Adjuvant chemotherapy of S-1 versus gemcitabine for resected pancreatic cancer: a phase 3, open-label, randomised, non-inferiority trial (JASPAC 01)

Programmed cell death 1 inhibitor sintilimab plus S-1 and gemcitabine for liver metastatic pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer with poor prognosis. When it metastasizes to the liver, treatment options become particularly limited and challenging. Current treatment options for liver metastatic PDAC are limited, and chemotherapy alone often proves insufficient. Immunotherapy, particularly programmed cell death 1 (PD-1) inhibitors like sintilimab, shows potential efficacy for various cancers but has limited reports on PDAC. This study compares the efficacy and safety of sintilimab plus S-1 and gemcitabine vs S-1 and gemcitabine alone in liver metastatic PDAC.

AIM

To explore the feasibility and effectiveness of combined PD-1 inhibitor sintilimab and S-1 and gemcitabine (combination group) vs S-1 and gemcitabine used alone (chemotherapy group) for treating liver metastatic pancreatic adenocarcinoma.

METHODS

Eligible patients were those with only liver metastatic PDAC, an Eastern Cooperative Oncology Group performance status of 0-1, adequate organ and marrow functions, and no prior anticancer therapy. Participants in the combination group received intravenous sintilimab 200 mg every 3 weeks, oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle, and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles or until disease progression, death, or unacceptable toxicity. Participants in the chemotherapy group received oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles. Between June 2020 and December 2021, 66 participants were enrolled, with 32 receiving the combination treatment and 34 receiving chemotherapy alone.

RESULTS

The group receiving the combined therapy exhibited a markedly prolonged median overall survival (18.8 months compared to 10.3 months, P < 0.05) and progression-free survival (9.6 months vs 5.4 months, P < 0.05). compared to the chemotherapy group. The incidence of severe adverse events did not differ significantly between the two groups (P > 0.05).

CONCLUSION

The combination of PD-1 inhibitor sintilimab with S-1 and gemcitabine demonstrated effectiveness and safety for treating liver metastatic PDAC, meriting further investigation.

Is distal pancreatectomy the optimal surgical procedure for pancreatic neck cancer?

BACKGROUND

The optimal resection for pancreatic neck cancer is challenging in clinical practice because we could dissect by pancreaticoduodenectomy or distal pancreatectomy. The purpose of this study was to evaluate the effectiveness of lymph node dissection and to help determine the optimal surgical treatment for pancreatic neck cancer.

METHODS

We retrospectively evaluated 462 patients with pancreatic cancer who underwent curative-intent pancreatectomy between 2012 and 2022, 35 of whom had pancreatic neck cancer without preoperative radiologic gastroduodenal artery contact. We analyzed the clinicopathological characteristics, lymph node metastasis stations, and the efficacy index of lymph node dissection, which was calculated by multiplying the frequency of lymph node metastasis to each station by the 5-year survival rate of patients with positive lymph nodes at each station.

RESULTS

The lymph node station with the greatest rate of metastasis was #11p (28.6%), followed by #8 (17.1%), #14 (14.3%), #13 (14.3%), #17 (9.5%), and #6 (4.8%). The efficacy indices of lymph node dissection were 14.3 for #11, 4.76 for #13, and 8.57 for #14. There were no significant differences in 5-year recurrence-free survival and 5-year overall survival between patients undergoing pancreaticoduodenectomy and those undergoing distal pancreatectomy (23.7% vs 54.7%, P = .142; 29.9% vs 51.1%, P = .179, respectively). Univariate survival analysis showed that tumor size ≥2 cm was associated with poor prognosis (hazard ratio, 3.842, P = .009).

CONCLUSIONS

PD with #11p lymph node dissection is preferable to DP in terms of survival benefit for pancreatic neck cancer with lymph node metastasis.

Intratumoural expression of dihydropyrimidine dehydrogenase is an independent prognostic factor in resected pancreatic ductal adenocarcinoma treated with adjuvant gemcitabine

Pancreatic ductal adenocarcinoma (PDAC) is associated with a poor prognosis, and biomarkers to guide treatment decisions in PDAC are generally lacking. Intratumoural expression of dihydropyrimidine dehydrogenase (DPD) is a potential prognostic parameter in patients with PDAC undergoing surgical resection and postoperative chemotherapy. In the present study, DPD was analysed by immunohistochemistry of a tissue microarray platform including a real-world cohort of 495 patients with PDAC who had undergone resection with curative intent at any of three tertiary centres, including Northern, Western and Southeastern regions of Sweden, between 1993 and 2019. DPD level (high/low) was analysed and overall survival associations were assessed in treatment subgroups using a multivariate Cox regression model accounting for potential confounders. In patients who had not received adjuvant chemotherapy (n=182), the median overall survival time was 11.6 months (95% CI 9.6-13.5), compared with 28.8 months (25.0-32.6) among those who had (n=313; log-rank P<0.001). The most common type of chemotherapy was gemcitabine single agent (Gem, n=239) followed by gemcitabine plus capecitabine (GemCape, n=39). Tumour-Node-Metastasis (TNM) stage and DPD expression were statistically significant prognostic parameters in the Gem group (HR 1.19, 95% CI 1.01-1.41, P=0.036), with high expression of DPD linked with worse survival. In addition, tumour grade and TNM stage were statistically significant prognostic factors in the group that did not receive any chemotherapy (P≤0.001). No statistically significant parameters were identified in the GemCape group. Taken together, intratumoural expression of DPD may be considered a prognostic marker for patients with PDAC treated with adjuvant gemcitabine following surgical resection, with low expression levels predicting better survival. Further studies in larger cohorts of patients receiving multi-drug or non-gemcitabine based regimens are warranted.

Clinical significance of resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma with occult para-aortic lymph node metastasis

BACKGROUND

This study aimed to determine the clinical significance of resection of pancreatic ductal adenocarcinoma diagnosed with occult para-aortic lymph node metastasis using intraoperative para-aortic lymph node sampling.

METHODS

Between January 2005 and May 2021, a total of 606 patients who underwent surgery for pancreatic ductal adenocarcinoma with intraoperative para-aortic lymph node sampling were retrospectively investigated and divided into the resected para-aortic lymph node-negative (n = 543), resected para-aortic lymph node-positive (n = 44), and unresected para-aortic lymph node-positive (n = 19) groups. Overall survival, clinicopathologic characteristics, and prognostic factors were analyzed.

RESULTS

The overall survival in the resected para-aortic lymph node-positive group was significantly worse than that in the resected para-aortic lymph node-negative group (3-year overall survival, 29.8% vs 48.4%, P < .001) and significantly better than that in the unresected para-aortic lymph node-positive group (3-year overall survival, 29.8% vs 0.0%, P = .008). In the resected para-aortic lymph node-positive group, adjuvant chemotherapy was an independent prognostic factor (hazard ratio = 2.689, P = .033). The overall survival of patients in the resected para-aortic lymph node-positive group who received adjuvant chemotherapy was comparable to that of patients in the resected para-aortic lymph node-negative group who had 4 or more regional lymph node metastases and received adjuvant chemotherapy (3-year overall survival, 33.9% vs 34.1%, P = .343). A logistic regression analysis showed that neoadjuvant therapy, age <65 years, creatinine clearance >60 mL/min, pancreatic body or tail tumor, and serum albumin level >3.5 g/dL were significant predictive factors for induction of adjuvant chemotherapy in 587 resected patients.

CONCLUSIONS

Resection may be acceptable for patients with para-aortic lymph node-positive pancreatic ductal adenocarcinoma who are likely to tolerate adjuvant chemotherapy.

Inhibitory effects of the combination of rapamycin with gemcitabine plus paclitaxel on the growth of pancreatic cancer tumors

We previously examined the antitumor effects of short interfering RNA nanoparticles targeting mammalian target of rapamycin (mTOR) in an orthotopic pancreatic cancer mouse model. We herein report the inhibitory effects of the mTOR inhibitor rapamycin on tumor growth in a novel established mouse model of pancreatic cancer using human pancreatic cancer cell line-derived organoids. Gemcitabine, 5-fluorouracil, and gemcitabine plus nab-paclitaxel are clinically used to treat advanced pancreatic cancer. In vitro assays showed that rapamycin strongly inhibited cell invasion, while gemcitabine, 5-fluorouracil, and gemcitabine plus paclitaxel primarily inhibited cell proliferation with minimal effects on invasion. In vivo mouse experiments demonstrated that rapamycin exhibited superior antitumor activity to S-1 (a metabolically activated prodrug of 5-fluorouracil) and another mTOR inhibitor, everolimus, while its efficacy was similar to that of gemcitabine plus paclitaxel (which was used instead of nab-paclitaxel due to concerns about allergic reactions in mice to human albumin) in a mouse model of pancreatic cancer using human pancreatic cancer cell line-derived organoids. Furthermore, the combination of rapamycin with gemcitabine plus paclitaxel exerted synergistic inhibitory effects on the growth of pancreatic cancer tumors. Although the inhibition of tumor growth was significantly stronger in everolimus-treated mice than in control mice, there were no additive anti-growth effects when combined with gemcitabine plus paclitaxel. The present results suggest that the combination of rapamycin with gemcitabine plus paclitaxel achieved the greatest reduction in tumor volumes in the mouse xenograft model and, thus, has significant clinical promise.

Phase II Trial of Adjuvant S-1 Following Neoadjuvant Chemotherapy and Surgery in Patients with Locally Advanced Esophageal Squamous Cell Carcinoma: The PIECE Trial

BACKGROUND

Neoadjuvant chemotherapy followed by surgery (NAC-S) is the standard therapy for locally advanced esophageal squamous cell carcinoma (ESCC) in Japan.

OBJECTIVE

The aim of this phase II trial was to assess the efficacy and safety of the addition of adjuvant S-1 after R0 resection in ESCC patients who received NAC-S.

PATIENTS AND METHODS

Key eligibility criteria included clinical stage IB-III (without T4 disease) ESCC, age 20-75 years, and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients received adjuvant therapy with four cycles of S-1 (80 mg/m2/day) administered orally for 4 weeks of 6-week cycles. The primary endpoint was 3 year relapse-free survival (RFS). If the lower confidence limit for 3 year RFS was >50%, we judged that the primary endpoint of this study was met.

RESULTS

A total of 52 patients were enrolled between January 2016 and January 2019. Two patients were excluded from analysis; five patients were determined to have R1 or R2 resection, and seven patients did not receive adjuvant S-1. The 3-year RFS and overall survival rates in the intention-to-treat population were 72.3% (90% confidence interval [CI] 59.9-81.5) and 85.0% (90% CI 73.9-91.6), indicating that the primary endpoint was met. Grade ≥3 adverse events with an incidence ≥10% included neutropenia (13.2%), anorexia (13.2%), and diarrhea (10.5%). There were no treatment-related deaths.

