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Altimari M, Wells A, Abad J, Chawla A. The differential effect of neoadjuvant chemotherapy and chemoradiation on nodal downstaging in pancreatic adenocarcinoma. Pancreatology 2023; 23:805-810. [PMID: 37599170 DOI: 10.1016/j.pan.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/11/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND/OBJECTIVES Neoadjuvant chemotherapy (NCT) and chemoradiotherapy (NCRT) enhance resectability in patients with pancreatic adenocarcinoma (PDAC). This study compares the effect of NCT and NCRT on lymph nodal downstaging and survival. METHODS The 2004-2016 National Cancer Database Pancreas Participant User File was used to identify patients who underwent surgery for PDAC. Fisher's exact, Wilcoxon rank-sum, multivariate logistic regression, and log-rank were used. Downstaging was defined as clinically node-positive patients who demonstrated node-negativity on pathology. RESULTS Of 42,545 patients meeting criteria, 3311 received NCT and 1511 received NCRT. After surgery for clinically node-positive disease, 23.3% of NCT patients and 41.3% of NCRT patients demonstrated nodal downstaging. Younger age and lower tumor grade independently predicted downstaging. Downstaging after neoadjuvant therapy was associated with improved survival versus no nodal treatment response (29.8 vs. 22.8 months, p < 0.001). Downstaging by NCT was associated with improved overall survival versus downstaging by NCRT (37.5 vs. 26.6 months, p = 0.001). No survival difference existed between those with no nodal response after NCT or NCRT (p = 0.101). CONCLUSIONS Although nodal downstaging is more likely post-NCRT, survival is superior in those downstaged post-NCT. Overall survival is determined by the systemic burden of disease. Post-therapy histologic analysis may be less prognostic post-NCRT.
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Affiliation(s)
- Marc Altimari
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Amy Wells
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - John Abad
- Division of Surgical Oncology, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Akhil Chawla
- Division of Surgical Oncology, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA; Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA; Northwestern Quality Improvement, Research & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Kamel MK, Shchatsko A, Keane CA, Serpa E, Al-Qudah G, Rahouma M, Nituica C, Blebea J, Marar O. Is There a Role for Neoadjuvant Systemic Therapy for cT4bM0 Colon Cancer? A Propensity Score-Matched Analysis of the National Cancer Database. Dis Colon Rectum 2023; 66:1435-1448. [PMID: 36876973 DOI: 10.1097/dcr.0000000000002763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Nonmetastatic T4b colon cancer has been traditionally treated with upfront surgery, often requiring technically challenging multiorgan resection. Neoadjuvant chemotherapy can potentially downsize these tumors and improve their resectability. OBJECTIVE This study aimed to explore trends and outcomes of neoadjuvant chemotherapy use compared to upfront surgery in patients with nonmetastatic T4b colon cancer. This study also sought to determine factors associated with increased neoadjuvant chemotherapy use and with overall survival. DESIGN Retrospective cohort study. SETTINGS Conducted using the National Cancer Database. PATIENTS Patients with nonmetastatic T4b colon cancer who underwent colectomy (2006-2016) were included in the study. Patients receiving neoadjuvant chemotherapy were propensity-matched (1:2) to those who underwent upfront surgery in either clinically node-negative or node-positive disease. MAIN OUTCOME MEASURES Postoperative outcomes (length of stay, 30-d readmission, 30/90-d mortality), oncologic resection adequacy (R0 rate, number of resected/positive nodes), and overall survival were the main outcome measures. RESULTS Neoadjuvant chemotherapy was used in 7.7% of the patients. Neoadjuvant chemotherapy use increased over the study period from 4% to 16% in the entire cohort, from 3% to 21% in patients with clinically node-positive disease, and from 6% to 12% in