Cancer in the elderly: pancreatic cancer

Arctigenin: pharmacology, total synthesis, and progress in structure modification

Arctium lappa L. is a prevalent medicinal herb and a health supplement that is commonly used in Asia. Over the last few decades, the bioactive component arctigenin has attracted the attention of researchers because of its anti-inflammatory, antioxidant, immunomodulatory, multiple sclerosis fighting, antitumor, and anti-leukemia properties. After summarising the research and literature on arctigenin, this study outlines the current status of research on pharmacological activity, total synthesis, and structural modification of arctigenin. The purpose of this study is to assist academics in obtaining a more comprehensive understanding of the research progress on arctigenin and to provide constructive suggestions for further investigation of this useful molecule.

Tumor innervation and clinical outcome in pancreatic cancer

Pancreatic cancer is a highly aggressive malignancy characterized by poor survival, recurrence after surgery and resistance to therapy. Nerves infiltrate the microenvironment of pancreatic cancers and contribute to tumor progression, however the clinicopathological significance of tumor innervation is unclear. In this study, the presence of nerves and their cross-sectional size were quantified by immunohistochemistry for the neuronal markers S-100, PGP9.5 and GAP-43 in a series of 99 pancreatic cancer cases versus 71 normal adjacent pancreatic tissues. A trend was observed between the presence of nerves in the tumor microenvironment of pancreatic cancer and worse overall patient survival (HR = 1.8, 95% CI 0.77-4.28, p = 0.08). The size of nerves, as measured by cross-sectional area, were significantly higher in pancreatic cancer than in the normal adjacent tissue (p = 0.002) and larger nerves were directly associated with worse patient survival (HR = 0.41, 95% CI 0.19-0.87, p = 0.04). In conclusion, this study suggests that the presence and size of nerves within the pancreatic cancer microenvironment are associated with tumor aggressiveness.

Short-term outcomes after minimally invasive versus open pancreaticoduodenectomy in elderly patients: a propensity score-matched analysis

BACKGROUND

To date, the evidence on the safety and benefits of minimally invasive pancreatoduodenectomy (MIPD) in elderly patients is still controversy. This study aim to compare the risk and benefit between MIPD and open pancreatoduodenectomy (OPD) in elderly patients.

METHODS

From 2016 to 2020, we retrospective enrolled 26 patients underwent MIPD and other 119 patients underwent OPD. We firstly compared the baseline characteristics, 90-day mortality and short-term surgical outcomes of MIPD and OPD. Propensity score matching was applied for old age patient (≥ 65-year-old vs. < 65-year-old) for detail safety and feasibility analysis.

RESULTS

Patients received MIPD is significantly older, had poor performance status, less lymph node harvest, longer operation time, less postoperative hospital stay (POHS) and earlier drain removal. After 1:2 propensity score matching analysis, elderly patients in MIPD group had significantly poor performance status (P = 0.042) compared to OPD group. Patients receiving MIPD had significantly shorter POHS (18 vs. 25 days, P = 0.028), earlier drain removal (16 vs. 21 days, P = 0.012) and smaller delay gastric empty rate (5.9 vs. 32.4% P = 0.036). There was no 90-day mortality (0% vs. 11.8%, P = 0.186) and pulmonary complications (0% vs. 17.6%, P = 0.075) in MIPD group, and the major complication rate is comparable to OPD group (17.6% vs. 29.4%, P = 0.290).

CONCLUSION

For elderly patients, MIPD is a feasible and safe option even in patients with inferior preoperative performance status. MIPD might also provide potential advantage for elderly patients in minimizing pulmonary complication and overall mortality over OPD.

Pancreatoduodenectomy for pancreatic head tumors in the elderly - Systematic review and meta-analysis

The age at which patients are undergoing pancreatoduodenectomy is increasing worldwide. The data on the outcome of this surgical procedure in the elderly is constantly expanding. This meta-analysis aims to assess the safety of pancreatoduodenectomy in elderly population, primarily focusing on morbidity and mortality. We searched the Medline, Embase and Cochrane databases to identify eligible studies. The most recent search was performed on 10th April 2017. Inclusion criteria were: (1) comparison of the characteristics and perioperative outcomes of older patients versus younger patients undergoing pancreatoduodenectomy; (2) objective evaluation of mortality or overall morbidity; and (3), publication in English. Exclusion criteria were: (1) a lack of comparative data; (2) a lack of primary outcomes or insufficient data to analyze; (3) a focus on procedures other than pancreatoduodenectomy; or (4), the impossibility of extraction of data specifically concerning pancreatoduodenectomy. Primary outcomes were overall morbidity and mortality. Secondary outcomes analyzed postoperative complications, R0 rate and length of hospital stay. 45 eligible studies were chosen, with a combined total of 21,295 patients. Older patients compared to younger patients had a higher risk of death (2.26% vs. 4.54%; RR: 2.23; 95% CI 1.74-2.87) and a higher complication rate (47.23% vs. 39.35%; RR: 1.17; 95% CI 1.12-1.24). There were no differences in pancreatic fistula occurrence (p = 0.27), bile leakage (p = 0.81), postoperative hemorrhage (p = 0.08), or R0 rate (p = 0.92). Our review confirms, that in the case of pancreatoduodenectomy, advanced age is a risk factor for increased non-surgical morbidity and, by extension, higher mortality.