CONCLUSION

Adjuvant S-1 after NAC-S showed promising efficacy with a manageable safety profile for patients with resectable ESCC and warrants further evaluation in larger studies.

Neoadjuvant Treatment with Changes in Chemotherapy Regimens According to Carbohydrate Antigen 19-9 Level for Resectable/Borderline Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

The response of carbohydrate antigen (CA) 19-9 to neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) may contribute to outcomes. This study aimed to investigate the effect of changes in NAT regimens based on CA19-9 level.

METHODS

This single-center retrospective study included patients with resectable/borderline resectable (R/BR)-PDAC undergoing NAT from 2008 to 2022. A CA19-9 level lower than 150 IU/mL after NAT was the criterion for resection. If the level did not decrease, the chemotherapy regimen was changed to satisfy the criterion. The patient cohort was divided into group A (satisfied criterion without changing chemotherapy), group B (did not receive chemotherapy change, could not satisfy the criterion), group C (received chemotherapy change, satisfied the criterion), and group D (received chemotherapy change, could not satisfy the criterion).

RESULTS

The study cohort included 283 patients. After first-line chemotherapy, 112 (39.6%) patients did not satisfy the criterion (groups B [n = 64], C [n = 32], and D [n = 16]). Of the 283 patients, 48 (17%) received a chemotherapy change (groups C and D). The patients in groups C and D showed significantly better overall survival (OS, 35.9 months) than the group B patients (25.7 months) (P = 0.035). The OS of the group C patients (63.8 months) was similar to the OS of the group A patients (n = 171: 56.3 months; P = 0.430). Multivariate analysis of the patients in groups B, C, and D identified chemotherapy change as an independent prognostic factor for OS and progression-free survival.

CONCLUSION

Changing the chemotherapy targeting the CA19-9 level can improve the outcome of R/BR-PDAC patients with poor biologic response to first-line NAT.

Changes in Skeletal Muscle Volume During Preoperative Chemotherapy Affect the Outcome of Pancreatic Cancer

BACKGROUND

This study aimed to investigate the effects of changes in clinicopathological factors during preoperative chemotherapy for pancreatic cancer, including skeletal muscle volume, on recurrence and prognosis after pancreatectomy.

METHODS

Data from 41 patients who underwent resection for pancreatic cancer after preoperative chemotherapy from 2012 to 2021 were retrospectively reviewed. Skeletal muscle volume was substituted for the psoas muscle area (PMA) at the level of the third lumbar vertebra. We investigated the relationship of clinicopathological factors during preoperative chemotherapy with disease-free survival (DFS) and overall survival (OS). The association between clinicopathological factors and a decrease in PMA was investigated.

RESULTS

In the multivariate analyses for DFS and OS, the factors associated with recurrence were as follows: decrease in PMA (P = 0.003) and the absence of adjuvant therapy (P = 0.03), and the factors associated with poor prognosis were as follows: decrease in PMA (P = 0.04) and the absence of adjuvant therapy (P = 0.008), and the resectability of borderline resectable and unresectable-locally advanced tumors (P = 0.033). All patients with partial response according to the Response Evaluation Criteria in Solid Tumors (version 1.1) had no decrease in PMA (P = 0.01). The proportion of patients with Evans classification ≥ II was significantly higher in the group without a decrease in PMA (P = 0.02). The proportion of patients with an average relative dose intensity of adjuvant therapy ≥0.6 was significantly higher in the group without a decrease in PMA (P = 0.02).

CONCLUSION

Changes in preoperative skeletal muscle volume during preoperative chemotherapy for pancreatic cancer is a potential predictor of recurrence and prognosis after pancreatectomy.

Impact of Preoperative Osteosarcopenia and Postoperative Administration of Pancrelipase on the Prognosis of Borderline Resectable and Unresectable Locally Advanced Pancreatic Cancer

BACKGROUND

This study aimed to identify postoperative recurrence and prognostic factors, including osteosarcopenia for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer and to examine the impact of postoperative pancreatic enzyme replacement therapy (PERT).

METHODS

We retrospectively examined 32 resected patients with BR and UR-LA pancreatic cancer. We investigated independent factors in the disease-free survival and overall survival. The relation of osteosarcopenia with the clinicopathological factors was investigated. Additionally, the association of the administration of a standard dose of pancrelipase, the amount of lipase required for patients with pancreatic exocrine insufficiency, for ≥6 months postoperatively with improvement of sarcopenia, osteopenia, and osteosarcopenia and completion rate of adjuvant chemotherapy was investigated.

RESULTS

Multivariate analyses identified osteosarcopenia (P = 0.049) and lymph node metastasis (P = 0.01) as independent recurrence predictors, and osteosarcopenia (P = 0.002), maximum tumor diameter ≥40 mm (P = 0.006), and no adjuvant therapy (P = 0.01) as independent prognostic predictors. In the osteosarcopenia group, serum CA19-9 levels were higher (P = 0.03). The administration of a standard dose of pancrelipase for ≥6 months postoperatively was none in the osteosarcopenia group (0% vs 42.9%, P = 0.01), while significantly improved postoperative sarcopenia (33% vs 0%, P = 0.004), increased number of cycles of adjuvant chemotherapy (n = 6 vs n = 3, P = 0.03), and the completion rate of adjuvant chemotherapy in excluding cases interrupted because of recurrence (86% vs 25%, P = 0.007).

CONCLUSIONS

Osteosarcopenia was an independent recurrent and prognostic factor in patients after pancreatectomy for locally advanced pancreatic cancer. Appropriate postoperative PERT may contribute to a better prognosis by improving sarcopenia and increasing the completion rate of adjuvant chemotherapy.

Neoadjuvant gemcitabine and S-1 in pancreatic ductal adenocarcinoma: Effects on nutritional status and pancreaticoduodenectomy outcomes

BACKGROUND

With the advent of improved chemotherapy options, neoadjuvant chemotherapy has gained acceptance as a multidisciplinary treatment approach for localized pancreatic ductal adenocarcinoma. This study aimed to clarify whether neoadjuvant chemotherapy with gemcitabine and S-1 influences preoperative nutritional status and postoperative outcomes, particularly in patients undergoing highly invasive pancreatic resection.

METHODS

Patients with resectable pancreatic ductal adenocarcinoma who underwent pancreaticoduodenectomy as upfront surgery or after neoadjuvant chemotherapy with gemcitabine and S-1 between January 2015 and December 2022 were assessed. In addition to perioperative surgical outcomes, preoperative nutritional status was evaluated using serum albumin, controlling nutritional status, and prognostic nutritional index.

RESULTS

A total of 158 patients who underwent upfront pancreaticoduodenectomy and 119 who received neoadjuvant chemotherapy with gemcitabine and S-1 before pancreaticoduodenectomy were evaluated. Preoperative nutritional assessments (serum albumin, controlling nutritional status score, and prognostic nutritional index) showed no significant differences between groups, either at the initial consultation or immediately before surgery. No significant differences were observed in postoperative outcomes, including blood loss, operation time, and morbidity. The neoadjuvant chemotherapy with gemcitabine and S-1 group had a significantly greater rate of negative tumor margins (R0 resection rate 86% vs 74%, P = .018), and improved overall survival (hazard ratio, 0.41; 95% confidence interval, 0.25-0.67, P < .001) compared with the upfront pancreaticoduodenectomy group.

CONCLUSIONS

Neoadjuvant chemotherapy with gemcitabine and S-1 does not adversely impact preoperative nutritional status and enhances the effectiveness of pancreaticoduodenectomy for resectable pancreatic ductal adenocarcinoma, leading to improved pathologically curative resection rates and overall survival.

Timing of TS1 adjuvant chemotherapy as a prognostic factor in recurrent pancreatic cancer after surgery

AIM

Prognosis of pancreatic cancer is improved by combining postoperative adjuvant chemotherapy and preoperative adjuvant chemotherapy with surgery, while the importance of extended dissection surgery has decreased. To better understand prognostic factors of recurrence, we focused on the timing of postoperative adjuvant chemotherapy in patients with pancreatic cancer.

METHODS

One hundred patients who underwent pancreatectomy or pancreaticoduodenectomy and chemotherapy for pancreatic cancer were classified into early and late postoperative adjuvant therapy initiation groups. Prognosis was evaluated retrospectively using known prognostic factors.

RESULTS

On receiver operating characteristic analysis, optimum cut-off between the early (<52 days; n = 60) and late adjuvant initiation groups (≥52 days; n = 40) was 52 days. The two groups were well-matched, except the early initiation group had more surgeries with D2 lymph node dissection (75 % vs 48 %; p = 0.01); fewer postoperative complications (17 % vs 59 %; p = 0.04), including less postoperative pancreatic fistula (13 % vs 35 %; p = 0.03); and longer disease-free survival (0.7 years v 0.5 years; p = 0.02). On multivariate evaluation, early initiation and completion of adjuvant therapy were associated with increased overall survival, while early initiation was associated with prolonged disease-free survival.

CONCLUSIONS

Prognosis of patients with pancreatic cancer is improved by earlier rather than later initiation of postoperative adjuvant therapy.

Pancreatic Adenocarcinoma: Long-Term Outcomes of Adjuvant Therapy in the ESPAC4 Phase III Trial

PURPOSE

The ESPAC4 trial showed that adjuvant chemotherapy with gemcitabine plus capecitabine (GemCap) produced longer overall survival (OS) than gemcitabine monotherapy. Subsequently, the PRODIGE24-CCTG PA.6 trial showed even longer survival for modified fluorouracil, folinic acid, irinotecan, and oxaliplatin (mFOLFIRINOX) than gemcitabine but had more restrictive eligibility criteria. Our aim was to analyze the ESPAC4 survival on long-term follow-up.

METHODS

The OS of 732 ESPAC4 patients comparing 367 randomly assigned to gemcitabine and 365 to GemCap was previously reported after a median follow-up time of 43.2 months (95% CI, 39.7 to 45.5) and 458 deaths. Analysis was now carried out after a median follow-up of 104 months (101-108) and 566 deaths.