patients with clinically node-negative disease. Factors associated with increased use of neoadjuvant chemotherapy included younger age (OR 0.97; 95% CI, 0.96-0.98; p < 0.001), male sex (OR 1.35; 95% CI, 1.11-1.64; p = 0.002), recent diagnosis year (OR 1.16; 95% CI, 1.12-1.20; p < 0.001), academic centers (OR 2.65; 95% CI, 2.19-3.22; p < 0.001), clinically node-positive (OR 1.23; 95% CI, 1.01-1.49; p = 0.037), and tumor located in the sigmoid colon (OR 2.44; 95% CI, 1.97-3.02; p < 0.001). Patients who received neoadjuvant chemotherapy had significantly higher R0 resection compared with upfront surgery (87% vs 77%; p < 0.001). On multivariable analysis, neoadjuvant chemotherapy was associated with higher overall survival (HR 0.76; 95% CI, 0.64-0.91; p = 0.002). On propensity-matched analyses, neoadjuvant chemotherapy was associated with a higher 5-year overall survival compared to upfront surgery in patients with clinically node-positive disease (57% vs 43%; p = 0.003) but not in patients with clinically node-negative disease (61% vs 56%; p = 0.090). LIMITATIONS Retrospective design. CONCLUSION Neoadjuvant chemotherapy use for nonmetastatic T4b has increased significantly on the national level, more so in patients with clinically node-positive disease. Patients with node-positive disease treated with neoadjuvant chemotherapy had higher overall survival compared to those who underwent upfront surgery. See Video Abstract at http://links.lww.com/DCR/C228 . EXISTE LUGAR PARA LA TERAPIA SISTMICA NEOADYUVANTE PARA EL CNCER DE COLON CTBM UN ANLISIS EMPAREJADO DE PUNTAJE DE PROPENSIN DE LA BASE DE DATOS NACIONAL DEL CNCER ANTECEDENTES:El cáncer de colon T4b no metastásico se ha tratado tradicionalmente con cirugía inicial, que frecuentemente requiere de una resección multiorgánica técnicamente desafiante. La quimioterapia neoadyuvante puede potencialmente reducir el tamaño y mejorar la resecabilidad de esos tumores.OBJETIVO:Explorar las tendencias y los resultados del uso de quimioterapia neoadyuvante en pacientes con cáncer de colon T4b no metastásico, en comparación con la cirugía inicial. Determinar los factores asociados con el aumento del uso de quimioterapia neoadyuvante y con la supervivencia general.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Utilizando de la Base de Datos Nacional del Cáncer.PACIENTES:Pacientes con cáncer de colon T4b no metastásico sometidos a colectomía (2006-2016). Los pacientes que recibieron quimioterapia neoadyuvante fueron emparejados por propensión (1:2) con aquellos sometidos a cirugía inicial, ya sea en enfermedad clínica con ganglios negativos o ganglios positivos.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios (duración de la hospitalización, reingreso a los 30 días, mortalidad a los 30/90 días), adecuación de la resección oncológica (tasa R0, número de ganglios resecados/positivos) y supervivencia general.RESULTADOS:La quimioterapia neoadyuvante se utilizó en el 7,7% de los pacientes. El uso de quimioterapia neoadyuvante aumentó durante el período de estudio del 4% al 16% en toda la cohorte; del 3% al 21% en pacientes con enfermedad clínica y ganglios positivos; y del 6% al 12% en pacientes con enfermedad clínica y ganglios negativos. Los factores asociados con un mayor uso de quimioterapia neoadyuvante incluyeron, edad más joven (OR 0,97, IC del 95 %: 0,96-0,98, p < 0,001), sexo masculino (OR 1,35, IC del 95 %: 1,11-1,64, p = 0,002), año de diagnóstico mas reciente (OR 1,16, 95% IC: 1,12-1,20, p < 0,001), centros académicos (OR 2,65, 95% IC: 2,19-3,22, p < 0,001), enfermedad clínica con ganglios positivos (OR 1,23, 95% IC: 1,01-1,49, p = 0,037), y tumor localizado en colon sigmoide (OR 2,44, 95% IC: 1,97-3,02, p < 0,001). Los pacientes que recibieron quimioterapia neoadyuvante tuvieron una resección R0 significativamente mayor en comparación con la cirugía inicial (87 % frente a 77 %, p < 0,001). En análisis multivariable, la quimioterapia neoadyuvante se asoció con una mayor supervivencia global (HR 0,76, IC del 95%: 0,64-0,91, p = 0,002). En los análisis de propensión pareada, la quimioterapia neoadyuvante se asoció con una mayor supervivencia general a los 5 años en comparación con la cirugía inicial en pacientes con enfermedad clínica con ganglios positivos (57% frente a 43%, p = 0,003), pero no en pacientes con enfermedad clínica y ganglios negativos (61% vs 56%, p = 0,090).