Antibody fragment-conjugated gemcitabine and paclitaxel-based liposome for effective therapeutic efficacy in pancreatic cancer

In this study, we have developed an antibody fragment (AF)-conjugated gemcitabine (GEM) and paclitaxel (PTX)-loaded liposome (AF-GPL) to enhance the therapeutic efficacy in pancreatic cancer treatment. The maleimide-thiol chemistry was utilized to conjugate AF on the liposome surface. The dual-drug loaded liposome was nanosized and exhibited a controlled release of both the drugs. Importantly, two drugs have different release pattern over a period of time. The AF-conjugated liposome showed enhanced cellular uptake in pancreatic cancer cells compared to that of non-targeted liposome. Two-fold higher internalization of particles might increase the intracellular concentration of anticancer drugs that might further increase the therapeutic efficacy in pancreatic cancer cells. AF-GPL showed significantly higher cytotoxic effect in pancreatic cancer cell compared to that of non-targeted GPL. The IC50 value of GEM, PTX, GPL and AF-GPL were 5.9 μg/ml, 4.2 μg/ml, 1.92 μg/ml, and 0.45 μg/ml, respectively. Consistently, AF-GPL (4.12) showed significantly higher ratio of Bax/Bcl-2 compared to that of non-targeted GPL (2.8). Importantly, AF-GPL induced a significant apoptosis of cancer cells with predominant amount of cells in late apoptosis cells. Overall, AF-conjugated nanosystem could potentially improve the therapeutic efficacy in pancreatic cancers.

A Panel of CA19-9, Ca125, and Ca15-3 as the Enhanced Test for the Differential Diagnosis of the Pancreatic Lesion

Background. Proper diagnosis of pancreatic lesion etiology is a challenging clinical dilemma. Studies suggest that surgery for suspected pancreatic ductal adenocarcinoma (PDAC) reveals a benign lesion in 5% to 13% of cases. The aim of our study was to assess whether routinely used biomarkers such as CA19-9, Ca125, Ca15-3, and CEA, when combined, can potentially yield an accurate test predicting pancreatic lesion etiology. Methods. We retrospectively analyzed data of 326 patients who underwent a diagnostic process due to pancreatic lesions of unknown etiology. Results. We found statistically significant differences in mean levels of all biomarkers. In logistic regression model, we applied levels CA19-9, Ca125, and Ca15-3 as variables. Two validation methods were used, namely, random data split into training and validation groups and bootstrapping. Afterward, we built ROC curve using the model that we had created, reaching AUC = 0,801. With an optimal cut-off point, it achieved specificity of 81,2% and sensitivity of 63,10%. Our proposed model has superior diagnostic accuracy to both CA19-9 (p = 0,0194) and CA125 (p = 0,0026). Conclusion. We propose a test that is superior to CA19-9 in a differential diagnosis of pancreatic lesion etiology. Although our test fails to reach exceptionally high accuracy, its feasibility and cost-effectiveness make it clinically useful.

Biodistribution of Self-Assembling Polymer-Gemcitabine Conjugate after Systemic Administration into Orthotopic Pancreatic Tumor Bearing Mice

Therapeutic efficacy of gemcitabine (GEM) is severely limited due to its rapid metabolism by enzymatic deamination in vivo. We recently determined its therapeutic efficacy before (F-GEM) and after conjugation to poly(ethylene glycol)-block-poly(2-methyl-2-carboxyl-propylene carbonate) (mPEG-b-PCC-g-GEM-g-DC, abbreviated as P-GEM) in subcutaneous and orthotopic pancreatic tumor bearing mice. In this study, pharmacokinetic (PK) parameters and biodistribution profiles of F-GEM and P-GEM were determined after intravenous injection into orthotopic pancreatic tumor bearing NSG mice. To assess the short-term toxicity, the levels of hematological, hepatic, and renal injury markers were measured after 24 h postadministration into these mice. P-GEM was distributed to all the major organs, with higher accumulation in the liver, spleen, and tumor compared to F-GEM. Area under the curve (AUC), elimination half-life (t_1/2), and mean residence time (MRT) of P-GEM treated group were significantly higher compared to those of F-GEM treated group: 246,425 ± 1605 vs 83,591 ± 1844 ng/mL × h as AUC, 5.77 ± 2.02 vs 1.99 ± 0.09 h as t_1/2, and 4.45 ± 0.15 vs 1.12 ± 0.13 h as MRT. Further, P-GEM exhibited negligible systemic toxicity as evidenced by almost similar alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values for both P-GEM and F-GEM. These results suggest that P-GEM protects GEM from degradation and provides sustained drug release, resulting in enhanced GEM delivery to the tumor by more than 2.5-fold compared to F-GEM. Hence, P-GEM is a promising gemcitabine conjugated polymeric micelle for treating pancreatic cancer.