RESULTS

The median OS was 29.5 months (27.5-32.1) for all patients, 28.4 months (25.2-32.0) in the gemcitabine group and 31.6 months (26.5-38.0) in the GemCap group (hazard ratio [HR], 0.83 [0.71 to 0.98]; P = .031). R0 patients given gemcitabine had a median survival of 32.2 months (27.9-41.6) compared with 49.9 months (39.0-82.3) for those given GemCap (HR, 0.63 [0.47 to 0.84]; P = .002). Lymph node-negative patients had significantly higher 5 year OS rates on GemCap (59% [49%-71%]) than gemcitabine (53% [42%-66%]; HR, 0.63 [0.41 to 0.98]; P = .04) but not those with positive lymph nodes (P = .225). The OS advantage for GemCap was retained in the PRODIGE24 subgroup of 193 (26.4%) ESPAC4 patients not eligible for PRODIGE24 with a median survival of 20.7 (16.2-27.3) months in patients allocated to gemcitabine compared with 25.9 (22.3-30.2) months for ineligible patients allocated to GemCap (HR, 0.71 [95% CI, 0.52 to 0.98]; χ2log-rank-1df = 4.31; P = .038).

CONCLUSION

GemCap is a standard option for patients not eligible for mFOLFIRINOX. Exploratory evidence suggests that GemCap may be particularly efficacious in R0 patients and also in lymph node-negative patients.

Outcomes following pancreaticoduodenectomy for octogenarians: a systematic review and meta-analysis

BACKGROUND

An increasing number of elderly patients are being diagnosed with pancreatic cancer, with increasing need to consider pancreatic surgery. This study aims to provide an updated systematic review and meta-analysis to evaluate the outcomes following pancreaticoduodenectomy in octogenarians.

METHODS

A systematic review and meta-analysis was performed via a search of Medline, PubMed and Cochrane databases. Studies comparing outcomes of patients >80 years to younger patients undergoing PD were included.

RESULTS

26 studies were included. This included 22481 patients, with 20134 (89.6%) aged <80 years old, and 2347 (10.4%) octogenarians. Octogenarians were associated with higher rates of mortality (OR 2.37 (95%CI 1.91-2.94, p < 0.00001)), all-cause morbidity (OR 1.60 (95%CI 1.30-1.96), p<0.00001) and re-operation (OR 1.41 (95%CI 1.13-1.75), p = 0.002). Octogenarians had a two-fold risk of cardiac complications and respiratory complications (OR 2.13 (95%CI 1.67-2.73), p < 0.00001), (OR 2.38 (95%CI 1.72-3.27), p < 0.0001). There was no difference in postoperative pancreatic fistula, post-pancreatectomy hemorrhage or delayed gastric emptying. Younger patients were more likely to return to adjuvant therapy (OR 0.20 (95%CI 0.12-0.34), p < 0.00001).

CONCLUSIONS

Octogenerians are associated with higher mortality rate, postoperative complications, and reduced likelihood to undergo adjuvant therapy. Careful preoperative assessment and selection of elderly patients for consideration of pancreatic surgery is essential.

Combination of S-1 and the oral ATR inhibitor ceralasertib is effective against pancreatic cancer cells

PURPOSE

In our previous study, we found that the Chk1 inhibitor prexasertib enhances the antitumour effect of the oral anticancer drug S-1 against pancreatic cancer cells. In this study, we investigated the effect of combining S-1 and ceralasertib, an oral inhibitor of ATR, which is located upstream of Chk1. Ceralasertib is currently being investigated in multiple clinical trials for various cancers.

METHODS

The cell-proliferation inhibitory effect was measured by MTT assay, using the pancreatic cancer cell lines BxPC-3, SUIT-2, PANC-1, and MIA PaCa-2, while apoptosis was measured by flow cytometry using PI/Annexin staining. The mechanism underlying the combined effect was analysed using western blotting, and the antitumor effect was analysed using a mouse xenograft model.

RESULTS

MTT assay revealed that the combination of S-1 and ceralasertib had a synergistic effect, leading to the suppression of cell proliferation. Measurement with PI/Annexin staining revealed that the combination of S-1 and ceralasertib induced apoptosis more efficiently than either drug alone. Western blotting results showed that ceralasertib inhibited S-1-induced activation of ATR and Chk1. The average estimated tumour volume after 3 weeks of administration was 601 mm3 in the S-1 group, 580 mm3 in the ceralasertib group, and 298 mm3 in the combination group.

CONCLUSION

The combination of S-1 and ceralasertib demonstrated a high antiproliferative effect in inhibiting tumour growth in vitro.

Preoperative nutritional status is a useful predictor of the feasibility of postoperative treatment in octogenarian-plus pancreatic ductal adenocarcinoma patients

BACKGROUND

The suitability of radical surgery for very elderly pancreatic cancer (PC) patients remains controversial due to concerns about postoperative functional reserve. Inflammatory-nutritional status may help identify elderly patients at risk of compromised postoperative treatment tolerance.

METHODS

This retrospective analysis included 121 patients over eighty who were diagnosed with PC in 2010-2019, 40 of whom underwent radical surgery. Surgical outcomes were compared with those of 205 younger patients (under 80 years-old) who underwent radical surgery. K-means cluster analysis was conducted with four inflammatory-nutritional indices (NLR, PLR, PNI, and mGPS) to define, and the indices using ordinal logistic analysis were evaluated in each cluster to create a formula named 'nutritional index (NTI)', which was then used to redefine the clusters. The predictive ability of the NTI was validated in other octogenarians who underwent pancreatectomy for PC between 2020 and 2023.

RESULTS

Patients older than eighty exhibited comparable overall survival to younger patients (median survival time, 30.7/37.1 months, p = 0.20). However, octogenarian-plus patients had lower rates of adjuvant chemotherapy (AC) initiation (45/80 %) and treatment upon recurrence (52/84 %), resulting in shorter survival after recurrence (7.4/11.1 months, p = 0.06). Inflammatory-nutritional status was significantly associated with overall survival, with poor nutritional status being linked to lower rates of AC initiation and/or treatment upon recurrence. NTI effectively predicted AC feasibility.

CONCLUSIONS

Radical surgery for octogenarian-plus PC patients meeting the current criteria was safe, but lower rates of postoperative treatment initiation may lead to poorer outcomes after recurrence. Inflammatory-nutritional status assessment could enhance surgical eligibility in octogenarian-plus PC patients.

Clinical significance and therapeutic implication of CD200 in pancreatic cancer

BACKGROUND

CD200, a negative regulator of T cells as well as a marker for cancer stem cells, represents a significant prognostic factor and potential therapeutic target in certain cancers. However, its clinical significance remains unknown in pancreatic ductal adenocarcinoma (PDAC).

METHODS

CD200 was assessed in 220 resected PDAC patients who underwent surgery with or without neoadjuvant chemoradiotherapy (NACRT). We examined the clinicopathological outcomes associated with CD200 and further assessed its clinical implications regarding immunological and cancer stem cell properties.

RESULTS

NACRT was associated with higher CD200 expression (66.4 % vs. 32.2 %, P < 0.001) compared to upfront surgery. CD200 was identified as an independent poor prognostic factor in NACRT (hazard ratio 1.90, 95 % confidence interval 1.12-3.23, P = 0.016), but not in upfront surgery patients. Post-recurrence survival was significantly worse in CD200+ patients compared to CD200- patients in the NACRT group, but there was no significant difference observed in the upfront surgery group. CD200 expression was correlated with significantly lower levels of CD4+, CD8+, and CD45RO+ tumor-infiltrating lymphocytes. Furthermore, the correlation of CD200 with pancreatic cancer stem cell markers CD44/CD24/ESA was stronger in irradiated human pancreatic cancer cells.

CONCLUSIONS

Our data underscore novel roles for CD200 in immune evasion as well as therapy resistance in pancreatic cancer. CD200 may represent a novel poor prognostic predictive factor and potential therapeutic target for PDAC with NACRT.

Characteristics and prognosis of patients with pancreatic adenocarcinoma not expressing CA19-9: Analysis of the National Cancer Database

BACKGROUND

Around 5-10 % of pancreatic cancer patients are non-expressors of carbohydrate antigen 19-9 (CA 19-9), which has an unknown impact on the aggressiveness and prognosis of pancreatic adenocarcinoma (PDAC). This study aimed to evaluate the characteristics and the prognosis of PDAC patients who do not express CA 19-9.

METHODS

Patients with PDAC diagnosed between 2010 and 2018 were identified in the National Cancer Database. Clinical characteristics were compared according to CA 19-9 levels stratified in four different groups: non-expressors (≤1.0 U/mL), normal range (1.1-37.0 U/mL), mildly elevated (37.1-97.9 U/mL), and CA 19-9 ≥98.0 U/mL. The characteristics were analyzed in the whole cohort and overall survival (OS) was evaluated in a subgroup of upfront resected patients who had cT1-3 tumors without distant metastases.

RESULTS

In total, 88,749 patients were included, of which 4.5 % were CA 19-9 non-expressors. The non-expressors had a higher risk of having distant metastasis at diagnosis, compared to patients with normal-range or mildly elevated CA 19-9 levels. In resected patients (n = 4008), CA 19-9 non-expressors had shorted median OS compared to patients with normal-range CA 19-9 levels (29.3 vs 34.4 months, p = 0.024). This OS association remained in a multivariable Cox regression model (adjusted HR 1.22, 95 % CI 1.04-1.44).

CONCLUSIONS

CA 19-9 non-expression is associated with distant metastatic disease at diagnosis and with death in resected non-metastatic patients compared to normal-range CA 19-9 levels. This clinically relevant subgroup requires alternative biomarkers, and may need consideration of more extensive preoperative staging and intensive perioperative systemic therapy.

Targeted Dynamic Phospho-Proteogenomic Analysis of Gastric Cancer Cells Suggests Host Immunity Provides Survival Benefit

Despite of massive emergence of molecular targeting drugs, the mainstay of advanced gastric cancer (GC) therapy is DNA-damaging drugs. Using a reverse-phase protein array-based proteogenomic analysis of a panel of 8 GC cell lines, we identified genetic alterations and signaling pathways, potentially associated with resistance to DNA-damaging drugs, including 5-fluorouracil (5FU), cisplatin, and etoposide. Resistance to cisplatin and etoposide, but not 5FU, was negatively associated with global copy number loss, vimentin expression, and caspase activity, which are considered hallmarks of previously established EMT subtype. The segregation of 19,392 protein expression time courses by sensitive and resistant cell lines for the drugs tested revealed that 5FU-resistant cell lines had lower changes in global protein dynamics, suggesting their robust protein level regulation, than their sensitive counterparts, whereas the cell lines that are resistant to other drugs showed increased protein dynamics in response to each drug. Despite faint global protein dynamics, 5FU-resistant cell lines showed increased signal transducer and activator of transcription 1 phosphorylation and PD-L1 expression in response to 5FU. In publicly available cohort data, expression of signal transducer and activator of transcription 1 and NFκB target genes induced by proinflammatory cytokines was associated with prolonged survival in GC. In our validation cohort, total lymphocyte count, rather than PD-L1 positivity, predicted a better relapse-free survival rate in GC patients with 5FU-based adjuvant chemotherapy than those with surgery alone. Moreover, total lymphocyte count+ patients who had no survival benefit from adjuvant chemotherapy were discriminated by expression of IκBα, a potent negative regulator of NFκB. Collectively, our results suggest that 5FU resistance observed in cell lines may be overcome by host immunity or by combination therapy with immune checkpoint blockade.

