Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer

High-intensity focused ultrasound (HIFU) for pancreatic carcinoma: evaluation of feasibility, reduction of tumour volume and pain intensity

OBJECTIVES

Prognosis of patients with locally advanced pancreatic adenocarcinoma is extremely poor. They often suffer from cancer-related pain reducing their quality of life. This prospective observational study aimed to evaluate feasibility, local tumour response, and changes in quality of life and symptoms in Caucasian patients with locally advanced pancreatic cancer treated by ultrasound-guided high-intensity focused ultrasound (HIFU).

METHODS

Thirteen patients underwent HIFU, five with stage III, eight with stage IV UICC disease. Ten patients received simultaneous palliative chemotherapy. Postinterventional clinical assessment included evaluation of quality of life and symptom changes using standardized questionnaires. CT and MRI follow-up evaluated the local tumour response.

RESULTS

HIFU was successfully performed in all patients. Average tumour reduction was 34.2 % at 6 weeks and 63.9 % at 3 months. Complete or partial relief of cancer-related pain was achieved in 10 patients (77 %), five of whom required less analgesics for pain control. Quality of life was improved revealing increased global health status and alleviated symptoms. HIFU treatment was well tolerated. Eight patients experienced transient abdominal pain directly after HIFU.

CONCLUSIONS

HIFU ablation of pancreatic carcinoma is a feasible, safe and effective treatment with a crucial benefit in terms of reduction of tumour volume and pain intensity.

KEY POINTS

• US-guided HIFU is feasible and safe for patients with unresectable pancreatic cancer. • HIFU can considerably reduce tumour volume and cancer-related pain. • Patients treated with HIFU experienced significant and lasting reduction of pain intensity. • HIFU has a crucial clinical benefit for patients with pancreatic cancer.

Selection of pancreatic cancer cell-binding landscape phages and their use in development of anticancer nanomedicines

It is hypothesized that the use of targeted drug delivery systems can significantly improve the therapeutic index of small molecule chemotherapies by enhancing accumulation of the drugs at the site of disease. Phage display offers a high-throughput approach for selection of the targeting ligands. We have successfully isolated phage fusion proteins selective and specific for PANC-1 pancreatic cancer cells. Doxorubicin liposomes (Lipodox) modified with tumor-specific phage fusion proteins enhanced doxorubicin uptake specifically in PANC-1 cells as compared with unmodified Lipodox and also compared with normal breast epithelial cells. Phage protein-targeted Lipodox substantially increased the concentration of doxorubicin in the nuclei of PANC-1 cells in spite of P-glycoprotein-mediated drug efflux. The in vitro cytotoxic activity obtained with pancreatic cell-targeted Lipodox was greater than that of unmodified Lipodox. We present a novel and straightforward method for preparing pancreatic tumor-targeted nanomedicines by anchoring pancreatic cancer-specific phage proteins within the liposome bilayer.

Racial/ethnic patterns of care for pancreatic cancer

INTRODUCTION

The small proportion of cancers diagnosed at the local disease stage, resectable at the time diagnosis, and responsive to chemotherapy contribute to poor survival making pancreatic cancer the fourth leading cause of cancer death among Americans. This emphasizes the importance of receiving appropriate palliative care. Racial/ethnic cancer treatment disparities have been observed for many cancer sites. We examine patterns of care in a population-based sample of African American, Hispanic and non-Hispanic white patients diagnosed with pancreatic cancer.

METHODS

Eligible cases were age 20 or older and newly diagnosed in 1998 with primary adenocarcinoma of the pancreas reported to the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) program and selected for the NCI Patterns of Care/Quality of Care (POC/QOC) project (n = 697).

RESULTS

Chemotherapy, the most frequently received treatment was less frequently received by African American patients (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.37-0.95) and radiation less frequently received by Hispanic compared to non-Hispanic white white patients (OR 0.50, 95% CI, 0.27-0.95) after adjustment for age, stage, size of tumor, and insurance status in a multivariate regression model. Cancer-directed surgery of the primary site was received by 14.1% of patients, which did not significantly differ by race/ethnicity. Uninsured patients less often were recommended for or received surgery (OR 0.09, 95% CI 0.01-0.62) and (OR 0.07, 95% CI, 0.01-0.49), respectively.