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:El uso de quimioterapia neoadyuvante para T4b no metastásico ha aumentado significativamente a nivel nacional, más aún en pacientes con enfermedad clínica y ganglios positivos. Los pacientes con enfermedad y ganglios positivos tratados con quimioterapia neoadyuvante tuvieron una mayor supervivencia general en comparación con la cirugía inicial. Consulte Video Resumen en http://links.lww.com/DCR/C228 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Mohamed K Kamel
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Anastasiya Shchatsko
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Charles A Keane
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Eduardo Serpa
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Ghaith Al-Qudah
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York
| | - Cristina Nituica
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - John Blebea
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Omar Marar
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Michigan
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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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Analysis of Risk Factors for Distant Metastasis of Pancreatic Ductal Adenocarcinoma without Regional Lymph Node Metastasis and a Nomogram Prediction Model for Survival. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2023; 2023:2916974. [PMID: 36865748 PMCID: PMC9974279 DOI: 10.1155/2023/2916974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 03/04/2023]
Abstract
Background Negative regional lymph nodes do not indicate a lack of distant metastasis. A considerable number of patients with negative regional lymph node pancreatic cancer will skip the step of regional lymph node metastasis and directly develop distant metastasis. Methods We retrospectively analyzed the clinicopathological characteristics of patients with negative regional lymph node pancreatic cancer and distant metastasis in the Surveillance, Epidemiology, and End Results database from 2010 to 2015. Multivariate logistic analysis and Cox analysis were used to determine the independent risk factors that promoted distant metastasis and the 1-, 2-, and 3-year cancer-specific survival in this subgroup. Results Sex, age, pathological grade, surgery, radiotherapy, race, tumor location, and tumor size were significantly correlated with distant metastasis (P < 0.05). Among these factors, pathological grade II and above, tumor site other than the pancreatic head, and tumor size >40 mm were independent risk factors for distant metastasis; age ≥60 years, tumor size ≤21 mm, surgery, and radiation were protective factors against distant metastasis. Age, pathological grade, surgery, chemotherapy, and metastasis site were identified as predictors of survival. Among them, age ≥40 years, pathological grade II and above, and multiple distant metastasis were considered independent risk factors for cancer-specific survival. Surgery and chemotherapy were considered protective factors for cancer-specific survival. The prediction performance of the nomogram was significantly better than that of the traditional American Joint Committee on Cancer tumor, node, metastasis staging system. We also established an online dynamic nomogram calculator, which can predict the survival rate of patients at different follow-up time points. Conclusion Pathological grade, tumor location, and tumor size were independent risk factors for distant metastasis in pancreatic ductal adenocarcinoma with negative regional lymph nodes. Older age, smaller tumor size, surgery, and radiotherapy were protective factors against distant metastasis. A new nomogram that was constructed could effectively predict cancer-specific survival in pancreatic ductal adenocarcinoma with negative regional lymph nodes and distant metastasis. Furthermore, an online dynamic nomogram calculator was established.