Prognostic nutritional index is an independent risk factor for continuing S-1 adjuvant chemotherapy in patients with pancreatic cancer who received neoadjuvant chemotherapy and surgical resection

PURPOSE

Reports on the association of perioperative nutritional and inflammatory status with the clinical course of adjuvant chemotherapy did not include neoadjuvant chemotherapy. We aimed to clarify the mechanism by which perioperative nutritional and inflammatory status affect the clinical course of postoperative adjuvant chemotherapy in patients with pancreatic cancer.

METHODS

We enrolled 123 patients with pancreatic cancer retrospectively who underwent surgical resection with neoadjuvant and S-1 adjuvant chemotherapy between January 2013 and December 2022. The duration of continuing S-1 treatment and the continuation rates at 3 and 6 months after initiating adjuvant chemotherapy were calculated using the Kaplan-Meier method. The log-rank test was used to evaluate statistical differences between the high and low prognostic nutritional index (PNI) groups. Univariable and multivariable analyses were performed to determine the risk factors for continuing S-1 adjuvant chemotherapy.

RESULTS

The optimal cut-off value for preoperative PNI was 45. Preoperative PNI was an independent risk factor for continuing S-1 adjuvant chemotherapy in patients who underwent perioperative adjuvant chemotherapy and surgical resection (hazard ratio = 2.435, 95% confidence interval = 1.229 - 4.824, p = 0.011). Low PNI was associated with lower S-1completion (p = 0.02) and higher S-1 withdrawal (p = 0.031). Additionally, the preoperative PNI status affected ≥ grade 2 adverse events caused by adjuvant chemotherapy (p < 0.001).

CONCLUSION

Preoperative PNI affected adjuvant chemotherapy continuation and related adverse events in patients who underwent neoadjuvant chemotherapy and curative resection. Additional perioperative anti-inflammatory management and nutritional support may be required to improve the clinical course of postoperative adjuvant chemotherapy and patient survival.

A case of needle tract seeding of pancreatic adenosquamous carcinoma after a single endoscopic ultrasound-guided tissue acquisition

Needle tract seeding (NTS) is a rare complication of endoscopic ultrasound-guided tissue acquisition (EUS-TA). Herein, we report the case of an 83 year-old man who presented with a solid mass in the pancreatic tail, measuring 35 mm in diameter, with cystic degeneration. EUS-TA was performed using a 22-gauge biopsy needle, with a single puncture via the stomach; however, no definitive pathological diagnosis was achieved. Due to the strong suspicion of malignancy, surgery was performed at the patient's request, and the postoperative pathological diagnosis was pancreatic adenosquamous carcinoma. One year after surgery, computed tomography revealed a string of bead-like nodules within the gastric wall. Esophagogastroduodenoscopy revealed three submucosal, tumor-like raised lesions aligned in a row on the upper posterior wall of the gastric body. EUS detected a solid mass with cystic degeneration. Histological findings from EUS-TA specimens were consistent with those from the pancreatic resection specimen, leading to a diagnosis of NTS. Although reports of NTS have been increasing in recent years, cases of NTS occurring after only a single puncture remain extremely rare. This case clearly demonstrates that NTS can occur even after a single puncture, highlighting the importance of obtaining thorough informed consent regarding this risk prior to performing EUS-TA.

Pylorus-preserving pancreatoduodenectomy preserving blood supply for pancreatic cancer with a history of proximal gastrectomy and sigmoidectomy: a case report

BACKGROUND

Blood supply to the remnant stomach should be preserved during pancreatectomy in patients with a history of gastrectomy. Moreover, ischemic complications should be considered when performing pancreatoduodenectomy in patients with celiac axis and superior mesenteric artery (SMA) stenosis. However, whether these surgical procedures can be safely performed remains unclear.

CASE PRESENTATION

A 75-year-old man had a history of laparoscopic proximal gastrectomy (PG) with double-flap technique for gastric cancer and laparoscopic sigmoidectomy for sigmoid cancer treated 4 years ago. Follow-up computed tomography (CT) revealed an irregular nodular tumor measuring 13 mm in the pancreatic head. The patient was diagnosed with resectable pancreatic head cancer without lymph node metastasis (cT1cN0M0, cStageIA) according to the Union for International Cancer Control, 8th edition. As a standard pancreatic cancer treatment, two courses of preoperative chemotherapy with gemcitabine plus S-1 were administered. CT after preoperative chemotherapy identified no significant changes in tumor size but revealed SMA stenosis due to atherosclerosis. Blood flow to the left-sided colon was supplied from the middle colic artery via the SMA because of the past sigmoidectomy with inferior mesenteric artery detachment. Therefore, SMA stent placement was performed 1 day preoperatively. Subsequently, pylorus-preserving pancreatoduodenectomy (PPPD) was performed, preserving the remnant stomach with the right gastroepiploic (RGE) artery and vein. After resection, indocyanine green fluorescence imaging confirmed a good blood supply to the remnant stomach. The operation time was 467 min, and the blood lost was 442 mL. Histopathologically, the tumor was diagnosed as moderate adenocarcinoma and pT1cN0M0, Stage IA. The postoperative course was uneventful. The patient was discharged on postoperative day 23. S-1 as adjuvant chemotherapy was administered on postoperative day 63. The patient has been alive without recurrence for 7 months.

CONCLUSIONS

We performed PPPD preserving blood supply for pancreatic head cancer in a patient with benign SMA stenosis and a history of PG and sigmoidectomy. Blood supply was preserved through preoperative SMA stent placement and a surgical procedure preserving the RGE vessels. Furthermore, S-1 adjuvant chemotherapy was successfully initiated. These multimodal therapies contributed to a favorable clinical outcome.

Variability of quality-of-life measurements and reporting in randomised controlled trials of pancreatic cancer: a systematic review

OBJECTIVES

This systematic review aims to evaluate the methodology used in pancreatic cancer (PC) randomised controlled trials (RCTs) measuring quality of life (QOL) and focuses on the type, frequency, survey compliance and duration of these assessments.

DESIGN

Systematic review of PC RCTs measuring QOL.

DATA SOURCES

A search of PubMed.gov and ClinicalTrials.gov was conducted for PC RCTs measuring QOL from inception to 21 March 2023. Only phase III RCTs were included. Studies were excluded if QOL was not measured, the study was phase I/II, in the second-line setting or unavailable in English. Data were independently extracted by two reviewers in a standardised fashion.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included the type of QOL instrument used, the timing and frequency of assessments, methods of analysis and survey completion rates (SCRs) over time. Secondary outcomes included patient demographics, significant QOL improvements and the frequency of trials measuring QOL.

RESULTS

Out of 269 studies screened, 54 RCTs were identified, and 24 measured QOL (involving 11 229 patients). Instruments used included the EORTC QLQ-C30 (n=15), FACT-HEP (n=3), Spitzer-QOL-Index (n=2), EQ-5D (n=2), LASA (n=1) and FACT-PA (n=1). Most trials assessed QOL until disease progression or death (10/24), with 4-week intervals being the most common (7/24). SCRs were reported in 15/24 trials, with disease stage influencing SCRs over time. In trials with metastatic, locally advanced/metastatic, and resectable disease, the median times to reach a 50% response rate-defined as the point where the number of surveys completed was half of the enrolled participants-were 12.41 weeks (n=2), 14.14 weeks (n=10), and 54.2 weeks (n=3), respectively." Only 2/24 trials reported significant QOL improvements between treatment arms. Patient age was reported in all trials, while race/ethnicity was only reported in 4/24 trials.

CONCLUSIONS

Significant variability exists in the timing, methods and reporting of QOL assessments in PC trials. There is a need for further research to assess the implications of missing data and consider the temporality of QOL assessment in patients with advanced cancers and poor prognosis.

Clinical impact of the prognostic nutritional index and skeletal muscle index for the incompletion of adjuvant chemotherapy for pancreatic cancer

BACKGROUND

Adjuvant chemotherapy is a standard therapeutic option for resected pancreatic cancer. However, the risk factors for incompletion of adjuvant chemotherapy remain unclear.

METHODS

We retrospectively reviewed the medical records of 72 patients who underwent radical pancreatectomy and received S-1 adjuvant chemotherapy for pancreatic cancer. The patients were assigned to two groups according to their completion or incompletion of adjuvant chemotherapy. We compared the perioperative skeletal muscle mass index (SMI) and nutritional status using prognostic nutritional index (PNI) between the two groups.

RESULTS

The completion and incompletion groups included 46 (64 %) and 26 (36 %) patients, respectively. Overall survival was shorter in the incompletion group than in the completion group (median survival time, 20.2 months vs. 42.0 months; log-rank, p = 0.018). Decreasing rate of PNI (12.7 % vs. 0.2 %, p = 0.010) and decreasing rate of SMI (26.9 % vs. 12.5 %, p = 0.001) were significantly larger in the incompletion group than in the completion group. Multivariate analysis showed that decreasing rate of PNI (p = 0.016), decreasing rate of SMI (p = 0.013), and old age (p = 0.049) were independent risk factors for incompletion of S-1 adjuvant chemotherapy. Regarding the time-series variations, PNI improved from 1 to 3 months after pancreatectomy in the completion group (p = 0.006). Furthermore, the decreasing slope of SMI was stronger in the incompletion group.

CONCLUSION

Postoperative decrease of PNI and SMI is associated with the incompletion of S-1 adjuvant chemotherapy.

Association of chemotherapy completion rates and overall survival with postoperative complications after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

INTRODUCTION

Despite the benefits of surgical resection and adjuvant chemotherapy for pancreatic ductal adenocarcinoma (PDAC), over 30 % of patients fail to complete adjuvant oncological treatment. Whether postoperative complications affect chemotherapy completion rates and overall survival remains uncertain. We hypothesized that postoperative complications would be associated with chemotherapy delays, omission, and reduced overall survival (OS).

METHODS

This was a retrospective analysis of patients undergoing pancreaticoduodenectomy for PDAC from 2008 to 2022 to assess whether serious surgical complications, defined as Clavien Dindo Grade 3b or higher, were associated with the omission or delay of adjuvant oncologic treatment as well as OS.