Outcomes of resected pancreatic cancer in patients age ≥70

OBJECTIVE

To determine outcomes of patients ≥70 years with resected pancreatic cancer.

METHODS

A study was conducted to identify pancreatic cancer patients ≥70 years who underwent surgery for pancreatic carcinoma from 2000 to 2012. Patients were excluded if they had neoadjuvant therapy. The primary endpoint was overall survival (OS).

RESULTS

We identified 112 patients with a median follow-up of surviving patients of 36 months. The median patient age was 77 years. The median and 5 year OS was 20.5 months and 19%, respectively. Univariate analysis (UVA) showed a significant correlation for increased mortality with N1 (P=0.03) as well as post-op CA19-9 >90 (P<0.001), with a trend towards decreased mortality with adjuvant chemoradiation (P=0.08). Multivariate analysis (MVA) showed a statistically significant increased mortality associated with N1 (P=0.008), post-op CA19-9 >90 (P=0.002), while adjuvant chemoradiation (P=0.04) was associated with decreased mortality.

CONCLUSIONS

These data show that in patients ≥70, nodal status, post-op CA19-9, and adjuvant chemoradiation, were associated with OS. The data suggests that outcomes of patients ≥70 years who undergo upfront surgical resection are not inferior to younger patients.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review

OBJECTIVES

To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas.

METHODS

Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival.

RESULTS

There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively.

CONCLUSIONS

Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Pancreatoduodenectomy with portal vein resection is feasible and potentially beneficial for elderly patients with pancreatic cancer

OBJECTIVES

We aimed to evaluate the feasibility and clinical benefit of pancreatoduodenectomy (PD) with portal vein resection (PVR) in elderly patients.

METHODS

This retrospective study enrolled 272 consecutive patients with pancreatic ductal adenocarcinoma who underwent PD between 2000 and 2012. The patients were categorized into 4 groups: elderly (≥70 years) and younger (<70 years) PD-PVR groups as well as elderly and younger PD groups. Preoperative patient background, postoperative course, and overall survival were compared.

RESULTS

Among the patients who underwent PD-PVR, the elderly group had significantly higher prevalence of comorbidity compared with the younger group (77% and 52%, respectively; P = 0.003), whereas there were no differences in the intraoperative and pathological characteristics. Postoperatively, morbidity and length of hospital stay were similar between the elderly and younger groups. Despite the fact that the proportion of patients who underwent adjuvant chemotherapy was lower in the elderly group (62% vs 83%; P = 0.005), the overall survival of the elderly group was comparable with that of the younger group, and both groups had a significantly more favorable prognosis than that of 36 patients with unresected tumors (P = 0.006 and P < 0.001, respectively).

CONCLUSIONS

Pancreatoduodenectomy with portal vein resection is safe and potentially beneficial for elderly patients with pancreatic cancer.

Outcomes of pancreaticoduodenectomy for pancreatic malignancy in octogenarians: an American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Most series analyzing outcomes of pancreaticoduodenectomy in octogenarians are limited by a small sample size. The investigators used the American College of Surgeons National Surgical Quality Improvement Program database for an analysis of the impact of advanced age on outcomes after pancreatic cancer surgery.

METHODS

The National Surgical Quality Improvement Program database from 2005 to 2010 was accessed to study the outcomes of 475 pancreaticoduodenectomies performed in patients ≥80 years of age compared with 4,102 patients <80 years of age using chi-square and Student's t tests. A multivariate logistic regression was used to analyze factors associated with 30-day mortality and the occurrence of major complications.

RESULTS

Octogenarians had significantly more preoperative comorbidities compared with patients <80 years of age. On multivariate analysis, age ≥80 years was associated with an increased likelihood of experiencing 30-day mortality and major complications compared with patients <80 years of age. On subgroup analysis, septuagenarians had a similar odds ratio of experiencing mortality or complications compared with octogenarians, whereas patients <70 years of age were at lower risk.

CONCLUSIONS

Although octogenarians have an increased risk for mortality and major complications compared with patients <80 years of age, on subgroup analysis, they do not differ from septuagenarians.

Stereotactic body radiotherapy in the treatment of pancreatic adenocarcinoma in elderly patients

Background

Treatment of pancreatic adenocarcinoma in the elderly is often complicated by comorbidities that preclude surgery, chemotherapy and/or conventional external beam radiation therapy (EBRT). Stereotactic body radiotherapy (SBRT) has thus garnered interest in this setting.