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Shi YJ, Liu BN, Li XT, Zhu HT, Wei YY, Zhao B, Sun SS, Sun YS, Hao CY. Establishment of a multi-parameters MRI model for predicting small lymph nodes metastases (<10 mm) in patients with resected pancreatic ductal adenocarcinoma. Abdom Radiol (NY) 2022; 47:3217-3228. [PMID: 34800159 PMCID: PMC9388457 DOI: 10.1007/s00261-021-03347-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate the potential role of MR findings and DWI parameters in predicting small regional lymph nodes metastases (with short-axis diameter < 10 mm) in pancreatic ductal adenocarcinomas (PDACs). METHODS A total of 127 patients, 82 in training group and 45 in testing group, with histopathologically diagnosed PDACs who underwent pancreatectomy were retrospectively analyzed. PDACs were divided into two groups of positive and negative lymph node metastases (LNM) based on the pathological results. Pancreatic cancer characteristics, short axis of largest lymph node, and DWI parameters of PDACs were evaluated. RESULTS Univariate and multivariate analyses showed that extrapancreatic distance of tumor invasion, short-axis diameter of the largest lymph node, and mean diffusivity of tumor were independently associated with small LNM in patients with PDACs. The combining MRI diagnostic model yielded AUCs of 0.836 and 0.873, and accuracies of 81.7% and 80% in the training and testing groups. The AUC of the MRI model for predicting LNM was higher than that of subjective MRI diagnosis in the training group (rater 1, P = 0.01; rater 2, 0.008) and in a testing group (rater 1, P = 0.036; rater 2, 0.024). Comparing the subjective diagnosis, the error rate of the MRI model was decreased. The defined LNM-positive group by the MRI model showed significantly inferior overall survival compared to the negative group (P = 0.006). CONCLUSIONS The MRI model showed excellent performance for individualized and noninvasive prediction of small regional LNM in PDACs. It may be used to identify PDACs with small LNM and contribute to determining an appropriate treatment strategy for PDACs.
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Affiliation(s)
- Yan-Jie Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Bo-Nan Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Hai-Tao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Yi-Yuan Wei
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Bo Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Shao-Shuai Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China.
| | - Chun-Yi Hao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, No.52 Fu Cheng Road, Hai Dian District, Beijing, 100142, China.
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da Costa WL, Tran Cao HS, Gu X, Massarweh NN. Bayesian Approach to Understand the Association Between Treatment Down-staging and Survival for Patients With Pancreatic Adenocarcinoma. Ann Surg 2022; 275:415-421. [PMID: 35120060 DOI: 10.1097/sla.0000000000005249] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the association between staging concordance, treatment sequencing, and response to neoadjuvant therapy (NAT) on the survival of patients with pancreatic ductal adenocarcinoma (PDAC). SUMMARY OF BACKGROUND DATA NAT is increasingly utilized in the management of patients with PDAC, but it is unclear whether its benefit is contingent on tumor down-staging. METHODS This was a cohort study of stage I-III PDAC patients in the National Cancer Database (2006-2015) treated with upfront resection or NAT followed by surgery. We determined staging concordance using patients' clinical and pathological staging data. For NAT patients, we used Bayesian analysis to ascertain staging concordance accounting for down-staging. RESULTS Among 16,597 patients treated at 979 hospitals, 13,982 had an upfront resection and 2,615 NAT followed by surgery. Overall survival (OS) at 5-years ranged from 26.0% (95% CI 24.9%-27.1%) among cT1-2N0 patients to 18.6% (17.9%-19.2%) among cT1-3N+ ones. Patients with cT3-4 or cN+ tumors had improved OS after NAT compared to upfront surgery (all p< 0.001), while there was no difference among patients with cT1-2N0 (P = 0.16) disease. Relative to accurately staged cT1-2-3N+ or cT4 patients treated with upfront surgery, NAT was associated with a lower risk of death [HR 0.46 (0.37-0.57) for N+; HR 0.56 (0.40-0.77) for T4 disease], even among those without tumor down-staging [HR 0.81 (0.73-0.90) for N+; HR 0.48 (0.39-0.60) for T4]. CONCLUSIONS NAT is associated with improved survival for PDAC, particularly for patients with more advanced disease and regardless of down-staging. Consideration should be given to recommending NAT for all PDAC patients.