RESULTS

A total of 920 patients were available for analysis. Pancreatic and bile leakage were associated with risk of chemotherapy omission (OR 1.97 [CI 95 % 1.25-3.12], p = 0.004 and OR 1.96 [CI 95 % 1.04-3.67], p = 0.032, respectively). No delay of adjuvant chemotherapy >90 days nor change in OS was found.

CONCLUSION

Major surgical complications influence the likelihood of omitting adjuvant chemotherapy but not delaying it > 90 days. Patients with pancreatic or bile leakage were at greater risk of not completing planned chemotherapy but had the same OS.

The impact of preoperative renal insufficiency on the outcomes of patients with pancreatic cancer undergoing pancreaticoduodenectomy

PURPOSE

This study evaluated the impact of renal function impairment on long-term survival outcomes and adjuvant therapy in patients with pancreatic cancer undergoing pancreaticoduodenectomy (PD).

METHODS

In this study, 264 patients who underwent PD for pancreatic head cancer between 2011 and 2021 were retrospectively analyzed. The patients were subsequently categorized into three groups according to the estimated glomerular filtration rate: normal group (> 90 mL/min/1.73 m2, n = 73), moderate group (45-90 mL/min/1.73 m2, n = 176), and severe group (< 45 mL/min/1.73 m2, n = 15). The primary outcomes evaluated were postoperative complications, overall survival (OS), and relapse-free survival (RFS). Additionally, the completion of adjuvant therapy and risk factors for adjuvant therapy discontinuation were analyzed.

RESULTS

The total proportion of patients with complications was significantly higher in the severe group (p = 0.008). The proportion of patients with severe complications (Clavien-Dindo classification ≥ IIIa) did not significantly differ between the chronic kidney disease (CKD) groups (p = 0.730). The proportion of patients in whom adjuvant therapy was completed was notably lower in the severe group (p = 0.011). Multiple logistic regression analysis revealed that CKD groups and hemoglobin levels ≤ 11.5 g/dL were independent predictors of adjuvant therapy completion failure (p = 0.016 and p = 0.016). There was no significant difference in the OS and RFS rates between the CKD groups (p = 0.499, p = 0.688).

CONCLUSIONS

In patients with pancreatic cancer and CKD, performing PD safely may be feasible; however, adjuvant therapy completion is challenging.

Clinical impact of intraoperative pancreatic transection margin analysis and additional resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

BACKGROUND

The prognostic impact of additional resection based on intraoperative frozen section analysis (FSA) of the pancreatic transection margin in patients with pancreatic ductal adenocarcinoma (PDAC) is controversial. The purpose of this study was to evaluate the prognosis based on the results of the first FSA of the pancreatic transection margin (1st FSA) and the clinical significance of additional resection.

METHODS

Patients who underwent pancreaticoduodenectomy for PDAC from 2000 to 2020 at a single center were included. Patients were divided into 3 groups based on the 1stFSA. Survival and prognostic factors were analyzed according to the 1stFSA.

RESULTS

A total of 311 patients were included in this study. The 1stFSA was negative in 272 patients (1stFSA-R0) and positive in 39 patients [carcinoma in situ (1stFSA-CIS), 21 patients; invasive carcinoma (1stFSA-IC), 18 patients]. Additional resections were performed on 37 patients [1stFSA-CIS, 20 patients; 1stFSA-IC, 17 patients], and R0 resection was achieved in 34 patients intraoperatively. Comparing median survival time to 1stFSA-R0 (36.4 months), 1stFSA-CIS was comparable (27.8 months, p = 0.276), although 1stFSA-IC was significantly worse (18.8 months, p = 0.001). On multivariate analysis, 1stFSA-IC was an independent prognostic factor (hazard ratio 2.68, 95 % confidence interval 1.16-6.17, p = 0.020).

CONCLUSIONS

1stFSA-CIS and 1stFSA-R0 had similar OS, implying that additional resection may be acceptable for 1stFSA-CIS. 1stFSA-IC was still an independent prognostic factor based on additional resection, and the prognostic significance of additional resection is uncertain for 1stFSA-IC.

Prognosis prediction of PDAC via detection of O-glycan altered extracellular vesicles in perioperative sera

Pancreatic ductal adenocarcinoma (PDAC) is a fatal malignancy due to the difficulty in diagnosis and poor prognosis because of the high recurrence rate, necessitating reliable biomarkers to improve the diagnosis and prognosis. However, the existing markers have limitations. We previously identified extracellular vesicles (EVs) recognized by O-glycan-binding lectins (Amaranthus caudatus agglutinin [ACA]) as a novel diagnostic biomarker for PDAC using an EV-counting system (ExoCounter). This retrospective study analyzed changes in ACA-positive EVs in perioperative PDAC serum and its association with prognosis using ExoCounter. Absolute EV levels in the pre- and postoperative sera of 44 patients who underwent curative pancreatectomy for PDAC were quantified using ExoCounter. The carbohydrate antigen 19-9 levels declined in most samples postoperatively, and presented no correlation with poor prognosis. In contrast, ACA-positive EVs increased in serum at 7 days postoperatively in 27 of 44 patients (61.4%). We therefore divided participants with ACA-positive EVs before and after surgery into elevation and decline groups. The overall survival (OS) and recurrence-free survival (RFS) of patients with higher ACA-positive EVs were significantly shorter than those with lower ACA-positive EVs (26.1 months vs. not reached, P = 0.018; 11.9 vs. 38.6 months, P = 0.013). Multivariable analysis revealed that ACA-positive EV elevation in postoperative serum was an independent prognostic factor for poor OS (hazard ratio [HR] = 3.891, P = 0.023) and RFS (HR = 2.650, P = 0.024). The detection of ACA-positive EVs in perioperative serum may be used to predict the prognosis of PDAC in the early postoperative period.

Survival outcomes of adjuvant chemotherapy in patients with stage I pancreatic cancer stratified by pathologic risk

BACKGROUND

This study aimed to evaluate the impact of adjuvant chemotherapy on survival in patients with stage I pancreatic ductal adenocarcinoma, stratified according to pathologic risk factors.

METHODS

A total of 259 patients with stage I pancreatic ductal adenocarcinoma who underwent radical resection were retrospectively analyzed. The patients were categorized into groups with and without pathologic risk based on the presence of perineural and/or lymphovascular invasion. Subset Kaplan-Meier survival and multivariate analyses were performed to determine the recurrence-free survival and overall survival.

RESULTS

Adjuvant chemotherapy did not significantly prolong recurrence-free survival (P = .213) but increased overall survival (P = .019) in patients with stage I pancreatic ductal adenocarcinoma. In subgroup analysis, adjuvant chemotherapy significantly improved recurrence-free survival (P = .037) and overall survival (P = .007) in patients with pathologic risk (n = 160). However, patients without pathologic risk (n = 99) showed no enhancement of recurrence-free survival (P = .870) and overall survival (P = .413) after adjuvant chemotherapy. Subset multivariate analyses indicated that adjuvant chemotherapy was an independent favorable prognostic factor in patients with pathologic risk but not in those without pathologic risk.

CONCLUSION

Adjuvant chemotherapy for stage I pancreatic ductal adenocarcinoma may provide survival benefits specifically to patients with pathologic risk.

Outcomes of Surgical Resection of Primary Lung Cancer After Pancreatic Cancer

OBJECTIVE

This study aimed to elucidate the therapeutic significance of lung resection for primary lung cancer after pancreatic cancer surgery in contemporary cases.

METHODS

This retrospective cohort study included patients who had lung nodules and performed pulmonary resection after pancreatic cancer surgery at seven hospitals affiliated with the Thoracic Surgery Study Group of Osaka University between January 2009 and December 2021. Patients in which surgery was performed for biopsy purposes, those with a history of other cancers with potential for lung metastasis, patients who did not give their consent for enrollment, and patients determined to be ineligible by the attending physician were excluded from the study.

RESULTS

A demographic analysis revealed that 17 patients were eligible for inclusion. Pathological diagnoses were established by institutional pathologists and occasionally aided by immunostaining and genetic testing. A survival analysis revealed a 3-year survival rate of 61.9% and a 5-year survival rate of 54.2% after lung resection. Subgroup analyses highlighted the impact of the interval between pancreatic cancer surgery and lung nodule detection, tumor diameter, and procedure on survival outcomes.

CONCLUSIONS

This study underscores the therapeutic implications of lung resection for primary lung cancer following surgery for pancreatic cancer. Despite the challenges in preoperative diagnosis and treatment decisions, surgical intervention demonstrates promise, especially in select cases. Further research is needed to determine the best therapeutic strategies for this group.

Endoscopic treatment of bile duct stones with benign choledochojejunal anastomotic stenosis

BACKGROUND AND AIMS

Endoscopic interventions for bile duct stones (BDSs) with benign choledochojejunal anastomotic stenosis (bCJS) are challenging. Therefore, we investigated endoscopic interventions for BDSs with bCJS.

METHODS

Seventeen patients with BDSs with bCJS were retrospectively analyzed. Patient characteristics, technical success, adverse events (AEs), and recurrence were evaluated.

RESULTS

In 17 patients, the median diameters of the bile duct and BDSs were both 8 mm. The median number of BDSs was 3. The technical success rate was 94% (16/17). Ten patients underwent balloon dilation at the choledochojejunal anastomotic site (CAS), the median diameter of balloon dilation was 10.5 mm, and waist disappearance was achieved in 2. Six patients had fully covered self-expandable metal stents (FCSEMSs) with a diameter of 10 mm placed at the CAS. BDSs were removed after balloon dilation or FCSEMS removal, and 6 of 16 patients were treated with a combination of lithotripsy and 5 with peroral direct cholangioscopy (PDCS). Regarding AEs, perforation at the CAS by balloon dilation occurred in 1 patient. The median follow-up was 3701 days. Nine of 16 patients (56%) had recurrence. The patients treated with a combination of PDCS at BDS removal (P = .022) and waist disappearance at the CAS by balloon dilation (P = .035) had significantly fewer recurrences.

CONCLUSIONS

Endoscopic interventions for BDSs with bCJS are useful and relatively safe; however, long-term follow-up showed frequent recurrences. Recurrence was common in patients not treated with the combination of PDCS at BDS removal and those without waist disappearance at the CAS by balloon dilation.