Methods

A retrospective review of 26 patients of age ≥ 80 with pancreatic adenocarcinoma treated with definitive SBRT+/-chemotherapy from 2007–2011 was performed. Twenty-seven percent of patients were stage I, 38% were stage II, 27% were stage III and 8% were stage IV. Patients most commonly received 24 Gy/1 fraction or 30-36 Gy/3 fractions. Kaplan-Meier was used to estimate overall survival (OS), local control (LC), cause specific survival (CSS) and freedom-from-metastatic disease (FFMD).

Results

The median age was 86 (range 80–91), and median follow-up was 11.6 months (3.5-24.6). The median planning target volume was 21.48 cm³ (6.1-85.09). Median OS was 7.6 months with 6/12 month OS rates of 65.4%/34.6%, respectively. Median LC was 11.5 months, 6-month and 12-month actuarial LC rates were 60.1% and 41.2%, respectively. There were no independent predictors for LC, but there was a trend for improved LC with prescription dose greater than 20 Gy (p = 0.063). Median CSS was 6.3 months, and 6-month and 12-month actuarial CSS were 53.8% and 23.1%, respectively. Median FFMD was 8.4 months, and 6-month and 12-month actuarial rates were 62.0% and 41.4%, respectively. Nine patients (47%) had local failures, 11 (58%) had distant metastasis, and 7 (37%) had both. There were no acute or late grade 3+ toxicities.

Conclusions

Definitive SBRT is feasible, safe and effective in elderly patients who have unresectable disease, have comorbidities precluding surgery or decline surgery.

Gemcitabine-loaded PLGA-PEG immunonanoparticles for targeted chemotherapy of pancreatic cancer

The aim of the present study was the direct covalent coupling of the epidermal growth factor receptor (EGFR)-specific monoclonal antibody (mAb) to the surface of poly(lactide)-co-glycolide (PLGA)-polyethylene glycol (PEG) nanoparticles in order to achieve a cell type-specific drug carrier system against pancreatic cancer. The PLGA-PEG-NH₂ diblock copolymer was synthesized by coupling reaction via amide linkage between PEG-diamine and activated PLGA. PLGA and PLGA-PEG-NH₂ nanoparticles loaded with gemcitabine were prepared using the double-emulsion solvent evaporation method. PLGA-PEG immunonanoparticles were prepared by glutaraldehyde mediated cross-linking method. The conjugated antibody was analysed by transmission electron microscopy and sodium dodecyl sulfate-polyacrylamide gel electrophoresis (PAGE) analysis. Cell viability study was performed using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and cell uptake study was performed on fluorescein isothiocyanate-loaded formulations using confocal microscopy. The PAGE results indicated that mAb integrity was remained intact in the formulations after conjugation. Biological activity was confirmed under cell culture conditions: antibody-conjugated nanoparticles showed specific targeting to EGFR-overexpressing MIA PaCa-2 cell lines as shown in fluorescence image using confocal microscopy. The obtained data provide the basis for the development of stable and biologically active carrier systems for direct targeting of tumour cells using antibody-conjugated PLGA-PEG nanoparticles. Direct covalent coupling of antibodies to nanoparticles using glutaraldehyde as a cross-linker is an appropriate method to achieve cell type-specific drug carrier systems based on PLGA-PEG nanoparticles and the anti-EGFR-decorated PLGA-PEG nanoparticles have potentials to be applied for targeted chemotherapy against EGFR positive cancers.

Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life?

OBJECTIVES

To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults.

DESIGN

Retrospective cohort study.

SETTING

Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

PARTICIPANTS

One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010.

MEASUREMENTS

A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery.

RESULTS

Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy.

CONCLUSION

Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.

Prognostic factors in metastatic pancreatic cancer: Older patients are associated with reduced overall survival

Pancreatic cancer is a major health concern worldwide and, despite the attempts at management, the prognosis of patients with metastatic pancreatic cancer remains poor, with a median survival of a few months. The aim of this study was to identify and evaluate clinicopathological factors and elucidate the clinical significance of patient age for the outcome of metastatic pancreatic cancer. Data from a total of 154 metastatic patients with a histologically confirmed diagnosis of pancreatic cancer, who were treated and followed-up in our clinic, were recorded from medical charts. The patient sample included 102 (66%) males with a median age of 58 years (range, 25–88 years). The majority of the patients had a poor performance status (64%), weight loss of >10% body weight (74%), tumor size of >3 cm (75%) and elevated tumor markers, including carcinoembryonic antigen (CEA) (66%) and carbohydrate antigen 19-9 (CA19-9) (85%). The distributions of prognostic factors depending on patient age were largely identical. The median survival time of patients with metastatic disease was 179 days and the 1-year survival rate was 7%. The median survival time of elderly patients was significantly lower compared to younger patients (148 vs. 198 days, respectively; P=0.039). The 1-year survival rates in elderly and younger patients were 3 and 10%, respectively. In the univariate and multivariate analyses, elderly patients had poorer outcomes compared with younger patients (P=0.04 and 0.05, respectively). In all patients, the univariate analysis demonstrated that similar prognostic factors, including the performance status of the patients and tumor markers, such as serum CEA and CA19-9 levels, were associated with survival. In the multivariate analysis, younger patients with a poor performance status had a significantly shorter overall survival compared to those with a good performance status (P=0.008). However, no significant prognostic factor affecting the outcome was identified in the elderly patients. In conclusion, patient age is a major prognostic factor affecting the survival of patients with metastatic pancreatic cancer and elderly patients without poor prognostic factors may be eligible for the available treatment options.