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Affiliation(s)
- Wilson Luiz da Costa
- Department of Medicine, Epidemiology, and Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiangjun Gu
- Department of Medicine, Epidemiology, and Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Nader N Massarweh
- Atlanta VA Health Care System, Decatur, GA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
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Oppliger FA, Prakash LR, Newhook TE, Chiang YJ, Ikoma N, Maxwell JE, Kim MP, Vauthey JN, Lee JE, Katz MH, Tzeng CWD. AJCC 8th edition pathologic nodal staging of resected pancreatic adenocarcinoma predicts survival regardless of treatment sequencing. Surg Oncol 2021; 40:101673. [PMID: 34894620 DOI: 10.1016/j.suronc.2021.101673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/29/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The primary aim was to compare overall survival (OS) between neoadjuvant therapy (NT) and surgery-first (SF) patients with pancreatic adenocarcinoma (PDAC) by nodal stage using the American Joint Commission on Cancer 8th Edition (AJCC8). BACKGROUND Rates of nodal positivity are consistently lower following NT versus SF sequencing. It's unclear whether post-NT nodal stage (ypNx) has similar survival compared to SF (pNx) using AJCC8. METHODS This is a single-institution retrospective cohort study with routine consideration of NT. Patients undergoing PDAC resection from 2010 to 2018 were analyzed and OS compared by nodal stage using AJCC8. RESULTS Of 450 total patients, 24% were treated with SF and 76% NT. SF patients had potentially resectable disease in 97% of the cases, whereas NT patients had more advanced clinical stages at diagnosis: borderline resectable 34%, locally advanced 5%. NT patients had higher rates of node-negativity (52.4% vs 22.7%) and lower rates of pathologic N2 disease (19.1% vs 43.6%) vs. SF (p < 0.001). For each pathologic nodal stage, SF and NT groups had similar 5-year OS [pN0/ypN0 52.7% vs. 53.6%, p = 0.723], [pN1/ypN1 37.0% vs. 36.7%, p = 0.872], and [pN2/ypN2 16.6% vs. 21.0%, p = 0.508]. CONCLUSIONS AJCC8 stratifies outcomes for each post-NT nodal stage similar to SF counterparts. Despite presenting with more advanced clinical stage, NT patients had lower rates of nodal metastases yet comparable OS when stratified by final nodal status. These data provide both hope for patients with obvious radiographic nodal disease at presentation and further support for considering NT sequencing for most patients diagnosed with localized PDAC.
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Affiliation(s)
- Federico A Oppliger
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kim SS, Lee S, Lee HS, Bang S, Park MS. Prognostic factors in patients with locally advanced or borderline resectable pancreatic ductal adenocarcinoma: chemotherapy vs. chemoradiotherapy. Abdom Radiol (NY) 2021; 46:655-666. [PMID: 32748250 DOI: 10.1007/s00261-020-02661-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To identify common and unique pre-treatment prognostic factors in patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC), treated with chemotherapy (CTx) or concurrent chemoradiotherapy (CRT). METHODS We enrolled 215 patients with BR/LA PDAC, who were treated with either CTx (n = 82) or CRT (n = 133) as a first-line treatment between 2013 and 2016. Clinical data and CT imaging findings for predicting overall survival (OS) and progression-free survival (PFS) were analyzed using Cox regression analysis. RESULTS Carbohydrate antigen (CA) 19-9 > 1000 U/mL (hazard ratio [HR] 1.91; p = 0.001) and non-homogeneous enhancement (HR 1.95; p < 0.001) were associated with shorter OS in all study populations. There was no significant difference in median OS (15.3 vs 16.8 months, p = 0.297) and PFS (10.0 vs 11.7 months, p = 0.321) between the CTx and CRT groups. Non-homogeneous enhancement (HR 2.04; p = 0.006) and presence of positive lymph node on CT (HR 2.38; p = 0.036) were associated with poor OS in the CTx group, while CA 19-9 > 1000 U/mL (HR 2.38; p = 0.001) and non-homogeneous enhancement (HR 1.73; p = 0.006) were independent predictors for poor OS in the CRT group. CONCLUSION Enhancement pattern on CT was a common prognostic factor for patients with PDAC treated with either CTx or CRT. Presence of positive lymph nodes on CT was a poor prognostic factor for the CTx group only, whereas CA 19-9 > 1000 U/mL was a poor prognostic factor for the CRT group only.