CONCLUSION

Differences in primary tumor size, stage and insurance status contributed to racial/ethnic differences in the receipt of cancer-directed surgery but did not explain differences in the receipt of chemotherapy for African American or radiation for Hispanic patients. More population-based research is needed to examine race/ethnicity, insurance status and receipt of treatment and palliative care for pancreatic cancer.

Neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic adenocarcinoma: feasibility, efficacy, and survival

BACKGROUND

We evaluated the feasibility and efficacy of neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic cancer.

MATERIALS AND METHODS

From October 2000 to August 2006, 245 patients with pancreatic adenocarcinoma underwent surgical exploration at our institution. Of these, 78 patients (32%) had undergone neoadjuvant therapy for initially unresectable disease, whereas the remaining patients (serving as the control group) were explored at presentation (n=167). All neoadjuvant patients received gemcitabine-based chemotherapy, often in conjunction with docetaxal and capecitabine in a regimen called GTX (81%). Seventy-five percent of neoadjuvant patients also received preoperative abdominal radiation (5,040 rad).

RESULTS

Neoadjuvant patients were younger than control-group patients (60.8 vs 66.2 years, respectively, p<0.002). Seventy-six percent of neoadjuvant patients were resected as compared to 83% of control patients (NS). Concomitant vascular resection was required in 76% of neoadjuvant patients but only 20% of NS (p<0.01). Complications were more frequent in the neoadjuvant group (44.1 vs 30.9%, p<0.05), and mortality was higher (10.2 vs 2.9%, p<0.03). Among the neoadjuvant patients, all but one of the deaths were in patients that underwent arterial reconstruction. Mortality for patients undergoing a standard pancreatectomy without vascular resection was 0.8% in this series. Of patients resected, negative margins were achieved in 84.7% of neoadjuvant patients and 72.7% of NS. Within the cohort of neoadjuvant patients, radiation significantly increased the complication rate (13.3 vs 54.6%, p<0.006), but did not affect median survival (512 vs 729 days, NS). Median survival for patients who received neoadjuvant therapy (503 days) was longer than NS that were found to be unresectable at surgery (192 days, p<0.001) and equivalent to NS that were resected (498 days).

CONCLUSIONS

Resection rate, margin status, and median survivals were equivalent when neoadjuvant patients were compared to patients considered resectable by traditional criteria, demonstrating equal efficacy. Surgical resection with venous reconstruction following neoadjuvant therapy for patients with locally advanced pancreatic cancer can be performed with acceptable morbidity and mortality. This approach extended the boundaries of surgical resection and greatly increased median survival for the "inoperable" patient with advanced pancreatic cancer.

Transitions of care and changes in distressing pain

This study employed a 22-state mortality follow-back survey to examine bereaved family members' perception of the level and pattern of distressing pain in decedents with cancer at the last two sites of care. Of the 1,578 individuals interviewed, 423 of their family members had cancer listed as the leading cause of death on the decedent's death certificate. Decedents were treated at home, hospitals, hospices, or nursing homes, with more than half of the respondents (n = 216) reporting that the decedent was at more than one site of care in the last month. Forty-two percent of decedents had distressing pain (defined as "quite a bit" or "very much") at their second to last place of care, with 40% having distressing pain at the last place. There was some variation in the degree of change depending on the transition between the second to last and last places of care. For many individuals, however, the transition to another place of care did not result in an improvement in the level of distressing pain. No significant differences were found in the change in distressing pain by transition of care. Increased attention is needed not only on how to adequately manage pain and pain-related distress but also on how to improve pain reduction measures in transitions between health care settings at the end of life.

Pancreatic cancer pain and its correlation with changes in tumor vasculature, macrophage infiltration, neuronal innervation, body weight and disease progression

To begin to understand the relationship between disease progression and pain in pancreatic cancer, transgenic mice that develop pancreatic cancer due to the expression of the simian virus 40 large T antigen under control of the rat elastase-1 promoter were examined. In these mice precancerous cellular changes were evident at 6 weeks and these included an increase in: microvascular density, macrophages that express nerve growth factor and the density of sensory and sympathetic fibers that innervate the pancreas, with all of these changes increasing with tumor growth. In somatic tissue such as skin, the above changes would be accompanied by significant pain; however, in mice with pancreatic cancer, changes in pain-related behaviors, such as morphine-reversible severe hunching and vocalization only became evident at 16 weeks of age, by which time the pancreatic cancer was highly advanced. These data suggest that in mice as well as humans, there is a stereotypic set of pathological changes that occur as pancreatic cancer develops, and while weight loss generally tracks disease progression, there is a significant lag between disease progression and behaviors indicative of pancreatic cancer pain. Defining the mechanisms that mask this pain in early and mid-stage disease and drive the pain in late-stage disease may aid in earlier diagnosis, survival, and increased quality of life of patients with pancreatic cancer.