Current status and prospect of gut and oral microbiome in pancreatic cancer: Clinical and translational perspectives

Pancreatic cancer is a highly lethal malignancy, and its diagnosis and treatment continue to pose significant challenges. Despite advancements in surgical and comprehensive treatment methods, the five-year survival rate remains below 12 %. With the rapid development of microbiome science, the gut and oral microbiota, which are readily accessible and can be sampled non-invasively, have emerged as a novel area of interest in pancreatic cancer research. Dysbiosis in these microbial communities can induce persistent inflammatory responses and affect the host's immune system, promoting cancer development and impacting the efficacy of treatments like chemotherapy and immunotherapy. This review provides an up-to-date overview of the roles of both gut and oral microbiota in the onset, progression, diagnosis, and treatment of pancreatic cancer. It analyzes the potential of utilizing these microbiomes as biomarkers and therapeutic targets from a clinical application perspective. Furthermore, it discusses future research directions aimed at harnessing these insights to advance the diagnosis and treatment strategies for pancreatic cancer. By focusing on the microbiome's role in clinical and translational medicine, this review offers insights into improving pancreatic cancer diagnosis and treatment outcomes.

Relationships between postoperative recurrences and standardized uptake value on 18F-fluorodeoxyglucose-positron emission tomography in patients with resectable and borderline resectable pancreatic ductal adenocarcinoma who underwent curative pancreatic resection after neoadjuvant chemoradiotherapy

BACKGROUND

This study aimed to examine postoperative recurrence after curative pancreatic resection following neoadjuvant chemoradiotherapy (NACRT) in patients with resectable (R-) and borderline resectable (BR-) pancreatic ductal adenocarcinoma (PDAC), focusing on its relationship with the standardized uptake value (SUV) on 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET).

METHOD

The postoperative initial recurrence patterns were examined in patients with R- and BR-PDAC who underwent NACRT followed by curative pancreatic resection. Data collected from three prospective clinical trials were retrospectively analysed.

RESULTS

After a median follow-up of 29 months, 91 (60 %) of 151 patients experienced postoperative recurrence. The median recurrence-free survival (RFS) for all patients was 18 months. The sites of first recurrence were lung-only in 24 (26 %) patients, liver-only in 23 (25 %), local-only in 11 (12 %), peritoneum-only in 10 (11 %), other single site in 5 (5 %), and multiple sites in 19 (21 %) patients. Multivariate analysis identified the maximum standardized uptake value (SUVmax) on FDG-PET at diagnoses ≥5.40 (hazard ratio [HR], 1.62; 95 % confidence interval [CI], 1.01-2.61; p = 0.045) and node-positive pathology (HR, 2.01; 95 % CI, 1.32-3.08; p = 0.001) as significant predictors of RFS. Furthermore, the SUVmax at initial diagnosis and after NACRT correlated with liver metastasis.

CONCLUSION

R- and BR-PDACs with high SUV on FDG-PET at diagnosis are risk factors for postoperative recurrence. Among patients who undergo surgery after NACRT, those with a high SUVmax at diagnosis or post-NACRT require careful attention for postoperative liver recurrence.

Clinical Implications of the Degree of Pancreatic Invasion in Ampulla of Vater Carcinoma

BACKGROUND

Ampulla of Vater carcinoma (AVC) stage T3 was subdivided according to the degree of pancreatic invasion into T3a (≤ 0.5 cm) and T3b (> 0.5 cm) by the 8th edition of the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) cancer staging system. However, the differences in clinicopathological features and survival outcomes between the two categories have not been well discussed.

PATIENTS AND METHODS

We retrospectively analyzed 133 consecutive patients who underwent pancreatoduodenectomy for AVC at our institution between 2002 and 2020. Clinicopathological features and survival outcomes of patients with AVC were analyzed, with a focus on the depth of pancreatic invasion. In addition, the survival outcomes of patients with T3 AVC were compared with those of patients with resectable pancreatic head carcinoma (R-PhC) who underwent pancreatoduodenectomy during the same period.

RESULTS

The overall survival (OS) in patients with T3b AVC (n = 12) was significantly worse than that in patients with T3a AVC (n = 39) [median survival time (MST) 9.2 vs. 74.5 months, p < 0.001). A multivariate analysis identified T3b tumor (hazard ratio 5.64, p = 0.009) as an independent prognostic factor. The OS of patients with T3a AVC was significantly better than that of patients with R-PhC who received adjuvant chemotherapy (n = 276, MST 35.0 months, p = 0.007). In contrast, the OS of patients with T3b AVC tended to be worse than that of patients with R-PhC managed without adjuvant chemotherapy, although this difference was not statistically significant (n = 163; MST, 17.5; p = 0.140).

CONCLUSIONS

AVC with > 0.5 cm invasion into the pancreas was associated with poor survival and represented advanced tumor progression to systemic disease.

Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer: Exploration of patients who did not require neoadjuvant treatment

Aim

The present study investigated the prognostic factors associated with actual 5-y recurrence-free survival (RFS) after upfront surgery for resectable pancreatic cancer (R-PC) in patients who were deemed not to require neoadjuvant treatment.

Methods

Between 2007 and 2016, 316 patients who underwent pancreatectomy for radiologically R-PC were retrospectively reviewed to evaluate the predictors of actual 5-y RFS. Predictors were identified using logistic regression analysis of preoperative evaluable factors. The cutoff values for continuous variables were determined based on a minimum p-value approach (model 1) or the value that maximized the rate of 5-y RFS survivors (model 2).

Results

Fifty-one patients (16.1%) achieved a 5-y RFS. A tumor size ≤23 mm, the absence of serosal invasion on computed tomography (CT), and Neutrophil-to-Lymphocyte Ratio <1.0, were significantly associated with the 5-y RFS in model 1. A Prognostic Nutritional Index ≥58 and the absence of serosal invasion and extrapancreatic nerve plexus invasion on CT were significantly associated with 5-y RFS in model 2. Only six (11.8%, model 1) and four (7.8%, model 2) patients had all three prognostic factors, and their 5-y RFS rates were 83.3% and 100%, respectively.

Conclusions

A modest number of patients who underwent upfront surgery achieved 5-y RFS, but only ~10% of them could be identified preoperatively. Based on these results, almost all R-PC patients are forced to undergo neoadjuvant treatment in daily practice.

Evaluation of a new scoring system for assessing nerve invasion in resected pancreatic cancer: A single-center retrospective analysis

Nerve invasion (NI) is a characteristic feature of pancreatic cancer. Traditional dichotomous statements on the presence of NI are unreasonable because almost all cases exhibit NI when sufficient pathological sections are examined. The critical implications of NI in pancreatic cancer highlight the need for a more effective criterion. This study included 511 patients, who were categorized into a training group and a testing group at a ratio of 7:3. According to the traditional definition, NI was observed in 91.2 % of patients using five pathological slides in our study. The prevalence of NI increased as more pathological slides were used. The criterion of 'two points of intraneural (endoneural) invasion in the case of four pathological slides' has the highest receiver operating characteristic (ROC) score. Based on this new criterion, NI was proved to be an independent prognostic factor for overall survival (OS) and disease-free survival (DFS) and was also correlated with tumor recurrence (P = 0.004). Interestingly, gemcitabine-based chemotherapy regimen is an independent favorable factor for patients with high NI. In the high NI group, patients who received a gemcitabine-based regimen exhibited a better prognosis than those who did not receive the gemcitabine-based regimen for OS (P = 0.000) and DFS (P = 0.001). In conclusion, this study establishes assessment criteria to evaluate the severity of NI in order to predict patient outcomes.

Clinical usefulness of C-reactive protein-albumin-lymphocyte (CALLY) index as a prognostic biomarker in patients undergoing surgical resection of pancreatic cancer

PURPOSE

The C-reactive protein-albumin-lymphocyte (CALLY) index, which simultaneously evaluates the nutritional, immunological, and inflammatory statuses, is a new prognostic biomarker in patients with various cancers; however, no study has reported the clinical significance of the CALLY index in patients with pancreatic cancer. This study aimed to investigate whether the preoperative CALLY index is a prognostic biomarker in patients undergoing surgical resection of pancreatic cancer.

METHODS

We retrospectively enrolled 461 patients with pancreatic cancer who underwent surgical resection between January 2013 and December 2022. The overall survival (OS) and relapse-free survival (RFS) rates were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression models.

RESULTS

The optimal cut-off value for the preoperative CALLY index was 1.9. In the low CALLY group, patients were older (p = 0.012), more patients underwent pancreaticoduodenectomy (p = 0.002), the median tumor size was larger (p < 0.001), more patients had pathologically confirmed metastatic lymph nodes (p = 0.015) and worse pathological stage (p = 0.015), and fewer patients received adjuvant chemotherapy (p = 0.003). A low CALLY index was associated with decreased OS (22.1 vs. 37.9 months) and RFS (12.4 vs. 16.4 months). Univariate and multivariate analyses showed that the preoperative CALLY index was an independent prognostic factor for OS (p < 0.001) and RFS (p = 0.045).

CONCLUSION

The preoperative CALLY index is a prognostic biomarker for both OS and RFS in patients undergoing surgery for pancreatic cancer.

Consensus, debate, and prospective on pancreatic cancer treatments

Pancreatic cancer remains one of the most aggressive solid tumors. As a systemic disease, despite the improvement of multi-modality treatment strategies, the prognosis of pancreatic cancer was not improved dramatically. For resectable or borderline resectable patients, the surgical strategy centered on improving R0 resection rate is consensus; however, the role of neoadjuvant therapy in resectable patients and the optimal neoadjuvant therapy of chemotherapy with or without radiotherapy in borderline resectable patients were debated. Postoperative adjuvant chemotherapy of gemcitabine/capecitabine or mFOLFIRINOX is recommended regardless of the margin status. Chemotherapy as the first-line treatment strategy for advanced or metastatic patients included FOLFIRINOX, gemcitabine/nab-paclitaxel, or NALIRIFOX regimens whereas 5-FU plus liposomal irinotecan was the only standard of care second-line therapy. Immunotherapy is an innovative therapy although anti-PD-1 antibody is currently the only agent approved by for MSI-H, dMMR, or TMB-high solid tumors, which represent a very small subset of pancreatic cancers. Combination strategies to increase the immunogenicity and to overcome the immunosuppressive tumor microenvironment may sensitize pancreatic cancer to immunotherapy. Targeted therapies represented by PARP and KRAS inhibitors are also under investigation, showing benefits in improving progression-free survival and objective response rate. This review discusses the current treatment modalities and highlights innovative therapies for pancreatic cancer.

Dendritic cells pulsed with multifunctional Wilms' tumor 1 (WT1) peptides combined with multiagent chemotherapy modulate the tumor microenvironment and enable conversion surgery in pancreatic cancer

BACKGROUND

We aimed to develop a chemoimmunotherapy regimen consisting of a novel Wilms' tumor 1 (WT1) peptide-pulsed dendritic cell (WT1-DC) vaccine and multiagent chemotherapy and to investigate the safety, clinical outcomes, and WT1-specific immune responses of patients with unresectable advanced pancreatic ductal adenocarcinoma (UR-PDAC) who received this treatment.