Inhibiting the growth of pancreatic adenocarcinoma in vitro and in vivo through targeted treatment with designer gold nanotherapeutics

Background

Pancreatic cancer is one of the deadliest of all human malignancies with limited options for therapy. Here, we report the development of an optimized targeted drug delivery system to inhibit advanced stage pancreatic tumor growth in an orthotopic mouse model.

Method/Principal Findings

Targeting specificity in vitro was confirmed by preincubation of the pancreatic cancer cells with C225 as well as Nitrobenzylthioinosine (NBMPR - nucleoside transporter (NT) inhibitor). Upon nanoconjugation functional activity of gemcitabine was retained as tested using a thymidine incorporation assay. Significant stability of the nanoconjugates was maintained, with only 12% release of gemcitabine over a 24-hour period in mouse plasma. Finally, an in vivo study demonstrated the inhibition of tumor growth through targeted delivery of a low dose of gemcitabine in an orthotopic model of pancreatic cancer, mimicking an advanced stage of the disease.

Conclusion

We demonstrated in this study that the gold nanoparticle-based therapeutic containing gemcitabine inhibited tumor growth in an advanced stage of the disease in an orthotopic model of pancreatic cancer. Future work would focus on understanding the pharmacokinetics and combining active targeting with passive targeting to further improve the therapeutic efficacy and increase survival.

Safety and feasibility of pancreaticoduodenectomy in the elderly: a matched study

OBJECTIVES

To compare the clinical outcomes after pancreaticoduodenectomy (PD) in patients older than 70 years old against a matched cohort of patients younger than 70.

METHODS

A search of the department database revealed that 285 consecutive patients underwent PD from 1996 to 2009. Forty-one patients (14%) were identified to be older than 70 years (group 1), and they were matched with 41 patients younger than 70 (group 2) according to sex, body mass index, American Society of Anesthesiologists score and tumor staging. Medical comorbidities, preoperative CA19-9 and hemoglobin levels, operative and histopathologic data, postoperative course, and survival outcomes were compared between the 2 groups of patients.

RESULTS

Statistical analyses revealed no significant difference between the 2 groups, except for preoperative CA19-9 and hemoglobin levels, operating time, duration of hospitalization, and the number of lymph nodes removed. These parameters, however, did not have an impact on morbidity, mortality, and overall survival.

CONCLUSIONS

Based on our study, perioperative morbidity, mortality, and overall survival are not poorer in patients older than 70. Thus, PD should not be contraindicated solely on the basis of chronological age. Moreover, PD can be rationally proposed to patients meeting the "fit elderly" definition.

Survival after pancreaticoduodenectomy for ampullary cancer is not affected by age

BACKGROUND

Although pancreaticoduodenectomy (PD) provides the best chance of survival for elderly patients with ampullary carcinoma, it is associated with considerable surgical risk. The aim of the present study was to compare the benefits and risks of pancreaticoduodenectomy as a treatment of ampullary carcinoma between young and elderly patients.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 171 consecutive patients treated at our hospital. Comparison of the biological aggressiveness of ampullary cancer between old and younger patients was also performed by immunohistochemical study of several prognostic biological markers, including MUC1, MUC2, CK17, and CDX2.

RESULTS

For patients in whom ampullary carcinoma was presumed resectable preoperatively, actuarial survival was significantly poorer in 55 elderly patients because 9 of them did not have PD (the other 46 had PD) than in 101 younger patients (all had PD). Multivariate analysis indicated that PD was the only independent prognostic factor; age was not. There were no significant differences in MUC1, CK17, MUC2, and CDX2 immunohistochemical staining of ampullary carcinomas between elderly and young patients. In spite of increased co-morbidities, PD could be performed as safely in elderly patients as in young patients. After PD, the actuarial survival was similar between old and young patients.

CONCLUSIONS

Our data support the conclusion that ampullary cancers in elderly patients should be treated as aggressively as in younger patients.