Feasibility of US-guided high-intensity focused ultrasound treatment in patients with advanced pancreatic cancer: initial experience

The study was approved by the university ethics committee, and informed consent was obtained from all patients. The purpose of this study was to prospectively evaluate ultrasonographically guided high-intensity focused ultrasound in the treatment of patients with advanced-stage pancreatic cancer. Eight patients underwent high-intensity focused ultrasound ablation, and laboratory and radiologic examinations were performed after intervention. Changes in symptoms and survival time were noted at follow-up. No complications were observed, and preexisting severe back pain disappeared after intervention. Follow-up images revealed an absence of tumor blood supply and shrinkage of the ablated tumor. Four patients died, and four patients were alive at the time of this writing, with a median survival time of 11.25 months. The authors conclude that high-intensity focused ultrasound ablation is safe and feasible in the treatment of advanced pancreatic cancer.

The HaP-T1 Syrian golden hamster pancreatic cancer model: cell implantation is better than tissue implantation

OBJECTIVES

Pancreatic cancer is characterized by a poor prognosis and an unsatisfactory response to conventional therapy. Appropriate experimental animal models that mimic the disease are essential to establish new therapies. The aim of this study was to compare homologous orthotopic cell implantation (OCI) and orthotopic tissue implantation (OTI) methods in the nitrosamine-derived HaP-T1 Syrian golden hamster pancreatic cancer model.

METHODS

Pancreatic tumors were induced in 32 Syrian hamsters by the OCI (n = 16) and OTI (n = 16) techniques. OTI and OCI subgroups (n = 4) were killed at 1, 2, 5, and 8 weeks post-implantation. Tumor uptake and growth and the rates of local invasion and metastases were compared at autopsy.

RESULTS

Tumor uptake was 100% by OCI and 88% by OTI. Induced pancreatic tumors were significantly larger in the OCI group (mean weight, 1.7 g vs. 0.26 g, P < 0.01.) The incidence of local invasion and rates of lymph node, liver, and peritoneal metastases were all significantly higher in the OCI group.

CONCLUSION

The OCI method is more effective than OTI in terms of tumor uptake. Tumor growth and the rates of local invasion and spontaneous metastases are higher with OCI than OTI. The OCI method is better than OTI and can contribute to the development of therapeutic strategies in pancreatic cancer research.

Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care

This update is devoted to discussion of optimal supportive and palliative care of patients with pancreatic cancer. Approximately 33,000 new cases of pancreatic cancer are predicted for the U.S. in 2002. Because diagnosis and intervention occur late in the course of this disease, the vast majority of patients already have metastatic disease at the time of diagnosis. These tumors are relatively resistant to systemic chemotherapy, making pancreatic cancer the fourth leading cause of cancer-related death in the U.S. and the Western world. For these reasons, efforts at identifying and treating disease-related symptomatology are priorities. This update overviews symptom management, supportive care strategies, and both standard and emerging palliative chemotherapy options. The incorporation of molecularly targeted therapies into treatment of metastatic pancreatic cancer is reviewed as well. These strategies are of relevance to internists, gastroenterologists, oncologists, and other specialists who care for patients with pancreatic cancer.

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Surgical palliation in advanced disease: recent developments

Despite many valuable technical innovations for the relief of suffering in advanced disease over the past few years, only recently have surgical oncologists attempted to more clearly define palliation. Previous definitions have been misleading, creating confusion about the merits of surgery in many situations and difficulty in posing questions for future prospective clinical trials. This report outlines recent progress in identifying and refining a philosophy of palliative surgery that would align it with the consensus of nonsurgical opinion summarized by the 1990 World Health Organization definition of palliative care and the emerging consensus among the medical specialties in the United States concerning principles of care at the end of life. Selected controversies and recent innovations, as well as guidelines for palliative surgery, are discussed.