-year OS rate for resected patients (n = 83) was 52% (95% CI 41-63), with a median OS of 25.4 months (95% CI 21.8-29.6). CONCLUSIONS For resectable PDAC, perioperative G+E is feasible. Further evaluation of neoadjuvant strategies in resectable PDAC is warranted with more active systemic regimens.
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Affiliation(s)
- Alice C Wei
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada. .,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Fang-Shu Ou
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Qian Shi
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Xiomara Carrero
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Hedy L Kindler
- University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | | | | | - Joseph Misdraji
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Eric Tamm
- MD Anderson Cancer Center, Houston, TX, USA
| | - Dushyant Sahani
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Malcolm Moore
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
| | - Elliot Newman
- New York University Langone Medical Center, New York, NY, USA
| | - Nipun Merchant
- University of Miami Miller School of Medicine-Sylvester Cancer Center, Miami, FL, USA
| | - Jordan Berlin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura W Goff
- Vanderbilt University Medical Center, Nashville, TN, USA
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Survival of patients with borderline resectable pancreatic cancer who received neoadjuvant therapy and surgery. Surgery 2019; 166:277-285. [PMID: 31272811 DOI: 10.1016/j.surg.2019.05.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/30/2019] [Accepted: 05/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND It is difficult to successfully deliver multimodality therapy to patients with operable pancreatic cancer. Data on the natural history of such efforts are necessary for physicians to guide shared decision-making with patients and families. We report the survival of consecutive patients with borderline resectable pancreatic cancer who received neoadjuvant therapy before surgery. METHODS Data regarding demographics, neoadjuvant therapy, surgery, pathology, and survival duration were abstracted on consecutive patients with borderline resectable pancreatic cancer diagnosed between 2009 and 2017 and not treated on available clinical trials. Borderline resectable pancreatic cancer was defined based on ≥1 of the following: local tumor anatomy, pretreatment serum carbohydrate antigen 19-9 >2,000 U/mL, and the presence of radiographic lesions indeterminate for metastases. RESULTS Neoadjuvant therapy was delivered to 185 patients with borderline resectable pancreatic cancer who were not enrolled in competing clinical trials; 13 (7%) patients received chemoradiation, 12 (7%) received chemotherapy, and 160 (86%) received both. Of the 185 patients, 115 (62%) completed all intended neoadjuvant therapy and surgery; 81 (70%) of 115 underwent pancreaticoduodenectomy; and vascular reconstruction was performed in 51 (44%). A margin negative resection was achieved in 111 (97%) of 115 patients, and 83 (72%) were node negative. Median overall survival for all 185 patients was 20 months; 31 months for the 115 patients who completed all neoadjuvant therapy and surgery as compared to 13 months for the 70 patients who were not resected (P < .0001). CONCLUSION After neoadjuvant therapy, surgical resection was performed in 62% of patients with borderline resectable pancreatic cancer. Those who normalized preoperative serum carbohydrate antigen 19-9 and had node negative pathology achieved the longest survival. To further improve median survival for all patients, we are incorporating adaptive approaches to neoadjuvant therapy sequencing based on objective assessments of response.
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Distal splenorenal and mesocaval shunting at the time of pancreatectomy. Surgery 2019; 165:298-306. [DOI: 10.1016/j.surg.2018.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
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Kluger MD, Chabot JA, Schrope BA. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2019; 166:951. [PMID: 30665618 DOI: 10.1016/j.surg.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Michael D Kluger
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY.
| | - John A Chabot
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY
| | - Beth A Schrope
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY
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