Radical surgery for pancreatic malignancy in the elderly

BACKGROUND

Improving life expectancy is associated with increasing incidence of pancreatic cancer. We reviewed morbidity and mortality in patients aged 65 years and older undergoing curative intent surgery in two centers in the Czech Republic.

METHODS

Data were retrieved by retrospective analysis of the medical records over the period 2000-2007. In total, 60 patients were included. The mean age was 71 years (median 70 years; range 65-85 years). Most patients (43, 72%) underwent hemipancreatoduodenectomy, combined in 4 with portomesenterial vessel resection. Twelve patients (20%) had distal pancreatectomy and 5 patients (8%) total pancreatectomy.

RESULTS

Overall morbidity was 28%. Only 10 patients (18%) developed serious surgical complications in terms of pancreatic leak (5, 8%), biliary leak (2, 3%), and intra-abdominal inflammatory collection (4, 7%). Four patients (6.6%) died within 30 days. The 1-year survival was 62.8%.

CONCLUSION

We can conclude that age per se is not a contraindication to surgery. Patient's overall general condition, co-existing co-morbidities, and ability to get over with any potential complications are more important. and IAP.

Fabrication of gold nanoparticles for targeted therapy in pancreatic cancer

The targeted delivery of a drug should result in enhanced therapeutic efficacy with low to minimal side effects. This is a widely accepted concept, but limited in application due to lack of available technologies and process of validation. Biomedical nanotechnology can play an important role in this respect. Biomedical nanotechnology is a burgeoning field with myriads of opportunities and possibilities for advancing medical science and disease treatment. Cancer nanotechnology (1-100 nm size range) is expected to change the very foundations of cancer treatment, diagnosis and detection. Nanomaterials, especially gold nanoparticles (AuNPs) have unique physico-chemical properties, such as ultra small size, large surface area to mass ratio, and high surface reactivity, presence of surface plasmon resonance (SPR) bands, biocompatibility and ease of surface functionalization. In this review, we will discuss how the unique physico-chemical properties of gold nanoparticles may be utilized for targeted drug delivery in pancreatic cancer leading to increased efficacy of traditional chemotherapeutics.

Gene expression profiling identifies novel key players involved in the cytotoxic effect of Artesunate on pancreatic cancer cells

Pancreatic cancer is one of the most aggressive human malignancies, with an extremely poor prognosis. The paucity of curative therapies has translated into an overall 5-year survival rate of less than 5%, underscoring a desperate need for new therapeutic options. Artesunate (ART), clinically used as anti-malarial agent, has recently revealed remarkable anti-tumor activity. However, the mechanisms underlying those activities in pancreatic cancer are not yet known. Here we evaluated the anti-tumor activity of Artesunate and the possible underlying mechanisms in pancreatic cancer. MiaPaCa-2 (poorly differentiated) and BxPC-3 (moderately differentiated) pancreatic cancer cell lines were treated with Artesunate and the effect was monitored by a tetrazolium-based assay (MTS) for evaluating cell viability and by flow cytometry and caspase 3/7 activation for apoptosis evaluation. In addition cDNA arrays were used to identify differentially expressed genes. The microarray data were then validated by RT-PCR and Western blotting. Moreover, pathways associated with these expression changes were identified using the Ingenuity Pathway Analysis. The expression analysis identified a common set of genes that were regulated by Artesunate in pancreatic cancer. Our results provide the first in vitro evidence for the therapeutic utility of Artesunate in pancreatic cancer. Moreover, we identified Artesunate as a novel topoisomerase IIalpha inhibitor that inhibits pancreatic cancer growth through modulation of multiple signaling pathways. The present analysis is a starting point for the generation of hypotheses on candidate genes and for a more detailed dissection of the functional role of individual genes for the activity of Artesunate in tumor cells.

Surgical palliation of unresectable pancreatic head cancer in elderly patients

AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer.

METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life.

RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree (P = 0.019, P = 0.029, respectively). The median hospital-free survival period and the median overall survival were also significantly longer in Group A (P = 0.001 and P < 0.001, respectively).

CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.

Do not deny pancreatic resection to elderly patients

INTRODUCTION

Radical resection is the only potential cure for pancreatic malignancies and a useful treatment for other benign diseases, such as pancreatitis. Over the last two decades, medical and surgical improvements have drastically changed the postoperative outcome of elderly patients undergoing pancreatic resection, and appropriate treatment for elderly potential candidates for pancreatic resection has become an important issue.

MATERIALS AND METHODS

Ninety-eight consecutive patients undergoing radical pancreatic resection between 2003 and 2006 at the Surgery Unit of the University of Modena, Italy, were considered and divided into two age groups, i.e., over 75-year-olds (group 1, 23 patients) and under 75-year-olds (group 2, 75 patients). The two groups were compared as regards demographic features, American Society of Anesthesiologists scores, comorbidities, previous major surgery, surgical procedure, postoperative mortality, and morbidity.