METHODS

Patients with UR-PDAC with stage III disease (locally advanced (LA-PDAC; n=6)), stage IV disease (metastatic (M-PDAC; n=3)), or recurrent disease after surgery (n=1) were enrolled in this phase I study. The patients received one cycle of nab-paclitaxel plus gemcitabine alone followed by 15 doses of the WT1-DC vaccine independent of chemotherapy. The novel WT1 peptide cocktail was composed of a multifunctional helper peptide specific for major histocompatibility complex class II, human leukocyte antigen (HLA)-A*02:01, or HLA-A*02:06 and a killer peptide specific for HLA-A*24:02.

RESULTS

The chemoimmunotherapy regimen was well tolerated. In the nine patients for whom a prognostic analysis was feasible, the clinical outcomes of long-term WT1 peptide-specific delayed-type hypersensitivity (WT1-DTH)-positive patients (n=4) were significantly superior to those of short-term WT1-DTH-positive patients (n=5). During chemoimmunotherapy, eight patients were deemed eligible for conversion surgery and underwent R0 resection (four patients with LA-PDAC, one patient with M-PDAC, and one recurrence) or R1 resection (one patient with M-PDAC), and one patient with LA-PDAC was determined to be unresectable. Long-term WT1-DTH positivity was observed in three of the four patients with R0-resected LA-PDAC. These three patients exhibited notable infiltration of T cells and programmed cell death protein-1+ cells within the pancreatic tumor microenvironment (TME). All patients with long-term WT1-DTH positivity were alive for at least 4.5 years after starting therapy. In patients with long-term WT1-DTH positivity, the percentage of WT1-specific circulating CD4+ or CD8+ T cells that produced IFN-γ or TNF-α was significantly greater than that in patients with short-term WT1-DTH positivity after two vaccinations. Moreover, after 12 vaccinations, the percentages of both circulating regulatory T cells and myeloid-derived suppressor cells were significantly lower in patients with long-term WT1-DTH-positive PDAC than in short-term WT1-DTH-positive patients.

CONCLUSIONS

Potent activation of WT1-specific immune responses through a combination chemoimmunotherapy regimen including the WT1-DC vaccine in patients with UR-PDAC may modulate the TME and enable conversion surgery, resulting in clinical benefits (Online supplemental file 1).

TRIAL REGISTRATION NUMBER

jRCTc030190195.

Nab-paclitaxel plus S-1 versus nab-paclitaxel plus gemcitabine in patients with advanced pancreatic cancer: a multicenter, randomized, phase II study

BACKGROUND

Encouraging antitumor activity of nab-paclitaxel plus S-1 (AS) has been shown in several small-scale studies. This study compared the efficacy and safety of AS versus standard-of-care nab-paclitaxel plus gemcitabine (AG) as a first-line treatment for advanced pancreatic cancer (PC).

METHODS

In this multicenter, randomized, phase II trial, eligible patients with unresectable, locally advanced, or metastatic PC were recruited and randomly assigned (1:1) to receive AS (nab-paclitaxel 125 mg/m2 on days 1 and 8; S-1 twice daily on days 1 through 14) or AG (nab-paclitaxel 125 mg/m2 on days 1 and 8; gemcitabine 1000 mg/m2 on days 1 and 8) for 6 cycles. The primary endpoint was progression-free survival (PFS).

RESULTS

Between July 16, 2019, and September 9, 2022, 62 patients (AS, n = 32; AG, n = 30) were treated and evaluated. With a median follow-up of 8.36 months at preplanned interim analysis (data cutoff, March 24, 2023), the median PFS (8.48 vs 4.47 months; hazard ratio [HR], 0.402; P = .002) and overall survival (OS; 13.73 vs 9.59 months; HR, 0.226; P < .001) in the AS group were significantly longer compared to the AG group. More patients had objective response in the AS group than AG group (37.50% vs 6.67%; P = .005). The most common grade 3-4 adverse events were neutropenia and leucopenia in both groups, and gamma glutamyl transferase increase was observed only in the AG group.

CONCLUSION

The first-line AS regimen significantly extended both PFS and OS of Chinese patients with advanced PC when compared with the AG regimen, with a comparable safety profile. (ClinicalTrials.gov Identifier: NCT03636308).

C-Reactive Protein-to-Albumin Ratio as a Predictive Indicator for Evaluating Tolerability in S-1 Adjuvant Chemotherapy after Curative Surgery for Pancreatic Cancer: An External Validation Cohort Study

BACKGROUND

S-1 in adjuvant chemotherapy (AC) administration after pancreatic cancer (PC) surgery has been standardized in Japan. The Ehime study confirmed that a postoperative higher C-reactive protein-to-albumin ratio (CAR) value predicted the risk of adverse event (AE)-related S-1 non-completion as an AC in patients with PC after curative surgery. This study aimed to investigate the index to predict S-1 tolerance among patients who underwent curative surgery for PC (the Dokkyo study).

METHODS

This retrospective validation cohort study included 172 patients at the Department of Hepato-Biliary Pancreatic Surgery, Dokkyo Medical University, Japan, from January 2010 to December 2022. All patients underwent nutritional screening using the postoperative CAR. S-1 completion status and its effect on prognosis were systematically followed up and investigated. We conducted a statistical analysis of predictive markers to investigate their association with S-1 completion.

RESULTS

Patients were categorized into the S-1 completion (N = 91) and non-completion (N = 81) groups. The S-1 completion group demonstrated a significantly lower CAR than the S1 non-completion group. Moreover, the current study revealed a significant difference in the S-1 completion rate, applying the CAR cutoff value of 0.05 established in the Ehime study. Additionally, univariate and multivariate analyses confirmed that a CAR of <0.05 was significantly associated with S-1 completion.

CONCLUSIONS

The Dokkyo study confirmed the results observed in the Ehime study. Consequently, an increased postoperative CAR value appeared as a universal applicable marker for the risk factor of AE-related S-1 non-completion after curative surgery for patients with PC.

High likelihood of BRCA2 reversion mutation in pancreatic cancer post-platinum-based chemotherapy: a case study

A 54-year-old man with resectable pancreatic cancer and abnormally high levels of carbohydrate antigen 19-9 (CA19-9) underwent 6 months of platinum-based chemotherapy. This treatment substantially reduced the primary tumor size and normalized CA19-9 levels. Subsequently, radical surgery was conducted. However, eight months post-surgery, CA19-9 levels re-elevated, and lymph-node recurrence was observed. The patient underwent treatment with poly(adenosine diphosphate ribose) polymerase inhibitors (PARPi) following the detection of frameshift L1904fs*5 via BRACAnalysis CDx. This mutation revealed a stop codon, leading to the inactivation of the BRCA function. Additionally, the patient tested positive for a mutation in the breast cancer susceptibility gene 2 (BRCA2). Two months after starting PARPi, there was evidence of tumor shrinkage. Nevertheless, 5 months later, CA19-9 levels increased again, and new metastatic tumors in the liver were identified. Genomic profiling test (FoundationOne CDx) of surgically resected specimens revealed a BRCA2 pL1908fs*2 mutation, indicating its location in the cis position on the same allele as the germline BRCA2 mutation. The pL1908fs*2 deletion, alongside the original L1904fs*5, resulted in three deletions, equating to one amino acid deletion. This deletion ultimately reversed the stop codon, leading to the restoration of BRCA2 functionality. Despite treatment with PARPi for postoperative recurrence, a sustained response was not achieved owing to BRCA reversion mutations. It is essential to acknowledge the rarity of BRCA reversion mutations, which limit the effectiveness of PARPi.

Preoperative Prediction of Long-Term Survival After Surgery in Patients with Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

Although some clinical trials have demonstrated the benefits of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma (PDAC), its optimal candidate has not been clarified. This study aimed to detect predictive prognostic factors for resectable PDAC patients who underwent upfront surgery and identify patient cohorts with long-term survival without neoadjuvant therapy.

PATIENTS AND METHODS

A total of 232 patients with resectable PDAC who underwent upfront surgery between January 2008 and December 2019 were evaluated.

RESULTS

The median overall survival (OS) time and 5-year OS rate of resectable PDAC with upfront surgery was 31.5 months and 33.3%, respectively. Multivariate analyses identified tumor diameter in computed tomography (CT) ≤ 19 mm [hazard ratio (HR) 0.40, p < 0.001], span-1 within the normal range (HR 0.54, p = 0.023), prognostic nutritional index (PNI) ≥ 44.31 (HR 0.51, p < 0.001), and lymphocyte-to-monocyte ratio (LMR) ≥ 3.79 (HR 0.51, p < 0.001) as prognostic factors that influence favorable prognoses after upfront surgery. According to the prognostic prediction model based on these four factors, patients with four favorable prognostic factors had a better prognosis with a 5-year OS rate of 82.4% compared to others (p < 0.001). These patients had a high R0 resection rate and a low frequency of tumor recurrence after upfront surgery.

CONCLUSIONS

We identified patients with long-term survival after upfront surgery by prognostic prediction model consisting of tumor diameter in CT, span-1, PNI, and LMR. Evaluation of anatomical, biological, nutritional, and inflammatory factors may be valuable to introduce an optimal treatment strategy for resectable PDAC.

Effects of transmembrane serine protease 4 on the survival in patients with pancreatic ductal adenocarcinoma undergoing surgery followed by adjuvant chemotherapy

PURPOSE

The transmembrane serine protease 4 (TMPRSS4) gene is upregulated in various human cancers. However, its biological functions in pancreatic ductal adenocarcinoma remain unclear. We examined the expression of TMPRSS4 in pancreatic ductal adenocarcinoma tissues and its correlation with clinicopathological parameters in patients with pancreatic ductal adenocarcinoma who underwent surgery.

METHODS

The TMPRSS4 expression was immunohistochemically examined in 81 PDAC patients with pancreatic ductal adenocarcinoma. We analyzed the association between the TMPRSS4 expression and clinicopathological factors, the recurrence-free survival (RFS), and the overall survival (OS) and examined the effect of TMPRSS4 expression on cell migration and sensitivity to 5-fluorouracil.

RESULTS

The expression rate of TMPRSS4 in the samples was 62.9% (51/81). The TMPRSS4 expression was not correlated with any clinicopathological feature. The five-year overall and recurrence-free survival rates were significantly lower in the TMPRSS4-positive group than in the TMPRSS4-negative group. On a multivariate analysis, TMPRSS4 positivity, poorly differentiated histology, and non-adjuvant chemotherapy predicted a poor OS, while TMPRSS4 positivity and poorly differentiated histology predicted a poor RFS. TMPRSS4-silenced pancreatic ductal adenocarcinoma cells showed higher sensitivity to 5- fluorouracil than did the control siRNA-transfected cells.