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Affiliation(s)
- Seung-Seob Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Sunyoung Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi-Suk Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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9
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Stark AP, Blum MM, Chiang YJ, Das P, Minsky BD, Estrella JS, Ajani JA, Badgwell BD, Mansfield P, Ikoma N. Preoperative Therapy Regimen Influences the Incidence and Implication of Nodal Downstaging in Patients with Gastric Cancer. J Gastric Cancer 2020; 20:313-327. [PMID: 33024587 PMCID: PMC7521984 DOI: 10.5230/jgc.2020.20.e29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/08/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose Nodal downstaging after preoperative therapy for gastric cancer has been shown to impart excellent prognosis, but this has not been validated in a national cohort. The role of neoadjuvant chemoradiation (NACR) in nodal downstaging remains unclear when compared with that of neoadjuvant chemotherapy alone (NAC). Furthermore, it is unknown whether the prognostic implications of nodal downstaging differ by preoperative regimen. Materials and Methods Using the National Cancer Database, overall survival (OS) duration was compared among natural N0 (cN0/ypN0), downstaged N0 (cN+/ypN0), and node-positive (ypN+) gastric cancer patients treated with NACR or NAC. Factors associated with nodal downstaging were examined in a propensity score-matched cohort of cN+ patients, matched 1:1 by receipt of NACR or NAC. Results Of 7,426 patients (natural N0 [n=1,858, 25.4%], downstaged N0 [n=1,813, 24.4%], node-positive [n=3,755, 50.4%]), 58.2% received NACR, and 41.9% received NAC. The median OS durations of downstaged N0 (5.1 years) and natural N0 (5.6 years) patients were similar to one another and longer than that of node-positive patients (2.1 years) (P<0.001). In the matched cohort of cN+ patients, more recent diagnosis (2010–2015 vs. 2004–2009) (odds ratio [OR], 2.57; P<0.001) and NACR (OR, 2.02; P<0.001) were independently associated with nodal downstaging. The 5-year OS rate of downstaged N0 patients was significantly lower after NACR (46.4%) than after NAC (57.7%) (P=0.003). Conclusions Downstaged N0 patients have the same prognosis as natural N0 patients. Nodal downstaging occurred more frequently after NACR; however, the survival benefit of nodal downstaging after NACR may be less than that when such is achieved by NAC.