RESULTS

There were no significant differences between the two groups concerning postoperative mortality, and the duration of hospital stay and days in the postoperative intensive care unit were also similar. Complications such as pancreatic fistulas, wound infections, and pneumonia were more frequent in the older group, but the differences were not statistically significant. The overall median survival was 29.4 months and did not differ significantly between the two groups when calculated using the log-rank test (p = 0.961).

DISCUSSION

In the light of these findings and as reported for other series, old age is probably not directly related with any increase in the rate of postoperative complications, but comorbidities (which are naturally related to the patients' previous life) may have a key role in the postoperative course.

Targeted delivery of gemcitabine to pancreatic adenocarcinoma using cetuximab as a targeting agent

One of the key challenges in anticancer therapy is the toxicity and poor bioavailability of the anticancer drugs. Nanotechnology can play a pivotal role by delivering drugs in a targeted fashion to the malignant cells that will reduce the systemic toxicity of the anticancer drug. In this report, we show a stepwise development of a nanoparticle-based targeted delivery system for in vitro and in vivo therapeutic application in pancreatic cancer. In the first part of the study, we have shown the fabrication and characterization of the delivery system containing gold nanoparticle as a delivery vehicle, cetuximab as a targeting agent, and gemcitabine as an anticancer drug for in vitro application. Nanoconjugate was first characterized physico-chemically. In vitro targeting efficacy, tested against three pancreatic cancer cell lines (PANC-1, AsPC-1, and MIA Paca2) with variable epidermal growth factor receptor (EGFR) expression, showed that gold uptake correlated with EGFR expression. In the second part, we showed the in vivo therapeutic efficacy of the targeted delivery system. Administration of this targeted delivery system resulted in significant inhibition of pancreatic tumor cell proliferation in vitro and orthotopic pancreatic tumor growth in vivo. Tumor progression was monitored noninvasively by measuring bioluminescence of the implanted tumor cells. Pharmacokinetic experiments along with the quantitation of gold both in vitro and in vivo further confirmed that the inhibition of tumor growth was due to targeted delivery. This strategy could be used as a generalized approach for the treatment of a variety of cancers characterized by overexpression of EGFR.

Constituents of Brazilian red propolis and their preferential cytotoxic activity against human pancreatic PANC-1 cancer cell line in nutrient-deprived condition

Human pancreatic cancer cells such as PANC-1 are known to exhibit marked tolerance to nutrition starvation that enables them to survive for prolonged period of time even under extremely nutrient-deprived conditions. Thus, elimination of this tolerance to nutrition starvation is regarded as a novel approach in anticancer drug development. In this study, the MeOH soluble extract of Brazilian red propolis was found to kill 100% PANC-1 cells preferentially in the nutrient-deprived condition at the concentration of 10 microg/mL. Further phytochemical investigation led to the isolation of 43 compounds including three new compounds, (6aS,11aS)-6a-ethoxymedicarpan (1), 2-(2',4'-dihydroxyphenyl)-3-methyl-6-methoxybenzofuran (2), and 2,6-dihydroxy-2-[(4-hydroxyphenyl)methyl]-3-benzofuranone (3). Among them, (6aR,11aR)-3,8-dihydroxy-9-methoxypterocarpan (21, DMPC) displayed the most potent 100% preferential cytotoxicity (PC(100)) at the concentration of 12.5 microM. Further study on the mode of cell death induced by DMPC against PANC-1 cells indicated that killing process was not accompanied by DNA fragmentation, rather through a nonapoptotic pathway accompanied by necrotic-type morphological changes.

Prognostic Factors in Periampullary and Pancreatic Tumor Resection in Elderly Patients

BACKGROUND

More than half of all patients with pancreatic adenocarcinoma are over 70 years of age. Life expectancy for the elderly population is increasing and currently major pancreatic resection provides the only meaningful chance of cure for periampullary and pancreatic tumors. Controversy over what constitutes the correct treatment of these tumors in elderly patients continues to this day. The aim of our study was to determine whether age alone or age plus some prognostic factors constitute contraindications to major pancreatic resections.

METHODS

Between 2000 and 2005, data from 88 consecutive patients who had major pancreatic resection for periampullary or pancreatic tumors were entered into a prospective database. Fifty-three patients under 70 years of age (young patients), and 35 patients 70 years of age or older (elderly patients) were compared with respect to several characteristics and the postoperative course.

RESULTS

Postoperative mortality and morbidity, length of hospital stay, and long-term survival were similar in the two groups. In the elderly group, the mortality rate was significantly higher in patients with chronic obstructive pulmonary disease (COPD), and the morbidity rate was significantly higher in patients with ASA 3 than in patients with ASA 1-2, in whom a pancreaticoduodenectomy or total pancreatectomy had been performed.