CONCLUSIONS

TMPRSS4 can be considered a prognostic factor and therapeutic target for pancreatic ductal adenocarcinoma.

Optimal treatment strategy for patients with pancreatic cancer having positive peritoneal cytology: A nationwide multicenter retrospective cohort study supervised by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND

The aim of this study was to determine the optimal treatment for patients with pancreatic cancer (PaCa) having positive peritoneal cytology (PPC).

METHODS

This multicenter retrospective study included patients with PPC treated at 78 high-volume centers between January 2012 and December 2020. Prognoses after resection (S-group) and initiation of nonsurgical treatment (N-group) were compared. Prognostic factors for survival in both groups were analyzed. Detailed characteristics of conversion surgery (CS) in the N-group were evaluated.

RESULTS

In total, 568 enrolled patients were classified into an S-group (n = 445) or an N-group (n = 123). Median survival times (MSTs) were 19.0 months and 19.3 months, respectively, with no significant difference in prognosis (p = .845). The intervenable prognostic factors for survival were adjuvant treatment in the S-group (p < .001) and CS in the N-group (p < .001). Following CS, the MST was prolonged to 45.6 months, and peritoneal or liver recurrence decreased considerably. CS can be expected if PPC is diagnosed before neoadjuvant treatment and when combination treatment is initiated.

CONCLUSION

Surgical resection may not be beneficial for improving survival when PPC is evident. Chemotherapy aiming for CS may be the optimal treatment for such patients.

Comparative Efficacy of 21 Treatment Strategies for Resectable Pancreatic Cancer: A Network Meta-Analysis

The primary treatment for operable pancreatic cancer (PC) involves surgery followed by adjuvant therapy. Nevertheless, perioperative or neoadjuvant chemotherapy (CT) may be used to mitigate the likelihood of recurrence and mortality. This network meta-analysis (NMA) assesses the comparative efficacy of various treatment approaches for resectable PC. A thorough search was carried out on January 31, 2023, encompassing PubMed/MEDLINE, Cochrane Library, and Embase databases. We incorporated randomized clinical trials (RCTs) that compared surgical interventions with or without (neo)adjuvant or perioperative therapies for operable PC. We conducted a fixed-effects Bayesian NMA. We presented the effect sizes in terms of hazard ratios (HRs) for overall survival (OS) along with 95% credible intervals (95% CrIs). The treatment was deemed statistically superior when the 95% credible interval (CrI) did not encompass a null value (hazard ratio < 1). Treatment rankings were established based on the surface under the cumulative ranking curve (SUCRA). A total of 24 studies were incorporated, comparing 21 treatments with surgery in isolation. Eleven treatments showed superior efficacy compared to surgery alone, with HRs ranging from 0.38 for perioperative treatments to 0.73 for adjuvant 5-fluorouracil. After the exclusion of studies conducted in Asia, it was found that the perioperative regimen of gemcitabine combined with nab-paclitaxel was the most effective regimen (SUCRA, p = 0.99). The findings endorse the utilization of perioperative CT, especially multi-agent CT, as the favored intervention for operable PC in Western nations.

MicroRNA-26a-5p is a reliable biomarker in the adjuvant setting for pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) has a high recurrence rate even after radical resection because of subclinical tumors. To manage them, a reliable biomarker that can indicate the presence of subclinical tumors and predict their chemosensitivity is required. This study aimed to identify a miRNA as a biomarker that can be used to individualize postoperative adjuvant chemotherapy using postoperative peripheral blood samples. Integrating miRNA microarray data from the blood of 18 patients with PDAC and the in vitro results regarding the phenotypes of chemoresistant PDAC cells, a candidate miRNA was identified. The relationships between candidate miRNA expression and chemosensitivity were examined in vitro and in clinical samples from other cohorts of 33 patients with recurrence. Comprehensive analyses of blood samples detected 5 candidate miRNAs. Of these, miR-26a-5p was considered a candidate biomarker of chemosensitive phenotypes. In validation experiments, chemosensitivity was inversely correlated with miR-26a-5p expression in vitro. Moreover, the ability of miR-26a-5p to predict chemosensitivity was clinically evaluated using blood samples. Patients with high miR-26a-5p expression in the blood after radical resection exhibited a significantly longer survival time after recurrence. Thus, we concluded that miR-26a-5p is a potentially useful biomarker for managing patients with PDAC, especially those undergoing adjuvant chemotherapy.

Peritoneal washing cytology status as a crucial prognostic determinant in patients with localized pancreatic ductal adenocarcinoma who underwent curative-intent resection following preoperative chemoradiotherapy

BACKGROUND

Prognostic implications of peritoneal washing cytology (CY) in patients with localized pancreatic ductal adenocarcinoma (PDAC) undergoing surgical resection following preoperative chemoradiotherapy (CRT) remain unclear. This study aimed to elucidate the prognostic significance and predictors of a positive CY status (CY+) after preoperative CRT.

METHODS

Clinical data from 141 patients with localized PDAC who underwent curative-intent resection after preoperative CRT were retrospectively analyzed to examine the association between CY+ and clinicopathological factors and survival.

RESULTS

CY+ was observed in six patients (4.3%). The CY+ group exhibited significantly higher preoperative serum levels of CA19-9 and a substantially greater incidence of tumor location in the pancreatic body or tail, along with pathological invasion to the anterior pancreatic capsule, than the CY- group. The CY+ group had a significantly higher incidence of peritoneal recurrence compared with the CY- group (83.3% vs. 18.5%, p = 0.002). Overall survival (OS) and recurrence-free survival (RFS) after surgery were significantly shorter in the CY+ group than in the CY- group (CY+ vs. CY-: 18.3 vs. 46.2 months, p = 0.001, and 8.9 vs. 17.7 months, p = 0.009, respectively). Multivariate analyses identified CY+ as an independent prognostic factor for worse OS (hazard ratio 5.00, 95% confidence interval 1.03-12.31) and RFS (hazard ratio 2.58, 95% confidence interval 1.04-6.43). Local invasion grade on imaging before CRT, limited histological response to CRT, and absence of adjuvant chemotherapy were independent predictors of worse OS and RFS.

CONCLUSION

Despite the relatively low incidence of CY+ after preoperative CRT, it emerged as an independent prognostic factor in patients with localized PDAC undergoing curative-intent resection following preoperative CRT.

Preoperative level of serum transthyretin as a novel biomarker predicting survival in resected pancreatic ductal adenocarcinoma with neoadjuvant therapy

BACKGROUND

Systemic inflammation and altered metabolism are essential hallmarks of cancer. We hypothesized that the rapid turnover protein transthyretin (TTR) (half-life: 2-3 days), compared with the conventional marker albumin (21 days), better reflects the inflammatory/metabolic dynamics of pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant therapy (NAT) and is a useful prognostic marker.

METHODS

Serum TTR and albumin levels were measured in 104 consecutive post-NAT PDAC patients before curative resection. The associations of preoperative TTR and albumin levels with overall survival (OS) after pancreatectomy were retrospectively analyzed.

RESULTS

The mean (SD) TTR and albumin levels were 21.6 (6.4) mg/dL (normal range: ≥22.0 mg/dL) and 3.9 (0.55) g/dL. A low (<22.0 mg/dL) post-NAT TTR level was associated with an advanced tumor stage and higher CEA and CRP levels. Patients with low TTR levels showed significantly worse OS compared with normal levels (3-year OS 39 % vs. 54 %, P = 0.037), although albumin levels did not. We modified prognostic biomarkers of systemic inflammation/metabolism, such as GPS, PNI, and CONUT scores, using the serum TTR instead of albumin level and successfully showed that modified scores were better associated with OS compared with original scores using serum albumin level.

CONCLUSIONS

Our data suggest that the TTR level is a promising prognostic biomarker for PDAC patients after NAT.

Prognostic impact of aberrant right hepatic artery involvement in patients with pancreatic cancer: A multicenter retrospective cohort study

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the prognostic value of aberrant right hepatic artery (A-RHA) involvement in patients with pancreatic cancer (PC).

METHODS

This study enrolled 474 patients who underwent upfront pancreatectomy or neoadjuvant treatment for resectable (R) or borderline resectable (BR) PC from four institutions. The patients were divided into three groups: A-RHA involvement group (n = 12), patients who had sole A-RHA involvement without major arterial involvement; BR-A group (n = 104), patients who had major arterial involvement; R/BR-PV group (n = 358), others.

RESULTS

All patients in the A-RHA involvement group underwent margin-negative resection. The median overall survival of the entire cohort in the A-RHA involvement, R/BR-PV, and BR-A groups was 41.2, 33.5, and 25.2 months, respectively. Although survival in the R/BR-PV group was significantly more favorable than that in the BR-A group (p = 0.0003), no significant difference was observed between the A-RHA involvement group and the R/BR-PV (p = 0.7332) and BR-A (p = 0.1485) groups.

CONCLUSIONS

The prognosis of patients with PC and sole A-RHA involvement was comparable to that of patients with R/BR-PV.

Is multidisciplinary treatment effective for invasive intraductal papillary mucinous carcinoma?

Background

Surgical resection is standard treatment for invasive intraductal papillary mucinous carcinoma (IPMC); however, impact of multidisciplinary treatment on survival including postoperative adjuvant therapy (AT), neoadjuvant therapy (NAT), and treatment for recurrent lesions is unclear. We investigated the effectiveness of multidisciplinary treatment in prolonging survival of patients with invasive IPMC.

Methods

This retrospective multi-institutional study included 1183 patients with invasive IPMC undergoing surgery at 40 academic institutions. We analyzed the effects of AT, NAT, and treatment for recurrence on survival of patients with invasive IPMC.

Results

Completion of the planned postoperative AT for 6 months improved the overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) of patients with stage IIB and stage III resected invasive IPMC, elevated preoperative carbohydrate antigen 19-9 level, lymphovascular invasion, perineural invasion, serosal invasion, and lymph node metastasis on un-matched and matched analyses. Of the patients with borderline resectable (BR) invasive IPMC, the OS (p = 0.001), DSS (p = 0.001), and RFS (p = 0.001) of patients undergoing NAT was longer than that of those without on the matched analysis. Of the 484 invasive IPMC patients (40.9%) who developed recurrence after surgery, the OS of 365 patients who received any treatment for recurrence was longer than that of those without treatment (40.6 vs. 22.4 months, p < 0.001).

Conclusion

Postoperative AT might benefit selected patients with invasive IPMC, especially those at high risk of poor survival. NAT might improve the survivability of BR invasive IPMC. Any treatment for recurrence after surgery for invasive IPMC might improve survival.