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Affiliation(s)
- Alexander P Stark
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariela M Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Loch FN, Asbach P, Haas M, Seeliger H, Beyer K, Schineis C, Degro CE, Margonis GA, Kreis ME, Kamphues C. Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging. World J Surg Oncol 2020; 18:213. [PMID: 32811523 PMCID: PMC7436989 DOI: 10.1186/s12957-020-01951-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lymph node staging of ductal adenocarcinoma of the pancreatic head (PDAC) by cross-sectional imaging is limited. The aim of this study was to determine the diagnostic accuracy of expanded criteria in nodal staging in PDAC patients. METHODS Sixty-six patients with histologically confirmed PDAC that underwent primary surgery were included in this retrospective IRB-approved study. Cross-sectional imaging studies (CT and/or MRI) were evaluated by a radiologist blinded to histopathology. Number and size of lymph nodes were measured (short-axis diameter) and characterized in terms of expanded morphological criteria of border contour (spiculated, lobulated, and indistinct) and texture (homogeneous or inhomogeneous). Sensitivities and specificities were calculated with histopathology as a reference standard. RESULTS Forty-eight of 66 patients (80%) had histologically confirmed lymph node metastases (pN+). Sensitivity, specificity, and Youden's Index for the criterion "size" were 44.2%, 82.4%, and 0.27; for "inhomogeneous signal intensity" 25.6%, 94.1%, and 0.20; and for "border contour" 62.7%, 52.9%, and 0.16, respectively. There was a significant association between the number of visible lymph nodes on preoperative CT and lymph node involvement (pN+, p = 0.031). CONCLUSION Lymph node staging in PDAC is mainly limited due to low sensitivity for detection of metastatic disease. Using expanded morphological criteria instead of size did not improve regional nodal staging due to sensitivity remaining low. Combining specific criteria yields improved sensitivity with specificity and PPV remaining high.
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Affiliation(s)
- Florian N Loch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - Patrick Asbach
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Matthias Haas
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hendrik Seeliger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Katharina Beyer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Schineis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Claudius E Degro
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Georgios A Margonis
- The Johns Hopkins University School of Medicine, Department of Surgery, 600 N. Wolfe Street, Blalock 688, Baltimore, MD, 21287, USA
| | - Martin E Kreis
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Carsten Kamphues
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Surgery, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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11
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Khattab A, Patruni S, Abel S, Hasan S, Ludmir EB, Finley G, Monga D, Wegner RE, Verma V. Long-term outcomes by response to neoadjuvant chemotherapy or chemoradiation in patients with resected pancreatic adenocarcinoma. J Gastrointest Oncol 2019; 10:918-927. [PMID: 31602330 DOI: 10.21037/jgo.2019.07.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Response of pancreatic adenocarcinoma to neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT) may be associated with prognosis, but long-term outcomes based on response to neoadjuvant therapy have not been well evaluated to date. Methods The National Cancer Database was queried for patients with pancreatic adenocarcinoma receiving nCT/nCRT. To evaluate response to nCT/nCRT, comparisons were made from cT and cN stage to the respective post-neoadjuvant therapy ypT and ypN stages. Based on these comparisons, patients were classified as responders, progressors, or non-responders. Statistical analyses included estimation of survival using Kaplan-Meier analysis, as well as multivariable Cox proportional hazards modeling. Results Of 2,028 patients, 30% had a response, 32% progressed, and 38% had no response; 1% of patients experienced pathologic complete response (pCR). Responders were more likely to have received multi-agent chemotherapy (P=0.0001) as well as radiotherapy (RT) (P=0.02) in the neoadjuvant setting. Response to nCT/nCRT was also associated with a higher R0 resection rate (P=0.02). At a median follow-up of 49 months, median overall survival (OS) was higher in responders than non-responders or progressors (29.9 vs. 24.3 vs. 22.2 months, P<0.001). The mean OS for patients experiencing pCR was 55.5 months. On multivariable analysis, treatment response was independently associated with OS (P=0.02). Conclusions Response to nCT/nCRT independently predicts long-term outcomes following resection of pancreatic adenocarcinoma; higher rates of treatment response were observed for patients receiving neoadjuvant RT as well as neoadjuvant multi-agent chemotherapy. These results may have implications on strategies to improve response rates.
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Affiliation(s)
- Ahmed Khattab
- Allegheny Health Network, Department of Internal Medicine, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Sunita Patruni
- Allegheny Health Network, Department of Internal Medicine, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Stephen Abel
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Gene Finley
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Dulabh Monga
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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