CONCLUSIONS

Age alone is not a contraindication for major pancreatic resection. In elderly patients a careful evaluation of the co-morbidities and of the type of surgical procedure is mandatory in order to allow the proper selection of those patients best suited for surgery in specialized centers.

Innovations in Treating the Elderly Who Have Biliary and Pancreatic Disease

Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.

Pancreatic Tumors: Diagnostic Patterns by 3D Gradient-Echo Post Contrast Magnetic Resonance Imaging with Pathologic Correlation

Magnetic resonance (MR) imaging has considerable potential in characterizing pancreatic masses. Certain features can be used by the radiologist to establish a definitive diagnosis for most pancreatic tumors including ductal adenocarcinoma, islet cell tumors, solid and papillary epithelial neoplasms, micro- and macrocystic adenoma, and metastases. Recognition of these tumors on imaging is important since it often changes the treatment approach and may obviate the need for surgery. Recent introduction of 3D gradient recalled echo (GRE) sequence such as volumetric interpolated breath hold examination (VIBE) has dramatically improved MR imaging by providing dynamic enhanced thin-slice images with fat saturation and high signal-to-noise ratio. In this article, special emphasis will be placed on the impact of 3D GRE sequence in the diagnosis of pancreatic neoplasms with pathologic correlation.

Identification of arctigenin as an antitumor agent having the ability to eliminate the tolerance of cancer cells to nutrient starvation

Tumor cells generally proliferate rapidly and the demand for essential nutrients as well as oxygen always exceeds the supply due to the unregulated growth and the insufficient and inappropriate vascular supply. However, cancer cells show an inherent ability to tolerate extreme conditions, such as that characterized by low nutrient and oxygen supply, by modulating their energy metabolism. Thus, targeting nutrient-deprived cancer cells may be a novel strategy in anticancer drug development. Based on that, we established a novel screening method to discover anticancer agents that preferentially inhibit cancer cell viability under the nutrient-deprived condition. After screening 500 medicinal plant extracts used in Japanese Kampo medicine, we found that a CH(2)Cl(2)-soluble extract of Arctium lappa exhibited 100% preferential cytotoxicity under the nutrient-deprived condition at a concentration of 50 microg/mL with virtually no cytotoxicity under nutrient-rich condition. Further bioassay-guided fractionation and isolation led to the isolation of arctigenin as the primary compound responsible for such preferential cytotoxicity; the compound exhibited 100% preferential cytotoxicity against nutrient-deprived cells at a concentration of 0.01 microg/mL. Furthermore, arctigenin was also found to strongly suppress the PANC-1 tumor growth in nude mice, as well as the growth of several of the tested pancreatic cancer cell lines, suggesting the feasibility of this novel antiausterity approach in cancer therapy. Further investigation of the mechanism of action of arctigenin revealed that the compound blocked the activation of Akt induced by glucose starvation, which is a key process in the tolerance exhibited by cancer cells to glucose starvation.

Angelmarin, a novel anti-cancer agent able to eliminate the tolerance of cancer cells to nutrient starvation

The CH(2)Cl(2)-soluble extract of Angelica pubescens was found to kill PANC-1 cancer cells preferentially under nutrition starvation at a concentration of 50 microg/ml, with virtually no cytotoxicity under nutrient-rich conditions. Further bioassay-guided fractionation and isolation led to the isolation of a novel compound named angelmarin as the primary compound responsible for the preferential cytotoxicity; the compound exhibited 100% preferential cytotoxicity against PANC-1 cells at a concentration of 0.01 microg/ml.

High operative risk of cool-tip radiofrequency ablation for unresectable pancreatic head cancer

BACKGROUND AND OBJECTIVES

To report and discuss the effect, complications and mortality of cool-tip radiofrequency ablation (RFA) for unresectable pancreatic cancer.

METHODS

During October 2003 to July 2004, sixteen patients with unresectable pancreatic cancer were treated by open cool-tip RFA. One-half of the 16 patients had tumors located in the pancreatic head. A 5-mm minimum safe distance between RFA site and major peripancreatic vessels was kept to avoid injury to the vessels.

RESULTS

Six of twelve patients with back pain got pain relief postoperatively. Pancreatic fistula occurred in three patients (18.8%) and healed smoothly in 7-10 days with routine abdominal drainage. The mortality was 25% (4/16). In the four death cases, tumors were all located in the pancreatic head; three patients with tumor close to portal vein died suddenly of massive gastrointestinal hemorrhage on the 4th, 30th, 40th postoperative day respectively and a 79-year-old patient died of acute renal failure on the 2nd postoperative day.

CONCLUSIONS

Standard use of cool-tip RFA was dangerous for pancreatic head cancer close to portal vein, in which a 5-mm minimum safe distance between RFA site and major peripancreatic vessels might not be enough to avoid injury to the vessels.